What is the management for a 36-week pregnant woman with new-onset hypertension and significant proteinuria?

Management of Preeclampsia at 36 Weeks Gestation

This patient meets criteria for preeclampsia without severe features and should be delivered immediately at 36 weeks gestation after maternal stabilization with blood pressure control and magnesium sulfate for seizure prophylaxis. 1

Diagnosis Confirmation

This 36-week primigravida has preeclampsia based on:

• New-onset hypertension (156/95 mmHg, exceeding 140/90 mmHg threshold) 1
• Significant proteinuria (3+ on dipstick, equivalent to ≥300 mg/24h or protein/creatinine ratio ≥30 mg/mmol) 1
• Normal hemoglobin (106 g/L), platelets (211), and AST indicate absence of severe features 1

The blood pressure of 156/95 mmHg does not meet criteria for severe hypertension (≥160/110 mmHg), and laboratory values show no evidence of HELLP syndrome, renal dysfunction, or hepatic injury. 1, 2

Immediate Management Steps

Blood Pressure Control

• Initiate antihypertensive therapy targeting diastolic BP 80-85 mmHg and systolic BP 110-140 mmHg to prevent progression to severe hypertension 1, 3
• First-line medications: oral labetalol, oral methyldopa, or oral nifedipine 1, 3
• Avoid reducing diastolic BP below 80 mmHg as this may compromise uteroplacental perfusion 1
• Never use ACE inhibitors, ARBs, or direct renin inhibitors due to severe fetotoxicity causing renal dysgenesis 1, 3

Hospital Assessment

• Admit to hospital for initial assessment and stabilization, as all newly diagnosed preeclampsia requires inpatient evaluation 1
• Obtain baseline laboratory tests: complete blood count with hemoglobin and platelets, liver enzymes (AST, ALT), creatinine, and uric acid 1, 3
• Assess for symptoms of severe features: severe persistent headache, visual disturbances (scotomata, blurred vision), right upper quadrant or epigastric pain, shortness of breath 1
• Perform clinical examination including deep tendon reflexes and clonus 1, 3

Magnesium Sulfate Administration

• Administer magnesium sulfate for seizure prophylaxis given the presence of proteinuria with hypertension 1, 4
• Loading dose: 4-5g IV over 5 minutes, followed by maintenance infusion of 1-2g/hour 5
• Continue magnesium sulfate during labor, delivery, and for 24 hours postpartum 1

Fetal Assessment

• Perform electronic fetal heart rate monitoring to confirm fetal well-being 1, 3
• Ultrasound evaluation for fetal biometry, amniotic fluid volume, and umbilical artery Doppler to assess for fetal growth restriction 1, 3

Delivery Planning

Proceed with delivery at 36 weeks gestation because:

• The ISSHP guidelines explicitly recommend delivery for all women with preeclampsia who have reached 37 weeks and zero days gestation 1
• At 36 weeks, this patient is close enough to term that expectant management offers no benefit and only increases maternal risk 1, 6
• Preeclampsia can rapidly progress to severe disease with life-threatening complications including eclampsia, stroke, hepatic rupture, and placental abruption 1, 7, 8

Delivery approach:

• Induction of labor is preferred over cesarean delivery unless standard obstetric indications for cesarean exist 5
• Neuraxial analgesia (epidural) is strongly recommended for labor and delivery, provided platelet count remains adequate (>70-80 × 10³/µL depending on institutional protocols) 7

Critical Monitoring During Expectant Period Before Delivery

If delivery cannot occur immediately due to logistical reasons:

• Blood pressure monitoring every 4 hours while awake 4
• Repeat laboratory tests at least twice weekly: hemoglobin, platelets, liver enzymes, creatinine, uric acid 1, 3
• Daily fetal kick counts and serial fetal heart rate monitoring 1
• Immediate delivery if any of the following develop:
  • Severe hypertension (≥160/110 mmHg) despite treatment 1
  • Progressive thrombocytopenia (platelets declining toward <100 × 10³/µL) 1, 2
  • Elevated liver enzymes (>2× upper limit of normal) 1, 2
  • Rising creatinine or worsening renal function 1
  • Pulmonary edema 1
  • Severe persistent headache, visual disturbances, or altered mental status 1
  • Right upper quadrant or epigastric pain 1
  • Non-reassuring fetal status 1

Common Pitfalls to Avoid

• Do not use blood pressure level alone to determine disease severity—serious organ dysfunction can develop at relatively mild blood pressure elevations 4, 2
• Do not delay delivery based on uric acid levels or degree of proteinuria, as these do not correlate with outcomes and should not guide timing of delivery 1, 4
• Do not use diuretics as they further reduce plasma volume, which is already compromised in preeclampsia and worsens uteroplacental perfusion 3
• Do not administer NSAIDs for analgesia if delivery occurs, as they can worsen renal function in preeclampsia 3
• Do not use low molecular weight heparin for prevention, as it is not indicated even with preeclampsia 1
• Do not attempt expectant management at 36 weeks—the risks of maternal complications outweigh any minimal fetal benefit from additional days in utero 1, 6

Postpartum Monitoring

• Continue close monitoring for 72 hours postpartum as preeclampsia can worsen or initially present after delivery 2
• Monitor blood pressure every 4 hours for the first 48 hours 4
• Continue antihypertensive medications as needed 1
• Educate patient on warning signs: severe headache, visual changes, right upper quadrant pain, shortness of breath 1