A 28-year-old primigravida at 32 weeks of 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 previous history of hypertension. Which is the investigation of choice to assess the severity and confirm the diagnosis of preeclampsia?

## Diagnosis and Assessment of Preeclampsia ### Clinical Presentation The patient presents with classic features of preeclampsia: - Hypertension ≥160/110 mmHg (severe range) - Proteinuria (2+) - Symptoms: headache, epigastric pain (warning signs) ### Investigation of Choice **Key Point:** 24-hour urinary protein estimation is the gold standard for confirming significant proteinuria and assessing severity in preeclampsia. It quantifies proteinuria objectively and helps distinguish preeclampsia from gestational hypertension. ### Diagnostic Criteria for Preeclampsia (ACOG/WHO) | Feature | Preeclampsia | Severe Preeclampsia | |---------|--------------|---------------------| | Blood Pressure | ≥140/90 mmHg | ≥160/110 mmHg | | Proteinuria | ≥300 mg/24 hrs | ≥5 g/24 hrs | | Symptoms | None or mild | Headache, epigastric pain, visual disturbances | | Laboratory | Normal | Elevated creatinine, low platelets, elevated LFTs | ### Role of 24-Hour Urinary Protein 1. **Confirms diagnosis**: Differentiates preeclampsia (≥300 mg/24 hrs) from gestational hypertension (no proteinuria) 2. **Assesses severity**: ≥5 g/24 hrs indicates severe preeclampsia 3. **Guides management**: Determines need for hospitalization, antihypertensive therapy, and timing of delivery 4. **Objective measurement**: More reliable than dipstick testing alone **High-Yield:** In India, RCH guidelines emphasize 24-hour urinary protein as the first-line investigation for confirming preeclampsia in all hypertensive pregnant women with proteinuria. ### Subsequent Investigations (After Confirmation) Once preeclampsia is confirmed, the following are done to assess severity: - Serum creatinine and liver enzymes (assess organ involvement) - Platelet count (HELLP syndrome screening) - NST/CTG (fetal well-being) ```mermaid flowchart TD A[Pregnant woman with HTN + Proteinuria]:::outcome --> B{Confirm proteinuria?}:::decision B -->|24-hour urine protein| C[≥300 mg/24 hrs]:::outcome C --> D{Assess severity}:::decision D -->|≥5 g/24 hrs| E[Severe Preeclampsia]:::urgent D -->|<5 g/24 hrs| F[Preeclampsia without severe features]:::outcome E --> G[Check LFTs, creatinine, platelets]:::action F --> H[Antihypertensive therapy + monitoring]:::action ``` **Clinical Pearl:** In resource-limited settings where 24-hour urine collection is difficult, spot urine protein-to-creatinine ratio (≥0.3) is an acceptable alternative, but 24-hour collection remains the gold standard in India's RCH protocols.