What is the management plan for a 33-year-old pregnant woman with chronic hypertension, fibroids, and a high-risk pregnancy at 17 weeks gestation, currently taking labetalol 100mg daily?

Management of Chronic Hypertension in Pregnancy at 17 Weeks

Continue labetalol 100mg daily with close monitoring, as the patient's blood pressure is well-controlled below 140/90 mmHg and current management is appropriate for chronic hypertension in pregnancy. 1

Current Blood Pressure Status

The patient's home blood pressure log demonstrates excellent control, with readings consistently below 140/90 mmHg (ranging from 96/64 to 118/79 mmHg over the past month). 1 This meets the guideline-recommended target of maintaining BP below 140/90 mmHg but not below 80 mmHg diastolic in pregnant women with chronic hypertension. 1

Medication Management

Labetalol remains the appropriate first-line agent at the current dose:

• Labetalol 100mg daily is providing adequate blood pressure control and should be continued without dose adjustment at this time. 1
• The European Society of Cardiology guidelines specifically recommend labetalol (along with extended-release nifedipine and methyldopa) as first-line therapy for hypertension in pregnancy. 1
• Labetalol can be titrated from 100mg twice daily up to 2400mg per day if needed, so there is substantial room for dose escalation if blood pressure rises. 1
• The current dose is well-tolerated without maternal or fetal side effects based on the clinical documentation. 2, 3

Critical Monitoring Parameters

The following surveillance is essential given her high-risk status:

• Continue twice-daily home blood pressure monitoring with the provided cuff, maintaining the current log format. 1
• Monitor specifically for blood pressure readings ≥140/90 mmHg, which would indicate need for medication adjustment. 1
• Watch for severe hypertension (≥160/110 mmHg), which constitutes an emergency requiring immediate hospitalization. 1
• The 24-hour urine protein of 225 mg/24h (reference <150) is mildly elevated but the protein/creatinine ratio of 115 mg/g (reference <150) remains within normal limits, indicating close monitoring for superimposed preeclampsia is warranted. 1

Preeclampsia Prevention and Surveillance

Low-dose aspirin should be initiated immediately if not already started:

• Low-dose aspirin (75-100mg daily) is recommended for women with chronic hypertension to reduce the risk of superimposed preeclampsia. 1
• Aspirin should be administered at bedtime, ideally started before 16 weeks gestation, and continued until delivery. 1
• The patient is at 20-25% risk of developing superimposed preeclampsia given her chronic hypertension. 1

Monitor for signs and symptoms of preeclampsia at each visit:

• Headache, visual disturbances, epigastric or right upper quadrant pain, excessive weight gain, or edema. 1
• Serial assessment of proteinuria, as worsening to ≥3g/24h would indicate superimposed preeclampsia. 1
• Laboratory monitoring including liver enzymes, platelets, and creatinine to detect HELLP syndrome or end-organ dysfunction. 1

Fetal Surveillance

Enhanced fetal monitoring is indicated:

• Serial ultrasounds for fetal growth assessment, as chronic hypertension increases risk of intrauterine growth restriction. 1
• The scheduled obstetric ultrasound within 1 week is appropriate given her high-risk status. 1
• Antepartum testing should be initiated in the third trimester to establish fetal well-being. 1

Additional Considerations

Thyroid management:

• Continue levothyroxine 50mcg daily with TSH monitoring as ordered, as the previous TSH of 1.5 indicates adequate control. 1

Fibroid monitoring:

• The history of hysteroscopic myomectomy in June 2025 requires observation with the scheduled ultrasound to assess for fibroid-related complications including pain, bleeding, or impact on fetal growth. 1

Common Pitfalls to Avoid

• Do not discontinue labetalol despite well-controlled blood pressure, as blood pressure typically rises in the third trimester and stopping medication increases risk of severe hypertension. 1, 4
• Avoid atenolol if medication changes are needed, as it is associated with fetal growth restriction related to duration of treatment. 1, 5
• Never use ACE inhibitors or ARBs, which are absolutely contraindicated due to severe fetotoxicity causing renal dysgenesis. 1
• Do not aggressively lower blood pressure below 120/80 mmHg, as excessive reduction may impair uteroplacental perfusion and compromise fetal growth. 1
• Avoid salt restriction, as pregnant women require normal intravascular volume and salt restriction may paradoxically increase preeclampsia risk. 1

When to Escalate Treatment

Increase labetalol dose if:

• Home blood pressure readings consistently reach 140-150/90-100 mmHg. 1
• Any single reading reaches ≥150-160/100-110 mmHg. 1

Seek immediate emergency care if:

• Blood pressure ≥160/110 mmHg (severe hypertension requiring hospitalization). 1
• Symptoms of preeclampsia develop (severe headache, visual changes, epigastric pain). 1
• Signs of fetal distress or decreased fetal movement occur. 1