I-36. A 33-year-old woman with diabetes mellitus, renal insufficiency, and hypertension presents to the hospital with seizures during week 38 of her pregnancy. Her blood pressure is 165/95 mmHg. She has 4+ proteinuria. Management should include all of the following EXCEPT:
A. Emergent delivery
B. Intravenous labetalol
C. Intravenous magnesium sulfate
D. Intravenous phenytoin
I-36. The answer is D. (See Harrison’s 19e Chapter 8) This patient has preeclampsia with severe features, and delivery should be performed as rapidly as possible. In mothers at <34 weeks of gestation, corticosteroids should be administered for fetal benefit and delivery delayed 24–48 hours if possible . Aggressive management of blood pressure, usually with labetalol or hydralazine intravenously, decreases maternal risk of stroke. However, like any hypertensive crisis, the decrease in blood pressure should be achieved slowly to avoid hypotension and risk of decreased blood flow to the fetus. Eclamptic seizures should be controlled with magnesium sulfate, which has been shown to be superior to phenytoin and diazepam in large randomized clinical trials. Women who have had preeclampsia appear to be at increased risk of cardiovascular and renal disease later in life.