What is the diagnosis and treatment for eclampsia (a severe complication of preeclampsia)?

From the Guidelines

Eclampsia requires immediate treatment with magnesium sulfate as the first-line anticonvulsant, typically given as a 4-6g IV loading dose over 15-20 minutes, followed by a continuous infusion of 1-2g per hour for at least 24 hours after the last seizure or delivery, as recommended by the most recent guidelines 1.

Key Management Points

• Magnesium sulfate is the preferred treatment for eclampsia, with all clinical practice guidelines recommending its use for treatment and prevention in women with severe preeclampsia or serious end-organ involvement 1.
• Blood pressure control is essential, with labetalol, hydralazine, or nifedipine used to maintain blood pressure below 160/110 mmHg, as recommended by the ISSHP classification, diagnosis, and management recommendations for international practice 1.
• Definitive treatment is delivery of the baby and placenta, which should be expedited once the patient is stabilized, with close monitoring for complications, including checking magnesium levels, urine output, respiratory rate, and deep tendon reflexes to prevent magnesium toxicity.

Monitoring and Treatment

• Women with preeclampsia should be assessed in hospital when first diagnosed, with some managed as outpatients once their condition is stable, and they can be relied on to report problems and monitor their blood pressure 1.
• Fetal monitoring should include an initial assessment to confirm fetal well-being, with serial fetal surveillance with ultrasound recommended in the presence of fetal growth restriction, and maternal monitoring should include blood pressure monitoring, repeated assessments for proteinuria, and twice weekly blood tests for hemoglobin, platelet count, and tests of liver and renal function 1.
• Delivery should be considered if the patient has reached 37 weeks' gestation or develops any of the following: repeated episodes of severe hypertension, progressive thrombocytopenia, progressively abnormal renal or liver enzyme tests, pulmonary edema, abnormal neurological features, or nonreassuring fetal status 1.

From the FDA Drug Label

In Pre-eclampsia or Eclampsia In severe pre-eclampsia or eclampsia, the total initial dose is 10 to 14 g of magnesium sulfate. Intravenously, a dose of 4 to 5 g in 250 mL of 5% Dextrose Injection, USP or 0. 9% Sodium Chloride Injection, USP may be infused. Simultaneously, IM doses of up to 10 g (5 g or 10 mL of the undiluted 50% solution in each buttock) are given Alternatively, the initial IV dose of 4 g may be given by diluting the 50% solution to a 10 or 20% concentration; the diluted fluid (40 mL of a 10% solution or 20 mL of a 20% solution) may then be injected IV over a period of three to four minutes Subsequently, 4 to 5 g (8 to 10 mL of the 50% solution) are injected IM into alternate buttocks every four hours as needed, depending on the continuing presence of the patellar reflex and adequate respiratory function. Alternatively, after the initial IV dose, some clinicians administer 1 to 2 g/hour by constant IV infusion. Therapy should continue until paroxysms cease A serum magnesium level of 6 mg/100 mL is considered optimal for control of seizures. A total daily (24 hr) dose of 30 to 40 g should not be exceeded.

The treatment for eclampsia involves administering magnesium sulfate with a total initial dose of 10 to 14 g.

• The initial dose can be given intravenously (4 to 5 g) or intramuscularly (up to 10 g).
• The dose is then repeated every 4 hours as needed, with a maximum daily dose of 30 to 40 g.
• The goal is to maintain a serum magnesium level of 6 mg/100 mL to control seizures.
• Therapy should continue until paroxysms cease 2.

From the Research

Definition and Treatment of Eclampsia

• Eclampsia is a rare but potentially life-threatening condition that occurs during pregnancy, characterized by the onset of seizures in association with pre-eclampsia 3, 4, 5, 6.
• Magnesium sulfate (MgSO4) is the most commonly used treatment for eclampsia and prophylaxis of eclampsia in patients with severe pre-eclampsia 3, 4, 5, 6.

Pharmacokinetics of Magnesium Sulfate

• MgSO4 is usually given by either the intramuscular or intravenous routes, with the intramuscular regimen consisting of a 4 g intravenous loading dose, followed by 10 g intramuscularly and then 5 g intramuscularly every 4 hours in alternating buttocks 3.
• The intravenous regimen is given as a 4 g dose, followed by a maintenance infusion of 1 to 2 g/h by controlled infusion pump 3.
• MgSO4 is almost exclusively excreted in the urine, with 90% of the dose excreted during the first 24 hours after an intravenous infusion 3.

Efficacy and Safety of Magnesium Sulfate

• MgSO4 has been shown to more than halve the risk of eclampsia, and probably reduces the risk of maternal death 4, 6.
• The risk of side effects, primarily flushing, is higher with MgSO4, affecting approximately 24% of women 4, 6.
• Maternal toxicity is rare when MgSO4 is carefully administered and monitored, with the first warning of impending toxicity being loss of the patellar reflex at plasma concentrations between 3.5 and 5 mmol/L 3.

Factors Affecting the Use of Magnesium Sulfate

• The use of MgSO4 for pre-eclampsia or eclampsia is affected by various factors, including provider competence and confidence, capability of health systems, and knowledge translation 7.
• These factors can influence the appropriate use of MgSO4, highlighting the need for improved implementation and policy development to ensure widespread availability and use of this life-saving treatment 7.