# Situation: The nurse works in the high-risk pregnancy unit of a provincial hospital that receives referred pregnant clients from rural health units (RHUs). A 26-year-old primigravida at 35 weeks' gestation, who was normotensive before pregnancy, has blood pressure readings of 150/96 mmHg and 152/98 mmHg taken 4 hours apart. Her urine protein/creatinine ratio is 0.2, platelet count is 92,000/µL (92 × 10⁹/L), aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are normal, and lactate dehydrogenase (LDH) is 380 IU/L. She denies headache, visual changes, and epigastric pain. How should the nurse classify her condition?

> source: MyMerci (mymerci.kr)  
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> language: ko  
> subject: Nursing Practice II — Maternal and Child Health Nursing

## 문제

Situation: The nurse works in the high-risk pregnancy unit of a provincial hospital that receives referred pregnant clients from rural health units (RHUs).

A 26-year-old primigravida at 35 weeks' gestation, who was normotensive before pregnancy, has blood pressure readings of 150/96 mmHg and 152/98 mmHg taken 4 hours apart. Her urine protein/creatinine ratio is 0.2, platelet count is 92,000/µL (92 × 10⁹/L), aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are normal, and lactate dehydrogenase (LDH) is 380 IU/L. She denies headache, visual changes, and epigastric pain. How should the nurse classify her condition?

## 보기

1. Gestational hypertension, because her proteinuria is below the diagnostic level
2. Preeclampsia without severe features, because her pressure is below 160/110 mmHg
3. Preeclampsia with severe features, because of her thrombocytopenia **✔ 정답**
4. HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome, because of her low platelets

**정답: 3**

## 해설

New hypertension after 20 weeks plus new thrombocytopenia meets the definition of preeclampsia even without proteinuria. A platelet count below 100,000/µL (100 × 10⁹/L) is a severe feature on its own, so the blood pressure does not need to reach 160/110 mmHg. HELLP syndrome also requires hemolysis (LDH of 600 IU/L or more) and liver enzymes more than twice normal, which she does not have.

## 심화 해설

Clinical Classification

The client’s presentation is best classified as preeclampsia with severe features. The decisive finding is the platelet count of 92,000/µL (92 × 10⁹/L), which falls below the 100,000/µL (100 × 10⁹/L) threshold that defines severe thrombocytopenia in pregnancy.

New-onset hypertension after 20 weeks of gestation, combined with any single severe feature, establishes preeclampsia with severe features—even when proteinuria is absent or below the diagnostic cutoff. The client’s urine protein/creatinine ratio of 0.2 is below the 0.3 threshold for significant proteinuria, but this does not exclude the diagnosis. The diagnostic criteria for preeclampsia have evolved to recognize that end-organ dysfunction, including thrombocytopenia, can occur without overt proteinuria.

Key point! A platelet count below 100,000/µL is independently sufficient to designate preeclampsia as severe. The blood pressure does not need to reach 160/110 mmHg when another severe feature is already present.

| Diagnostic Consideration | Why It Does Not Fit |
| --- | --- |
| Gestational hypertension | Gestational hypertension requires blood pressure ≥140/90 mmHg after 20 weeks without proteinuria or other severe features. The client’s thrombocytopenia is a severe feature, which moves her out of this category. |
| Preeclampsia without severe features | This requires hypertension plus proteinuria or another mild feature, but no severe features. A platelet count below 100,000/µL is a severe feature, so this classification is excluded. |
| HELLP syndrome | HELLP requires hemolysis, elevated liver enzymes, and low platelets. The client’s LDH of 380 IU/L is below the 600 IU/L threshold for hemolysis, and her AST and ALT are normal. Only the low platelet criterion is met. |

Why Thrombocytopenia Matters

Thrombocytopenia in preeclampsia reflects underlying endothelial dysfunction and platelet activation. As the disease progresses, platelets adhere to damaged vascular endothelium and aggregate in the microcirculation, leading to peripheral consumption and a falling platelet count. This process parallels the systemic vasospasm and microangiopathy that characterize the hypertensive disorders of pregnancy.

Platelet count serves as a simple, accessible marker of disease severity in pregnancy-induced hypertension. A meta-analysis of observational studies found that women with preeclampsia have significantly lower platelet counts than normotensive pregnant women, supporting the use of platelet count in risk stratification. The platelet count is not merely a laboratory curiosity—it reflects the degree of systemic involvement and helps identify patients at higher risk for adverse maternal and perinatal outcomes.

Watch out! The absence of headache, visual changes, and epigastric pain does not rule out severe disease. Severe features may be laboratory-based (thrombocytopenia, elevated creatinine, elevated liver enzymes) or symptom-based (cerebral or visual disturbances, epigastric pain). The client’s denial of symptoms only means she lacks symptomatic severe features; her laboratory values still meet criteria for severe preeclampsia.

Distinguishing Preeclampsia with Severe Features from HELLP

HELLP syndrome is considered a severe variant or complication of preeclampsia, occurring in approximately 10–20% of cases with severe preeclampsia. However, the diagnostic criteria are distinct. HELLP requires evidence of hemolysis (elevated LDH, decreased haptoglobin, or schistocytes on peripheral smear), elevated liver enzymes (AST or ALT more than twice the upper limit of normal), and low platelets (below 100,000/µL). The client meets only the platelet criterion.

| Feature | Client’s Value | HELLP Threshold | Preeclampsia Severe Feature Threshold |
| --- | --- | --- | --- |
| Platelet count | 92,000/µL | Below 100,000/µL | Below 100,000/µL |
| LDH | 380 IU/L | 600 IU/L or higher | Not a standalone criterion |
| AST/ALT | Normal | More than twice normal | More than twice normal |

A single severe feature is enough to classify preeclampsia as severe, but HELLP requires all three components—hemolysis, elevated liver enzymes, and low platelets—to be present simultaneously. The client’s normal liver enzymes and LDH below the hemolysis threshold exclude HELLP, while her thrombocytopenia alone confirms severe preeclampsia.

Clinical Implications for Nursing Care

Classification drives management. Preeclampsia with severe features typically warrants hospitalization, close maternal and fetal surveillance, antihypertensive therapy, magnesium sulfate for seizure prophylaxis, and planning for delivery—often before 37 weeks if maternal or fetal status deteriorates. The nurse should monitor platelet trends, blood pressure, urine output, and neurologic status, and report any new symptoms such as headache, visual changes, or right upper quadrant pain, which may signal progression toward eclampsia or HELLP.

The platelet count is particularly valuable in settings where referral from rural health units is common. It is inexpensive, widely available, and provides objective evidence of disease severity that can guide timely transfer to a higher level of care.

## 임상 시나리오

Preeclampsia with Severe Features: Platelet ThresholdRecognizing thrombocytopenia as an independent severe criterion
New-onset hypertension after 20 weeks plus any single severe feature establishes preeclampsia with severe features, even when proteinuria is absent or below the 0.3 urine protein/creatinine ratio cutoff.

A platelet count below 100,000/µL (100 × 10⁹/L) is independently sufficient to classify preeclampsia as severe. Blood pressure does not need to reach 160/110 mmHg when another severe feature is already present.

CautionDo not label as HELLP syndrome unless hemolysis is present with LDH ≥600 IU/L and liver enzymes are more than twice normal. Isolated low platelets with normal AST/ALT and LDH 380 IU/L does not meet HELLP criteria.

## 핵심 개념

- **preeclampsia with severe features** — new-onset hypertension after 20 weeks plus any severe feature such as thrombocytopenia below 100,000/µL, even without proteinuria
- **thrombocytopenia in pregnancy** — platelet count below 100,000/µL (100 × 10⁹/L) is a severe feature of preeclampsia
- **HELLP syndrome** — hemolysis with LDH ≥600 IU/L, elevated liver enzymes more than twice normal, and low platelets
- **urine protein/creatinine ratio** — ratio of 0.3 or higher indicates significant proteinuria; lower values do not exclude preeclampsia when other severe features are present

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