Successful management of severe pre -eclampsia complicated by massive proteinuria and fetal growth restriction in a primigravida

Yoolia*

Physician Assistant, OBG Department, Kauvery Hospital, Hosur, Tamil Nadu

*Correspondence

Abstract

Pre-Eclampsia is a multi-system hypertensive disorder unique to pregnancy and remains a major cause of maternal and perinatal morbidity and mortality worldwide. We report the case of a 27 year -aged primigravida at 33 weeks +6days of gestation who presented with severe pre-eclampsia associated with significant proteinuria and fetal growth restriction. Clinical evaluation revealed hypertension, proteinuria, and elevated serum uric acid levels. A 24-hour urinary protein estimation demonstrated nephrotic -range proteinuria (4435mg/day).Ultrasound examination revealed fetal abdominal circumference below the 10^th percentile suggestive of fetal growth restriction .Following maternal stabilization with anti-hypertensive therapy, Magnesium sulfate prophylaxis and corticosteroid administration for fetal lung maturity , a semi elective lower segment caesarian section was performed. A live preterm female neonate weight -1.6kg was delivered. Both maternal and neonatal outcomes were favorable. This case highlights the importance of early diagnosis, multidisciplinary management and timely delivery in severe pre-eclampsia complicated by significant proteinuria and fetal growth restriction.

Key words: Pre-Eclampsia; Perinatal morbidity

Introduction

Pre-eclampsia is a pregnancy hypertensive disorder characterized by the development of hypertension after 20 weeks of gestation accompanied by proteinuria and or /evidence of maternal organ dysfunction. It affects approximately 2-8% of pregnancies worldwide and remains a significant contributor to maternal and neonatal morbidity and mortality. Severe pre-eclampsia may lead to life threatening complications including eclampsia, HELLP syndrome, pulmonary edema, renal impairment, and placental insufficiency. Fetal complications include growth restriction, pre maturity, and increased perinatal mortality. This report describes a case of severe pre-eclampsia with nephrotic -range proteinuria and fetal growth restriction in a primigravida managed successfully by preterm cesarean delivery

Case presentation

The patient is a 27-year-old female pregnant for the first time (primigravida) at 33 weeks of gestation. She was admitted to the hospital on April 27, 2026, with an associated condition of gestational hypothyroidism

Chief complaints

Elevated blood pressure detected during routine antenatal visit
Increased fetal edema for 2 days
No h/o Headache /blurring of vision /bowel and bladder disturbance

Menstrual history

Regular menstrual cycles

LMP -03/09/2025

EDD -10/06/2026

Obstetric history of Primigravida, Spontaneous conception, Booked and immunized at Kauvery hospital, Hosur

Medical history

She was diagnosed have gestational hypothyroidism for 7 weeks of gestation. Started on medication (T.Thyronorm 25 mcg) doses modified at 13 weeks of gestation as (T.Thyronorm 25 mcg Monday -Friday & Thyronorm 50 mcg Saturday and Sunday). No h/o DM/BA /HTN/TB/Epilepsy

Antenatal investigation and surveillance

NT Scan -Nasal bone present, Doppler study -Bilateral uterine artery high resistance flow
Intervention -Started on T.Ecospirin 150mg OD
Double marker -Low risk screening
Anomaly scan -No congenital anomalies detected
Growth scan at 28 weeks
AFI -8 CM Started on Argipreg ( L-Arginine (3 g) and Proanthocyanidins (75 mg) per sachet
Growth scan before delivery
Single live intrauterine gestation 32-33 weeks abdominal circumference < 10^th percentile, EFW-2020+/-296 gms, liquor and doppler study -Normal

Clinical examination

General examination
Conscious and oriented
Afebrile
Mild -moderate bilateral pedal edema (+)

Her admission vitals:

BP-16/100 mmHg
PR-102 Bpm
RR -18/min
SpO2-97% in room air

Systemic cxamination

CVS -S1, S2 heard
RS – Breath sounds vesicular both lung fields
PA -Uterus corresponding to 32-33 weeks, FHR (+)

Investigations

Hb -11.2 g/dl
TWBC 11,010 cells /cumm
Platelets -1.71 lakhs /cumm
Creatinine -0.5 mg/dl
Uric acid -7.9 mg/dl
SGOT -26 U/L, SGPT -15 U/L
24 hours urine protein 4435 mg/day

Final diagnosis

Primigravida at 33 weeks +6 days of POG with severe Pre-eclampsia Significant proteinuria and Gestational hypothyroidism

Management: The patient was admitted to the intensive care unit for close monitoring

Medical management

Oral antihypertensive therapy for the management of hypertension
Labetolol 200mg -100mg-200mg -100mg-200mg
Nicardia Retard 20mg BD
Treatment Goal
Maintain BP below 140/90mmHg
Prevent maternal complications like stroke, Placental abruption, Heart failure, Renal injury

Seizure prophylaxis

Magnesium Sulphate therapy;
Loading dose administered ( 4g + 12ml NS)
Maintenance dose continued ( 5g + 40ml NS) – 5ml/hr
Monitoring magnesium toxicity
Respiratory rate, Urine output, presence of patellar reflexes.
Calcium gluconate kept available as antidote

Multidisciplinary care

Nephrology Consultation obtained due to massive proteinuria (4435mg)
Investigation advised after delivery;
ANA by immunofluorescence
Serum C3 &C4
Anti-dsDNA antibodies
Serum PLA2R antibodies

Plan

Exclude underlying renal disease
Differentiate nephrotic syndrome from isolated preeclampsia –related proteinuria
Physician opinion obtained for evaluation and management of severe hypertension associated with preeclampsia
Antihypertensive medications reviewed and optimized
No evidence of cardiac or other systemic complication requiring additional intervention

Fetal surveillance

Daily fetal movement count
Intermittent fetal heart rate monitoring
Non- Stress Test ( NST) to assess fetal well being done twice a day
Amniotic fluid index (AFI) Monitoring
Antenatal corticosteroids given for fetal lung maturity and improve neonatal survival in preterm delivery

Obstetric intervention

Considering:

Severe pre-eclampsia
Significant proteinuria
Risk of maternal complications
Gestational age nearing 34 weeks

Decision for delivery made

Risks explained

Maternal	Fetal
Eclampsia	Prematurity
HELLP Syndrome	Respiratory distress
Pulmonary edema	NICU stay

DVT

The patient underwent semi-elective LSCS under spinal anesthesia on 28/04/2026

Neonatal outcome

Live preterm male baby
Birth weight -1.6kg
Immediate cry after birth
Evaluated by pediatric team

Shifted for NICU for care and monitoring and shifted to ward on Day -2 in stable condition

Post-operative care

ICU Observation:

Uneventful postoperative recovery
Magnesium sulphate
Continued for 24 hours of postpartum, as the prophylaxis against epileptic seizure, Magnesium toxicity value, and vitals monitoring and Intake and output monitoring done, Neurological status carried out.
Regular BP monitoring and levels were managed with Inj.Labetalol infusion as advised by Physician.

POD -1: Labetalol infusion tapered down and started on oral anti-hypertensive as the BP level brought under control.

Patients were closely observed for warning signs of worsening pre-eclampsia such as severe headache, visual disturbance, epigastric pain, pulmonary edema however no such complication occurred

Laboratory parameters including CBC, LFT, RFT, Platelet counts remain stable throughout the postoperative period intravenous fluids were cautious to avoid fluid overload

POD-2: As the patient symptomatically, better vitals stable she was shifted to ward with same line management.

Additional treatment: IV antibiotics, analgesics, antiemetic’s, PPI and thromboprophylaxis given.

Progress during hospital

POD-3 Findings

Surgical wound healthy, dressing clean and dry, ambulating independently and no neurological symptoms BP levels maintained with regular oral hypertensive medication Oral feeds tolerated well, Breastfeeding techniques counselled and neonatal care guidance were provided. Hemoglobin level on POD-3 Hb – 11.7g/dl and the patient’s general condition showed progressive improvement. As the blood pressure remains controlled and the patient clinically stable, Discharged in stable condition POD-3 with anti-hypertensive medication, oral antibiotics, analgesics and PPI.

Discharge advice

Home BP monitoring.
Immediately Review if headache/blurred vision.
Continue medications as advice.
Follow-up with OBG and Nephrology OPD.
To do TSH, FT3, FT4 after 6 week
General Advice
Adequate hydration
Wound care
Continue nutritional supplements

Review and follow-up

Reviewed after 4 days. Mother and the baby remained clinically stable. Patient’s BP well -controlled .Anti-hypertensive dose adjustment done. Satisfactory wound healing no evidence of postpartum complication noted. Continued follow-up was advised.to ensure complete recovery and long term cardiovascular and renal health.

Discussion

Preeclampsia is a multi-system hypertensive disorder of pregnancy associated with significant maternal and fetal risk . This primigravida presented at 33 weeks gestation with severe hypertension and massive proteinuria. Early diagnosis, intensive monitoring, anti-hypertensive therapy, magnesium sulphate prophylaxis and antenatal corticosteroids were instituted. Timely semi-elective LSCS helps prevent maternal and fetal complication and resulted in favorable outcome.

Conclusion

This case highlights the strength and resilience of a young mother. Who faced a life-threatening pregnancy complication at a crucial stage of gestation. Despite the challenges posed by severe pre-eclampsia timely diagnosis, vigilant monitoring, multidisciplinary care and decisive intervention leads to a successful outcome for both mother and baby. Careful maternal and fetal monitoring, optimal blood pressure control, seizure prophylaxis with magnesium sulphate and planned preterm delivery helped prevent disease progression and serious complications. The safe delivery of the baby and the mother’s uneventful recovery reflect not only the effectiveness of evidence based medical management but also resilience and courage demonstrated by the patient through the treatment.

Successful management of severe pre -eclampsia complicated by massive proteinuria and fetal growth restriction in a primigravida

Successful management of severe pre -eclampsia complicated by massive proteinuria and fetal growth restriction in a primigravida

Yoolia*

Nightingale Journals