Pregnant woman at 33 weeks with headache, visual blurring and thrombocytopenia
A 31-year-old woman, G2P1, at 33 weeks and 4 days by dating ultrasound, is admitted to a district hospital with a severe frontal headache and blurred vision for six hours. Her blood pressure is 168/114 mmHg on two readings 15 minutes apart. She has brisk tendon reflexes and right upper quadrant tenderness. Urine dipstick shows protein 3+. Platelets 88,000/µL, AST 96 U/L, creatinine 1.1 mg/dL. Fetal heart rate tracing shows a baseline of 150 beats/min with minimal variability and no decelerations. The hospital has magnesium sulfate and antihypertensives but no neonatal intensive care unit; the nearest NICU is four hours away by road. She has received no corticosteroids. The anaesthetist is 45 minutes away.
1. How would you classify her hypertensive disorder and what immediate maternal management would you start?
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This is severe preeclampsia with severe features, likely with partial HELLP syndrome: BP at least 160/110 mmHg, headache, visual symptoms, right upper quadrant pain, proteinuria, thrombocytopenia (88,000/µL), and elevated AST. Immediate priorities are maternal stabilisation: admit to a monitored bed, secure IV access, commence continuous maternal and fetal monitoring, and control blood pressure. Give intravenous labetalol 20 mg, escalating to 40–80 mg every 10–15 minutes if needed, or oral nifedipine 10 mg if IV access is delayed; target systolic 140–150 mmHg and diastolic 90–100 mmHg, avoiding abrupt hypotension. Start magnesium sulfate for seizure prophylaxis. Insert a urinary catheter for strict output, check reflexes, and repeat platelets, liver enzymes, and renal function. Do not give diuretics or fluid overload; restrict maintenance fluids to about 80 mL/hour. Give betamethasone 12 mg intramuscularly, two doses 24 hours apart, if delivery can be delayed 24–48 hours for fetal lung maturity, but maternal stabilisation and delivery planning take priority.
2. Write the magnesium sulfate regimen and the monitoring required to prevent toxicity.
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Give a loading dose of magnesium sulfate 4–6 g IV over 20 minutes (for example, 4 g of 20% solution diluted), followed by 1–2 g/hour by infusion pump. If there is no pump, alternate intramuscular regimens may be used, but infusion is preferred. Monitor respiratory rate (keep at least 12–16/min), deep tendon reflexes (loss is an early sign of toxicity), urine output (at least 30 mL/hour), and oxygen saturation. Reduce or stop the infusion if reflexes are absent, respiration is depressed, or urine output falls. Keep 10% calcium gluconate 10 mL at the bedside as the antidote and give it IV slowly for toxicity. Magnesium does not treat hypertension; continue antihypertensives. Do not give magnesium for more than 24 hours after delivery unless there is ongoing eclampsia risk. Document the regimen and monitoring clearly because magnesium toxicity is a preventable cause of maternal death.
3. How would you decide on timing and mode of delivery given that there is no NICU in the hospital?
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Delivery is the definitive treatment. At 33+4 weeks with severe features, delivery is indicated after maternal stabilisation; do not expect conservative management to be safe. The absence of a NICU changes logistics, not the indication. Give corticosteroids and, if the mother is stable and there is no fetal compromise, arrange urgent transfer to a centre with a NICU within the corticosteroid window. If transfer is unsafe or the mother deteriorates - uncontrolled BP, worsening platelets or liver enzymes, abruption, or a non-reassuring fetal tracing - deliver locally and arrange neonatal resuscitation and referral. Mode of delivery depends on cervical favourability and fetal status: caesarean for an unfavourable cervix, fetal compromise, or maternal deterioration; vaginal delivery with monitoring is reasonable if the cervix is favourable. Anticipate neonatal prematurity and plan for warmth, feeding support, and referral.