A 28-year-old primigravida at 32 weeks gestation presents to the antenatal clinic with a blood pressure of 160/110 mmHg, proteinuria (2+), and complaints of headache and epigastric pain. She has no prior history of hypertension. What is the most appropriate investigation to assess severity and guide immediate management?

## Clinical Context: Preeclampsia with Severe Features This patient presents with **severe preeclampsia** (BP ≥160/110 mmHg, proteinuria, and symptoms of end-organ involvement: headache and epigastric pain). The immediate priority is to assess **maternal organ dysfunction** and determine if eclampsia or HELLP syndrome is developing. ## Why Serum Creatinine and LFTs Are Correct **Key Point:** Serum creatinine and liver function tests (AST/ALT, bilirubin, platelet count) are the **gold-standard investigations** to detect: - **Renal involvement** (elevated creatinine, proteinuria progression) - **Hepatic involvement** (elevated transaminases, right upper quadrant pain) - **Thrombocytopenia** (part of HELLP syndrome) These results directly guide **escalation of care** (ICU admission, delivery timing, use of magnesium sulphate prophylaxis, and antihypertensive therapy). **High-Yield:** In severe preeclampsia, LFTs and renal function are **mandatory baseline investigations** per RCOG/ACOG guidelines before any other intervention. ## Investigation Comparison Table | Investigation | Timing | Purpose | Role in Severe PE | |---|---|---|---| | **Serum Cr + LFTs** | **Stat** | Assess organ dysfunction | **Mandatory — guides severity & delivery** | | 24-hr urine protein | Delayed (24 hrs) | Quantify proteinuria | Useful for diagnosis, not acute severity | | Doppler ultrasound | Elective | Assess fetal growth/placental function | Adjunct, not acute severity assessment | | NST/CTG | Stat | Assess fetal well-being | Essential for fetal monitoring, but does NOT assess maternal severity | **Clinical Pearl:** The epigastric pain + elevated transaminases = **HELLP syndrome** until proven otherwise. Platelet count <100,000 + hemolysis + elevated LFTs = delivery is indicated regardless of gestational age. ## Management Algorithm ```mermaid flowchart TD A["Severe Preeclampsia at 32 weeks"]:::outcome --> B["Stat: BP, Cr, LFTs, CBC, coagulation"]:::action B --> C{"HELLP or eclampsia?"}:::decision C -->|"Yes"| D["Deliver immediately + MgSO4"]:::urgent C -->|"No"| E{"Maternal/fetal stability?"}:::decision E -->|"Unstable"| D E -->|"Stable"| F["Corticosteroids + expectant management"]:::action F --> G["Repeat labs q12-24h"]:::action ```