Severe pre-eclampsia at 36 weeks with no local neonatal intensive care
Oyuna, a 34-year-old G2P1 at 35+6 weeks, is admitted to the aimag maternity hospital with a 3-day history of frontal headache and "flashing lights". Blood pressure is 168/112 mmHg on two readings 15 minutes apart; urine protein is 3+ by dipstick; reflexes are brisk; she has not seized. Platelets are 92,000/mcL, AST 110 U/L, creatinine 1.1 mg/dL, haemoglobin 11.8 g/dL. Fetal heart rate is 150 beats/min, there are no contractions and the cervix is closed. The hospital has magnesium sulfate, nifedipine, hydralazine, oxytocin and a functioning operating theatre, but no neonatal intensive care. The nearest tertiary hospital with a neonatal unit is 6 hours away by road; the weather is clear. The family asks to wait until 37 weeks for the baby's sake.
1. Classify her hypertensive disorder and justify the diagnosis.
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This is severe pre-eclampsia with severe features. Pre-eclampsia is new hypertension after 20 weeks with proteinuria or maternal organ dysfunction. She has a blood pressure of 168/112 mmHg, which is severe-range, and 3+ proteinuria. She also has symptoms of severe disease: persistent frontal headache and visual flashes. The platelet count of 92,000/mcL is below 100,000/mcL, and AST is elevated, both indicating maternal organ involvement.
She has no history of hypertension before pregnancy, which makes chronic hypertension less likely, although that history should be confirmed. Eclampsia is excluded only because she has not seized; her brisk reflexes and symptoms mean she is at high risk of seizure. The diagnosis is not "mild" despite the gestational age: severity is defined by the blood pressure, symptoms and laboratory abnormalities, not by whether the baby is preterm.
2. Write the immediate drug and monitoring plan, including magnesium sulfate.
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Admit to a quiet, dark room with continuous maternal and fetal monitoring. Start magnesium sulfate for seizure prophylaxis: a loading dose of 4 g IV over 20 minutes plus 10 g IM (5 g into each buttock), then 5 g IM every 4 hours. If an infusion pump is available, an alternative is 4 g IV loading followed by 1 g/hour infusion. Check respirations, deep tendon reflexes and urine output before every dose; keep calcium gluconate at the bedside. Do not give further magnesium if respirations are below 12/min, reflexes are absent, or urine output is low.
Lower blood pressure with oral nifedipine 10 mg or IV hydralazine 5-10 mg, aiming for about 130-150/80-100 mmHg rather than a sudden drop. Insert a urinary catheter and record output hourly. Monitor fetal heart rate, platelet count, liver enzymes and creatinine. Give corticosteroids for fetal lung maturity if delivery can be delayed 24-48 hours without maternal deterioration, but do not delay delivery for steroids if she becomes unstable.
3. How would you counsel the family about timing and place of delivery?
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Explain that the only cure for pre-eclampsia is delivery, and that at 36 weeks the baby is mature enough that the risks of continuing outweigh the benefits. Waiting until 37 weeks risks placental abruption, eclampsia, stroke, liver rupture and fetal death. The mother's headache, visual symptoms, low platelets and high liver enzymes make this severe disease, not a variant that can be watched at home.
Because there is no neonatal intensive care here, the preferred plan is in-utero transfer to the tertiary hospital after her blood pressure is controlled and magnesium is running, with a midwife accompanying her and calcium gluconate available. If she becomes unstable, or transfer is delayed, deliver at the aimag hospital with a paediatric team present and arrange neonatal transfer after birth. Document the counselling, the family's questions and the decision. Do not agree to wait simply because the family is frightened.