Severe pre-eclampsia at 34 weeks in a hospital without obstetric care
A 29-year-old woman, gravida 2 para 1, at 34 weeks and 2 days gestation, presents with a 6-hour history of severe frontal headache and visual flashes. Blood pressure is 178/112 mmHg on repeated measurement. Urine dipstick shows 3+ protein. Platelets are 98 × 10⁹/L, ALT 110 U/L, and creatinine 88 µmol/L. She has right upper quadrant tenderness and brisk reflexes. The fetal heart rate is 150 beats/min on Doppler. The hospital has no obstetric unit or neonatal intensive care; the nearest tertiary centre is 90 minutes away by road. Helicopter transfer is requested but delayed by low cloud. She is alert and has no seizure. There is one adult ICU bed and no on-site obstetrician.
1. Outline your first 30 minutes of management, including drug doses and monitoring. Justify each intervention in relation to maternal and fetal risk.
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The first priority is to prevent eclampsia and maternal stroke while arranging retrieval. I would give magnesium sulfate 4 g IV over 20 minutes (or 4–6 g according to local protocol), then 1 g/h, with monitoring of respiratory rate, reflexes, and urine output. For blood pressure, labetalol 20 mg IV or hydralazine 5 mg IV, repeated as needed to keep systolic below 160 and diastolic below 110 mmHg. I would place her in the left lateral position, give oxygen if saturations fall, secure two IV lines, catheterise for output, and monitor fetal heart rate continuously if possible. Bloods for full blood count, liver function, renal function, coagulation, and group and save are needed, but treatment should not wait. The reasoning is that magnesium reduces seizure risk and hypertension control reduces intracranial haemorrhage; delivery is definitive but must occur at a facility with neonatal and obstetric care.
2. The retrieval team will not arrive for 2 hours. What must be achieved before transfer, and what should not delay transfer? Explain your reasoning.
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Before transfer I want magnesium running, blood pressure controlled below 160/110, a secure airway if there is any concern about consciousness, reliable IV access, and a documented escort with resuscitation equipment. I would give antenatal corticosteroids if they can be given without delaying transfer, because they reduce neonatal respiratory distress at 34 weeks. I would not delay transfer for a full platelet count, coagulation, or a neurology review. The reasoning is that the mother is at risk of eclampsia and stroke now, and the fetus is at risk of abruption or hypoxia; the tertiary centre offers delivery and neonatal care that this hospital cannot. If transfer is delayed by weather, I would escalate to a second retrieval service and continue magnesium and antihypertensives. Delivery in the current hospital would be a last resort because there is no neonatal intensive care.
3. She has a generalised seizure while awaiting transfer. Describe your immediate management and how you would modify the transfer plan.
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A seizure in this setting is eclampsia until proven otherwise. I would call for help, protect the airway, give oxygen, place her in the left lateral position, and give magnesium sulfate 2 g IV over 5 minutes (or 4 g if not already loaded, according to protocol). I would check glucose and treat hypertension. If the seizure recurs, I would consider a further magnesium bolus or an alternative such as diazepam, but only after magnesium. I would not give phenytoin routinely. The transfer plan changes: the seizure makes transfer more urgent, so I would request the fastest available vehicle and consider intubation if she remains unconscious or has repeated seizures. The reasoning is that eclampsia is life-threatening and delivery is the definitive treatment; the receiving unit needs early warning.