A 28-year-old G2P1 at 28 weeks gestation is found to have a blood pressure of 152/98 mmHg on two occasions 4 hours apart. Urine dipstick shows 1+ protein. She is asymptomatic with normal reflexes and no edema. Fetal heart rate is 140 bpm with reactive NST. What is the most appropriate next step in management?

Explanation

## Clinical Diagnosis This patient has **gestational hypertension progressing toward preeclampsia**: - BP ≥140/90 mmHg on two occasions (new-onset hypertension in pregnancy) - Minimal proteinuria (1+ = trace, <0.3 g/24 h) - Asymptomatic, no severe features - Fetal status reassuring (reactive NST) **Key Point:** This is **non-severe preeclampsia** (or high-risk gestational hypertension). Management differs fundamentally from severe preeclampsia and depends on gestational age and maternal/fetal stability. ## Preeclampsia Severity Classification | Feature | Non-Severe PE | Severe PE | |---------|---------------|----------| | **Systolic BP** | 140–159 mmHg | ≥160 mmHg | | **Diastolic BP** | 90–109 mmHg | ≥110 mmHg | | **Proteinuria** | <5 g/24 h | ≥5 g/24 h or 3+ dipstick | | **Symptoms** | None or mild | Headache, RUQ pain, visual changes | | **Platelets** | ≥100,000/μL | <100,000/μL | | **Creatinine** | ≤1.1 mg/dL | >1.1 mg/dL | | **Delivery timing** | 37 weeks (term) | 34 weeks or urgent if unstable | **High-Yield:** At 28 weeks with non-severe preeclampsia, the goal is **expectant management** to allow fetal maturity while monitoring closely for progression to severe disease. ## Management Algorithm ```mermaid flowchart TD A[New-onset HTN in pregnancy]:::outcome --> B{Severe features present?}:::decision B -->|Yes| C[Severe Preeclampsia]:::urgent C --> D[IV MgSO4 + Delivery plan]:::action B -->|No| E[Non-severe PE/Gestational HTN]:::outcome E --> F{GA < 37 weeks?}:::decision F -->|Yes| G[Outpatient management + Corticosteroids]:::action F -->|No| H[Delivery at 37 weeks]:::action G --> I[24-h urine protein + Oral antihypertensive]:::action I --> J[Weekly monitoring until delivery]:::action ``` **Clinical Pearl:** Proteinuria of 1+ on dipstick is often not significant; 24-hour urine collection is the gold standard to quantify protein excretion and confirm preeclampsia diagnosis. Trace proteinuria (<0.3 g/24 h) may represent gestational hypertension alone. **Mnemonic:** **SAFE** expectant management in non-severe PE at <37 weeks: - **S**tart oral antihypertensive (nifedipine, methyldopa, labetalol) - **A**ssess proteinuria (24-hour urine) - **F**etal monitoring (NST, growth scans) - **E**xpect delivery at 37 weeks (or earlier if severe features develop) ## Why Hospitalization Is Not Indicated Here - Asymptomatic with reassuring fetal status - No severe features (BP <160/110, no symptoms, normal reflexes) - Outpatient management with close follow-up is safe and cost-effective - Hospitalization reserved for severe PE, suspected abruption, or fetal compromise [cite:ACOG Practice Bulletin 202; Williams Obstetrics 26e Ch 40]