Severe pre-eclampsia at 36 weeks in a sub-centre with no vehicle
A 19-year-old primigravida at 36 weeks by her mother and child protection (MCP) card attends a sub-centre at 5 p.m. with a 3-day history of headache and blurred vision. She has no bleeding and no labour pains, and fetal movements are normal. Blood pressure is 152/104 mmHg and, 20 minutes later, 158/106 mmHg. Urine dipstick shows albumin 2+. Fetal heart rate is 144 beats per minute, fundal height is 34 cm, and there is pitting oedema of both feet. The sub-centre has no doctor on duty, no magnesium sulphate, no vehicle and no blood. The community health centre is 22 km away and the district hospital 60 km away; a jeep can be arranged in about 30 minutes, but the road is flooded at one culvert. The mother-in-law wants her to go home and take a herbal decoction, saying her own three deliveries were at home. The ASHA is present and the family trusts her.
1. What is the diagnosis, how severe is it, and where and how urgently should she be referred? Justify your answer.
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Diagnosis: pre-eclampsia with severe features at 36 weeks in a primigravida.
Why severe: blood pressure ≥140/90 with proteinuria 2+ establishes pre-eclampsia. The headache and blurred vision are cerebral and visual symptoms, which count as a severe feature in their own right, irrespective of the number. A reading of 158/106 is also close to the 160/110 threshold for severe hypertension. She is therefore at risk of eclampsia (convulsions), abruption, pulmonary oedema, HELLP syndrome, fetal growth restriction and fetal distress.
Destination: the district hospital, 60 km away, because she may need a caesarean section, magnesium sulphate, blood and newborn resuscitation - a CEmONC facility. Refer to the CHC 22 km away only if it is a functioning First Referral Unit with 24-hour anaesthesia, operative delivery, blood and a paediatrician; otherwise a nearer facility that cannot deliver her surgically only adds delay. The sub-centre cannot manage her at all.
Urgency: immediate - today, not tomorrow, and definitely not a home delivery. Justification: eclampsia can occur without warning, and the risk rises with every hour of uncontrolled blood pressure. The flooded culvert is a transport problem to solve now (alternative route, 108 ambulance, tractor to the main road), not a reason to wait. Fundal height of 34 cm at 36 weeks also raises the possibility of growth restriction, another reason for delivery in a monitored facility.
2. What will you do before and during the transfer, and what will you do if she convulses on the way?
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Before transfer:
- Do not send her alone. The ASHA or ANM travels with her, carrying the MCP card and a referral slip recording blood pressure readings and times, urine albumin, gestational age, fetal heart rate, drugs given and the time - and why she is being referred.
- Telephone the receiving hospital while the jeep is being arranged, so the team is ready.
- Magnesium sulphate loading should be given before referral only where staff are trained and the drug is stocked; this sub-centre has none, so the priority is movement to where it exists. Do not spend an hour hunting for it.
- Left lateral position, quiet, dim surroundings, minimal handling; nil by mouth.
- Record blood pressure every 15 minutes, fetal heart every 15–30 minutes, and watch for worsening headache, epigastric pain, visual change, bleeding or contractions. Antihypertensives only if prescribed by a medical officer.
If she convulses en route: protect her from falling or striking objects, do not restrain her limbs, turn her to the left side, keep the airway clear, do not force a spoon or cloth between her teeth, note the time and duration, give oxygen if available, and drive on to the hospital - eclampsia is an obstetric emergency requiring immediate delivery. On arrival, hand over the time of the fit and everything given.
3. How would you counsel the mother-in-law and the family, and what would you document?
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Counselling approach: do not argue or shame her. Her three home deliveries are real experience, and dismissing them makes her dig in. Use the ASHA as the ally she is, and explain in local terms: the headache and blurred vision mean the high blood pressure is affecting the brain; the placenta may separate or the baby may stop growing; a fit can come anywhere, including at home, where nobody can stop it. The district hospital is the only place with magnesium sulphate, blood and an operation theatre. Ask the mother-in-law to travel with her - giving her a role converts an opponent into an escort. Keep it short, check what they have understood, and let them ask questions.
Respect autonomy but be clear: this is a medical emergency and the recommendation is immediate referral. If they still refuse, do not abandon them: explain the danger signs (severe headache, blurred vision, epigastric pain, bleeding, convulsion, reduced fetal movement), give the ASHA's phone number, plan a home visit tomorrow, and inform the medical officer.
Document: both blood pressure readings with times, urine albumin, fetal heart rate, fundal height, the referral decision and time, the mode of transport and who accompanies her, the name of the receiving hospital, the counselling given, who was present, and - if it comes to it - the informed refusal in their own words and the advice given. Record it in the sub-centre register, the MCP card and the referral slip. Documentation is what protects the patient and shows that duty of care continued.