What are the management and treatment options for a patient at 34 weeks of gestation?

Management at 34 Weeks of Gestation

At 34 weeks of gestation, management depends critically on whether complications such as preeclampsia, intrauterine growth restriction (IUGR), or preterm labor are present—uncomplicated pregnancies continue routine prenatal care, while complicated pregnancies require specific interventions based on maternal and fetal status.

Uncomplicated Pregnancy at 34 Weeks

For women without complications at 34 weeks:

• Continue routine prenatal monitoring with standard visits every 2 weeks until 36 weeks 1
• Assess fetal movement and maternal well-being at each visit 2
• Measure symphysis-fundal height as a reasonable screening tool for fetal growth 2
• No intervention is required unless complications develop 1

Preeclampsia at 34 Weeks

Initial Management Approach

Women with preeclampsia onset between 34 and 37 weeks should be managed with an expectant conservative approach rather than immediate delivery, as maternal outcomes are similar but perinatal outcomes are significantly better with expectant management 3, 4.

Maternal Monitoring Requirements

• Hospitalize initially to confirm diagnosis and assess severity 5
• Monitor blood pressure every 4 hours (more frequently if severe hypertension present) 5
• Perform twice-weekly blood tests including hemoglobin, platelet count, liver transaminases, creatinine, and uric acid 3
• Clinical assessment for clonus and neurological symptoms at each evaluation 3, 5
• Limit total fluid intake to 60-80 mL/hour to prevent pulmonary edema 5

Blood Pressure Management

For severe hypertension (≥160/110 mmHg):

• Administer oral nifedipine 10 mg, repeat every 20 minutes to maximum 30 mg 5
• Alternative: IV labetalol 20 mg bolus, then 40 mg after 10 minutes if needed, followed by 80 mg every 10 minutes to maximum 220 mg 5
• Avoid sublingual nifedipine due to risk of precipitous blood pressure drops 5
• Do not combine calcium channel blockers with IV magnesium due to myocardial depression risk 5

For non-severe hypertension (140-159/90-109 mmHg):

• Target diastolic BP of 85 mmHg and systolic BP between 110-140 mmHg with oral antihypertensives 5

Seizure Prophylaxis

Administer magnesium sulfate for convulsion prophylaxis in women with preeclampsia and severe hypertension, or hypertension with neurological signs or symptoms 3, 5.

• Continue magnesium sulfate for 24 hours postpartum 5
• Monitor carefully when combining with nifedipine due to possibility of excessive blood pressure fall 6

Fetal Monitoring in Preeclampsia

• Perform ultrasound assessment of fetal biometry, amniotic fluid, and umbilical artery Doppler at diagnosis 3, 5
• Repeat ultrasound every 2 weeks if initial assessment normal 3
• Increase frequency of amniotic fluid and Doppler assessment if fetal growth restriction present 3

Indications for Immediate Delivery at 34 Weeks with Preeclampsia

Deliver immediately if any of the following develop, regardless of gestational age 3, 5:

• Inability to control BP despite using ≥3 classes of antihypertensives in appropriate doses
• Maternal pulse oximetry <90%
• Progressive deterioration in liver function, creatinine, hemolysis, or platelet count
• Ongoing neurological features (severe intractable headache, repeated visual scotomata, or eclampsia)
• Placental abruption
• Reversed end-diastolic flow in umbilical artery Doppler
• Non-reassuring cardiotocograph or stillbirth

Important caveat: The level of BP itself is not a reliable way to stratify immediate risk—some women develop serious organ dysfunction at relatively mild BP levels 3.

Intrauterine Growth Restriction (IUGR) at 34 Weeks

Management Based on Doppler Findings

For IUGR with absent end-diastolic velocity (AEDV) at 34 weeks, deliver at 33-34 weeks as neonatal morbidity/mortality rates with AEDV exceed complications of prematurity at this gestational age 7.

• Administer antenatal corticosteroids if absent or reversed end-diastolic flow noted at 34 weeks (Level A recommendation) 3
• Observe closely for 48-72 hours after steroid administration as there may be transient return of end-diastolic flow in two-thirds of cases 3

For IUGR with decreased diastolic flow (but not absent/reversed):

• Manage expectantly with increased surveillance 3, 7
• Consider delivery at ≥37 weeks 3, 7

For IUGR with reversed end-diastolic velocity (REDV):

• Deliver at 30-32 weeks due to severe placental dysfunction 7
• At 34 weeks, delivery is already indicated 7

Surveillance Protocol for IUGR

• Perform umbilical artery Doppler 2-3 times per week for absent end-diastolic velocity 7
• Consider cesarean delivery for IUGR with absent/reversed end-diastolic velocity based on clinical scenario 7
• Administer magnesium sulfate for fetal neuroprotection if delivery anticipated <32 weeks 7

Preterm Labor at 34 Weeks

Treatment of preterm labor up to 34 weeks is important to delay delivery for 48 hours for administration of antenatal corticosteroids 1.

However, at exactly 34 weeks, the benefit of tocolysis is questionable:

• The incidence of respiratory distress syndrome at 34 weeks is 14.9%, which is significantly higher than at 35-36 weeks 8
• Fetal lung maturity studies should be considered and delivery possibly delayed through the thirty-fourth week to decrease neonatal morbidity 8
• After completing 34 weeks, routine cesarean delivery for preterm labor is not recommended 1

Corticosteroid Administration

Administer antenatal corticosteroids if delivery anticipated before 33 6/7 weeks or between 34 0/7 and 36 6/7 weeks in women at risk of delivery within 7 days 7.

• Corticosteroids are effective in reducing neonatal mortality and morbidity between 24 and 34 weeks' gestation 9
• For IUGR with abnormal Dopplers, corticosteroids should be given despite theoretical concerns about increased metabolic demands 3

Severe Vaginal Bleeding at 34 Weeks

For severe vaginal bleeding with maternal instability at 34 weeks, stabilize the mother hemodynamically with crystalloid fluid resuscitation while preparing blood products, then proceed to urgent cesarean section once stable enough to tolerate anesthesia 10.

Resuscitation Protocol

• Insert central venous catheter to assess intravascular volume and guide fluid resuscitation 10
• Insert urinary catheter to monitor urine output as marker of adequate perfusion 10
• Administer fresh frozen plasma and platelets to correct coagulopathy with goal platelet count >50,000/mm³ before surgery 10
• Correct hypovolemia as evidenced by improved central venous pressure and urine output before proceeding to surgery 10

At 34 weeks gestational age, the fetus is viable and delivery is appropriate for maternal indications 10.

Key Clinical Pitfalls to Avoid

• Do not attempt to diagnose "mild versus severe" preeclampsia clinically—all cases may become emergencies rapidly 3
• Do not use serum uric acid or level of proteinuria as indication for delivery 3
• Do not use plasma volume expansion routinely in preeclampsia 3
• Avoid grapefruit juice in patients on nifedipine—it should be stopped at least 3 days prior to initiating nifedipine 6
• Do not combine IV magnesium with calcium channel blockers due to myocardial depression risk 5
• Do not use diuretics in preeclampsia as they further reduce plasma volume 5