A 28-year-old primigravida at 32 weeks of gestation attends an ASHA (Accredited Social Health Activist) camp in a tribal block of Jharkhand. She has attended no antenatal check-ups. On screening, her blood pressure is 160/100 mmHg, and she has 3+ proteinuria. The ASHA refers her to the sub-centre for further evaluation. The ANM at the sub-centre confirms severe preeclampsia. The sub-centre has no obstetric facilities, no magnesium sulphate, and no blood bank. What is the most appropriate next step in management?

Explanation

## Severe Preeclampsia: Referral Pathway in Primary Health Care **Key Point:** Severe preeclampsia is a medical emergency. A sub-centre (the lowest tier of the public health system) lacks the infrastructure (ICU, obstetric team, magnesium sulphate, blood transfusion, emergency delivery capability) to manage this life-threatening condition. **Immediate referral to a secondary/tertiary facility is non-negotiable.** ## Clinical Features Indicating Severity **High-Yield:** Red flags for severe preeclampsia in this case: - BP ≥160/100 mmHg (severe range) - Proteinuria 3+ (nephrotic range) - Primigravida at 32 weeks (high risk for eclampsia and complications) - No prior antenatal care (unmonitored disease progression) ## Referral Criteria and Management Algorithm ```mermaid flowchart TD A[Preeclampsia suspected]:::outcome --> B{Severe features present?}:::decision B -->|Yes: BP ≥160/100, 3+ proteinuria, symptoms| C[IMMEDIATE referral to district hospital]:::urgent B -->|No: Mild-moderate| D[Sub-centre monitoring + oral agents]:::action C --> E[Stabilization: MgSO4, antihypertensives]:::action E --> F[Delivery planning based on gestational age]:::action F --> G[Maternal and fetal outcome]:::outcome ``` ## Why Sub-Centre Management Fails | Resource Needed | Sub-Centre Capacity | Consequence of Absence | |-----------------|-------------------|------------------------| | Magnesium sulphate (seizure prophylaxis) | None | Risk of eclampsia (seizures, coma, death) | | Emergency obstetric care | None | Cannot manage complications (abruption, HELLP, acute kidney injury) | | Blood bank | None | Cannot transfuse if PPH or DIC develops | | ICU/HDU monitoring | None | Cannot detect deterioration in real-time | | Neonatal resuscitation | Limited | Preterm infant at 32 weeks needs NICU | **Clinical Pearl:** The sub-centre's role in preeclampsia is **early detection and referral**, not management. Keeping a woman with severe preeclampsia at the sub-centre is a violation of the referral protocol and exposes her to preventable maternal death. **Mnemonic: SEVERE-REFER** — **S**evere **E**clampsia **V**ascular **E**mergency **R**equires **E**mergent **R**eferral **E**very **R**ound. [cite:Park 26e Ch 9; FIGO Guidelines on Hypertension in Pregnancy]