HELLP at 33 weeks in a hospital without a blood bank
A 30-year-old woman, G2P1 with one previous caesarean for fetal distress, attends a district hospital at 33 weeks by a first-trimester dating scan. She has had a severe frontal headache and right upper quadrant pain for eight hours and has vomited twice. Blood pressure is 168/112 mmHg and 172/110 mmHg on repeat, with 3+ proteinuria on dipstick. She is afebrile, has brisk reflexes with two beats of clonus, and her fundal height is 32 cm. Bloods: haemoglobin 10.2 g/dL, platelets 86,000/µL, AST 190 U/L, ALT 175 U/L, LDH 940 U/L, creatinine 1.1 mg/dL, uric acid 7.9 mg/dL, PT/INR normal, fibrinogen 320 mg/dL. CTG shows a baseline of 155 beats/min with reduced variability and two late decelerations in 20 minutes. The hospital has no blood bank, no NICU, no neonatologist and no adult intensive care; the nearest tertiary centre is 90 minutes away by road, and a functioning ambulance with a trained paramedic is available. She is 4 cm dilated with a closed, thick cervix and the fetal head at −2 station.
1. State the diagnosis and write the drug orders for the first 30 minutes.
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Diagnosis Severe pre-eclampsia with HELLP syndrome: haemolysis (LDH 940 with a falling haemoglobin), elevated liver enzymes (AST 190), and thrombocytopenia (86,000). The headache, clonus and right upper quadrant pain mark it as severe, and the CTG is non-reassuring. Fibrinogen and INR are still normal, which is reassuring but does not exclude impending DIC.
First 30 minutes
- Two large-bore cannulae, catheter with hourly urinalysis, continuous CTG, left lateral position, oxygen if SpO2 falls below 94%.
- Magnesium sulphate: 4 g IV over 15–20 minutes as a loading dose, then 1 g/hour infusion. If IV access is delayed, the Pritchard regimen (5 g IM into each buttock, then 5 g IM every 4 hours) is acceptable. Monitor deep tendon reflexes, respiratory rate and urine output; keep calcium gluconate 1 g IV drawn up as antidote.
- Antihypertensives: labetalol 20 mg IV, escalating to 40 mg then 80 mg at 10-minute intervals, or an infusion at 1–2 mg/min; alternatives are hydralazine 5–10 mg IV or oral nifedipine 10 mg. Target 140–150/90–100 mmHg - lowering too fast compromises uteroplacental flow.
- Strict fluid balance: about 85 mL/hour total, because pulmonary oedema is a leading cause of death in severe pre-eclampsia.
- Betamethasone 12 mg IM, repeated in 24 hours, if delivery can be deferred.
- Six-hourly platelets, LDH, liver enzymes and renal function.
2. Should she be delivered here or transferred to the tertiary centre? Justify your decision and state what would change it.
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The two propositions Delivery is definitely indicated: HELLP at 33 weeks with a non-reassuring CTG, headache and clonus means continuing the pregnancy is unsafe for mother and fetus. The real question is where.
My call: stabilise and transfer in utero, with delivery on arrival
- Platelets of 86,000 with a downward trend plus a likely caesarean mean blood products will probably be needed, and this hospital has no blood bank.
- A 33-week fetus is very likely to need CPAP or nasal prongs, and there is no NICU or neonatologist - delivering here exposes the baby to avoidable harm.
- She is not actively bleeding, the fibrinogen is normal, there is no abruption and no eclampsia, and a functioning ambulance with a paramedic is available now. This is a stabilise-then-transfer situation, not an immediate-delivery situation.
- Magnesium sulphate must run continuously during transfer, with a written antihypertensive plan, a second IV line, and a pre-briefed plan to divert to the nearest facility if she deteriorates.
What would change the decision Eclampsia, abruption, DIC, uncontrollable hypertension, non-reassuring CTG that becomes terminal, or a long ambulance delay - then deliver locally after arranging emergency blood from a nearby facility, and resuscitate the neonate with the available nursing staff. Document the reasoning and the discussion with the tertiary centre.
3. Her platelets fall to 48,000/µL over the next four hours and a caesarean is now needed. Plan the anaesthetic and haematological management, and the drugs to avoid after delivery.
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Anaesthesia
- At 48,000/µL and falling, neuraxial anaesthesia is generally avoided - spinal haematoma risk is unacceptable, particularly while platelets are still declining. Recheck the count immediately before any block; a stable count above 70,000–80,000 in pre-eclampsia is usually regarded as acceptable for spinal, but 48,000 is not.
- Plan a general anaesthetic with rapid-sequence induction: pre-eclampsia brings airway oedema, a small cricoid ring and hypertensive surges at laryngoscopy, so anticipate a difficult intubation with a smaller tube, a bougie and senior anaesthetic help. Attenuate the pressor response and keep the blood pressure controlled.
- Invasive arterial monitoring; the single anaesthetist should call in a second anaesthetist before induction.
Haematology
- Transfuse platelets before surgery to keep the count above 50,000/µL (higher if active bleeding or DIC develops), and cross-match 4 units of red cells with fresh frozen plasma and cryoprecipitate on standby.
- Recheck fibrinogen, INR and LDH; a falling fibrinogen with rising LDH signals DIC and needs cryoprecipitate.
Drugs to avoid after delivery Ergometrine and methylergometrine (hypertensive crisis), NSAIDs (platelet dysfunction and renal effects), and fluid boluses. Use an oxytocin infusion for the third stage, with active management of postpartum haemorrhage because thrombocytopenia plus a coagulopathy makes bleeding the main threat.