Severe pre-eclampsia at 33 weeks in a district hospital without a neonatal unit
A 31-year-old woman, gravida 2 para 1, presents at 33 weeks and 4 days' gestation to a district hospital with a two-day history of frontal headache and 'flashing lights'. She had one previous uncomplicated vaginal delivery at term. Blood pressure is 172/114 mmHg on two readings 15 minutes apart; urine protein is 3+ on dipstick. She is alert but reports visual disturbance, reflexes are brisk with two beats of clonus, and there is no epigastric pain. Investigations: platelets 86 × 10⁹/L, ALT 132 U/L, creatinine 96 µmol/L, haemoglobin 112 g/L, uric acid raised. Cardiotocography shows a baseline of 150 beats/min with normal variability and no decelerations. The hospital has no neonatal intensive care unit, no on-site obstetric anaesthetist overnight, and the tertiary unit with a level 3 NICU is 90 minutes away by road. An ambulance is available.
1. What is your diagnosis and immediate drug management, with the safety monitoring that must accompany it?
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This is pre-eclampsia with severe features at 33 weeks and 4 days: blood pressure above 160/110, visual symptoms, hyperreflexia with clonus, proteinuria, thrombocytopenia and transaminitis. She is at high risk of eclampsia and needs treatment now, not after transfer.
Give magnesium sulfate for seizure prophylaxis: a 4 g intravenous loading dose over 20 minutes, then 1 g per hour by infusion, continued for 24 hours after delivery or after the last seizure. Monitor respiratory rate, deep tendon reflexes, urine output and oxygen saturation hourly; watch for pulmonary oedema (the risk is increased by fluid overload, so keep total fluids to roughly 80 mL/hour). Have calcium gluconate 10% available as the antidote. Reduce or stop the infusion if reflexes are absent, respiratory rate falls below 12, or urine output falls below 25 mL/hour.
Lower the blood pressure: labetalol 20 mg intravenously, escalating to 40–80 mg at 10-minute intervals up to 300 mg total, or hydralazine 5 mg intravenously repeated, or oral nifedipine 10 mg. Aim for 130–150 systolic and 80–100 diastolic - do not normalise the pressure abruptly, as this can reduce uteroplacental perfusion. Insert a urinary catheter for output monitoring, secure two large-bore cannulae, and take blood for full blood count, coagulation, renal and liver function. Alert the anaesthetist and the neonatal team.
2. Should she be delivered here or transferred, and how do corticosteroids and fetal status affect the decision?
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She should be stabilised and transferred in utero to the tertiary unit with a level 3 NICU, provided she can be stabilised. At 33 weeks and 4 days, the baby will almost certainly need neonatal intensive care, which this hospital cannot provide; delivering here risks a neonate who needs ventilation and a 90-minute transfer after birth.
Give antenatal corticosteroids before transfer - dexamethasone 6 mg intramuscularly every 12 hours for four doses, or betamethasone 12 mg every 24 hours for two doses. Steroids take about 24 hours to have optimal effect on respiratory distress syndrome, and in a stable mother with severe features at this gestation it is reasonable to delay delivery 24–48 hours to complete the course while monitoring closely. The CTG is currently normal, but this does not guarantee safety: continue monitoring, and treat any deterioration as an indication to deliver.
Delivery is the definitive treatment. Proceed immediately, at the nearest facility with the necessary support, if there is an eclamptic seizure, uncontrollable blood pressure despite treatment, suspected abruption, progressive HELLP with liver or renal deterioration, pulmonary oedema, or a non-reassuring fetal heart trace. Do not let the desire for steroids override maternal safety. Pre-alert the tertiary obstetric, anaesthetic and neonatal teams before departure, and ensure magnesium and antihypertensives continue in the ambulance with a midwife or doctor escort.
3. What would make you abandon transfer, and what postnatal advice and follow-up does she need?
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Abandon or abort transfer if: she seizes, develops severe breathlessness from pulmonary oedema, has a blood pressure that remains above 160/110 despite repeated doses of two agents, shows signs of abruption (pain, bleeding, abnormal CTG), or the fetal heart becomes non-reassuring - in these situations delivery at the district hospital with the available team, plus neonatal resuscitation and immediate postnatal transfer of the baby, is safer than a long road journey. Also do not transfer if the ambulance or escort cannot maintain magnesium infusion and monitoring.
Postnatally: continue magnesium for 24 hours after delivery, keep monitoring blood pressure for at least 72 hours and at a follow-up visit, since pre-eclampsia can worsen or first appear after delivery. Check platelets, liver and renal function until improving. Counsel her that she has a raised lifetime risk of cardiovascular disease, hypertension and recurrent pre-eclampsia - arrange blood pressure review, weight and lifestyle advice, and advise early booking and aspirin prophylaxis in any future pregnancy. Explain the warning symptoms to report: headache, visual change, epigastric pain, breathlessness, reduced urine output. Debrief the delivery and document the birth weight centile, placental findings and neonatal course, and ensure the baby's follow-up is arranged.