Severe pre-eclampsia at 33+4 weeks in a peripheral health centre

Working diagnosis: severe pre-eclampsia at 33+4 weeks with features of impending eclampsia. The reasoning is that the blood pressure is in the severe range on two readings, proteinuria is present, and she has cerebral (headache, visual disturbance) and hepatic (right upper quadrant pain) symptoms plus clonus and brisk reflexes. There is no seizure, so it is not yet eclampsia, but the threshold for magnesium prophylaxis is met.

First 30 minutes:

1. Call for help, move her to a quiet room, left lateral position, and start 15-minute observations: blood pressure, pulse, respirations, SpO2, reflexes, fluid balance and a baseline CTG.
2. Two large-bore IV cannulae. Blood for full blood count, platelets, urea, creatinine, electrolytes, liver enzymes, uric acid, and group and save. Catheterise if she cannot void, because urine output is both a monitoring and a magnesium safety parameter.
3. Lower the blood pressure: labetalol 20 mg IV slowly, then 40 mg and 80 mg at 10-minute intervals to a maximum of 300 mg, or hydralazine 5 mg IV repeated at 5-10 mg every 20-30 minutes. Aim for 140-150/90-100. Do not drop the pressure abruptly below 130/80: placental perfusion is pressure-dependent and a fast fall can cause fetal compromise.
4. Magnesium sulfate 4 g IV over 15-20 minutes, then 1 g/hour by infusion pump. Before each increment check that respirations are at least 16/min, the patellar reflex is present and urine output is at least 30 mL/hour.
5. Betamethasone 12 mg IM now and the second dose in 24 hours.
6. Telephone the referral hospital, give an SBAR report and start arranging transfer as soon as the loading dose is complete and the blood pressure is controlled.

Do not delay transfer for the 24-hour steroid interval. The evidence-based benefit is greatest when delivery occurs between 24 hours and 7 days after the first dose, but a first dose given before departure still confers benefit even if delivery happens sooner. The risks to the mother of staying at a centre without intensive care, blood bank or neonatal ventilation outweigh completing the second dose on site; the second dose can be given at the referral hospital at the correct time.

Before leaving: loading dose of magnesium completed and the maintenance infusion running; blood pressure below 160/110 with a written repeat-dose plan; no seizure; airway and IV access secured; the receiving unit has accepted the referral and knows the estimated arrival time.

Travel with her: a midwife escort and a driver who can assist; magnesium infusion on a charged pump with spare battery; calcium gluconate 1 g (10 mL of 10%) drawn up and labelled as the antidote; the next dose of labetalol or hydralazine; oxygen; suction; blood pressure cuff and Doppler; her antenatal card, partograph, observation chart, blood results and a written referral letter.

During transfer: observations every 15 minutes (blood pressure, pulse, respirations, SpO2, consciousness, reflexes, urine output), left lateral tilt, continuous fetal monitoring only if it does not compromise the mother's care - otherwise auscultate hourly. Watch for the classic magnesium toxicity sequence: loss of reflexes, respiratory depression, then cardiac arrest. If a seizure occurs en route, stop the vehicle, protect the airway, give magnesium 4 g IV over 5-10 minutes (or 2 g if a full loading dose has just been given, with senior advice) and pre-alert the hospital.

This is eclampsia on a background of severe pre-eclampsia. The first priority is maternal resuscitation, not delivery: call for help, note the time, protect her from injury, place her in the left lateral position, do not force anything into the mouth, give oxygen, suction secretions when the seizure stops, and monitor SpO2 and consciousness.

Drug: magnesium sulfate is the anticonvulsant of choice. Give a further 4 g IV over 5-10 minutes in addition to the maintenance infusion. If she has already received a full loading dose very recently, many protocols use 2 g with senior obstetric review, because the risk of toxicity rises with cumulative dose, particularly if renal function is impaired. If seizures recur despite magnesium, the next step is usually a specialist decision about intubation, ventilation and an alternative agent such as a benzodiazepine - not simply more magnesium.

Before giving magnesium, and before each subsequent hour, check:

• Respiratory rate at least 16/min.
• Patellar reflex present (its loss is the earliest clinical sign of toxicity).
• Urine output at least 30 mL/hour or 100 mL per 4 hours.
• Level of consciousness and SpO2.
• Renal function, because magnesium is cleared by the kidney and the maintenance dose must be reduced in renal impairment.

If toxicity occurs, stop the infusion and give calcium gluconate 1 g IV over 10 minutes as the antidote, with oxygen and ventilatory support if needed. After the seizure is controlled, the definitive treatment is delivery, so the team must plan the mode and timing; ergometrine must be avoided in the third stage because it raises blood pressure.