Severe Preeclampsia at 33 Weeks in a Municipal RHU
Maria, a 33-year-old G3P2, arrives unbooked at a municipal RHU at 33 weeks by her last menstrual period. She reports a frontal headache since yesterday and blurred spots in front of her eyes. On examination, her blood pressure is 168/112 mmHg and, after 15 minutes of rest in a quiet room, 164/110 mmHg. Urine dipstick shows 3+ protein; she has brisk patellar reflexes and right upper quadrant tenderness. Fundal height is 30 cm, fetal heart rate is 150 beats/min, and there are no contractions or vaginal bleeding. The RHU has magnesium sulfate, hydralazine, dexamethasone, and a functioning ambulance bay, but no blood bank and no obstetrician on site. The nearest CEmONC facility is 2 hours away over rough roads; the ambulance driver is off-site but can return in 45 minutes. A physician is reachable only by phone. The midwife is the only skilled provider on duty.
1. Classify her hypertensive disorder and outline, in priority order, the first 60 minutes of management. Include what you would give, what you would withhold, and the monitoring that determines whether magnesium sulfate is continued.
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Working diagnosis: severe preeclampsia with severe features at 33 weeks - headache, visual symptoms, right upper quadrant pain, BP ≥160/110, and 3+ proteinuria. She is at high risk of eclampsia, abruption, pulmonary edema, and fetal compromise.
First 60 minutes:
- Call the physician and activate referral to a CEmONC facility; stabilization begins before the ambulance arrives.
- Place her in a quiet room, left lateral tilt, oxygen if SpO2 is below 95%, and insert two large-bore IV lines with lactated Ringer's at a restrained rate (about 75–100 mL/hr) to avoid pulmonary edema.
- Under a standing order or physician order, start magnesium sulfate: 4 g IV over 20 minutes plus 10 g IM (5 g in each buttock), then 5 g IM every 4 hours alternating buttocks. Keep calcium gluconate 1 g IV at the bedside.
- Treat BP ≥160/110 with hydralazine 5 mg IV, repeated every 20 minutes up to three doses per protocol, or labetalol/nifedipine per order; aim for a gradual fall to 140–150/90–100, not a sudden drop.
- Give the first dose of dexamethasone 6 mg IM if delivery is not immediately forced, but do not delay transfer for the full course.
- Monitor BP and pulse every 15 minutes, respirations, patellar reflex, urine output (at least 30 mL/hr), fetal heart rate, and vaginal bleeding.
- Withhold diuretics, ACE inhibitors, and ergometrine; restrict oral intake.
Reasoning: magnesium prevents and treats seizures, but delivery is the definitive treatment. The monitoring parameters - respirations, reflex, and urine output - determine whether the maintenance dose can continue safely.
2. The ambulance is still 30 minutes away when she reports a severe headache and then has a generalized tonic-clonic seizure. Describe your immediate actions and how you would adjust the magnesium sulfate regimen, including the antidote.
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Immediate actions: protect her from injury, place her in the left lateral position, suction secretions, give oxygen at 10–15 L/min, pad the side rails, do not force objects into her mouth, and do not restrain her limbs. Time the seizure and call for emergency help.
Magnesium adjustment: if she has already received the loading dose, give magnesium sulfate 2 g IV over 5 minutes for the seizure; if she has not been loaded, give 4 g IV over 5 minutes plus 10 g IM, then continue 5 g IM every 4 hours. Recurrent seizures can be treated with another 2 g IV over 5 minutes.
After the seizure: check glucose, continue oxygen and fetal monitoring. Fetal bradycardia often follows a maternal seizure and may resolve; do not rush to cesarean delivery for a transient tracing unless there is abruption or persistent bradycardia. Transfer after she is stabilized.
Antidote: calcium gluconate 1 g IV slowly if respirations fall below 12–16/min, the patellar reflex disappears, or urine output falls below 30 mL/hr. The reasoning is that eclampsia is a magnesium-responsive emergency, but airway protection and avoidance of aspiration are equally urgent.
3. She refuses transfer because she says the baby will be born too early and she has no money. How do you respond, and what legal and documentation steps apply?
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Response: explore her fear and correct misinformation - at 33 weeks with severe features, continuing the pregnancy risks eclampsia, abruption, and fetal death, and the CEmONC facility offers the best chance for both. Involve her husband or chosen family member, call the physician, and ask the medical social worker or PhilHealth officer to address financial concerns.
Legal and ethical steps: a competent adult may refuse treatment, so do not forcibly transfer her. Explain the risks and alternatives in plain language, offer a second opinion by phone, and continue magnesium sulfate, antihypertensive treatment, and monitoring within the midwife's scope. Document the discussion, her exact words, the risks explained, who witnessed the refusal, and the continued care given. Use an informed-refusal form if available and notify the physician and municipal health officer.
Reasoning: the midwife must respect autonomy while avoiding abandonment. Documentation protects the patient and shows that the refusal was informed, not a failure to offer care.