Severe pre-eclampsia at 33 weeks in a hospital without neonatal ventilation
A 29-year-old primigravida at 33+2 weeks by sure dating attends a rural hospital with headache and blurred vision. Blood pressure is 168/112 mmHg on two readings 15 minutes apart, urine dipstick is 3+ protein, reflexes are brisk with three beats of clonus, platelets are 96 × 10⁹/L, ALT 118 U/L, creatinine 88 µmol/L and haemoglobin 11 g/L. The fetal heart is 148 bpm and the CTG is reactive without decelerations; estimated fetal weight is 1.9 kg on bedside ultrasound. The hospital stocks magnesium sulfate, nifedipine, hydralazine, betamethasone, and has a functioning theatre, but the paediatric unit has no neonatal ventilator and there is no blood bank, only two units of O-negative blood. The consultant obstetrician is 2 hours away and a trained anaesthetist is on site. The nearest tertiary unit with level 3 neonatal care is 4 hours away by road, and the ambulance is currently out on another call.
1. Set out your management for the first 6 hours, in priority order, with the monitoring that makes each step safe.
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Mother first, because her deterioration is what kills.
- Seizure prevention. Magnesium sulfate 4 g IV over 15–20 minutes, then 1 g/hour for 24 hours. If she convulses, 4 g over 5 minutes plus a further 2 g. Monitoring is not optional: respiratory rate (stop if <12/min), patellar reflex (loss is an early sign of toxicity), hourly urine output (oliguria causes accumulation; aim ≥30 mL/h), SpO₂, and serum magnesium if available (target roughly 2–3.5 mmol/L). Have calcium gluconate 10% 10 mL at the bedside as the antidote.
- Blood pressure control. Nifedipine 10 mg orally or hydralazine 5 mg IV, repeated as needed. Target 130–150/80–100, not a normal blood pressure: dropping the mean arterial pressure by more than about 25% acutely reduces uteroplacental perfusion and can cause fetal distress.
- Baseline investigations and cross-match: full blood count, film, LFTs, renal function, coagulation, group and hold; repeat platelets 6-hourly given the count of 96.
- Steroids - betamethasone 12 mg IM, second dose in 24 hours, if delivery is expected within 7 days.
- Fluid restriction to about 80 mL/hour with strict input–output charting, because pulmonary oedema is a common iatrogenic complication.
- Continuous CTG, left lateral tilt, and telephone the consultant and the tertiary unit now, not later.
2. When and how should this pregnancy be delivered, given that there is no neonatal ventilator on site?
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Delivery is the only definitive treatment, and she has severe features by both blood pressure and biochemistry (platelets <100, transaminases raised). Expectant management beyond the steroid window is not justified here.
The realistic options:
- Stabilise, give steroids, and transfer in utero to the level 3 unit - best for a 1.9 kg fetus likely to need respiratory support. This is only defensible if the mother is stable enough for a 4-hour journey; with platelets of 96 and rising transaminases, she can deteriorate en route, and the only ambulance is currently unavailable, so this must be arranged, not assumed.
- Deliver locally after the 48-hour steroid window if transfer cannot be secured or if she deteriorates first. The paediatric team must be present and the limitation of no ventilation stated openly to the family.
Do not wait beyond 48 hours if any of these appear: uncontrollable hypertension, platelets falling further or HELLP developing, non-reassuring CTG, pulmonary oedema, renal impairment, abruption, or eclampsia.
Mode of birth: vaginal delivery is reasonable if the presentation is cephalic, the CTG is normal and the cervix is favourable - induction with a balloon catheter or vaginal prostaglandin, with continuous monitoring and theatre ready. Caesarean section for fetal compromise, malpresentation, failed induction, or maternal deterioration. For the third stage use oxytocin, not ergometrine, which raises blood pressure.
3. She delivers by caesarean section and remains hypertensive on day 1. What do you do in the next 24 hours and at discharge, and which drugs must be avoided?
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The risk does not end with delivery; most eclampsia and much maternal morbidity occurs postpartum.
First 24 hours:
- Continue magnesium sulfate for 24 hours after delivery, with the same respiratory, reflex and urine-output monitoring.
- Control blood pressure with labetalol, nifedipine or hydralazine, aiming below 150/100; escalate if ≥160/110 persists.
- Recheck platelets, LFTs and renal function, and watch for delayed postpartum pre-eclampsia presenting with headache, visual symptoms, epigastric pain or breathlessness.
- Thromboprophylaxis with low-molecular-weight heparin: preterm delivery, caesarean section and pre-eclampsia all stack up risk.
- Analgesia: paracetamol; use NSAIDs cautiously or avoid given hypertension, low platelets and renal involvement.
At discharge:
- Home blood pressure monitoring and review within a week, since hypertension can worsen at day 3–6 and persist for weeks.
- Continue an antihypertensive; enalapril and nifedipine are acceptable while breastfeeding. A postpartum ACE inhibitor is fine, but an antenatal one would have been contraindicated.
Drugs to avoid antenatally: ACE inhibitors and angiotensin receptor blockers (fetal renal damage), atenolol (growth restriction), and ergometrine (further hypertension).
Counsel her that recurrence is likely, that aspirin from 12 weeks and early booking are indicated next time, and that pre-eclampsia raises her long-term cardiovascular risk.