36 weeks, headache and visual disturbance, 40 km from a blood bank
A 19-year-old primigravida at 36 weeks' gestation is brought to the sub-centre at 7 p.m. by her mother-in-law. She has had a frontal headache since morning, has vomited twice, and says the light from the tube hurts her eyes. Blood pressure is 148/98 mmHg on two readings 15 minutes apart; urine albumin is 2+ on the dipstick; she has swelling of both feet. She lives 25 km away on a mud road; the last bus has gone, and the nearest facility with a caesarean section and a blood bank is the district hospital, 40 km away. Her husband is working in another district and the family wants to go home and 'come back tomorrow morning'. Fetal heart rate is 142/min. She has no antenatal card and no history of fits.
1. What is the most likely diagnosis, and what makes this an emergency rather than a 'come back tomorrow' problem?
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Diagnosis: pre-eclampsia with severe features at 36 weeks. The BP of 148/98 mmHg with 2+ proteinuria establishes pre-eclampsia; the headache, vomiting and photophobia are the features that make it severe.
Why it is an emergency
- Imminent eclampsia: headache and visual symptoms reflect cerebral vasospasm and oedema. A first fit can occur at any time, at home, on a mud road, or in a vehicle with no one able to manage the airway.
- Other maternal risks: abruption, HELLP syndrome, pulmonary oedema and acute kidney injury can develop within hours; the low platelet count and liver involvement that accompany severe pre-eclampsia are precisely why a blood bank is needed.
- Fetal risk: reduced placental perfusion causes growth restriction and fetal distress; at 36 weeks the baby is mature enough that delivery is the definitive treatment.
- Logistics are part of the diagnosis: 40 km, a mud road, no bus at night and no antenatal card mean that delay converts a manageable condition into a death. The family's plan of 'tomorrow morning' is a plan for an unattended fit.
Reasoning: severity in pre-eclampsia is judged by symptoms and organ involvement, not by the BP number alone. A reading of 148/98 with a headache is not the same clinical problem as 148/98 with no symptoms.
2. Outline your actions from now until she reaches the district hospital, including what you would say to the family.
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Immediate nursing care
- Place her in the left lateral position in a quiet, dimly lit room; minimal handling, no unnecessary examinations, no loud conversation.
- Do not give sedatives or any drug to lower BP unless prescribed; do not leave her alone.
- Record BP every 15 minutes, fetal heart rate, respiratory rate, deep tendon reflexes and clonus, urine output, and any epigastric pain or visual change.
- Keep her nil by mouth in case anaesthesia is needed.
- If a fit occurs: protect the airway, left lateral, suction if available, oxygen, do not force anything into the mouth, note the time and duration, and call for help.
Arrange transfer
- Call 108 or the medical officer now; send a referral slip with the BP readings, urine albumin, symptoms and their onset, gestational age, fetal heart rate and drugs given.
- Accompany her or send a trained attendant; carry the sub-centre register.
What to tell the family, in simple words "Her blood pressure is high and her headache and blurred vision are warning signs that a fit can come at any time. A fit at home can kill her or the baby. The district hospital has the team and blood needed for a safe delivery. We are going now, in the ambulance, and I will inform her husband."
Reasoning: everything before arrival is aimed at preventing a first fit and at making the handover so clear that no time is lost repeating examinations at the other end.
3. Why must the referral note record the BP readings, urine albumin, symptoms and time of onset? What would you do if the family refuses to go?
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Why the details matter
- Time of onset of headache and visual symptoms tells the receiving team how long cerebral involvement has been present and how urgent magnesium sulphate is.
- Both BP readings with times show a trend, not a single snapshot; this influences the decision to deliver rather than observe.
- Urine albumin distinguishes pre-eclampsia from gestational hypertension and supports the diagnosis in a woman with no antenatal card.
- Fetal heart rate and gestational age determine whether the baby needs a paediatric team at delivery.
- Continuity: the receiving doctor can act on arrival instead of repeating a 40 km journey's worth of assessment. The note is also the legal record of what was found and advised.
If the family refuses
- Explain the danger again in plain language, with the mother-in-law and, by telephone, the husband; state clearly that a fit can cause death or brain damage.
- Record the refusal, the advice given, the time, and the names of those present; inform the medical officer, the village health nurse and the ASHA worker.
- Arrange the earliest possible review and leave written danger signs with the family.
- Do not physically restrain her, but do not pretend the refusal did not happen.
Reasoning: the note protects the patient and is also the nurse's professional defence; the refusal record is what allows the system to follow up rather than abandon her.