Severe Hypertension in Pregnancy
A 19-year-old primigravida at 32 weeks is referred from the antenatal clinic with a blood pressure of 164/112 mm Hg on two readings 20 minutes apart. She has no headache or visual symptoms, urine dipstick shows 2+ protein, and the fetal heart rate is 145 beats/min. Which of the following is the most appropriate immediate next step in management?
- A.Admit for observation without drug therapy
- B.Admit and begin antihypertensive therapy nowCorrect
- C.Admit for 24-hour urine protein quantification first
- D.Discharge with daily home blood pressure checks
Explanation
A blood pressure of 160/110 mm Hg or higher in pregnancy is a hypertensive emergency and requires admission with antihypertensive treatment started within 30 to 60 minutes, because the dominant maternal cause of death in pre-eclampsia is haemorrhagic stroke driven by severe systolic hypertension. First-line agents are oral or intravenous labetalol, oral immediate-release nifedipine, or intravenous hydralazine, with the target being a gradual fall to approximately 140/90 mm Hg while avoiding precipitous drops that compromise placental perfusion. Proteinuria on dipstick alongside new hypertension after 20 weeks already establishes pre-eclampsia, so waiting for a 24-hour collection before treating delays therapy without changing the immediate decision. Investigation proceeds in parallel with treatment: full blood count, liver enzymes, creatinine, protein-creatinine ratio, cardiotocography and ultrasound for growth and amniotic fluid. Magnesium sulfate is added for seizure prophylaxis in severe pre-eclampsia, and antenatal corticosteroids are given at 32 weeks for fetal lung maturity. Observation alone is inadequate at this blood pressure level, and discharge is unsafe because deterioration to eclampsia, abruption or HELLP can occur within hours. Nulliparity, extremes of maternal age and the third trimester are all recognised risk factors here. Definitive treatment remains delivery, timed by disease severity and gestational age.
Why each option
- A.
- Admission is correct but withholding antihypertensives at 164/112 mm Hg leaves the woman exposed to stroke and eclampsia. Severe-range hypertension requires urgent pharmacological control.
- B.
- Correct. Severe-range blood pressure requires admission plus prompt antihypertensive therapy with labetalol, nifedipine or hydralazine, targeting roughly 140/90 mm Hg.
- C.
- Quantifying proteinuria is part of the workup but is not the immediate priority. Dipstick proteinuria with new severe hypertension is already enough to act on.
- D.
- Discharge is unsafe at this blood pressure. Severe pre-eclampsia can progress to eclampsia, abruption or HELLP within hours and needs inpatient monitoring.
Reference: ACOG Practice Bulletin No. 222, Gestational Hypertension and Preeclampsia, reaffirmed 2023
This is one of 3,009 questions in the MedBoardSA SMLE bank, with timed test mode, tutor mode, and progress tracking by topic.
Practise the full bank