Obgyn · Year 3 · from Obgyn
Case 1: Preeclampsia with Severe Features
Patient Demographics
- Age: 28 years
- Sex: Female
- Occupation: Teacher
Chief Complaint
"I have a terrible headache that won't go away and I'm seeing spots."
History of Present Illness
The patient is G1P0 at 34 weeks 3 days gestation. She noticed a persistent frontal headache starting yesterday that is not relieved by acetaminophen. This morning she noted visual disturbances described as "flashing lights" in her peripheral vision. She has also noticed increased swelling in her hands and face over the past week. At her prenatal visit last week, her blood pressure was 128/82 mmHg.
Past Medical History
- No prior hypertension
- No diabetes
- First pregnancy (nulliparity is a risk factor for preeclampsia)
Risk Factors for Preeclampsia
- Nulliparity (strongest risk factor)
- First pregnancy with this partner (immunologic theory)
Physical Examination Findings
- Vital Signs: BP 168/108 mmHg (repeated: 172/110 mmHg), HR 88 bpm, RR 18, SpO2 99%
- General: Alert, appears uncomfortable, periorbital and facial edema
- Cardiovascular: Regular rhythm, no murmurs
- Abdomen: Gravid, non-tender, fundal height 33 cm
- Neurologic: Hyperreflexia (3+ deep tendon reflexes with 2 beats of clonus)
- Extremities: 3+ pitting edema of hands and lower extremities
Diagnostic Workup
- Urinalysis: 3+ protein
- Spot urine protein/creatinine ratio: 1.2 (>0.3 is significant)
- Complete Blood Count: Hgb 12.1, Platelets 145,000 (low-normal)
- Complete Metabolic Panel: Creatinine 0.9 (normal), AST 42, ALT 38 (mildly elevated)
- LDH: 280 (mildly elevated)
- Uric Acid: 7.2 mg/dL (elevated)
- Fetal Assessment: NST reactive, AFI 12 cm, EFW 2,100 grams
Diagnosis
Preeclampsia with Severe Features at 34 weeks
- Severe-range blood pressure (>160/110 mmHg on multiple readings)
- Neurologic symptoms (severe headache, visual disturbances)
- Hyperreflexia with clonus
- Significant proteinuria
Management Plan
Immediate Blood Pressure Control:
- IV Labetalol 20 mg bolus
- BP after 10 minutes: 158/102 (inadequate response)
- IV Labetalol 40 mg bolus
- BP after 10 minutes: 142/88 (goal <160/110 achieved)
Magnesium Sulfate for Seizure Prophylaxis:
- Loading dose: 4 g IV over 20 minutes
- Maintenance: 2 g/hour continuous infusion
- Monitor: reflexes hourly, urine output, respiratory rate
Antenatal Corticosteroids:
- Betamethasone 12 mg IM now, repeat in 24 hours
- For fetal lung maturity (34 weeks)
Delivery Planning:
- Preeclampsia with severe features at 34 weeks: delivery indicated
- Allow 24-48 hours for corticosteroids if maternal/fetal status stable
- Assess cervix for induction candidacy
Hospital Course
Hours 0-24:
- Blood pressure controlled on labetalol 200 mg PO every 8 hours
- Magnesium continued, no signs of toxicity
- First betamethasone dose given
- Symptoms (headache, visual changes) improved
- Serial labs stable
Hours 24-48:
- Second betamethasone dose given
- Cervix: 2 cm, 50% effaced, -2 station (Bishop score 5)
- Decision: proceed with induction of labor
Induction and Delivery:
- Cervical ripening with Foley bulb
- Oxytocin augmentation
- Magnesium continued throughout labor
- Vaginal delivery after 14 hours of labor
- Female infant, 2,050 grams, Apgar 8/9
Postpartum:
- Magnesium continued for 24 hours after delivery
- Blood pressure initially elevated, required labetalol continuation
- Symptoms resolved
- Discharged on postpartum day 3 on labetalol with BP monitoring
- Follow-up in 1 week for BP check
Counseling
- Risk of recurrence in future pregnancies: 20-40%
- Low-dose aspirin recommended starting at 12 weeks in future pregnancies
- Long-term cardiovascular risk monitoring recommended
Clinical Image
Image Description: Clinical illustration depicting the multi-system effects of preeclampsia including hypertension, proteinuria, neurologic symptoms, and potential progression to eclampsia or HELLP syndrome.
Attribution: Educational illustration. Public domain medical education resource.