33 weeks with severe pre-eclampsia in a hospital without obstetric intensive care
Ms Lam, 34, gravida 2 para 1, is 33 weeks and 4 days pregnant and attends a district hospital with a two-day history of frontal headache and 'flashing lights'. BP is 166/112 mmHg on two readings 10 minutes apart; urinalysis shows 3+ protein; she has right upper quadrant tenderness. Bloods: platelets 96 × 10⁹/L, ALT 128 U/L, creatinine 88 µmol/L, haemoglobin 11.2 g/dL. Over the past four hours her urine output is 90 mL. The cardiotocograph shows a baseline of 150 beats/min with reduced variability and no decelerations. The hospital has a level 1 special care baby unit that cannot provide ventilation and no on-site obstetric intensive care; the tertiary centre is 45 minutes away by ambulance. The obstetric registrar is in theatre and the midwife-in-charge is asking you, the registered nurse, to 'keep her stable until the registrar comes out'.
1. Set out the nurse's priorities for the first 30 minutes, with the rationale for each.
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Recognise the severity first. Headache, visual disturbance, BP 166/112, 3+ proteinuria, RUQ pain, platelets 96 and ALT 128 with reduced urine output meet the criteria for severe pre-eclampsia with possible HELLP syndrome. Reduced CTG variability may reflect maternal disease, magnesium or fetal compromise. 'Keeping her stable' is not a plan; the plan is escalation, treatment and preparation for delivery or transfer.
First 30 minutes:
- Call the obstetric consultant and anaesthetist now, and tell the midwife-in-charge that this needs senior review out of theatre. Escalation is the first action, not the last.
- Left lateral position, quiet environment, minimal stimulation; continuous maternal and fetal monitoring.
- Two large-bore IV cannulae, blood for full blood count, film, clotting, urea and electrolytes, liver function, group and save, and cross-match as advised.
- Antihypertensive treatment as prescribed - usually labetalol or nifedipine - with BP every 10–15 minutes until controlled. Systolic above 160 or diastolic above 110 carries a stroke risk.
- Magnesium sulphate loading dose as prescribed (commonly 4 g IV over 15–20 minutes, then 1 g/hour) for seizure prophylaxis, with the monitoring described below.
- Urinary catheter and hourly urine output; strict fluid balance, because pulmonary oedema is a real risk with oliguria and IV fluids.
- Alert the neonatal unit and theatre; prepare for possible delivery.
2. The magnesium sulphate infusion is running. What must the nurse monitor, what findings would prompt stopping it, and what is the antidote and its dose?
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Why monitoring matters here: magnesium is renally excreted and her creatinine is 88 µmol/L with urine output of only 90 mL in four hours, so accumulation and toxicity are realistic, not theoretical.
Monitor at least hourly and document:
- Respiratory rate - report below 12–16/min.
- Deep tendon reflexes - loss of the patellar reflex is an early sign of toxicity.
- Urine output - report below 30 mL/hour (or roughly 0.5 mL/kg/hour).
- Level of consciousness and ability to speak; look for drowsiness, confusion, slurred speech.
- Oxygen saturation and continuous ECG where available.
- Fetal heart rate, because magnesium can reduce variability.
Stop the infusion and call the doctor immediately if: reflexes are absent, respiratory rate falls below 12/min, urine output falls below 30 mL/hour, there is confusion or drowsiness, or there are signs of pulmonary oedema (crackles, increasing breathlessness, falling saturation).
Antidote: calcium gluconate 10% 10 mL (1 g) by slow intravenous injection over about 10 minutes, prescribed and given under medical direction, with continuous cardiac and respiratory monitoring. Keep it immediately available wherever magnesium is running.
Communication: tell the patient the infusion will make her feel warm and flushed, and that she must report feeling weak, drowsy or breathless. Record each observation with a time so that a trend can be seen, and hand over the cumulative dose.
3. The consultant decides that delivery is indicated and that the baby needs a unit that can ventilate. How should the nurse contribute to the transfer and delivery decision, and what must be documented?
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Frame the clinical problem. At 33 weeks and 4 days with severe pre-eclampsia and possible HELLP, delivery is the definitive treatment; the question is where and when. A level 1 unit cannot ventilate a preterm baby, so either the mother is transferred in utero to the tertiary centre or she is delivered here with neonatal transfer arranged afterwards.
The nurse's contribution is information and risk-surfacing, not the decision:
- Report the trends - BP control, urine output, platelet and ALT trajectory, CTG, magnesium dose and toxicity checks.
- Ask explicitly: is there time for antenatal corticosteroids, and what is the risk of delivery during a 45-minute transfer? Severe hypertension, worsening platelets or fetal compromise may make transfer unsafe.
- Ask who will escort the ambulance and what equipment is needed; a woman on magnesium requires continuous monitoring and a clinician able to manage a seizure or arrest en route.
- Inform Ms Lam and her partner honestly about what is happening and why, and obtain consent for procedures.
Documentation: times of all observations and drugs, the consultant's decision and who made it, the reason for transfer or delivery, the antenatal steroid and magnesium doses, the neonatal team's involvement, the family conversation and the transfer checklist. Record what you escalated and when - if the registrar's theatre list delayed review, that should be visible in the notes.