Severe preeclampsia with HELLP for labour epidural24-year-old woman, 78 kg, primigravida at 36 weeks

The patient

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1. Consider

   What are the issues?

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   • A 24-year-old primigravida at 36 weeks with preeclampsia and HELLP features, asking for a labour epidural. Patient
   • At term her airway is already swollen, and preeclampsia makes it worse; she is also an aspiration risk.
   • Severe features in her: systolic over 160, transaminases four times normal, headache, platelets under 100. Disease
   • Her platelets fell from 112 to 84 in 6 hours; the trend matters as much as the number.
   • Her main dangers are cerebral haemorrhage, pulmonary oedema, eclampsia and coagulopathy.

2. Prepare

   Is an epidural safe for her now?

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   • Pressure first: 164/108 needs treating within 30–60 minutes, before any needle. Disease
   • Escalating IV labetalol, 5, 10, 20 mg; or IV hydralazine 5–10 mg every 20–30 minutes; target under 160/110.
   • If IV drugs are delayed or fail, oral nifedipine 10–20 mg, repeated after 20 minutes.
   • A count of 70 or more makes the epidural reasonable, but hers is falling fast.
   • So a fresh count and clotting screen just before placement; HELLP can turn DIC-like.
   • If they're acceptable, the epidural goes in early: she will likely need a caesarean. Airway

3. Plan

   How do you manage her through labour?

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   • Magnesium continues at 1–2 g/h as her seizure prophylaxis. Disease
   • Total IV fluid limited to about 80 mL/h, drug diluents included, with a strict balance chart.
   • Usual labour epidural doses, started slowly with her left uterine displacement maintained.
   • Hourly reflexes, breathing rate and urine output to catch magnesium accumulation.
   • No methylergonovine after delivery; it can provoke a hypertensive crisis in her. After surgery
   • HDU monitoring continues for at least 24 hours after birth.

4. Crisis

   Two hours later she is breathless, coughing pink froth; SpO2 88% on air, RR 32, BP 172/110, HR 118. What do you do?

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   • Acute pulmonary oedema: sit her up, high-flow oxygen, call for senior help and the obstetrician. Crisis
   • Stop all background fluids; positive balance drives oedema in preeclampsia.
   • Bedside echo for her ventricle, filling and lung water.
   • Nitroglycerin infusion, 0.5–5 mcg/kg/min, lowers her preload and pressure.
   • A loop diuretic once her filling looks adequate.
   • If she tires, intubate with laryngoscopy pressor surges blocked; hypertension then risks a bleed. After surgery

5. Crisis

   Later she is drowsy and weak; RR 8, patellar reflexes absent, SpO2 91%, BP 128/80. What do you do?

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   • Magnesium toxicity until shown otherwise: stop the infusion and call for help. Crisis
   • Support breathing with bag and mask on 100% oxygen; intubate if it stays inadequate.
   • Calcium gluconate 1 g, 10 mL of 10%, IV over at least 2 minutes.
   • Urgent magnesium level: reflexes vanish above 6 mEq/L, apnoea and arrest come above 10.
   • Check urine output and creatinine; poor renal clearance is the usual reason it builds up.
   • Magnesium restarts only with reflexes back and a level inside 4–8 mEq/L. After surgery