Pre-eclampsia in a district hospital with no NICU
A 28-year-old woman, G2P1, at 34 weeks gestation, presents to a district hospital in Sabah with severe headache and visual blurring. Her blood pressure is 170/110 mmHg, urine protein 3+, platelets 90,000/µL, and ALT 120 U/L. The hospital has no neonatal intensive care unit and only two units of cross-matched blood. The nearest tertiary center is 3 hours by road; helicopter transfer is available only in daylight, and it is now 8 PM. She has received one dose of dexamethasone. Her husband refuses transfer, citing cost and wanting to wait for his mother’s advice. The fetal heart rate is 150 bpm. The on-call obstetrician is off-site but reachable by phone.
1. What are your immediate priorities in the first hour? Explain the reasoning behind each action.
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The first-hour priorities are maternal stabilisation and prevention of eclampsia. Start magnesium sulfate (4 g IV loading over 20 minutes, then 1 g/hour) because severe hypertension with neurological symptoms indicates severe pre-eclampsia and high seizure risk; monitor deep tendon reflexes, respiratory rate, and urine output to detect toxicity. Give antihypertensives such as labetalol 20 mg IV, repeated as needed, to keep BP below 160/110 mmHg while avoiding a precipitous drop that could reduce uteroplacental perfusion. Insert two large-bore IV cannulae, send full blood count, renal and liver function, coagulation profile, and cross-match. Platelets of 90,000/µL mean avoid intramuscular injections and prepare for possible thrombocytopenia. Continuous fetal monitoring is needed because maternal hypoxia or hypotension can cause fetal distress. Notify the consultant obstetrician, anaesthetist, and paediatric team early; their input is critical given the lack of NICU. The reasoning is to prevent maternal stroke or eclampsia while preparing for the only definitive treatment-delivery.
2. How do you approach the decision to transfer versus manage locally, considering the constraints and the husband’s refusal?
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The decision must balance maternal risk, fetal risk, and transfer hazards. Maternal severe features at 34 weeks warrant delivery in a facility with blood products and neonatal support. Local delivery is possible but dangerous: no NICU means a preterm neonate may die or suffer disability, and two units of blood are inadequate if postpartum haemorrhage occurs. Night road transfer for 3 hours is risky, but delaying until daylight may allow progression to eclampsia or abruption. The husband cannot legally override the patient if she has capacity. Speak to the patient directly, explore her understanding and preferences, and provide clear information about the risks of both options. If she agrees to transfer, arrange a trained escort and blood products. If she refuses, document a capacity assessment, involve senior clinicians, and seek legal advice. The reasoning is that autonomy governs, but beneficence requires offering the safest realistic option.
3. What documentation and communication steps are essential?
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Document the blood pressure, symptoms, platelet count, and the discussion with the patient and husband. Record the risks explained: eclampsia, placental abruption, maternal stroke, neonatal prematurity and death. Note the husband’s concerns and the patient’s decision. If transfer is arranged, record the time of referral, accepting consultant, mode of transport, and escort. If refused, document the capacity assessment and safety-net advice. Communicate with the tertiary centre and the on-call consultant. Good documentation supports continuity of care and is medico-legally essential; it also demonstrates that the patient was informed and that you acted in her best interests.