BACKGROUND: Preeclampsia is a multisystem hypertensive disorder of pregnancy associated with significant maternal and fetal morbidity. Although third spacing and fluid accumulation may occur in severe disease, maternal ascites is an uncommon manifestation. Recognition of this atypical presentation is important to facilitate timely diagnosis and appropriate management.

CASE REPORT: We present the case of a 23-year-old woman at 30 weeks and 2 days of gestation who developed severe preeclampsia superimposed on chronic hypertension, complicated by marked maternal third spacing and large-volume ascites while admitted for fetal growth restriction with intermittent absent end-diastolic flow on umbilical artery Doppler. Her clinical course was notable for profound capillary leak syndrome with significant fluid accumulation, including ascites (1.8 L) and pleural effusions. The extent of third spacing represented an unusual manifestation of severe hypertensive disease and created additional diagnostic and management considerations. Careful clinical assessment and recognition of the relationship between her fluid accumulation and severe preeclampsia were essential to guiding management and determining the need for delivery in the setting of maternal and fetal risk.

CONCLUSIONS: Severe preeclampsia may present with atypical manifestations beyond the classic features of hypertension and proteinuria. Profound capillary leak with marked third spacing, large-volume ascites, and pleural effusions can occur and may complicate the clinical evaluation of affected patients. Awareness of the uncommon presentation may facilitate earlier recognition of disease severity and prevent delays in management. In patients with severe hypertensive disease and unexplained fluid accumulation, preeclampsia should remain an important consideration. Prompt recognition of maternal or fetal deterioration and timely escalation of care are critical to optimizing outcomes and expediting delivery when clinically indicated.

Keywords: Ascites, Delivery, Obstetric, Fetal Monitoring, Obstetrics, Pre-Eclampsia