What is the management for a pregnant patient at 36.5 weeks gestation with severe proteinuria and a headache, suggestive of preeclampsia with severe features?

Management of Severe Preeclampsia at 36.5 Weeks Gestation

This patient has severe preeclampsia with severe features (protein/creatinine ratio 10.4, severe proteinuria, headache, elevated uric acid) and requires immediate magnesium sulfate administration for seizure prophylaxis, urgent blood pressure control if any reading reaches ≥160/110 mmHg, and delivery after maternal stabilization. 1

Immediate Stabilization Protocol

Magnesium Sulfate Administration

• Administer magnesium sulfate immediately for seizure prophylaxis given the presence of headache (a neurological symptom indicating severe features) 1, 2
• Loading dose: 4-5g IV over 5 minutes, followed by maintenance infusion of 1-2g/hour continuous IV 1
• Alternative regimen: 4g IV loading dose plus 10g IM (5g in each buttock), then 4-5g IM every 4 hours as needed 2
• Continue magnesium sulfate through delivery and for 24-48 hours postpartum 1

Blood Pressure Management

• Measure blood pressure immediately and continuously monitor 1
• If BP ≥160/110 mmHg persisting >15 minutes, initiate IV labetalol immediately 1
  • Dosing: 20mg IV bolus, then 40mg after 10 minutes, then 80mg every 10 minutes to maximum 220mg 1
  • Target BP: Systolic 110-140 mmHg and diastolic 85 mmHg (minimum <160/105 mmHg) 1
• Alternative agents: IV nicardipine or hydralazine 1
• Avoid short-acting oral nifedipine, especially with concurrent magnesium sulfate, due to risk of uncontrolled hypotension 1

Critical Monitoring Requirements

Maternal Monitoring

• Hourly urine output via Foley catheter with target ≥100 mL/4 hours (>35 mL/hour) 1
• Deep tendon reflexes before each magnesium dose to monitor for toxicity 1
• Respiratory rate monitoring (magnesium toxicity causes respiratory depression) 1
• Oxygen saturation on room air (maternal early warning if <95%) 1
• Continuous assessment for severe headache, visual disturbances, epigastric/right upper quadrant pain 1

Laboratory Monitoring

• Repeat labs immediately: Complete blood count, comprehensive metabolic panel, liver enzymes (AST, ALT, LDH), creatinine, uric acid 1
• Given your patient's labs showing hemoglobin 10.1, platelets 161, AST 36, ALT 7, LDH 327, and elevated uric acid 9, monitor for progression to HELLP syndrome 3, 1
• The alkaline phosphatase of 337 is elevated but expected in pregnancy; focus on transaminases and platelets for HELLP 3
• Repeat labs at least twice weekly or more frequently with any clinical deterioration 1

Fetal Monitoring

• Continuous fetal heart rate monitoring 1
• Ultrasound assessment of fetal status, biometry, amniotic fluid, and umbilical artery Doppler 1

Delivery Planning

Timing and Indications

• At 36.5 weeks gestation with severe features, deliver after maternal stabilization with magnesium sulfate and blood pressure control 1
• This gestational age (≥34 weeks) with severe features is an indication for delivery 3, 1
• Vaginal delivery is preferred unless cesarean is indicated for obstetric reasons 1
• Induction of labor is associated with improved maternal outcomes 1

Absolute Indications for Immediate Delivery

Your patient already meets criteria for expedited delivery, but watch for these additional absolute indications requiring immediate delivery 1:

• Inability to control BP despite ≥3 classes of antihypertensives
• Progressive thrombocytopenia (current platelets 161 are acceptable but monitor closely)
• Progressively abnormal liver/renal function tests
• Pulmonary edema
• Severe intractable headache (your patient has headache—assess severity)
• Repeated visual scotomata or convulsions
• Non-reassuring fetal status

HELLP Syndrome Considerations

Your patient's laboratory values warrant close monitoring for HELLP syndrome progression 3:

• Hemoglobin 10.1 (mild anemia, assess for hemolysis with peripheral smear) 3
• Platelets 161 (low-normal, monitor for progressive thrombocytopenia) 3
• AST 36, ALT 7 (currently normal, but LDH 327 is elevated—monitor for rising transaminases) 3
• The elevated LDH (327) and uric acid (9) suggest endothelial dysfunction 3

Epigastric or right upper quadrant pain is a hallmark symptom of HELLP syndrome—specifically ask about this 3, 1

Critical Medications to Avoid

• ACE inhibitors, ARBs, and direct renin inhibitors are absolutely contraindicated due to severe fetotoxicity 3
• Diuretics are contraindicated as they further reduce plasma volume in preeclampsia 1
• Avoid sodium nitroprusside except as last resort due to risk of fetal cyanide poisoning 1

Special Considerations

• Do not use the level of proteinuria (your patient's P/C ratio of 10.4) as an indication for delivery timing—the decision is based on gestational age, blood pressure control, and presence of severe features 1, 4
• The 24-hour urine protein of 7774mg (7.7g) confirms severe proteinuria but does not independently dictate management beyond confirming the diagnosis 4, 5
• Do not repeat proteinuria measurements—the amount does not correlate with maternal outcomes and may lead to unnecessary interventions 4
• The normal-range blood pressure you report is reassuring, but preeclampsia can rapidly progress—continuous monitoring is essential 1
• Magnesium sulfate should not be continued beyond 5-7 days due to risk of fetal abnormalities, but this is not a concern for immediate delivery planning 2