Claire is a 35-year-old G1 with Type 1 DM. She had an episode of pyelonephritis at 26 weeks gestation and did well following this, and was last seen at 30 weeks. At 32 weeks Claire presents in St. Catharines with a headache and RUQ pain. Her husband says that Claire’s swelling, especially in her face, has worsened over the past 2 days. BP is 160/105. FH is normal. She has 4+ urine protein. Hb 142 g/L, platelets 152, AST 67, ALT 75, INR/PTT normal, fibrinogen 5.8 g/L, glucose 6.5 mM/L, creatinine 100 uM, urea 4.2 mM. Urinary ketones are negative. She is given morphine and oral labetalol. Her symptoms settle and BP is 145/95. Ultrasound shows a cephalic fetus with normal head and femur measurements but the abdominal measurement lags by 3 weeks. There is marked oligohydramnios. Doppler studies are abnormal. MUMC is called and a decision is made to transfer Claire. On arrival, she complains of severe RUQ pain. BP is 170/110. She has made very little urine and it is dark tea coloured. Hb 137 g/L, platelets 100, AST 265, ALT 310. Her urinary protein to creatinine ratio is 500 mg/mmol. She is given a dose of nifedipine and MgSO4 is started. A decision is made to do an immediate C/S with spinal.