How should a 35‑week pregnant woman with hypertension and fetal intra‑uterine growth restriction be managed?

Management of Pregnancy with Hypertension at 35 Weeks with IUGR

At 35 weeks gestation with hypertension and IUGR, you should immediately perform umbilical artery Doppler assessment to guide delivery timing, control blood pressure to target diastolic 85 mmHg (systolic 110-140 mmHg), and plan delivery at 37 weeks if Doppler shows only decreased diastolic flow, or earlier (33-34 weeks) if absent end-diastolic velocity is present.

Immediate Assessment and Stabilization

Blood Pressure Management

• Treat blood pressure urgently if ≥160/110 mmHg using oral nifedipine or intravenous labetalol/hydralazine in a monitored setting 1
• For persistent hypertension ≥140/90 mmHg, initiate or adjust antihypertensive therapy targeting diastolic BP of 85 mmHg (systolic 110-140 mmHg) to reduce severe hypertension and complications 1
• Acceptable oral agents include methyldopa, labetalol, oxprenolol, and nifedipine 1
• Reduce or cease antihypertensives if diastolic BP falls <80 mmHg to avoid placental hypoperfusion 1

Maternal Monitoring Protocol

• Assess for preeclampsia features: proteinuria (urine protein/creatinine ratio ≥30 mg/mmol), neurological symptoms (headache, visual changes), and clonus 1
• Obtain blood tests twice weekly minimum: complete blood count (hemoglobin, platelets), liver enzymes, creatinine, and uric acid 1
• Consider hospital admission for initial assessment when preeclampsia is first diagnosed; stable patients may transition to outpatient management if reliable 1

Fetal Surveillance Strategy

Critical Umbilical Artery Doppler Assessment

The single most important test is umbilical artery Doppler, as it determines delivery timing and surveillance intensity 1

• Perform umbilical artery Doppler immediately to classify IUGR severity 1
• Assess fetal biometry, amniotic fluid volume, and confirm IUGR diagnosis (estimated fetal weight <10th percentile) 1

Surveillance Frequency Based on Doppler Findings

Normal or Decreased Diastolic Flow (but present end-diastolic velocity):

• Weekly umbilical artery Doppler evaluation 1
• Weekly cardiotocography (non-stress testing) 1
• Fetal biometry every 2 weeks 1
• Plan delivery at 37 weeks gestation 1, 2

Absent End-Diastolic Velocity (AEDV):

• Doppler assessment 2-3 times per week due to potential rapid deterioration 1, 3
• Daily cardiotocograph monitoring 1
• Twice weekly amniotic fluid assessment 1
• Administer antenatal corticosteroids if not previously given 1
• Deliver at 33-34 weeks gestation 1

Reversed End-Diastolic Velocity (REDV):

• Immediate hospitalization required 1, 4
• Cardiotocography 1-2 times daily 1, 4
• Umbilical artery Doppler 3 times weekly 1
• Administer antenatal corticosteroids and magnesium sulfate for neuroprotection 1, 4
• Deliver at 30-32 weeks gestation 1

Delivery Planning at 35 Weeks

Timing Decision Algorithm

Since this patient is at 35 weeks:

• If umbilical artery Doppler shows normal or decreased diastolic flow: Continue expectant management with weekly surveillance until 37 weeks 1
• If absent end-diastolic velocity is present: The patient has already passed the recommended 33-34 week delivery window, so proceed with delivery preparation now 1
• If reversed end-diastolic velocity is present: The patient has significantly exceeded the 30-32 week delivery recommendation, so deliver immediately after corticosteroid administration 1

Indications for Immediate Delivery (Regardless of Gestational Age)

Deliver immediately if any of the following develop 1:

• Repeated severe hypertension despite 3 antihypertensive classes
• Progressive thrombocytopenia or abnormal liver/renal function tests
• Pulmonary edema
• Severe intractable headache, repeated visual scotomata, or eclamptic seizures
• Non-reassuring fetal status on cardiotocography

Antenatal Corticosteroids

• Administer betamethasone or dexamethasone if delivery anticipated between 34 0/7 and 36 6/7 weeks and no prior course given 1
• At 35 weeks, corticosteroids reduce neonatal respiratory morbidity 1

Magnesium Sulfate

• Not indicated for neuroprotection at 35 weeks (only recommended <32 weeks) 1
• Administer for seizure prophylaxis if severe hypertension with proteinuria or neurological symptoms present 1

Mode of Delivery Considerations

• Cesarean delivery should be considered based on the entire clinical scenario, particularly with absent or reversed end-diastolic velocity where fetal tolerance of labor may be poor 1
• Induction of labor is reasonable if fetal status is reassuring and cervix is favorable 1

Critical Pitfalls to Avoid

Do not delay delivery based on proteinuria level or uric acid - these should not guide delivery timing 1

Do not assume IUGR reflects hypertension severity - IUGR may represent underlying fetal susceptibility rather than maternal disease severity, requiring independent fetal surveillance 5

Do not perform surveillance less frequently than recommended - progression from absent to reversed end-diastolic flow can occur within days, mandating intensive monitoring 3

Do not use middle cerebral artery or ductus venosus Doppler for routine management decisions - umbilical artery Doppler is the validated surveillance tool 1

Recognize that every additional day in utero up to 32 weeks increases intact survival by 1-2%, but this benefit must be balanced against maternal and fetal risks 1. At 35 weeks with concerning Doppler findings, the balance favors delivery.