A 28-year-old primigravida at 32 weeks of gestation attends an Auxiliary Nurse Midwife (ANM) clinic in a sub-centre in rural Uttar Pradesh for routine antenatal care. The ANM records blood pressure 140/90 mmHg (baseline 110/70 mmHg), proteinuria 1+ on dipstick, and no symptoms. The sub-centre has no laboratory facilities for 24-hour urine protein or liver function tests. According to the WHO guidelines on Primary Health Care and antenatal care, what is the most appropriate action?

Explanation

## Antenatal Hypertension and Pre-eclampsia Screening at Sub-Centre Level ### Clinical Presentation Analysis The patient has: - **New-onset hypertension** (BP 140/90 mmHg, baseline 110/70 mmHg) = ≥ 30 mmHg systolic or ≥ 15 mmHg diastolic rise - **Proteinuria 1+** on dipstick - **Gestational age 32 weeks** (high-risk period for pre-eclampsia) - **No severe symptoms** (no headache, epigastric pain, visual disturbance, or seizures) This constellation meets the definition of **pre-eclampsia** (hypertension + proteinuria after 20 weeks gestation). **Key Point:** Pre-eclampsia is a medical emergency requiring specialist evaluation. The sub-centre is not equipped to diagnose or manage it; referral is mandatory. ### PHC-Level Responsibilities When a sub-centre ANM detects signs suggestive of pre-eclampsia: | Action | Rationale | |--------|----------| | **Refer to PHC/District Hospital** | Confirm diagnosis with 24-h urine protein, LFTs, platelet count, serum creatinine | | **Initiate aspirin** (if not already given) | Low-dose aspirin (75–150 mg daily) reduces pre-eclampsia progression in high-risk pregnancies | | **Arrange transport** | Ensure safe, timely referral with a companion | | **Document findings** | Communicate clinical findings to receiving facility | | **Avoid delays** | Do not wait for private tests; refer immediately | **High-Yield:** The sub-centre is a **screening and referral point**, not a diagnostic or treatment centre. Suspected pre-eclampsia is a red-flag diagnosis requiring higher-level care. ### Why NOT Immediate Admission or Labour Induction? - The patient is **asymptomatic** (no severe features) - **Gestational age 32 weeks**: preterm delivery carries neonatal morbidity/mortality risk - Delivery is indicated only if: - Severe pre-eclampsia (severe hypertension + symptoms or lab abnormalities) - Eclampsia (seizures) - HELLP syndrome - Fetal compromise **Clinical Pearl:** The **ACOG/WHO classification** distinguishes: - **Gestational hypertension**: elevated BP, no proteinuria → monitor closely - **Pre-eclampsia**: hypertension + proteinuria → refer for specialist assessment - **Severe pre-eclampsia**: severe BP elevation (≥160/110) or end-organ dysfunction → urgent delivery This patient has pre-eclampsia (non-severe) and needs referral for confirmation and management planning, not immediate delivery. **Mnemonic: REFER-PE** — Recognize hypertension + proteinuria, Evaluate at higher level, Fetal monitoring, Early referral, Reduce delays, Pre-eclampsia protocol. [cite:Park 26e Ch 10; WHO Antenatal Care Guidelines 2016]