The 30-Minute Clock and the Magnesium Ladder

Which patient are you treating?

Recheck the blood pressure at 10-minute intervals during treatment, and do not aim for normotension — a target of roughly 140–150 over 90–100 mmHg preserves uteroplacental perfusion.

Serum magnesium6.5 mg/dL

The therapeutic range is roughly 4–7 mEq/L, about 5–8 mg/dL. Slide upward and watch what appears — and in what order.

Now run the hourly check. Tick anything that is true of your patient right now.

Respiratory rate below 12 per minute Deep tendon reflexes absent (patellar, or biceps/brachioradialis if an epidural blocks the patellar) Urine output below 30 mL per hour, or below 100 mL in 4 hours Sudden fall in level of consciousness

Magnesium toxicity recognised

Reflexes gone, respirations 10

The maintenance infusion is running at 2 g per hour. She is drowsy and her patellar reflexes cannot be elicited. Put the response in order.

Steps placed0 / 6

HELLP can occur with only modest hypertension, which is exactly why it is missed. Enter the panel.

Platelet count (per microlitre) Lactate dehydrogenase (units/L) Total bilirubin (mg/dL) AST as a multiple of the upper limit of normal Schistocytes reported on the peripheral smear Right upper quadrant or epigastric pain, with nausea and malaise she describes as feeling like influenza

The three symptoms that change the plan in any hypertensive patient are persistent headache unrelieved by paracetamol, visual scotomata or blurring, and epigastric or right upper quadrant pain — and that epigastric pain is stretching of the hepatic capsule, not indigestion.

Treat the pressure, then watch the magnesium