A 27-year-old primigravida presented to hospital with a complaint of high blood pressure at home. She is in her 37th week of gestation but so far she could not feel any uterine contractions. Her past medical history is unremarkable. Her medical records show normal progress of pregnancy and normal vaginal delivery is anticipated. An ultrasound examination at the 12th week of gestation confirmed gestational age.
Physical examination: She is not pale, jaundiced or cyanosed, heart rate 87/min, respiratory rate 18/min, blood pressure 148/95 mmHg, and body temperature 36.9°C. Generalized edema could be detected but the rest of physical examination is normal. Fundal height is consistent with 36 weeks of gestation, fetal presentation is cephalic and fetal heart rate is reassuring. Proteinuria of 2.5 g/24 hour was demonstrated.
Which of the following management options should be done next?
Correct Answer E:
Vaginal examination and calculation of Bishop score (choice E) is the next management option for this expectant mother. This patient has mild preeclampsia as indicated by blood pressure 140/90 but < 160/110 mmHg and urinary protein > 300mg but < 5g/24 hours. She is in the 37th week of gestation and the fetus is mature. Immediate induction of labour is the best management option. However, induction of labour should not be attempted before evaluating the likelihood of success by vaginal examination and assessing cervical characteristics and calculating the Bishop score. This score is calculated based on cervical position, consistency, effacement, and dilatation and station of the fetal head. Each of these five components is graded from zero to three. A score or 9 or higher are associated with a high likelihood of successful vaginal delivery with induction of labour. If the score is < 9 cervical ripening agents can be used to augment the score before induction of labour.
→ Immediate induction of labour (choice A) is not the correct choice. Before induction of labour is attempted the Bishop score should be calculated and cervical ripening agents used with scores < 9.
→ Immediate delivery by Caesarean section (choice B) is not the correct choice. This should be considered only if there is an indication for Caesarean section like obstruction, herpes of the vulva, failure of labour to progress, placental abruption or any other indication. Mild preeclampsia is not an indication for delivery by Caesarean section.
→ Immediate start of antihypertensive treatment (choice C) is not the correct choice. Antihypertensive treatment is indicated only in severe preeclampsia (blood pressure 160/110 mmHg and proteinuria 5 g/24 hours, oliguria, pulmonary edema, right upper quadrant pain, impaired liver function, thrombocytopenia, and fetal growth retardation).
→ Amniocentesis and amniotic fluid analysis for fetal maturity (choice D) is not the correct option. This can be considered if gestational age is uncertain. In our patient gestational age was ascertained by ultrasound early in pregnancy.
Key point:
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