A 32-year-old multiparous woman at 28 weeks of gestation is referred from a peripheral clinic with a blood pressure of 152/98 mmHg and 1+ proteinuria on urine dipstick. She denies headache, visual disturbances, or epigastric pain. Platelet count is 220,000/μL, serum creatinine 0.9 mg/dL, and AST 28 U/L. Fetal biometry is appropriate for gestational age with normal amniotic fluid volume. Which of the following is the most appropriate management?

Explanation

## Clinical Diagnosis This patient presents with **gestational hypertension** or **preeclampsia without severe features** at 28 weeks gestation. ### Differential Classification | Feature | Finding | Interpretation | |---------|---------|----------------| | **BP elevation** | 152/98 mmHg | Elevated but <160/110 | | **Proteinuria** | 1+ on dipstick | Mild; needs quantification | | **Symptoms** | None (no headache, visual changes, epigastric pain) | No severe features | | **Platelets** | 220,000/μL | Normal | | **Liver enzymes** | AST 28 U/L | Normal | | **Renal function** | Creatinine 0.9 mg/dL | Normal | | **Fetal status** | Normal biometry, AFV | Reassuring | **Key Point:** The absence of severe hypertension (≥160/110), severe proteinuria (≥5 g/24 h), thrombocytopenia (<100,000/μL), elevated transaminases, or symptoms of end-organ dysfunction distinguishes this from **severe preeclampsia**. ## Diagnostic Clarification: Gestational Hypertension vs. Preeclampsia **High-Yield:** The 1+ proteinuria on dipstick is insufficient to diagnose preeclampsia; 24-hour urine protein or spot urine protein-to-creatinine ratio (UPCR) is required. - **Gestational hypertension:** Elevated BP in second half of pregnancy WITHOUT proteinuria or end-organ dysfunction - **Preeclampsia:** Elevated BP + proteinuria (≥0.3 g/24 h) OR end-organ dysfunction - **Preeclampsia without severe features:** BP 140–159/90–109 mmHg + mild proteinuria (<5 g/24 h) + no severe features ## Management Rationale ### Inpatient Observation and Workup **Clinical Pearl:** At 28 weeks with new-onset hypertension and proteinuria, inpatient assessment is standard to: 1. Quantify proteinuria (24-hour urine or UPCR) 2. Assess for end-organ dysfunction (CBC, liver enzymes, renal function) 3. Establish baseline BP and monitor trends 4. Initiate antihypertensive therapy if indicated 5. Arrange fetal monitoring (NST, growth assessment) ### Antihypertensive Therapy **Mnemonic: LAME** (first-line agents in pregnancy) - **L**abetalol - **A**mlodipine (long-acting calcium channel blocker) - **M**ethyldopa - **E**ssential: Avoid ACE inhibitors, ARBs, and atenolol - **Target:** Reduce BP by 10–15% initially; avoid excessive lowering (risk of placental hypoperfusion) - **Threshold for treatment:** BP ≥160/110 mmHg (severe) or ≥140/90 mmHg if proteinuria or end-organ dysfunction present ### Why NOT Magnesium Sulphate? **Warning:** Magnesium sulphate is for **seizure prophylaxis in severe preeclampsia or eclampsia**, not for mild-to-moderate hypertension without severe features. This patient has no indication for magnesium sulphate. ### Why NOT Discharge Home? - Proteinuria + hypertension at 28 weeks requires quantification and close monitoring - Risk of progression to severe preeclampsia is significant; outpatient-only management is inadequate at this stage - Single corticosteroid dose without full assessment is premature ### Why NOT Delivery at 28 Weeks? - Preeclampsia without severe features at <34 weeks is managed expectantly with maternal and fetal monitoring - Delivery is indicated only if severe features develop or at 37 weeks (or earlier if maternal/fetal compromise) - Neonatal morbidity/mortality at 28 weeks is substantial; maternal risk does not yet justify iatrogenic prematurity --- ## Management Algorithm ```mermaid flowchart TD A["New-onset hypertension + proteinuria at 28 weeks"]:::outcome --> B{"Severe features present?"}:::decision B -->|"Yes (BP ≥160/110 + symptoms/labs)"| C["Admit, MgSO4, deliver within 24 hrs"]:::urgent B -->|"No (BP 140-159/90-109, mild proteinuria, no symptoms)"| D["Admit for assessment"]:::action D --> E["Quantify proteinuria<br/>CBC, LFTs, renal function<br/>NST, growth scan"]:::action E --> F{"Preeclampsia confirmed?"}:::decision F -->|"Yes"| G["Start antihypertensive<br/>Weekly monitoring<br/>Deliver at 37 weeks or if severe"]:::action F -->|"No (gestational HTN)"| H["Antihypertensive if BP ≥160/110<br/>Outpatient monitoring"]:::action ``` --- ## Summary At 28 weeks with hypertension and mild proteinuria but no severe features, **inpatient observation, antihypertensive initiation, and 24-hour urine protein quantification** are standard. This allows accurate diagnosis and safe expectant management with close monitoring, avoiding unnecessary early delivery while preventing progression to severe preeclampsia.