Severe pre-eclampsia at 33 weeks in a district hospital without a blood bank
A 29-year-old G2P1 at 33 weeks' gestation presents to a district hospital in a rural area with a 2-day history of frontal headache and blurred vision. She has no prior hypertension. On arrival, BP is 170/114 mmHg on two readings 15 minutes apart, pulse 96/min, and urine dipstick shows 3+ protein. She is alert but has brisk reflexes and one episode of vomiting. Platelet count is 92 × 10^9/L, AST is 78 U/L, and creatinine is 88 µmol/L. The facility has magnesium sulfate, hydralazine, and a functioning ambulance, but no blood bank, no neonatal intensive care unit, and no obstetrician on site after 5 p.m.; the nearest tertiary centre is 3 hours away by road. Fetal heart rate is 140 beats/min and the CTG is category I. The patient is accompanied by her husband and has given consent for referral.
1. What is the immediate management priority in the first 60 minutes, and how do you justify each intervention?
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This is severe pre-eclampsia with severe features: BP ≥160/110, headache and visual symptoms, proteinuria, thrombocytopenia, and raised AST. The first priority is maternal stabilisation, not immediate delivery at this facility.
- Magnesium sulfate for seizure prophylaxis: load with 4 g IV over 20 minutes, then maintenance according to local protocol (for example 1 g/hour IV or 10 g IM). Monitor respiratory rate, deep tendon reflexes, and urine output; have calcium gluconate available.
- Antihypertensive treatment for sustained BP ≥160/110: give hydralazine 5 mg IV, repeat every 20 minutes as needed, aiming for 140–150/90–100 mmHg. Do not drop the BP abruptly, because cerebral and placental perfusion may fall.
- Left lateral position, oxygen if needed, and strict fluid balance: avoid fluid overload, which worsens pulmonary oedema.
- Bloods and cross-match: repeat platelets, AST, creatinine, and coagulation screen; arrange group and save even though there is no blood bank on site.
The reasoning is that magnesium prevents eclampsia, while controlled BP reduction lowers stroke risk. Delivery is definitive, but at 33 weeks it should be planned where neonatal care and blood products are available unless the mother deteriorates first.
2. Should she be delivered at the district hospital or transferred? Explain the decision with reference to maternal and fetal risks.
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She should be stabilised and transferred, not delivered electively at the district hospital, because the facility cannot provide neonatal intensive care or blood products. At 33 weeks, delivery is likely to produce a preterm infant who may need respiratory support; a 3-hour road transfer before delivery gives the baby the best chance of appropriate neonatal care. The maternal risks of transfer must be weighed against the risks of delivering in a setting without a blood bank if abruption or HELLP syndrome develops.
Transfer is appropriate only after the magnesium load is running, BP is below 160/110, and the airway and venous access are secure. The ambulance should have a midwife or nurse able to monitor BP, reflexes, and fetal heart rate. If she develops uncontrolled hypertension, eclamptic seizures, suspected abruption, or non-reassuring fetal status before departure, delivery locally becomes the safer option despite the neonatal limitations. The decision is therefore conditional: transfer after stabilisation, but deliver locally if maternal or fetal deterioration makes transfer unsafe.