A 32-year-old multigravida at 32 weeks gestation is referred from a peripheral clinic with a blood pressure of 152/98 mmHg, mild headache, and 1+ proteinuria on urine dipstick. She has no visual disturbances, epigastric pain, or respiratory symptoms. On examination, reflexes are normal with no clonus. Platelet count is 150,000/μL, serum creatinine is 0.9 mg/dL, and AST is 28 U/L. Fetal heart rate is reassuring. What is the most appropriate immediate next step in management?

Question

Accepted Answer

B. Admit for inpatient antihypertensive therapy and daily fetal monitoring until delivery at 37 weeks. ## Clinical Diagnosis This patient presents with **preeclampsia without severe features** at 32 weeks gestation: **Key Point:** The clinical presentation is characterized by: - New-onset hypertension (≥140/90 mmHg) at ≥20 weeks gestation - Proteinuria (1+ on dipstick) - **Absence of severe features:** no severe/persistent headache, no visual disturbances, no epigastric/RUQ pain, normal reflexes, no clonus, platelets ≥100,000/μL, creatinine <1.1 mg/dL, AST within normal limits ## Diagnostic Classification | Feature | Finding | Severe Preeclampsia Threshold | |---------|---------|-------------------------------| | Systolic BP | 152 mmHg | ≥160 mmHg | | Diastolic BP | 98 mmHg | ≥110 mmHg | | Headache | Mild/non-persistent | Severe/persistent | | Visual disturbances | Absent | Present | | Epigastric/RUQ pain | Absent | Present | | Reflexes | Normal | Brisk/clonus | | Platelets | 150,000/μL | <100,000/μL | | Serum creatinine | 0.9 mg/dL | >1.1 mg/dL | | AST | 28 U/L | >2× ULN | ## Management Algorithm for Preeclampsia Without Severe Features at <34 Weeks ``` Preeclampsia without severe features at 32 weeks ↓ Inpatient admission for initial evaluation and monitoring ↓ Antihypertensive therapy ONLY if BP ≥160/110 mmHg (per ACOG) ↓ Administer betamethasone (fetal lung maturity, <34 weeks) ↓ Daily fetal monitoring (NST, AFI) + serial labs ↓ Expectant management → plan delivery at 37 weeks (or earlier if severe features develop) ``` ## Rationale for Correct Answer — Option A **High-Yield:** Per ACOG guidelines, preeclampsia without severe features at <34 weeks is managed with **inpatient admission** for the following reasons: 1. **Initial inpatient evaluation** is standard to confirm the diagnosis, assess for evolution to severe features, and establish baseline labs and fetal status. 2. **Antihypertensive therapy** per ACOG is reserved for BP ≥160/110 mmHg (severe-range). This patient's BP of 152/98 mmHg does NOT meet the threshold for pharmacologic treatment; however, close monitoring is mandatory. 3. **Daily fetal surveillance** (NST and amniotic fluid assessment) is performed during inpatient stay. 4. **Planned delivery at 37 weeks** (or earlier if severe features develop) is the goal of expectant management. 5. **Betamethasone** is administered given gestational age <34 weeks in anticipation of possible preterm delivery. **Clinical Pearl (ACOG Practice Bulletin 222):** While some stable patients with preeclampsia without severe features may be transitioned to outpatient management after initial inpatient evaluation, the **immediate next step** upon presentation is **inpatient admission** — not direct outpatient discharge. Outpatient management is only considered after a period of inpatient observation confirms stability and patient reliability. ## Why NOT Option B (Outpatient Labetalol) - ACOG does **not** recommend initiating antihypertensives for BP <160/110 mmHg in preeclampsia without severe features. - Sending a newly diagnosed preeclamptic patient at 32 weeks directly to outpatient management without inpatient evaluation is not the standard of care. - Outpatient follow-up may be appropriate after initial inpatient stabilization, not as the immediate first step. ## Why NOT Option C (Betamethasone + Delivery in 24 Hours) - Delivery within 24 hours is indicated for **severe** preeclampsia at <34 weeks only when expectant management is not feasible or safe. - This patient has no severe features; immediate delivery would be premature and increase neonatal morbidity. - Betamethasone is appropriate but does not mandate delivery within 24 hours in the absence of severe features. ## Why NOT Option D (Urgent Cesarean Section) - There is no obstetric or maternal indication for urgent cesarean section. - Mode of delivery is determined by obstetric factors, not by preeclampsia without severe features alone. - Cesarean section at 32 weeks carries significant neonatal morbidity without maternal benefit in this scenario. ## Reference *ACOG Practice Bulletin No. 222: Gestational Hypertension and Preeclampsia* (2020, reaffirmed 2023); Williams Obstetrics, 26th edition, Chapter on Hypertensive Disorders.

Answer

A. Start oral labetalol and arrange outpatient follow-up with home blood pressure monitoring twice weekly

Answer

C. Perform urgent cesarean section for maternal safety

Answer

D. Administer intramuscular betamethasone and plan delivery within 24 hours

Explanation

Clinical Diagnosis

Diagnostic Classification

Management Algorithm for Preeclampsia Without Severe Features at <34 Weeks

Rationale for Correct Answer — Option A

Why NOT Option B (Outpatient Labetalol)

Why NOT Option C (Betamethasone + Delivery in 24 Hours)

Why NOT Option D (Urgent Cesarean Section)

Reference

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Feature	Finding	Severe Preeclampsia Threshold
Systolic BP	152 mmHg	≥160 mmHg
Diastolic BP	98 mmHg	≥110 mmHg
Headache	Mild/non-persistent	Severe/persistent
Visual disturbances	Absent	Present
Epigastric/RUQ pain	Absent	Present
Reflexes	Normal	Brisk/clonus
Platelets	150,000/μL	<100,000/μL
Serum creatinine	0.9 mg/dL	>1.1 mg/dL
AST	28 U/L	>2× ULN