Pre-eclampsia at a Remote Sub-Centre
A 19-year-old primigravida at 34 weeks attends the sub-centre where you are posted. Her blood pressure is 148/96 mmHg on two readings four hours apart and a urine dipstick shows 1+ protein. She has had a frontal headache since morning that did not ease with paracetamol, and her feet are swollen; she has gained 4 kg in the last two weeks. She has no blurred vision and no epigastric pain. She lives 40 km from the district hospital and there is no vehicle available after 7 pm. Her ASHA worker is with her. The sub-centre has no blood bank, no paediatrician and no magnesium sulphate on the shelf; the district hospital is a 90-minute drive in daylight and the nearest ambulance takes 50 minutes to reach her.
1. Classify her condition and decide whether she should be referred. Justify your answer using the findings that drive the decision.
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Classification: pre-eclampsia with severe features. The blood pressure of 148/96 is in the pre-eclampsia range (≥140/90) rather than the severe range of ≥160/110. However, a persistent new headache that does not respond to paracetamol is itself a severe feature, signalling cerebral involvement and a real risk of eclampsia. Supporting findings are proteinuria, rapid weight gain of 4 kg in two weeks and oedema.
Decision: refer now, in daylight, to the district hospital - not keep her at the sub-centre. The reasons are concrete: she needs magnesium sulphate and monitoring of reflexes, respiratory rate and urine output, which this facility cannot provide; she may need antihypertensives, a blood bank, an anaesthetist and a special-care nursery for a 34-week baby; and the 7 pm transport cutoff means waiting converts a manageable referral into an emergency at night on a 40 km road.
While waiting: left lateral rest, quiet environment, BP every 15–30 minutes, reflexes and urine output recorded, fetal heart checked, nothing by mouth if surgery may be needed, ASHA to escort with the referral slip and case record. Sedatives and diuretics are not given.
2. She goes into labour at 8 pm and delivers before transport arrives. The liquor was meconium-stained and the baby is not crying. Describe your first five actions.
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- Call for help, note the time of birth, and dry the baby immediately with a pre-warmed cloth under a radiant warmer or overhead lamp, discard the wet cloth, cover the head with a cap. Drying is also stimulation, and heat loss is the fastest way to kill a small baby.
- Assess breathing and heart rate - is the baby breathing or gasping, and what is the heart rate (count for 6 seconds and multiply by 10). Do not hold the baby upside down, slap it, or put water in its mouth.
- Position the head neutral and clear the airway - suction the mouth first, then the nose, with a bulb syringe, only if secretions obstruct breathing. In meconium-stained liquor with a non-vigorous baby, routine deep tracheal suction is not done at this level; keep suctioning gentle and brief.
- If apnoeic, gasping or heart rate under 100, start positive-pressure ventilation with a self-inflating bag and mask at 40–60 breaths per minute, room air initially, watching for chest rise; reassess the heart rate after 30 seconds of effective ventilation.
- If the heart rate is under 60 after effective ventilation, begin chest compressions at 3 compressions to 1 breath (90 compressions and 30 breaths per minute) with oxygen if available, and arrange immediate transfer of mother and baby together, keeping the baby warm against the mother's skin once breathing is established.
The cord is clamped and cut after 1–3 minutes if the baby is breathing; the baby is not bathed or fed.
3. What should you NOT do for the mother in the next 24 hours, and what danger signs must the family be told to report immediately?
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Do NOT:
- Give diazepam or other sedatives - they mask the warning signs of impending eclampsia and depress the newborn.
- Give diuretics or severely restrict salt; the problem is vasospasm and volume depletion is harmful.
- Start magnesium sulphate if respiratory rate, deep tendon reflexes and urine output cannot be monitored hourly - respiratory depression is the risk.
- Leave her unsupervised, or wait until morning for review, or discharge her before 24 hours of stable blood pressure.
- Give ergometrine for the third stage if her blood pressure is high; use oxytocin instead.
Danger signs to teach the family, in plain words: severe headache, blurred vision or spots before the eyes, pain in the upper abdomen, vomiting, passing very little urine, fits or twitching, breathlessness, heavy vaginal bleeding, fever, and the baby feeding poorly or feeling cold.
Also explain that blood pressure can rise again between days 3 and 7 after delivery, so she must return for a check in the first week regardless of how well she feels, and discuss breastfeeding and postpartum family planning before she leaves.