A 28-year-old primigravida at 32 weeks of gestation attends the antenatal clinic in a rural primary health centre in Uttar Pradesh. She reports no antenatal check-ups so far. On examination, her blood pressure is 148/96 mmHg, urine dipstick shows 2+ proteinuria, and she has mild pedal edema. Fetal heart rate is 142 bpm and regular. What is the most appropriate next step in management according to RCH guidelines?

Explanation

## Clinical Assessment This patient presents with classic features of preeclampsia at 32 weeks: - Hypertension (≥140/90 mmHg) - Proteinuria (≥2+ on dipstick) - Edema - Primigravida status (risk factor) ## RCH Protocol for Preeclampsia Management **Key Point:** Any pregnant woman with BP ≥140/90 mmHg + proteinuria ≥2+ constitutes a **high-risk obstetric emergency** and requires immediate referral to a facility capable of managing complications (eclampsia, HELLP, placental abruption, fetal distress). **High-Yield:** According to RCH and JSOG guidelines, preeclampsia at <34 weeks is a **Category 4 obstetric emergency** — it mandates tertiary-level care with: - Continuous fetal monitoring capability - Capacity for emergency cesarean section - Neonatal ICU for preterm infant management - Facilities for magnesium sulphate and antihypertensive therapy ## Why Referral is Mandatory | Complication Risk | Reason | |---|---| | Eclampsia | Can occur suddenly; seizures are life-threatening | | Placental abruption | Hypertensive crisis → placental separation | | HELLP syndrome | Hemolysis, elevated LFTs, low platelets — requires ICU | | Fetal distress | Placental insufficiency from vasoconstriction | | Preterm delivery | May be necessary to save maternal life | **Clinical Pearl:** A PHC lacks the infrastructure for: - Continuous cardiotocography (CTG) - Emergency cesarean section - Intensive monitoring for magnesium sulphate toxicity - Neonatal resuscitation for a 32-week infant Thus, **urgent referral to a tertiary centre** is the standard of care and aligns with RCH guidelines for safe motherhood. ## Correct Management Algorithm ```mermaid flowchart TD A[Pregnant woman with BP ≥140/90 + proteinuria ≥2+]:::outcome --> B{Gestational age?}:::decision B -->|<34 weeks| C[Preeclampsia at <34 weeks]:::urgent B -->|≥34 weeks| D[Preeclampsia at term]:::outcome C --> E[Urgent referral to tertiary centre]:::action E --> F[Magnesium sulphate + antihypertensive]:::action D --> G[Delivery planning + monitoring]:::action F --> H[Fetal monitoring + maternal labs]:::action ```