Severe pre-eclampsia at 33 weeks in a hospital without neonatal intensive care

This is severe pre-eclampsia with severe features, and the platelet count of 88 × 10^9/L plus AST elevation means it also meets criteria for HELLP syndrome until proven otherwise. She is at high risk of eclampsia and abruption; delivery is the definitive treatment.

First 60 minutes.

• Admit to a single room with a dim light, minimal stimulation, and assign one nurse to monitor.
• Magnesium sulphate as a loading dose of 4 g intravenous over 15–20 minutes (20% solution, 20 mL diluted), followed by 1 g/hour by infusion pump, or the Pritchard regimen if no pump is reliable (4 g IV plus 10 g deep intramuscular, 5 g into each buttock, then 5 g IM every 4 hours alternating sides).
• Antihypertensive: nifedipine 10 mg orally, repeated after 30 minutes if diastolic pressure remains above 110 mmHg, or hydralazine 5 mg intravenous slowly with repeat at 20-minute intervals. Aim for systolic 140–150 mmHg and diastolic 90–100 mmHg; do not drop the pressure too quickly, because placental perfusion falls with it.
• Insert a urinary catheter, record output hourly (aim above 30 mL/hour), and start a fluid balance chart. Restrict maintenance fluid to about 80 mL/hour of crystalloid; free fluid causes pulmonary oedema in pre-eclampsia.
• Bloods: full blood count, AST/ALT, creatinine, urate, coagulation profile, group and crossmatch, and repeat platelets every 6–12 hours.
• Dexamethasone 12 mg intramuscularly, two doses 12 hours apart, or 6 mg four times daily, for fetal lung maturity if expectant management is planned for 24–48 hours.
• Document reflexes, respiratory rate and urine output before every magnesium dose, and keep calcium gluconate at the bedside.

Three options, each with a distinct risk profile:

Deliver now by caesarean section. Removes the maternal risk within hours, but a 33-week baby born in a hospital without a NICU may die of respiratory distress or sepsis, and there is no blood bank for a possible haemorrhage or HELLP-related bleeding.

Expectant management to 34 weeks with steroids. Gains 48 hours of lung maturation, and 33–34 weeks is a period when neonatal outcomes improve measurably with antenatal steroids. But expectant management is only defensible with stable maternal parameters and a reassuring fetal trace; she has a falling platelet count, symptoms of severe disease, and no ability to monitor closely. The risk of abruptio placentae, eclampsia or progressive HELLP within those 48 hours is real, and there is no intensive care or blood bank if it happens.

Transfer to the tertiary unit. Best neonatal outcome and access to blood products, but a 6-hour road journey with a woman who could convulse en route, and air transfer depends on approval and money the family may not have.

Recommendation.

• Give the first dose of dexamethasone and magnesium now, stabilise her, and attempt transfer to the tertiary unit if the baby is alive and the family can fund or obtain approval for it - the neonatal benefit is worth the journey if she is stable.
• If transfer is not possible within about 6 hours, deliver by caesarean section after steroids and magnesium, at a time when the theatre team, anaesthetist and a cross-matched (even if not transfusable) blood supply are prepared.
• If she deteriorates at any point - uncontrolled BP, worsening platelets, non-reassuring fetal heart, abruption - deliver immediately regardless of steroid timing. Maternal safety takes priority.

Magnesium is renally excreted, so monitoring is clinical and tied to renal function.

Every hour, by the nurse: respiratory rate, deep tendon reflexes (patellar), level of consciousness, and urine output via catheter. Before each maintenance dose or each hour of infusion, confirm: respiratory rate at least 16/min, reflexes present, urine output at least 30 mL/hour (some protocols use 100 mL per 4 hours), and no drowsiness or slurred speech.

Signs of toxicity, in order of appearance: loss of patellar reflex (roughly 3.5–5 mmol/L), respiratory depression (around 5–6.5 mmol/L), then cardiac arrest. Oliguria and rising creatinine accelerate toxicity.

If oliguria develops (under 30 mL/hour for 2 consecutive hours):

• Reduce the magnesium infusion to 0.5 g/hour, or hold it, rather than stopping entirely if she is still at risk of eclampsia.
• Reassess volume status; pre-eclampsia causes intravascular depletion, so a cautious 250 mL crystalloid challenge may be appropriate, but do not overload her.
• Check creatinine and repeat at least daily; a rising creatinine with falling output means the drug will accumulate.
• If reflexes are absent or respiratory rate falls below 12/min, stop magnesium immediately, give oxygen, and administer calcium gluconate 1 g (10 mL of 10%) intravenously over 10 minutes as antidote; call for senior help.
• Continue monitoring for at least 24 hours after delivery, because eclampsia can occur postpartum, and continue magnesium for 24 hours after delivery or after the last seizure.