What is the management for a primigravida (first-time pregnant woman) at 37 weeks gestation with severe hypertension, irritated state, and absent end diastolic flow?

Immediate Delivery is Indicated

This patient requires immediate delivery given she is at 37 weeks gestation with severe hypertension and absent end-diastolic flow (AEDF) on umbilical artery Doppler. 1

Clinical Reasoning

This patient presents with:

• Severe hypertension (160/100 mmHg) at 37 weeks gestation
• Irritability suggesting possible neurological involvement
• Fundal height discrepancy (35 weeks at 37 weeks GA) indicating fetal growth restriction
• Absent end-diastolic flow on umbilical artery Doppler

This constellation of findings represents preeclampsia with fetal growth restriction and severely abnormal placental function. 1

Immediate Management Steps

1. Admit to Hospital Immediately

• All women with preeclampsia should be assessed in hospital when first diagnosed 1
• The presence of severe hypertension and AEDF mandates inpatient management 1

2. Initiate Antihypertensive Therapy

• Target blood pressure: diastolic 85 mmHg and systolic <160 mmHg 1
• First-line agents include:
  • Oral labetalol (100 mg twice daily, up to 2400 mg/day) 1
  • Oral nifedipine 1
  • Oral methyldopa 1
• For hypertensive crisis (≥160/110 mmHg), use IV labetalol 1

3. Administer Magnesium Sulfate for Seizure Prophylaxis

• This patient has severe hypertension with neurological signs (irritability), which mandates MgSO4 for convulsion prophylaxis 1

4. Proceed to Delivery

The definitive indication for delivery is the combination of:

• ≥37 weeks gestation with preeclampsia 1
• Absent end-diastolic flow on umbilical artery Doppler 1

The ISSHP guidelines explicitly state that women with preeclampsia should be delivered at 37 weeks gestation, and that reversed end-diastolic flow (or absent flow) is an absolute indication for delivery regardless of other factors. 1

5. Mode of Delivery

Cesarean section is likely indicated given:

• Absent end-diastolic flow on Doppler 1
• Unfavorable cervix (only 1 cm dilated, though soft) 1
• Primigravida status with severe preeclampsia
• Fetal growth restriction

However, the cervical exam shows some favorable features (soft cervix, 1 cm dilation), so induction of labor could be considered if fetal monitoring is reassuring and the maternal condition is stable. 1 The decision should involve an experienced obstetrician. 1

Critical Monitoring Before Delivery

Maternal Assessment:

• Blood pressure monitoring every 15-30 minutes until controlled 1
• Laboratory tests immediately: complete blood count (platelets), liver transaminases, creatinine, uric acid 1
• Clinical assessment for clonus, visual symptoms, severe headache 1
• Urine protein quantification if not already done 1

Fetal Assessment:

• Continuous cardiotocography given AEDF 1
• Ultrasound assessment of amniotic fluid volume 1
• The fundal height discrepancy (35 weeks at 37 weeks) confirms fetal growth restriction 1

Why Immediate Delivery is Non-Negotiable

At 37 Weeks with AEDF:

The ISSHP guidelines state that in cases of absent end-diastolic flow, delivery should be considered no later than 34 weeks gestation. 1 This patient is already at 37 weeks, which is 3 weeks beyond the recommended delivery threshold for AEDF.

Perinatal Risk with AEDF:

Research demonstrates that AEDF carries extremely high perinatal mortality (approaching 60% in some studies) when delivery is delayed. 2, 3, 4 One landmark study showed that all perinatal deaths occurred in fetuses with reversed flow, and that AEDF "always precedes the appearance of fetal distress." 2

Term Gestation Eliminates Prematurity Concerns:

At 37 weeks, the fetus is term, eliminating concerns about prematurity that might justify expectant management at earlier gestations. 1

Common Pitfalls to Avoid

Do NOT attempt expectant management

• While some studies suggest AEDF can be observed for longer periods at earlier gestations 5, this patient is already at term with severe maternal hypertension 1
• The combination of severe preeclampsia + AEDF + term gestation = immediate delivery 1

Do NOT delay for "fetal lung maturity"

• Corticosteroids are not indicated at 37 weeks 1
• The fetal lungs are mature at this gestation 1

Do NOT use ACE inhibitors, ARBs, or direct renin inhibitors

• These are strictly contraindicated in pregnancy due to severe fetotoxicity 1

Do NOT underestimate the neurological risk

• The patient's "irritability" may represent evolving eclampsia 1
• Blood pressure ≥160/110 mmHg is a surrogate marker for stroke risk 1

Summary Algorithm

1. Admit immediately 1
2. Start antihypertensive therapy (labetalol, nifedipine, or methyldopa) targeting diastolic BP 85 mmHg 1
3. Administer MgSO4 for seizure prophylaxis 1
4. Obtain labs (CBC, liver enzymes, creatinine) and continuous fetal monitoring 1
5. Deliver immediately - likely by cesarean section given AEDF and unfavorable cervix 1