What is the most appropriate initial management for an 18-year-old primigravid woman at 38 weeks' gestation with newly elevated blood pressure (hypertension), proteinuria, and symptoms suggestive of preeclampsia?

Management of Preeclampsia in an 18-Year-Old Primigravida at 38 Weeks' Gestation

The most appropriate initial management for this patient with newly diagnosed preeclampsia at 38 weeks' gestation is hospitalization for delivery, as delivery is the definitive treatment for preeclampsia at term (≥37 weeks). 1

Diagnosis Assessment

This patient presents with clear signs of preeclampsia:

• New-onset hypertension (148/94 mmHg) after 20 weeks' gestation
• Significant proteinuria (+2 on dipstick)
• Symptoms of nausea and vomiting (which may be related to preeclampsia)

Key Diagnostic Points:

• Blood pressure elevation from her baseline of 120/80 mmHg to 148/94 mmHg meets criteria for hypertension in pregnancy
• Proteinuria of +2 on dipstick indicates significant proteinuria (equivalent to >300 mg/L) 1
• At 38 weeks' gestation, this represents term preeclampsia

Management Algorithm

1. Initial Assessment and Hospitalization

   • All women with newly diagnosed preeclampsia should be initially evaluated in a hospital setting 1
   • Monitor maternal vital signs, especially blood pressure every 4 hours while awake
   • Perform baseline laboratory tests: complete blood count, liver enzymes, creatinine, and uric acid

2. Definitive Management

   • For preeclampsia at ≥37 weeks' gestation, delivery is the recommended treatment 1
   • This eliminates the underlying cause of preeclampsia (placental factors)
   • Expectant management at term offers no benefit and increases maternal and fetal risks

3. Blood Pressure Management

   • Blood pressure consistently ≥140/90 mmHg should be treated with antihypertensive medication 2
   • Target diastolic BP around 85 mmHg and systolic BP <160 mmHg
   • First-line medications include oral methyldopa, labetalol, or nifedipine 1

4. Seizure Prophylaxis

   • Consider magnesium sulfate for seizure prophylaxis, especially if severe hypertension or neurological symptoms develop 1, 3
   • Initial dose: 4-5g IV in 250mL of fluid over 15-20 minutes, followed by maintenance infusion

5. Fetal Monitoring

   • Continuous fetal heart rate monitoring during labor
   • Current assessment shows reassuring fetal status with heart tones in the 130s/min with appropriate accelerations

Why Other Options Are Not Appropriate

• High-calcium, low-salt diet: While calcium supplementation may be beneficial for prevention in high-risk women with low calcium intake, it is not a treatment for established preeclampsia 1
• Low-fat, low-cholesterol diet: Not indicated for management of preeclampsia
• Bed rest in left lateral position: While this position may improve uteroplacental perfusion temporarily, it is not a definitive treatment for term preeclampsia and does not prevent disease progression 1
• Oral antihypertensives alone: While appropriate as part of management, they do not address the underlying pathology; delivery is required at term
• Oral magnesium oxide: Not the appropriate form or dose for seizure prophylaxis in preeclampsia; IV magnesium sulfate is the standard if seizure prophylaxis is needed 3

Important Considerations

• The severity of preeclampsia can change rapidly, and all cases should be considered potentially severe 1
• Proteinuria level alone should not guide management decisions or timing of delivery 1, 4
• Blood pressure control is essential to prevent cerebrovascular complications, but delivery remains the definitive treatment at term
• Close maternal and fetal monitoring is essential throughout the process

Postpartum Management

• Continue blood pressure monitoring for at least 72 hours postpartum
• Antihypertensive medications should be continued and gradually tapered as needed
• Follow-up at 3 months to ensure resolution of hypertension and proteinuria 1
• Counsel regarding increased lifetime cardiovascular risk following preeclampsia

In conclusion, for this 18-year-old primigravida at 38 weeks with newly diagnosed preeclampsia, hospitalization for delivery is the most appropriate management strategy to minimize maternal and fetal risks.