What is the best management plan for a 47-year-old female, gravida 12, para 10, at 33 weeks and 1 day gestation, presenting with severe hypertension?

Management Plan for Severe Preeclampsia at 33 Weeks Gestation

Immediate Blood Pressure Management

Your patient requires urgent continuation of IV antihypertensive therapy with a target BP of 140-150/90-105 mmHg, ongoing MgSO4 for seizure prophylaxis, and close maternal-fetal monitoring with delivery planning based on maternal stability and fetal status. 1, 2

Current Acute BP Control

• The AC (likely labetalol or hydralazine) drip initiated by OB is appropriate for BP ≥160/110 mmHg, which represents a hypertensive emergency requiring treatment within 60 minutes 2
• Target BP should be systolic 140-150 mmHg and diastolic 90-105 mmHg to prevent maternal stroke while maintaining placental perfusion 1, 2
• Monitor BP every 5-10 minutes during acute treatment phase 2
• If current IV agent is ineffective, acceptable alternatives include:
  • IV labetalol: 20 mg bolus, then 40 mg at 10 min, then 80 mg every 10 min (max cumulative 220-300 mg) 2
  • IV hydralazine: 5 mg, then 5-10 mg every 20-30 min 1, 2
  • Oral nifedipine immediate-release: 10-20 mg, repeatable every 20-30 min (max 30 mg) 2

Critical Safety Considerations

• Avoid combining nifedipine with MgSO4 due to risk of precipitous hypotension 2
• Labetalol is contraindicated if patient has asthma, heart block, or decompensated heart failure 2
• Never use sublingual nifedipine due to uncontrolled hypotension risk 2

Magnesium Sulfate Continuation

Continue MgSO4 for seizure prophylaxis as this patient has severe hypertension with preeclampsia 1

• MgSO4 is indicated for women with preeclampsia who have proteinuria and severe hypertension, or hypertension with neurological signs/symptoms 1
• MgSO4 prevents eclampsia, halving the seizure rate (approximately 100 women need treatment to prevent 1 seizure) 1
• Continue throughout labor and for at least 24 hours postpartum 3

Corticosteroid Administration

The dexamethasone initiated by OB is appropriate for fetal lung maturity at 33 1/7 weeks gestation 4

• Steroids are effective in reducing neonatal mortality and morbidity when administered between 24-34 weeks' gestation in severe preeclampsia 3
• Complete the full course as planned 4

Maternal Monitoring Protocol

Implement intensive maternal surveillance with the following schedule: 1

• BP monitoring: Continuous or every 4 hours minimum while awake 1
• Clinical assessment: Check for clonus, headache, visual changes, right upper quadrant pain at least twice daily 1
• Laboratory tests (minimum twice weekly): 1
  • Complete blood count with platelet count
  • Liver transaminases (AST/ALT)
  • Serum creatinine
  • Uric acid
  • Hemoglobin
• Repeat labs immediately if clinical status changes 1
• Assess for proteinuria if not already documented 1
• Monitor oxygen saturation and consider ICU transfer if <90% 5

Fetal Monitoring Protocol

Establish comprehensive fetal surveillance: 1

• Initial assessment: Confirm fetal well-being with non-stress test and biophysical profile 1
• Ultrasound evaluation: Assess fetal biometry, amniotic fluid volume, and umbilical artery Doppler 1
• Ongoing surveillance:
  • If initial assessment normal: repeat ultrasound every 2 weeks 1
  • If fetal growth restriction present: more frequent amniotic fluid and Doppler assessments 1
• Continuous fetal heart rate monitoring during acute BP management 2

Expectant Management vs. Delivery Decision

At 33 1/7 weeks with severe preeclampsia, pursue conservative expectant management at a center with Maternal-Fetal Medicine expertise UNLESS maternal or fetal indications for delivery emerge 1

Absolute Indications for Immediate Delivery (regardless of gestational age): 1

• Inability to control BP despite ≥3 classes of antihypertensives in appropriate doses
• Progressive thrombocytopenia (platelets <100,000/µL)
• Progressively abnormal liver function tests (transaminases >2x upper limit normal)
• Progressive renal dysfunction (creatinine >1.1 mg/dL or doubling of baseline)
• Pulmonary edema or maternal oxygen saturation <90%
• Severe persistent headache, repeated visual scotomata, or eclampsia
• Severe persistent right upper quadrant pain
• Placental abruption
• Non-reassuring fetal status (reversed end-diastolic flow on umbilical artery Doppler, non-reassuring cardiotocograph, or stillbirth)

If Maternal-Fetal Status Remains Stable:

• Continue expectant management until 34 weeks' gestation (after completing steroid course) 1
• Plan delivery at 37 weeks if condition remains stable without severe features 1

Transition to Maintenance Antihypertensive Therapy

Once acute BP control achieved, transition to oral antihypertensives: 1, 2

• First-line oral agents: 1
  • Methyldopa
  • Labetalol (if no contraindications)
  • Long-acting nifedipine
  • Oxprenolol
• Target diastolic BP of 85 mmHg in office (systolic 110-140 mmHg) 1
• Reduce or cease antihypertensives if diastolic BP falls <80 mmHg 1
• Treat persistent BP ≥140/90 mmHg to reduce likelihood of severe hypertension and complications 1

Hospital Setting Requirements

This patient requires inpatient management at a facility with: 1

• Maternal-Fetal Medicine expertise for preeclampsia <34 weeks
• Neonatal intensive care unit capabilities
• 24-hour anesthesia and operative delivery availability
• Ability to perform continuous maternal-fetal monitoring

Common Pitfalls to Avoid

• Do not use BP level alone to stratify risk - some women develop serious organ dysfunction at relatively mild BP levels 1
• Do not attempt to classify as "mild vs. severe" preeclampsia clinically - all cases may become emergencies rapidly 1
• Do not use serum uric acid or level of proteinuria as indications for delivery 1
• Do not manage expectantly at BP ≥160/110 mmHg but emergently treat it - this is logically inconsistent 1
• Do not discharge to outpatient management until maternal condition is clearly stable and patient can reliably report problems and monitor BP 1

Postpartum Planning

Prepare for high-risk postpartum period: 5, 4

• Preeclampsia can worsen or initially present after delivery 4
• Monitor as inpatient or closely at home for minimum 72 hours postpartum 4
• Continue antihypertensive medications with gradual tapering rather than abrupt cessation 5
• BP monitoring at least every 4 hours while awake for first 3 days 5
• Avoid NSAIDs for analgesia unless other options ineffective 5