A 37-year-old woman, gravida 1 para 0, comes to the emergency department at 37 weeks gestation for a severe headache unrelieved by acetaminophen. For the past several days, the patient has experienced fatigue, headaches, and blurred vision. She reports good fetal movement and has no abdominal pain, vaginal bleeding, or fluid leakage. The patient's pregnancy has been complicated by gestational hypertension that has not required antihypertensive therapy. She has no other chronic medical conditions or previous surgeries. The patient takes a prenatal vitamin daily. Blood pressure is 170/110 mm Hg and pulse is 80/min. Fetal monitoring shows a baseline of 140/min, moderate variability, no decelerations, and no accelerations. Fundal height is 37 cm. Physical examination shows edema of the hands and face. Cervical examination reveals the cervix to be closed, long, and posterior. Deep tendon reflexes are 2+. Urine dipstick shows 3+ protein. A complete blood count and liver function panel are unremarkable. A biophysical profile shows a score of 8/8 and a fetus in vertex presentation. Which of the following is the best next step in management of this patient?

Question

A 37-year-old woman, gravida 1 para 0, comes to the emergency department at 37 weeks gestation for a severe headache unrelieved by acetaminophen.  For the past several days, the patient has experienced fatigue, headaches, and blurred vision.  She reports good fetal movement and has no abdominal pain, vaginal bleeding, or fluid leakage.  The patient's pregnancy has been complicated by gestational hypertension that has not required antihypertensive therapy.  She has no other chronic medical conditions or previous surgeries.  The patient takes a prenatal vitamin daily.  Blood pressure is 170/110 mm Hg and pulse is 80/min.  Fetal monitoring shows a baseline of 140/min, moderate variability, no decelerations, and no accelerations.  Fundal height is 37 cm.  Physical examination shows edema of the hands and face.  Cervical examination reveals the cervix to be closed, long, and posterior.  Deep tendon reflexes are 2+.  Urine dipstick shows 3+ protein.  A complete blood count and liver function panel are unremarkable.  A biophysical profile shows a score of 8/8 and a fetus in vertex presentation.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c036_7f7a_8f63_435b9579a002_MD0005_00 At 37 weeks gestation, this patient has a blood pressure of >160/110 mm Hg, proteinuria, and signs of end-organ damage (eg, headache, visual symptoms), a presentation consistent with preeclampsia with severe features. Severe elevations in blood pressure increase the risk of seizure, stroke, hepatorenal failure, and abruptio placentae. In addition, preeclampsia causes placental infarction and ischemia, which can result in fetal growth restriction and demise. Risk factors for preeclampsia include nulliparity and advanced maternal age (>35). The initial management of preeclampsia with severe features is maternal stabilization. Short-acting antihypertensives (eg, labetalol, hydralazine) are administered for blood pressure control. Intravenous magnesium sulfate is used for seizure prophylaxis. Once the patient's condition is stabilized, delivery planning is initiated. (Choices B and E) The only definitive treatment for preeclampsia is delivery, which is deferred until after maternal stabilization. The delivery route (eg, vaginal, cesarean) depends on maternal stability and fetal well-being. (Choice C) Patients who have preeclampsia without severe features are delivered at >37 weeks gestation. Patients who have preeclampsia with severe features are delivered at >34 weeks gestation. This patient has a normal biophysical profile, and inpatient observation is not indicated. (Choice D) Amniocentesis for fetal lung maturity is performed when the lung maturity status affects management decisions. The decision to initiate a medically indicated delivery is based on balancing the risks of fetal complications from delivery against the risks of fetal/maternal complications from pregnancy continuation. Because the risks of pregnancy continuation in this patient are severe, delivery is indicated; amniocentesis would not affect management and therefore is not indicated. Educational objective: Patients who have preeclampsia with severe features require stabilization with blood pressure control (eg, hydralazine, labetalol) and magnesium sulfate for seizure prophylaxis. At >34 weeks gestation, delivery is initiated after maternal stabilization is established. References: Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/24150027) Management of hypertensive disorders in pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/25259900)

A 37-Year-Old Woman, Gravida 1 Para 0, Comes to the Emergency