What is the best management approach for a pregnant lady at [GESTATIONAL_AGE] weeks of gestation, presenting with agitation, hypertension (Blood Pressure: 160/100), and a non-corresponding fundal height?

Management of Pregnant Woman with Severe Hypertension and Concerning Features

This patient requires immediate hospital admission for stabilization, evaluation for preeclampsia/eclampsia, and likely delivery depending on gestational age and maternal-fetal status. The combination of severe hypertension (160/100 mmHg), agitation (a maternal early warning sign), and non-corresponding fundal height (suggesting either fetal growth restriction or other placental pathology) represents a potentially life-threatening hypertensive emergency requiring urgent intervention 1.

Immediate Management Priorities

Hospital Admission is Mandatory

• Admit immediately for observation and stabilization - this is not a case for outpatient management 1.
• The agitation represents a maternal early warning criterion indicating changed mental status, which signals potential progression to eclampsia 1.
• Blood pressure ≥160/100 mmHg meets criteria for severe hypertension requiring urgent treatment within 15 minutes to 1 hour 1, 2.

Urgent Blood Pressure Control

• Initiate antihypertensive therapy immediately with target BP of 140-150/90-100 mmHg 1.
• First-line agents include:
  • IV labetalol (20 mg bolus, then 40 mg after 10 minutes, then 80 mg every 10 minutes up to 220 mg total) 1
  • Oral nifedipine (10 mg, repeat every 20 minutes to maximum 30 mg) 1
  • IV hydralazine (5 mg bolus, then 10 mg every 20-30 minutes to maximum 25 mg), though this is associated with more maternal hypotension and adverse effects 1

Comprehensive Maternal-Fetal Assessment

Maternal evaluation must include:

• Complete blood count with platelets (assess for HELLP syndrome) 2, 3
• Liver transaminases (hepatic involvement) 2, 3
• Serum creatinine (renal function) 2, 3
• 24-hour urine protein or spot protein:creatinine ratio (≥0.3 g/day or ≥30 mg/mmol defines preeclampsia) 1, 2
• Assessment for symptoms of impending eclampsia: severe headache, visual disturbances, epigastric pain 1

Fetal evaluation must include:

• Ultrasound for fetal biometry and amniotic fluid assessment (the non-corresponding fundal height suggests growth restriction or oligohydramnios) 2, 4
• Umbilical artery Doppler velocimetry if growth restriction suspected 1
• Continuous fetal heart rate monitoring 3, 4

Seizure Prophylaxis

• Administer magnesium sulfate given the agitation and severe hypertension, which indicate high risk for eclampsia 1, 3.
• The ISSHP recommends MgSO4 for all women with preeclampsia and symptoms such as agitation/neurological changes 1, 3.
• Continue through labor and 24 hours postpartum 3.

Decision Between IOL, Cesarean Section, or Expectant Management

Gestational Age is the Critical Determinant

At ≥37 weeks gestation:

• Immediate delivery is indicated regardless of whether this is gestational hypertension or preeclampsia 1, 3.
• Attempt vaginal delivery (induction of labor) unless obstetric contraindications exist 3.
• Cesarean section should be reserved for standard obstetric indications, not hypertension alone 3.

At 34-36+6 weeks gestation:

• Delivery is recommended for preeclampsia with severe features 1.
• If preeclampsia without severe features and BP controlled, may consider brief expectant management with intensive monitoring 1.

At <34 weeks gestation:

• Expectant management at a tertiary center with Maternal-Fetal Medicine expertise may be considered IF 1:
  • Blood pressure can be controlled with ≤3 antihypertensive agents
  • No maternal organ dysfunction (normal platelets, liver enzymes, creatinine)
  • No severe neurological symptoms beyond the initial presentation
  • Reassuring fetal status
• However, delivery is mandatory if any of the following develop 1:
  • Inability to control BP despite ≥3 antihypertensive classes
  • Progressive thrombocytopenia or liver dysfunction
  • Persistent severe neurological features (the agitation in this case is concerning)
  • Reversed end-diastolic flow on umbilical artery Doppler
  • Non-reassuring fetal status

Critical Pitfalls to Avoid

• Do not delay treatment waiting for laboratory results - severe hypertension (≥160/110 mmHg) requires treatment within 15 minutes regardless of other findings 1.
• Do not assume this is "just" gestational hypertension - the agitation and non-corresponding fundal height suggest preeclampsia with severe features or placental insufficiency 1.
• Do not use atenolol - it is associated with fetal growth restriction when used long-term 1.
• Avoid ACE inhibitors, ARBs, and direct renin inhibitors - these are strictly contraindicated due to fetotoxicity 1.
• Do not give short-acting nifedipine with magnesium sulfate without careful BP monitoring, as precipitous hypotension can occur 1.

The Answer to the Question

Given the information provided, "Admit for observation" is the most appropriate immediate answer, as this allows for:

1. Urgent BP stabilization
2. Complete maternal-fetal evaluation to determine if preeclampsia is present
3. Assessment of gestational age and fetal status
4. Determination of optimal delivery timing and route

IOL or CS cannot be definitively chosen without knowing:

• The exact gestational age
• Whether preeclampsia criteria are met
• Fetal status and viability
• Cervical favorability (for IOL consideration)
• Response to initial BP management

The severe hypertension with agitation and abnormal fundal height makes expectant outpatient management unsafe 1. Once admitted and stabilized, delivery will likely be indicated at ≥37 weeks, or earlier if maternal-fetal status deteriorates 1, 3.