Obstetrics and gynaecology · Easy
This case is fictional and exists for study. It describes no real patient.
32 years · female
A 32-year-old primigravida at 34 weeks gestation presents to the maternity triage unit with a 24-hour history of a severe frontal headache and blurred vision. She reports no epigastric pain or vaginal bleeding. Her pregnancy has been uncomplicated until now. On examination, she has severe peripheral oedema up to her mid-calves. Her neurological examination demonstrates brisk deep tendon reflexes throughout with 3 beats of ankle clonus bilaterally. Dipstick urinalysis shows 3+ protein. The bed-side protein-to-creatinine ratio is significantly elevated.
Vital signs
- HR
- 86 bpm
- BP
- 164/108 mmHg
- RR
- 18/min
- Temp
- 36.8 °C
- SpO₂
- 98%
Examination findings
- Bilateral pitting pedal oedema extending to mid-calves
- Brisk deep tendon reflexes with 3 beats of clonus bilaterally
- Urinalysis positive for 3+ protein
Investigations
| Urine protein:creatinine ratio | 68 mg/mmol | reference: < 30 |
| Platelets | 180 10^9/L | reference: 150-400 |
| Alanine aminotransferase (ALT) | 28 U/L | reference: < 35 |
| Serum creatinine | 72 µmol/L | reference: 45-90 |
Question 1 of 3
What is the most likely diagnosis?
Pre-eclampsia is defined as new-onset hypertension (systolic BP >= 140 mmHg or diastolic BP >= 90 mmHg) occurring after 20 weeks of gestation, accompanied by significant proteinuria (urine PCR >= 30 mg/mmol or 300 mg/24h) or organ dysfunction. Gestational hypertension lacks significant proteinuria or systemic features. Chronic hypertension is diagnosed prior to 20 weeks gestation. Eclampsia refers to the occurrence of grand mal seizures in a patient with pre-eclampsia, which this patient has not experienced.
Teaching point: Pre-eclampsia is characterized by new hypertension developing after 20 weeks gestation combined with proteinuria or maternal organ dysfunction.
Question 2 of 3
Which of the following is the most appropriate first-line oral antihypertensive agent to manage this patient's blood pressure?
NICE guidelines recommend oral labetalol as first-line treatment for hypertension in pregnancy (including gestational hypertension and pre-eclampsia), provided there are no contraindications such as severe asthma. Oral nifedipine or methyldopa are suitable alternatives if labetalol is contraindicated. ACE inhibitors (e.g., enalapril) and ARBs are strictly contraindicated in pregnancy due to teratogenicity and fetal renal toxicity. Amlodipine and spironolactone are not standard first-line therapies in pregnancy.
Teaching point: Labetalol is the first-line antihypertensive in pregnancy; ACE inhibitors and ARBs are strictly contraindicated.
Question 3 of 3
Which medication should be administered to prevent the development of eclamptic seizures in this patient?
Intravenous magnesium sulphate is the drug of choice for both the prevention of eclampsia in patients with severe pre-eclampsia and for the treatment of eclamptic seizures. Benzodiazepines (like diazepam) and standard antiepileptics (such as phenytoin or levetiracetam) are not first-line agents for severe pre-eclampsia or eclamptic seizure control.
Teaching point: Intravenous magnesium sulphate is the primary treatment for seizure prophylaxis and control in severe pre-eclampsia and eclampsia.
Key learning points
- Pre-eclampsia is diagnosed after 20 weeks gestation in the presence of new hypertension plus proteinuria or evidence of maternal end-organ dysfunction.
- First-line medical therapy for severe hypertension in pregnancy is oral labetalol, provided there is no severe asthma or heart block.
- Intravenous magnesium sulphate is given to prevent seizures in severe pre-eclampsia and to treat eclamptic seizures.
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