A 32-year-old primigravida at 34 weeks gestation presents to the antenatal clinic with a blood pressure of 158/102 mmHg. She reports a 2-week history of progressive headache and right upper quadrant pain. On examination, she has 3+ proteinuria on dipstick and brisk reflexes with 3 beats of clonus. Platelet count is 95,000/μL, serum creatinine 1.4 mg/dL (baseline 0.8 mg/dL), and AST 120 IU/L. What is the most appropriate immediate management?

Explanation

## Diagnosis: Severe Preeclampsia with Features of HELLP Syndrome **Key Point:** This patient meets criteria for severe preeclampsia (BP ≥160/110 mmHg, proteinuria, symptoms) with evidence of end-organ dysfunction: thrombocytopenia (95,000/μL), elevated transaminases (AST 120), and rising creatinine. The presence of hemolysis (implied by elevated LDH if checked), elevated liver enzymes, and low platelets constitutes HELLP syndrome—a medical emergency. **High-Yield:** Management of severe preeclampsia/HELLP at any gestational age requires: 1. **Seizure prophylaxis:** IV magnesium sulphate (4 g IV bolus, then 1 g/hour infusion) is the gold standard and reduces eclampsia risk by ~50%. 2. **Fetal maturity support:** Antenatal corticosteroids (betamethasone 12 mg IM × 2 doses, 24 hours apart) for fetal lung maturity at 34 weeks. 3. **Delivery:** Expedite delivery (vaginal or cesarean based on obstetric factors) once mother is stabilized—this is the only definitive cure for preeclampsia. **Clinical Pearl:** Magnesium sulphate is neuroprotective and anticonvulsant; it does NOT lower blood pressure. Antihypertensives (labetalol, hydralazine, or nifedipine) are used only if SBP >160 or DBP >110 to prevent maternal stroke, but they are NOT first-line for seizure prevention. **Mnemonic: HELLP** = **H**emolysis, **E**levated **L**iver enzymes, **L**ow **P**latelets. Platelet count <100,000/μL is a hallmark. ## Why Immediate Delivery? At 34 weeks with severe preeclampsia and HELLP, the maternal and fetal risks of continuing pregnancy outweigh the benefits of expectant management. Delivery should occur within 12–24 hours of diagnosis (vaginal if cervix favorable; cesarean if not or if maternal/fetal distress). [cite:Williams Obstetrics 26e Ch 34]