Eclampsia and HELLP syndrome — structured oral station (12 minutes)

Opening prompt — "Tell me what you do from the doorway."

Model response — say the six words, then act on them. ^[3][1]

• "Call. I say 'eclampsia' out loud and put out the obstetric emergency call — consultant obstetrician, anaesthetist, midwifery coordinator, neonatal team."
• "Airway. I remove hazards and pad the rails. I do not restrain her and I put nothing in her mouth. Once the clonic phase ends I roll her into the left lateral position and open the airway with a jaw thrust, suctioning if she has vomited."
• "Oxygen 15 L per minute by reservoir mask. I time the seizure — most self-terminate within about 90 seconds — and I get a bedside glucose while someone secures intravenous access."^[3]
• "Magnesium. Magnesium sulfate per the current protocol loading and maintenance doses, continued for 24 hours after birth or after the last seizure, whichever is later."^[4][2]
• "Pressure. Treat severe-range hypertension within 30 to 60 minutes — labetalol, hydralazine, or immediate-release nifedipine per the current protocol doses."^[3]
• "Then the baby. I expect a post-ictal bradycardia and I expect it to recover as I oxygenate and reposition her. I do not take a seizing, hypoxic, hypertensive woman to theatre — mother first, then baby."^[3][5]

Examiner is listening for: a named sequence, no restraint, left lateral, a magnesium dose, a blood pressure dose, and the explicit refusal to deliver before stabilising. ^[3]

Probe 1 — "Why magnesium rather than diazepam or phenytoin?"

• "The Collaborative Eclampsia Trial randomised 1,687 women with eclampsia. Magnesium reduced recurrent convulsions by 52% compared with diazepam — 13.2% versus 27.9% — and by 67% compared with phenytoin — 5.7% versus 17.1%."^[1]
• "Against phenytoin, women on magnesium were also less likely to be ventilated, to develop pneumonia and to be admitted to intensive care, and their babies were less likely to be intubated at birth or admitted to special care."^[1]
• "For prophylaxis, Magpie randomised 10,141 women with preeclampsia across 33 countries and cut eclampsia by 58%, from 1.9% to 0.8%, with a probable reduction in maternal death. The Cochrane review pools this to a risk ratio of 0.41 with a number needed to treat of about 100."^[2][6]
• "Mechanistically magnesium is not a general antiepileptic — it works through cerebral vasodilatation, NMDA receptor antagonism, membrane stabilisation and reduced blood-brain barrier permeability, which is why it beats drugs that are better anticonvulsants in other settings."^[8][1]

Probe 2 — "She seizes again 30 minutes later on the infusion. What do you do?"

• "A further bolus of magnesium per current protocol, and I continue the maintenance infusion. Dose varies by maternal weight and protocol."^[3][4]
• "This is not a treatment failure. In the UKOSS national study 26% of women had recurrent fits despite 99% receiving magnesium, so I would not switch drugs."^[5][1]
• "If she continues to seize after that, I escalate to intensive care and anaesthetics, secure the airway, and image the brain — I am now looking for intracranial haemorrhage, cerebral venous sinus thrombosis or a non-eclamptic cause."^[3][8]

Probe 3 — "An hour later she is drowsy, her patellar reflexes are absent and her respiratory rate is 9. Talk me through this."

• "Magnesium toxicity. The ladder is predictable: reflexes go first, then respiration, then the heart."^[3][4]
• "I stop the infusion immediately and give calcium gluconate per the current protocol dose, with airway and ventilatory support."^[3][4]
• "Then I look for why: magnesium is cleared renally, so I check the creatinine and the urine output. If output has fallen below about 100 mL over four hours or the creatinine has risen, the infusion rate needs reducing or holding when I restart."^[3][4]
• "Routine serum levels are not needed when renal function is normal and clinical monitoring is being done properly — hourly reflexes, respiratory rate, conscious level and urine output. I would send a level here because there are signs of toxicity."^[4][3]

Probe 4 — "You are in a rural hospital with no infusion pump and a four-hour retrieval. Does anything change?"

• "The drug does not change, only the route. The Pritchard intramuscular regimen is an intravenous load plus intramuscular doses into alternate buttocks per the current protocol."^[1][7]
• "The Cochrane review of alternative magnesium regimens found insufficient evidence to prefer any single alternative schedule, so I use the regimen my service can deliver safely and reliably rather than improvising."^[7]
• "The absolute rule is that I stabilise before I move her. I do not put a woman who is still fitting or still severely hypertensive into an ambulance. A doctor or trained midwife escorts, the magnesium runs in transit, and I phone the receiving unit myself."^[4][3]

Probe 5 — "Her partner is in the corridor, shaking, saying he thinks she is dying. What do you say?"

This is a scored domain, not a courtesy. Demonstrate it out loud. ^[4]

• Step out with a midwife, take him somewhere he can sit, use his name and hers.
• "She has had a fit. It is caused by her blood pressure and the pregnancy, and it has a name — eclampsia. It looks terrifying and I am not going to pretend otherwise."
• "She has stopped fitting. We have given her a medicine called magnesium that makes another fit much less likely, and we are bringing her blood pressure down. A whole team is with her."^[2][3]
• "What happens next is that we get her stable and then we deliver the baby, because that is the only thing that ends this. The baby's doctors are already here."
• Do not promise an outcome. Offer to take him to her once she is settled, allocate a staff member to stay with him, and commit to a debrief afterwards. Say plainly that seeing a seizure is traumatic and that support will be offered to both of them.^[4][5]

Probe 6 — "What is the follow-up plan?"

• "Magnesium for 24 hours after birth, continued antihypertensives with the day 3 to 6 blood pressure peak anticipated, and repeat bloods until the platelets and transaminases are clearly improving."^[3][4]
• "Disposition: UKOSS found 56% of women with eclampsia needed intensive care or high dependency for a median of two days, so I would plan for that rather than be surprised by it."^[5]
• "A structured debrief, documentation, and an incident or near-miss review. Then the long game: after preeclampsia the relative risk of later hypertension is 3.70 and of ischaemic heart disease 2.16, so she needs annual cardiovascular review for life and an early-booking plan with aspirin next time."^[9][4]