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?

Explanation

## 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.