What is the treatment for a 26-year-old pregnant woman at 30 weeks gestation with jaundice, hypertension (high blood pressure), and elevated liver enzymes, including aspartate transaminase (AST) and alanine transaminase (ALT), with a prenatal vitamin as her only medication?

From the Guidelines

The patient should be treated with urgent antihypertensive therapy and magnesium sulfate for seizure prophylaxis, and delivery should be considered within 24-48 hours after stabilization, as her condition is consistent with severe preeclampsia with elevated liver enzymes and renal impairment, which poses significant risks to both maternal and fetal health. This 26-year-old woman at 30 weeks gestation is presenting with hypertension (165/100 mmHg), jaundice, elevated liver enzymes (AST 485, ALT 500), elevated bilirubin, and renal impairment (Cr 1.2), which are classic signs of this life-threatening complication of preeclampsia. Management should begin with administration of magnesium sulfate for seizure prophylaxis (4-6g IV loading dose followed by 1-2g/hour continuous infusion) 1, and antihypertensive therapy to maintain blood pressure below 160/110 mmHg (labetalol 20-40mg IV every 10-15 minutes or hydralazine 5-10mg IV every 20 minutes) 1. Antenatal corticosteroids (betamethasone 12mg IM, two doses 24 hours apart) should also be considered to accelerate fetal lung maturity. The patient should be transferred to a tertiary care center with neonatal intensive care capabilities if not already there. Continuous maternal and fetal monitoring is essential.

• Key management points include:
  • Urgent treatment of severe hypertension with oral nifedipine or intravenous labetalol or hydralazine 1
  • Administration of magnesium sulfate for convulsion prophylaxis in women with preeclampsia who have proteinuria and severe hypertension, or hypertension with neurological signs or symptoms 1
  • Fetal monitoring with assessment of fetal biometry, amniotic fluid, and UA Doppler with ultrasound at first diagnosis and thereafter at 2 weekly intervals if the initial assessment was normal 1
  • Maternal monitoring with BP monitoring, repeated assessments for proteinuria if not already present, clinical assessment including clonus, and twice weekly blood tests for Hb, platelet count, liver transaminases, creatinine, and uric acid 1
• The definitive treatment is delivery because preeclampsia is caused by placental factors that trigger widespread endothelial damage and microvascular thrombosis, which resolves only with removal of the placenta. Delivery should be considered if the patient develops any of the following: repeated episodes of severe hypertension despite maintenance treatment with 3 classes of antihypertensive agents; progressive thrombocytopenia; progressively abnormal renal or liver enzyme tests; pulmonary edema; abnormal neurological features, such as severe intractable headache, repeated visual scotomata, or convulsions; or nonreassuring fetal status 1.

From the FDA Drug Label

TRANDATE Tablets are indicated in the management of hypertension. TRANDATE Tablets may be used alone or in combination with other antihypertensive agents, especially thiazide and loop diuretics. The patient's high blood pressure 165/100 mm Hg suggests that she may benefit from antihypertensive treatment.

• Labetalol is indicated for the management of hypertension 2. Given the patient's condition, labetalol may be considered as a treatment option for her high blood pressure.

From the Research

Treatment of HELLP Syndrome

The patient's symptoms, including jaundice, high blood pressure, and elevated liver enzymes, are consistent with HELLP syndrome, a severe form of preeclampsia. The treatment of HELLP syndrome involves:

• Maternal stabilization and timely delivery, as there is no current treatment for HELLP syndrome 3
• Corticosteroids, such as dexamethasone, may be used to improve platelet counts and reduce liver enzymes, although the evidence is not conclusive 4, 5, 6
• Management of severe pre-eclampsia, including identification of high-risk patients, optimization of antenatal care, early intervention, and identification and early management of complications 7

Management of Severe Pre-eclampsia

The management of severe pre-eclampsia includes:

• Oral anti-hypertensive agents, such as labetalol, nifedipine, and methyldopa, as first-line treatment 7
• Intravenous anti-hypertensives, such as labetalol, hydralazine, and glyceryl trinitrate, if oral agents are not effective 7
• Magnesium sulphate to prevent seizures 7
• Close attention to regular clinical examination, assessment of fluid balance, neurologic status, and monitoring of other vital signs 7

Role of Corticosteroids

Corticosteroids, such as dexamethasone, may have a beneficial effect on HELLP syndrome by:

• Reducing liver enzymes and improving platelet counts 5, 6
• Blunting the release of antiangiogenic and inflammatory factors suggested to play a role in the pathophysiology of HELLP syndrome 6
• Shortening the disease course and reducing maternal morbidity 6