A 28-year-old primigravida at 32 weeks of gestation presents to the antenatal clinic in a rural primary health centre in Uttar Pradesh. She reports no antenatal care visits so far. On examination, her blood pressure is 160/110 mmHg, she has 3+ proteinuria on urine dipstick, and her reflexes are brisk with ankle clonus present. The health worker informs you that the nearest tertiary centre is 80 km away. According to the RCH (Reproductive and Child Health) guidelines for management of severe preeclampsia in resource-limited settings, what is the most appropriate immediate management?

Explanation

## Management of Severe Preeclampsia in RCH Framework **Key Point:** The presence of severe features (BP ≥160/110 mmHg, proteinuria 3+, and hyperreflexia with clonus indicating imminent eclampsia) mandates magnesium sulphate prophylaxis and urgent referral as per RCH guidelines. ### Clinical Assessment This patient has **severe preeclampsia with warning signs of eclampsia** (ankle clonus, brisk reflexes). At 32 weeks, the pregnancy is previable by standard criteria but maternal safety is the priority. ### RCH-Recommended Protocol for Severe Preeclampsia | Feature | Action | |---------|--------| | **Seizure prophylaxis** | IM magnesium sulphate 10 g stat (5 g in each buttock) | | **Antihypertensive** | Immediate-acting agent (nifedipine or labetalol) | | **Definitive management** | Transfer to tertiary centre for delivery planning | | **Timing** | Do NOT delay transfer for stabilization | **High-Yield:** Magnesium sulphate is the **gold standard** for seizure prophylaxis in severe preeclampsia globally and in RCH guidelines—it reduces eclampsia risk by ~50% and is safe even in resource-limited settings. ### Why Immediate Referral? - Eclampsia risk is imminent (clonus present) - Tertiary centre has ICU, blood bank, and capability for emergency delivery - Primary health centre lacks infrastructure for complications (pulmonary edema, HELLP, DIC, acute kidney injury) **Clinical Pearl:** The RCH framework emphasizes that **magnesium sulphate should NEVER be withheld** while arranging transfer—it is given immediately, then the patient is transferred. This is not a "stabilize first, then refer" scenario. **Mnemonic: MAGNESIUM SULPHATE IN SEVERE PE** — **M**aternal safety first, **A**dminister IM 10 g stat, **G**et to tertiary centre, **N**ever delay transfer, **E**clampsia prevention is the goal, **S**eizure prophylaxis non-negotiable, **I**nclude in RCH protocol, **U**rgent referral, **M**anage complications at appropriate level.