What is the appropriate management for a primigravida (first-time pregnant woman) at 32 weeks of gestation with mild headache, no abdominal pain or visual disturbance, hypertension (elevated blood pressure), and proteinuria (+3 protein in urine)?

Management of Preeclampsia at 32 Weeks Gestation

This patient requires immediate hospitalization for close monitoring and stabilization, not delivery at this time (Option B). 1, 2

Clinical Diagnosis

This primigravida presents with preeclampsia without severe features at 32 weeks gestation:

• Blood pressure 150/90 mmHg (elevated but <160/110 mmHg) 3
• Significant proteinuria (+3 on dipstick) 3
• Mild headache only, without visual disturbances, epigastric pain, or other severe features 3, 1

Hospitalization is mandatory for all pregnant women with preeclampsia at the time of diagnosis, regardless of gestational age or severity. 1, 2 This is critical because preeclampsia can rapidly progress to an emergency, and the condition should not be classified as "mild" versus "severe" clinically. 2

Why Not Immediate Delivery?

At 32 weeks gestation, delivery should be delayed to allow for fetal maturation unless severe features develop. 3 The guidelines are clear:

• Delivery is indicated at ≥37 weeks for any preeclampsia 1, 2
• At <34 weeks without severe features, expectant management with close monitoring is appropriate 3
• Immediate delivery (vaginal or cesarean) is reserved for severe preeclampsia with features threatening maternal or fetal wellbeing 3

Inpatient Management Protocol

Blood Pressure Control

• Initiate oral antihypertensive therapy targeting diastolic BP 85 mmHg and systolic BP 110-140 mmHg 1, 2
• First-line agents: methyldopa, labetalol, or oral nifedipine 3, 1
• Monitor BP every 4 hours or more frequently if needed 1, 2

Seizure Prophylaxis

Magnesium sulfate should be administered for seizure prophylaxis given the presence of headache, even though mild. 1, 2 Women with preeclampsia who have symptoms such as headache require magnesium sulfate during labor and for 24 hours postpartum. 1, 4

Maternal Monitoring

• Clinical evaluation including deep tendon reflexes and clonus 1
• Laboratory tests at admission and at least twice weekly: hemoglobin, platelets, liver transaminases, creatinine, uric acid 1, 2
• Watch for alarm signs: severe headache, visual disturbances, epigastric pain, dyspnea 1, 2

Fetal Monitoring

• Initial cardiotocography and ultrasound for biometry, amniotic fluid, and umbilical artery Doppler 2
• Corticosteroids for fetal lung maturity should be administered at ≤34 weeks gestation 3

Indications for Immediate Delivery

Delivery should be pursued if any of the following develop:

• Gestational age reaches 37 weeks 1, 2
• Blood pressure ≥160/110 mmHg (severe hypertension requiring urgent treatment) 3, 2
• Signs of maternal organ dysfunction: deteriorating renal function, elevated liver enzymes, low platelets, pulmonary edema 3
• Neurological symptoms worsen: severe persistent headache, visual disturbances, altered mental status 3, 1
• Fetal distress or intrauterine growth restriction 3

Common Pitfalls to Avoid

• Do not attempt outpatient management - all preeclampsia requires hospitalization at diagnosis 1, 2
• Do not rush to cesarean section - vaginal delivery should be attempted unless obstetric contraindications exist 1, 2
• Do not withhold magnesium sulfate - headache, even if mild, warrants seizure prophylaxis in preeclampsia 1, 2, 4
• Do not delay corticosteroids - fetal lung maturity is critical at 32 weeks if preterm delivery becomes necessary 3

The baseline proteinuria at this gestational age significantly increases risk for superimposed complications and adverse outcomes, making close inpatient monitoring essential. 5