What are the management and treatment options for a 31-year-old female at 37 weeks of gestation with hypoalbuminemia (low albumin level of 25 g/L)?

Management of Hypoalbuminemia at 37 Weeks Gestation

This patient requires immediate delivery given she has reached 37 weeks gestation with hypoalbuminemia (25 g/L), which likely indicates preeclampsia with severe features. 1

Immediate Assessment Required

Confirm preeclampsia diagnosis by documenting:

• Blood pressure measurements on at least two occasions 15 minutes apart 1
• Proteinuria assessment using urine protein/creatinine ratio (≥30 mg/mmol is abnormal) 1
• Complete blood count focusing on hemoglobin and platelet count 1
• Liver transaminases (AST, ALT), creatinine, and uric acid 1

The albumin level of 25 g/L is concerning because:

• Research demonstrates that albumin <20 g/L is associated with thrombocytopenia, elevated liver enzymes, severe proteinuria, and need for platelet transfusion 2
• While 25 g/L is above this critical threshold, it is significantly below normal pregnancy values (mean 33.41 g/L in third trimester) and suggests severe preeclampsia 2, 3
• Hypoalbuminemia in preeclampsia results from increased capillary permeability, hepatic dysfunction from reduced hepatic blood flow, and proteinuria 2, 4, 5

Blood Pressure Management Before Delivery

If blood pressure ≥140/90 mmHg but <160/110 mmHg:

• Initiate oral antihypertensive therapy targeting diastolic BP of 85 mmHg and systolic BP 110-140 mmHg 1, 6
• First-line agents: oral nifedipine, labetalol, or methyldopa 1, 6
• Reduce or cease antihypertensives if diastolic BP falls <80 mmHg 1

If blood pressure ≥160/110 mmHg (hypertensive emergency):

• Initiate urgent treatment within 15 minutes in a monitored setting 1
• Use oral nifedipine or intravenous labetalol or hydralazine 1
• Never use ACE inhibitors, ARBs, or direct renin inhibitors due to severe fetotoxicity causing renal dysgenesis 1, 7

Magnesium Sulfate Administration

Administer magnesium sulfate for seizure prophylaxis if:

• Proteinuria is present with severe hypertension (≥160/110 mmHg) 1
• Any neurological signs or symptoms exist (headache, visual changes, hyperreflexia with clonus) 1, 6

Do not give magnesium sulfate concomitantly with calcium channel blockers due to risk of severe hypotension from synergism 1

Fetal Assessment Before Delivery

Perform immediately:

• Biophysical profile including fetal biometry, amniotic fluid volume, fetal breathing movements, body movements, and tone 6
• Continuous electronic fetal heart rate monitoring to assess for non-reassuring fetal status 6
• Umbilical artery Doppler if not recently performed 1

Delivery Planning

Proceed with delivery after maternal stabilization because:

• All women with preeclampsia at ≥37 weeks gestation should be delivered 1, 6
• The hypoalbuminemia (25 g/L) combined with 37 weeks gestation meets delivery criteria regardless of other features 1

Mode of delivery:

• Prefer vaginal delivery unless cesarean is indicated for standard obstetric reasons 6
• Delivery should occur in a hospital with maternal intensive care capabilities and neonatal intensive care unit 7

Critical Management Pitfalls to Avoid

Do not:

• Use plasma volume expansion routinely—it is not recommended in preeclampsia 1
• Use diuretics as they further reduce plasma volume already compromised in preeclampsia and worsen uteroplacental perfusion 1, 7
• Delay delivery based on albumin level alone or attempt to "correct" the albumin before delivery 2
• Use serum uric acid level or degree of proteinuria as sole indications for delivery timing 1, 7
• Administer NSAIDs for analgesia as they worsen renal function in preeclampsia 7
• Underestimate disease severity—all preeclampsia cases can rapidly become emergencies 1, 6

Postpartum Considerations

After delivery:

• Continue blood pressure monitoring as 10% of maternal deaths from hypertensive disorders occur postpartum 1
• Monitor for postpartum complications including stroke and eclampsia 1
• Acceptable antihypertensives for breastfeeding mothers include labetalol, nifedipine, enalapril, and metoprolol 1