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Dds final diagnosis management

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preeclampsia AND delivery

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ACOG severe hypertension pregnancy 34 weeks delivery preeclampsia guideline

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https://www.aafp.org/afp/2019/1115/p649

Provisional diagnosis

Primigravida at 36 weeks with acute severe-range hypertension: BP 160/100 mmHg.
  • If repeat BP remains systolic ≥160 mmHg after 15 minutes, treat as preeclampsia with severe features / severe gestational hypertension until proven otherwise.
  • A firm diagnosis of preeclampsia requires proteinuria or maternal end-organ dysfunction. She is currently asymptomatic, so urgently investigate for proteinuria and severe features.
  • Fundal height 32-34 weeks at 36 weeks suggests possible fetal growth restriction, requiring ultrasound assessment.
Severe-range gestational hypertension is managed the same as preeclampsia with severe features because maternal risk is similar, per the ACOG summary.

Immediate management

  1. Admit urgently to a high-risk obstetric unit.
  2. Repeat BP promptly using correct cuff and technique. Severe hypertension persisting for 15 minutes requires treatment.
  3. Establish IV access, left lateral position, strict input-output charting, and avoid fluid overload.
  4. Maternal assessment:
    • Ask for headache, visual symptoms, epigastric/right upper quadrant pain, vomiting, dyspnea, reduced urine output, and decreased fetal movements.
    • Check reflexes, clonus, oxygen saturation, urine output.
  5. Investigations:
    • Urine protein-creatinine ratio or 24-hour urine protein.
    • CBC with platelet count.
    • LFTs: AST/ALT, bilirubin, LDH.
    • Renal function: serum creatinine, urea, electrolytes.
    • Coagulation profile if thrombocytopenia, abruption, or HELLP is suspected.
    • Blood group, cross-match.
    • Ultrasound for fetal growth, liquor volume, placental assessment, Doppler studies.
    • CTG/NST for fetal well-being.
Preeclampsia may be diagnosed without proteinuria if hypertension is accompanied by platelets ≤100,000/µL, creatinine ≥1.1 mg/dL or doubled, transaminases twice normal, pulmonary edema, or neurological/visual symptoms. Henry's Clinical Diagnosis and Management by Laboratory Methods, section “Preeclampsia.”

Stabilization

Control severe BP

Give one of the following according to local protocol, aiming to prevent maternal stroke:
  • IV labetalol
  • IV hydralazine
  • Oral immediate-release nifedipine
Acute severe hypertension should be treated as soon as possible, ideally within 60 minutes, as summarized in the ACOG-based guidance.

Prevent seizures

Magnesium sulfate for seizure prophylaxis:
  • Common regimen: 4 g IV loading dose over 5-20 minutes, then 1-2 g/hour infusion.
  • Monitor respiratory rate, patellar reflexes, urine output, and serum magnesium if toxicity/renal impairment is suspected.
  • Keep 10% calcium gluconate available for magnesium toxicity.

Definitive management

At 36 weeks, once stabilized, delivery is indicated. Do not manage expectantly or wait until 37 weeks if severe-range BP is confirmed.
  • Start antenatal corticosteroids only if considered locally appropriate, but do not delay indicated delivery to complete steroids.
  • Induce labour if:
    • Mother is stable after treatment
    • CTG is reassuring
    • No contraindication to vaginal delivery
    • Cervix is favourable, or cervical ripening is feasible
  • Cesarean delivery if:
    • Non-reassuring fetal status
    • Uncontrolled severe hypertension or maternal deterioration
    • HELLP syndrome, abruption, eclampsia, pulmonary edema
    • Failed induction or another obstetric indication
An unengaged head alone is not an automatic indication for cesarean section.
Continue magnesium sulfate for 24 hours postpartum, monitor BP closely, and treat postpartum hypertension. Delivery at ≥34 weeks after maternal stabilization is recommended for severe features, per ACOG guidance.
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