Pre-eclampsia at 34 weeks: admit and stabilise
The case
A 26-year-old primigravida at 34 weeks' gestation has a blood pressure of 154/102 mmHg on two readings 30 minutes apart. She has a headache. Her urine protein:creatinine ratio is 52 mg/mmol. Booking blood pressure was 108/68 mmHg. Platelets are 148 × 10^9/L, ALT 38 U/L and creatinine 82 micromol/L. Fetal growth is on the 28th centile with normal Doppler studies. She has no visual disturbance or epigastric pain. What is the most appropriate immediate management?
Options
- AAdmit, treat the blood pressure, give corticosteroids and monitor closely
- BDischarge with a blood pressure diary and review
- CAdmit, treat the blood pressure and plan delivery at 37 weeks regardless
- DOral labetalol as an outpatient with review in 48 hours
- EImmediate caesarean section
Think it through before you read on. Which single option is best, and why are the other four wrong?
Show the answer and explanation
Answer
A. Admit, treat the blood pressure, give corticosteroids and monitor closely
Why this is the right answer
This woman has pre-eclampsia: new hypertension after 20 weeks (154/102 mmHg on repeated readings) with significant proteinuria (protein:creatinine ratio of 30 mg/mmol or more). Headache is a neurological symptom that adds concern. Her platelets, liver enzymes and creatinine are still normal and the fetus is growing well, so she does not yet have severe features.
The Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) guideline for hypertension in pregnancy (2023) directs that pre-eclampsia is managed in hospital, because it can deteriorate rapidly and unpredictably. Outpatient care is reserved for gestational hypertension without proteinuria or symptoms.
Blood pressure of 140/90 mmHg or more is treated, aiming for about 135/85 mmHg and avoiding sudden drops that reduce placental perfusion. First-line oral agents are labetalol, nifedipine and methyldopa. Severe hypertension (160/110 mmHg or more) is an emergency and is brought down with oral immediate-release nifedipine or intravenous labetalol or hydralazine.
Because delivery before 37 weeks is likely, a course of betamethasone is given to mature the fetal lungs. Magnesium sulfate is started if there are severe features suggesting imminent eclampsia (severe headache, visual symptoms, clonus).
Monitoring includes blood pressure at least four-hourly, twice-weekly bloods (platelets, liver enzymes, creatinine), symptom review and fetal surveillance. Delivery is the only cure and is timed between 34 and 37 weeks depending on the clinical course; at 37 weeks it is recommended for all women with pre-eclampsia.
Why the other options are wrong
- B
Pre-eclampsia with proteinuria and headache needs inpatient monitoring; it can progress to eclampsia within hours.
- C
Delivery timing must respond to maternal and fetal condition; fixing 37 weeks ignores possible deterioration.
- D
A single drug with outpatient review misses rapid deterioration in symptomatic pre-eclampsia.
- E
Without severe features, fetal compromise or maternal instability, immediate delivery at 34 weeks is not indicated.
High-yield takeaway
Pre-eclampsia is admitted, blood pressure is treated at 140/90 or above with labetalol, nifedipine or methyldopa, steroids are given before 37 weeks, and delivery is planned at 34 to 37 weeks by clinical course.
Reference: SOMANZ Hypertension in Pregnancy Guideline (2023)
Common questions
What blood pressure needs treatment in pregnancy?
140/90 mmHg or above, aiming for about 135/85 mmHg. 160/110 mmHg or above is severe and is treated urgently.
When is delivery recommended in pre-eclampsia?
Between 34 and 37 weeks depending on the clinical course, and at 37 weeks for everyone with pre-eclampsia.
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