A 32-year-old primigravida at 34 weeks of gestation presents to the antenatal clinic with a blood pressure of 158/102 mmHg. She reports a persistent frontal headache for the past 6 hours and blurred vision for 2 hours. On examination, she has 3+ proteinuria and brisk deep tendon reflexes. Fetal heart rate is 140 bpm with normal variability. Laboratory investigations show platelet count 95,000/μL, serum creatinine 1.4 mg/dL (baseline 0.8 mg/dL), and LDH 650 IU/L. What is the most appropriate immediate management?

Explanation

## Clinical Diagnosis This patient has **severe preeclampsia with features of HELLP syndrome** (Hemolysis, Elevated Liver enzymes, Low Platelets). ### Key Clinical Features Present | Feature | Finding | Significance | |---------|---------|---------------| | BP | 158/102 mmHg | Severe range (≥160/110) | | Symptoms | Headache, blurred vision | Cerebral involvement | | Proteinuria | 3+ | Severe renal involvement | | Reflexes | Brisk + clonus likely | Hyperreflexia indicates CNS irritability | | Platelets | 95,000/μL | Thrombocytopenia (HELLP) | | Creatinine | 1.4 mg/dL (↑ from 0.8) | Acute kidney injury | | LDH | 650 IU/L | Elevated (hemolysis marker) | **Key Point:** The combination of severe hypertension, neurological symptoms (headache, visual disturbance), thrombocytopenia, elevated creatinine, and elevated LDH defines **severe preeclampsia with HELLP syndrome** — a medical emergency requiring immediate intervention. ### Management Algorithm ```mermaid flowchart TD A[Severe Preeclampsia/HELLP at 34 weeks]:::outcome --> B{Maternal/Fetal Stability?}:::decision B -->|Stable| C[IV MgSO4 for seizure prophylaxis]:::action B -->|Unstable| D[Urgent delivery]:::urgent C --> E[Antihypertensive therapy]:::action E --> F[Assess fetal maturity]:::decision F -->|Mature/Unstable| G[Delivery within 12-24 hrs]:::action F -->|Immature/Stable| H[Corticosteroids + expectant care]:::action G --> I[Vaginal delivery or CS based on obstetric factors]:::outcome ``` ### Why This Answer Is Correct **High-Yield:** Severe preeclampsia with HELLP requires **magnesium sulphate for seizure prophylaxis** (reduces eclampsia risk by ~50%) and **planned delivery within 12–24 hours** after maternal stabilization [cite:ACOG Practice Bulletin 202]. 1. **Magnesium sulphate** — First-line seizure prophylaxis in severe preeclampsia; loading dose 4–6 g IV over 20–30 min, then 1–2 g/hr maintenance. 2. **Antihypertensive therapy** — Acute control with IV labetalol or oral nifedipine to prevent maternal complications (stroke, pulmonary edema, abruption). 3. **Delivery timing** — At 34 weeks with HELLP, delivery is indicated within 12–24 hours because: - HELLP syndrome carries high maternal mortality (0.5–1.4%) and morbidity. - Fetal maturity is reasonable at 34 weeks; neonatal morbidity is acceptable. - Maternal organ dysfunction (thrombocytopenia, renal impairment) worsens with delay. **Clinical Pearl:** HELLP syndrome is a contraindication to expectant management — delivery is always indicated regardless of gestational age once diagnosis is confirmed [cite:Williams Obstetrics 26e Ch 40]. ### Fetal Considerations - **Fetal heart rate 140 bpm with normal variability** = reassuring; no acute fetal distress. - Delivery by **vaginal route preferred** if no obstetric contraindication (cervical favorability, no placental abruption). - **Corticosteroids** (betamethasone 12 mg IM × 2 doses, 24 hrs apart) should be given if not already administered to accelerate fetal lung maturity.