A 28-year-old multiparous woman at 28 weeks gestation is referred from the community health center with a blood pressure of 152/98 mmHg on two occasions 4 hours apart. She denies headache, visual disturbances, or epigastric pain. Urine dipstick shows 1+ protein. Full blood count, liver function tests, and serum creatinine are all normal. Fetal heart rate is 140 bpm with normal amniotic fluid volume. What is the most appropriate next step in management?

Explanation

## Diagnosis: Gestational Hypertension (Stage 1) or Mild Preeclampsia—Requires Risk Stratification **Key Point:** This patient has elevated BP (152/98 mmHg) but minimal proteinuria (1+, not ≥2+) and NO severe features (no symptoms, normal labs, normal fetal status). She does NOT yet meet criteria for severe preeclampsia and does NOT require immediate magnesium sulphate or emergency delivery. **High-Yield:** Classification of hypertensive disorders in pregnancy: | Feature | Gestational HTN | Mild Preeclampsia | Severe Preeclampsia | |---------|-----------------|-------------------|---------------------| | **BP** | ≥140/90 (no proteinuria) | ≥140/90 + proteinuria | ≥160/110 OR ≥140/90 + severe features | | **Proteinuria** | None | <5 g/24 h | ≥5 g/24 h OR ≥3+ dipstick | | **Severe features** | No | No | Yes (symptoms, labs, fetal) | | **Management** | Antihypertensive if BP ≥160/110; close monitoring | Antihypertensive if BP ≥160/110; weekly labs; plan delivery at 37 weeks | Mg²⁺ sulphate; corticosteroids; expedite delivery | **Clinical Pearl:** The diagnosis of preeclampsia requires **both** hypertension **and** proteinuria (≥1+ on dipstick or ≥0.3 g/24 h). A single elevated BP reading is not sufficient; confirm on repeat measurement 4 hours apart (✓ done here). **Mnemonic: SEVERE features** = **S**ystolic BP ≥160, **E**pigastric/RUQ pain, **V**isual disturbances, **E**levated liver enzymes, **R**enal dysfunction, **E**dema/pulmonary edema. This patient has NONE. ## Management Strategy at 28 Weeks Admit for observation and baseline investigations (CBC, LFTs, creatinine, 24-hour urine protein). If BP remains ≥150/100 mmHg on repeat measurement, start antihypertensive (labetalol or nifedipine preferred in pregnancy). Plan delivery at 37 weeks if preeclampsia confirmed; earlier if severe features develop. [cite:ACOG Practice Bulletin 202; Williams Obstetrics 26e Ch 34]