In a patient who is 29 weeks + 6⁄7 days pregnant with severe pre‑eclampsia and a breech‑presenting fetus, should delivery be performed now?

Delivery is Mandatory at 29 6/7 Weeks with Severe Preeclampsia and Breech Presentation

Deliver immediately after maternal stabilization—severe preeclampsia at any gestational age with severe features requires expedited delivery following urgent blood pressure control and magnesium sulfate administration, regardless of fetal presentation. 1, 2

Immediate Stabilization Protocol (Before Delivery)

Urgent Antihypertensive Therapy

• Initiate IV antihypertensive therapy immediately if BP ≥160/110 mmHg persists for more than 15 minutes to prevent maternal cerebral hemorrhage 1, 2
• First-line agent: IV labetalol 20 mg bolus, then 40 mg after 10 minutes, followed by 80 mg every 10 minutes (maximum cumulative dose 220 mg) 1, 2
• Alternative agents: IV hydralazine 5-10 mg every 20 minutes or IV nicardipine starting at 5 mg/hour, increased by 2.5 mg/hour every 5-15 minutes to maximum 15 mg/hour 1
• Target blood pressure: Systolic 110-140 mmHg and diastolic 85 mmHg (absolute minimum <160/105 mmHg) 1, 2

Seizure Prophylaxis

• Administer magnesium sulfate immediately: loading dose 4-5 g IV over 5 minutes, followed by maintenance infusion 1-2 g/hour 1, 2
• Continue magnesium sulfate throughout labor/delivery and for 24 hours postpartum 3
• Monitor deep tendon reflexes before each dose, respiratory rate, and urine output (target ≥100 mL per 4 hours) 1, 2

Fetal Lung Maturity

• Administer antenatal corticosteroids (betamethasone 12 mg IM every 24 hours × 2 doses) immediately, as gestational age is <34 weeks 4, 1
• Do not delay delivery beyond 48 hours waiting for steroid effect if maternal condition deteriorates 1

Absolute Indications for Immediate Delivery at 29 6/7 Weeks

Any of the following mandate delivery regardless of gestational age after maternal stabilization:

• Inability to control BP despite ≥3 classes of antihypertensives in appropriate doses 1, 2
• Progressive thrombocytopenia (declining platelet counts on serial measurements) 1
• Progressively abnormal liver or renal function tests (worsening trends, not static elevations) 1
• Pulmonary edema or maternal oxygen saturation <90% 1, 2
• Severe intractable headache, repeated visual scotomata, or eclamptic seizures 1, 2
• Non-reassuring fetal status on continuous monitoring 1, 2
• Placental abruption 1

Critical Laboratory Assessment Before Delivery

• Complete blood count focusing on hemoglobin and platelet count (platelets <100,000/μL define severe features) 1, 2
• Comprehensive metabolic panel: liver transaminases (AST/ALT ≥2× upper limit defines severe features), creatinine (>1.1 mg/dL or doubling of baseline defines severe features), uric acid 1
• Spot urine protein/creatinine ratio ≥30 mg/mmol confirms significant proteinuria 1

Mode of Delivery Considerations

• Vaginal delivery is preferred for women with hypertensive disorders of pregnancy unless obstetric indications dictate cesarean section 1, 2
• Breech presentation at 29 6/7 weeks is an obstetric indication for cesarean delivery in most cases, but the decision should be based on standard obstetric criteria, not the presence of preeclampsia 1
• Continue antihypertensive therapy throughout labor and delivery to maintain systolic <160 mmHg and diastolic <110 mmHg 1, 2

Maternal Monitoring During Stabilization

• Continuous blood pressure monitoring until hemodynamically stable 2
• Hourly urine output via Foley catheter with target ≥100 mL per 4 hours (or >35 mL/hour) 1, 2
• Oxygen saturation monitoring (maternal early warning if <95%) 1
• Assess for maternal agitation, confusion, non-remitting headache, visual changes, epigastric or right upper quadrant pain 1, 2

Fluid Management

• Limit total IV fluid administration to 60-80 mL/hour to avoid pulmonary edema 1
• Do not use routine plasma volume expansion—it does not improve maternal outcomes and may exacerbate complications 1, 3

Critical Pitfalls to Avoid

• Do not attempt expectant management at <34 weeks with severe features present—the presence of severe preeclampsia mandates delivery after stabilization 1
• Do not use serum uric acid levels or degree of proteinuria as criteria for delivery timing—decisions should be based on maternal-fetal clinical status 1
• Do not underestimate disease severity based on "mild" classification—all preeclampsia can rapidly progress to life-threatening complications 1
• Do not delay delivery waiting for "better" gestational age—maternal mortality and morbidity take precedence over fetal prematurity concerns when severe features are present 1, 2

Setting of Care

• This patient requires management in a facility with appropriate obstetrical care, maternal intensive care capabilities, and NICU for premature infants 1
• If not already at a tertiary center, arrange immediate medicalized transport after initiating magnesium sulfate and blood pressure control 2

Postpartum Management

• Continue magnesium sulfate for 24 hours postpartum 3
• Monitor BP at least every 4-6 hours while awake for minimum 3 days postpartum, as eclampsia can first appear in this period 1, 3
• Avoid NSAIDs for postpartum analgesia, especially with renal dysfunction, as they can worsen hypertension and renal function 1, 3
• Schedule comprehensive review at 3 months postpartum to confirm normalization of BP, urinalysis, and laboratory abnormalities 1