Reproductive · Year 2 · from Reproductive
Case 1: Preeclampsia with Severe Features
Clinical Image
Source: Wikipedia - Preeclampsia - CC BY-SA 4.0
Case Presentation
A 32-year-old G1P0 at 34 weeks gestation presents to labor and delivery with a severe headache, visual changes ("seeing spots"), and right upper quadrant pain for the past 6 hours. Her pregnancy has been uncomplicated until now. Blood pressure is 168/108 mmHg (confirmed on repeat after 15 minutes). Physical examination reveals 3+ pitting edema of the lower extremities, brisk deep tendon reflexes (3+), and right upper quadrant tenderness without peritoneal signs. Fetal heart rate tracing shows a baseline of 145 bpm with moderate variability and no decelerations. Laboratory studies reveal: platelet count 89,000/uL (low), AST 245 U/L (elevated), ALT 198 U/L (elevated), creatinine 1.2 mg/dL (elevated from baseline 0.6), LDH 580 U/L (elevated), and urine protein/creatinine ratio 1.2 (significant proteinuria). Peripheral smear shows schistocytes. The diagnosis is preeclampsia with severe features and HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets). Magnesium sulfate is initiated for seizure prophylaxis (4g IV loading dose, then 2g/hour). IV labetalol is given for blood pressure control. Betamethasone is administered for fetal lung maturity. After 24 hours of maternal stabilization and completion of a steroid course, she undergoes cesarean delivery due to an unfavorable cervix. A healthy 2.1 kg infant is delivered. The mother's blood pressure and laboratory values normalize over the following week.
Key Learning Points
- Preeclampsia is defined as hypertension (>140/90) after 20 weeks gestation with proteinuria or end-organ dysfunction; severe features include BP >160/110, thrombocytopenia, renal insufficiency, liver involvement, or neurologic symptoms
- HELLP syndrome is a severe variant characterized by hemolysis (schistocytes, elevated LDH, low haptoglobin), elevated liver enzymes, and low platelets
- Magnesium sulfate prevents seizures (eclampsia); delivery is the only definitive treatment for preeclampsia
- At gestational ages <34 weeks, corticosteroids for fetal lung maturity should be given before delivery when maternal and fetal status allow a 24-48 hour delay