A 32-year-old multigravida at 24 weeks of gestation attends her routine antenatal visit. Her blood pressure is 148/96 mmHg (baseline 110/70 mmHg). Urine dipstick shows 2+ proteinuria. Full blood count and liver function tests are normal. Serum creatinine is 0.9 mg/dL. What is the most appropriate next step in management?

Question

Accepted Answer

B. Perform 24-hour urine protein estimation and repeat BP after 15 minutes. ## Clinical Presentation The patient presents with: - Elevated BP (148/96 mmHg) with baseline normal (110/70 mmHg) → rise of ≥30 mmHg systolic or ≥15 mmHg diastolic - Proteinuria (2+) - Normal renal and hepatic function - Gestation 24 weeks (viable, but preterm) This constellation suggests **possible preeclampsia**, but diagnosis requires confirmation. ## Diagnostic Criteria for Preeclampsia **Key Point:** Preeclampsia is defined as new-onset hypertension (≥140/90 mmHg) after 20 weeks PLUS proteinuria (≥0.3 g/24 h) or other features of end-organ dysfunction. Diagnosis must be confirmed before treatment escalation. **High-Yield:** A single elevated BP reading does NOT diagnose hypertension in pregnancy. Repeat measurement after 15 minutes is mandatory to exclude white-coat effect or transient elevation. ## Diagnostic Algorithm at 24 Weeks with Suspected Preeclampsia ```mermaid flowchart TD A[BP ≥140/90 + Proteinuria at 24 weeks]:::outcome --> B[Repeat BP after 15 min rest]:::action B --> C{BP still ≥140/90?}:::decision C -->|No| D[Likely white-coat effect
Routine follow-up]:::outcome C -->|Yes| E[Confirm diagnosis:
24-hour urine protein
or spot urine PCR]:::action E --> F{Proteinuria ≥0.3 g/24h
or PCR ≥30 mg/mmol?}:::decision F -->|Yes| G[Preeclampsia confirmed
Assess severity]:::outcome F -->|No| H[Gestational hypertension
Outpatient monitoring]:::outcome G --> I{Severe features present?
Symptoms, labs abnormal}:::decision I -->|Yes| J[Admit, antihypertensives,
Corticosteroids, plan delivery]:::action I -->|No| K[Outpatient monitoring
with frequent visits]:::action ``` ## Why 24-Hour Urine Protein is Next Step | Step | Rationale | |------|----------| | **Repeat BP** | Exclude white-coat effect; single reading insufficient for diagnosis | | **24-hour urine protein** | Confirm proteinuria objectively; diagnostic criterion for preeclampsia | | **Assess severity** | Normal labs (Cr, LFTs, CBC) suggest non-severe preeclampsia if confirmed; guides outpatient vs. inpatient management | **Clinical Pearl:** At 24 weeks with suspected preeclampsia but normal end-organ function tests, expectant management with close monitoring is appropriate if non-severe. Delivery is indicated only if severe preeclampsia, fetal compromise, or maternal indication arises. **Mnemonic:** CONFIRM FIRST — **C**onfirm diagnosis; **O**btain 24-h urine; **N**ormal labs reassure; **F**requent follow-up; **I**npatient if severe; **R**epeat BP; **M**onitoring outpatient; **F**etal assessment; **I**ntervention only if indicated; **R**eview at each visit; **S**teroids if <34 weeks; **T**herapy escalate if worsening. ## Management Principles at 24 Weeks (Preterm) 1. **Confirm diagnosis** with 24-hour urine protein before initiating antihypertensives. 2. **Assess severity** using clinical and laboratory criteria. 3. **If non-severe preeclampsia:** expectant management with antepartum fetal monitoring, twice-weekly BP checks, and corticosteroids if delivery anticipated before 34 weeks. 4. **If severe preeclampsia or maternal/fetal indication:** admit, initiate antihypertensives, administer corticosteroids, plan delivery at 34 weeks or earlier if unstable.

Answer

A. Perform emergency caesarean section

Answer

C. Admit for inpatient monitoring and antihypertensive therapy

Answer

D. Start oral nifedipine 10 mg immediately and review in 1 week

Explanation

Clinical Presentation

Diagnostic Criteria for Preeclampsia

Diagnostic Algorithm at 24 Weeks with Suspected Preeclampsia

Why 24-Hour Urine Protein is Next Step

Management Principles at 24 Weeks (Preterm)

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Step	Rationale
Repeat BP	Exclude white-coat effect; single reading insufficient for diagnosis
24-hour urine protein	Confirm proteinuria objectively; diagnostic criterion for preeclampsia
Assess severity	Normal labs (Cr, LFTs, CBC) suggest non-severe preeclampsia if confirmed; guides outpatient vs. inpatient management