Severe preeclampsia at 33 weeks in a hospital without a neonatal unit
A 32-year-old woman, gravida 2 para 1, at 33 weeks and 2 days by early dating scan, attends a district hospital with a two-day history of severe frontal headache and flashing lights. Blood pressure is 176/112 mmHg on repeat measurement, reflexes are brisk with three beats of clonus, and she has proteinuria of 3+ on dipstick. Platelets 96 x 10^9/L, AST 92 U/L, ALT 88 U/L, creatinine 0.9 mg/dL, no pulmonary oedema, no vaginal bleeding. The fetal heart rate is 140 with normal variability and no decelerations; she is not contracting and the cervix is closed. The hospital has no neonatal intensive care unit and no maternal-fetal medicine specialist on site; the tertiary unit is 90 minutes away by road. Magnesium sulfate, antihypertensives and corticosteroids are stocked, and the ambulance service is available.
1. Give your first-hour medication orders with doses and targets, and justify each one.
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Magnesium sulfate for seizure prophylaxis: loading dose 4-6 g intravenously over 15-20 minutes, then 1-2 g per hour. Monitor deep tendon reflexes, respiratory rate, urine output and conscious level; keep calcium gluconate at the bedside. This is the single intervention most likely to prevent eclampsia.
Blood pressure control: intravenous labetalol 10-20 mg, escalating every 10-20 minutes, or hydralazine 5-10 mg intravenously. Target roughly 140-150/90-100 mmHg; avoid abrupt profound drops, which can cause placental hypoperfusion and fetal distress. Avoid ACE inhibitors and angiotensin receptor blockers.
Fetal lung maturity: betamethasone 12 mg intramuscularly, repeated in 24 hours (or dexamethasone 6 mg every 12 hours, four doses).
Supportive measures: continuous fetal monitoring, strict fluid balance and input/output chart, avoid fluid overload, and check full blood count, liver enzymes, renal function and coagulation serially. Avoid diuretics unless there is pulmonary oedema.
2. Transfer to the tertiary unit, or deliver here? Construct the decision explicitly.
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At 33 weeks with severe features, delivery is indicated for uncontrollable blood pressure, eclampsia, pulmonary oedema, abruption, non-reassuring fetal status, or progressive HELLP. She currently has none of these, so there is a narrow window in which a short course of corticosteroids and transfer to a unit with neonatal intensive care and blood products improves neonatal outcome substantially.
Decision: stabilise, load magnesium sulfate, control blood pressure, give the first dose of corticosteroid, then arrange urgent maternal-fetal transfer, accepting that delivery may occur en route or immediately on arrival. Communicate the plan to the receiving team before departure and document it.
I would deliver locally instead if she deteriorates (refractory hypertension, neurological symptoms, falling platelets, rising transaminases, abnormal fetal tracing) or if transfer is delayed beyond a timeframe in which the risk of eclampsia or abruption outweighs the neonatal benefit. The choice must be time-stamped and revisited hourly rather than set once.
3. During transfer preparation the fetal tracing shows a prolonged deceleration to 90 beats per minute lasting three minutes. What is your differential and what do you do?
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Differential: placental insufficiency or abruption, maternal hypotension from antihypertensives, maternal seizure or hypoxia, cord compression, and uterine hyperstimulation (unlikely as she is not contracting and is on no oxytocin).
Actions, in parallel:
- Reposition to left lateral tilt, give an intravenous fluid bolus, stop any further antihypertensive if she is hypotensive, and administer oxygen while assessing.
- Examine for vaginal bleeding and check maternal pulse, blood pressure and oxygen saturation; treat suspected seizure with further magnesium sulfate.
- Escalate to the most senior clinician available and call anaesthesia, paediatrics and the operating team; prepare for immediate delivery if the deceleration does not resolve within about ten minutes.
- If delivery is required, it happens here, not en route; inform the tertiary unit.
Document times, interventions and the reasoning for the change of plan.