A 38-year-old woman gravida 3, para 2 at 28 weeks’ gestation presents to the clinic for a prenatal visit. She is concerned about swelling of her hands and feet which began 2 days ago. She denies shortness of breath, dizziness, or loss of consciousness. Past medical history is significant for two prior pregnancies that were uncomplicated. She takes a prenatal vitamin daily. She does not drink alcohol or use drugs but did smoke half a pack of cigarettes daily and stopped when she found out she was pregnant. Family history is significant for a cesarean section delivery in her mother at age 26 years for eclampsia and diagnosis of hypertension at age 47 years. Vital signs are temperature 37.1° C (98.6° F), blood pressure 159/100 mmHg, pulse 95 beats/min, and respirations 18/min. Pelvic examination shows a uterus consistent with 28-week gestation. Fetal heart rate is at 152 beats/min.
Labs were done and results are as follows:
Hematocrit: 35%
Leukocyte count: 10,000/mm3
Platelets: 158,000/mm3
Creatinine: 1.0 mg/dL
Aspartate aminotransferase (AST): 20 U/L
Alanine aminotransferase (ALT): 18 U/L
Urinalysis
Specific Gravity: 1.012
RBC: 1/hpf
WBC: 0/hpf
Protein: 4+
Which of the following is the most appropriate next step in management?
The correct answer is:
E) Labetalol
This patient is presenting with preeclampsia without severe features. Management is dependent on the hemodynamic stability of the mother and the fetus, the age of gestation, and the presenting symptoms. Because the mother is stable, and the gestational age is < 37 weeks, conservative treatment is appropriate. Antihypertensives like labetalol, hydralazine, or methyldopa are the mainstays for lowering blood pressure. Magnesium sulfate for prophylaxis of seizures and dexamethasone for fetal lung maturity should also be administered.
Answer choice A: Admission to the intensive care unit, is incorrect. Admission to the ICU is not warranted as the patient is stable and is not presenting with severe features (e.g., elevated creatinine, hepatic dysfunction, new-onset headache or visual disturbances, platelet count < 100,000, pulmonary edema).
Answer choice B: Cesarean delivery, is incorrect. Cesarean delivery is not appropriate as urgent delivery is not necessary and will only cause harm to the fetus as it is preterm.
Answer choice C: Hydrochlorthiazide, is incorrect. Hydrochlorothiazide is a diuretic used to manage hypertension but is advised as second-line in pregnant patients.
Answer choice D: Induction of labor, is incorrect. Induction of labor is not appropriate as urgent delivery is not necessary and will only cause harm to the fetus as it is preterm.
Key Learning Point
Patients with preeclampsia without severe features are managed based on stability of the mother and the stability and age of gestation of the fetus. Conservative management focuses on lowering blood pressure with labetalol, hydralazine, or methyldopa.
