What are the differences in management and treatment between pre-eclampsia and eclampsia?

From the Guidelines

Pre-eclampsia and eclampsia are two distinct conditions that require different management approaches, with the primary goal of preventing maternal mortality and morbidity, as well as ensuring the best possible outcomes for the fetus. The management of pre-eclampsia involves close monitoring of blood pressure, proteinuria, and maternal/fetal wellbeing, with antihypertensive medications like labetalol (200-800 mg orally twice daily), nifedipine (30-90 mg extended-release daily), or methyldopa (250-500 mg orally three times daily) to maintain blood pressure below 160/110 mmHg, as recommended by the ISSHP classification, diagnosis, and management recommendations for international practice 1. In contrast, eclampsia, characterized by seizures, requires immediate stabilization with airway management, oxygen, and seizure control using magnesium sulfate (4-6g IV loading dose over 15-20 minutes, followed by 1-2g/hour continuous infusion for at least 24 hours after the last seizure), as stated in the ESC Council on Hypertension position document on the management of hypertensive emergencies 1. Some key points to consider in the management of these conditions include:

• The importance of urgent treatment of blood pressure ≥ 160/110 mm Hg in a monitored setting, using acceptable agents such as oral nifedipine or intravenous labetalol or hydralazine, as endorsed by the ISSHP 1.
• The recommendation to treat blood pressures consistently at or > 140/90 mm Hg, aiming for a target diastolic BP of 85 mm Hg, to reduce the likelihood of developing severe maternal hypertension and other complications, as stated in the ISSHP classification, diagnosis, and management recommendations for international practice 1.
• The use of magnesium sulfate prophylaxis in severe cases of pre-eclampsia to prevent progression to eclampsia, as recommended by the ISSHP classification, diagnosis, and management recommendations for international practice 1.
• The need for aggressive blood pressure control and expedited delivery in eclampsia cases, as stated in the ESC Council on Hypertension position document on the management of hypertensive emergencies 1.
• The importance of postpartum monitoring for at least 72 hours, as complications can still develop after delivery, as noted in the example answer. Overall, the management of pre-eclampsia and eclampsia requires a comprehensive approach that takes into account the severity of the condition, the presence of complications, and the need for urgent intervention to prevent maternal mortality and morbidity, as emphasized by the American Family Physician recommendation statement on screening for preeclampsia 1.

From the FDA Drug Label

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 main difference in management and treatment between pre-eclampsia and eclampsia is the severity of the condition and the presence of seizures.

• Pre-eclampsia is managed with magnesium sulfate to prevent seizures, with a total initial dose of 10 to 14 g.
• Eclampsia is treated with magnesium sulfate to control seizures, with a similar dosing regimen as pre-eclampsia, but with a focus on controlling ongoing seizures. The treatment goals are to prevent seizures in pre-eclampsia and to control seizures in eclampsia, with a target serum magnesium level of 6 mg/100 mL 2. Key considerations include monitoring for signs of magnesium toxicity, such as respiratory depression and cardiac arrest, and adjusting the dose accordingly 2.

From the Research

Differences in Management and Treatment

The management and treatment of pre-eclampsia and eclampsia differ in several ways:

• Magnesium Sulfate Administration: Magnesium sulfate is the primary treatment for eclampsia and is also used for prophylaxis in severe pre-eclampsia 3. The dosage and administration of magnesium sulfate may vary depending on the severity of the condition and the patient's response to treatment.
• Antihypertensive Therapy: Antihypertensive therapy is used to manage severe hypertension in pre-eclampsia, whereas in eclampsia, the primary focus is on controlling seizures and preventing further complications 4, 5.
• Intensive Care Unit (ICU) Admission: Patients with eclampsia typically require admission to an ICU for close monitoring and management, whereas those with pre-eclampsia may be managed in a labor and delivery unit or a maternal-fetal medicine unit 4.
• Delivery: Delivery is the ultimate treatment for both pre-eclampsia and eclampsia, but the timing and mode of delivery may vary depending on the severity of the condition and the gestational age of the fetus 5.

Pharmacological Management

The pharmacological management of pre-eclampsia and eclampsia includes:

• Magnesium Sulfate: Magnesium sulfate is the drug of choice for preventing and treating eclampsia, and is also used for prophylaxis in severe pre-eclampsia 3, 6.
• Antihypertensive Agents: Antihypertensive agents, such as hydralazine, verapamil, and propranolol, are used to manage severe hypertension in pre-eclampsia 7.
• Corticosteroids: Corticosteroids, such as dexamethasone, may be used to promote fetal lung maturity in cases of pre-eclampsia where delivery is planned before 34 weeks of gestation 7.

Essential Medicines Lists (EMLs)

Essential Medicines Lists (EMLs) are critical in ensuring the availability of essential medicines for the management of pre-eclampsia and eclampsia:

• Magnesium Sulfate: Magnesium sulfate is listed in 86.2% of EMLs in low- and middle-income countries (LMICs) 7.
• Antihypertensive Agents: Antihypertensive agents, such as hydralazine and verapamil, are listed in over 80% of EMLs in LMICs 7.
• Corticosteroids: Corticosteroids, such as dexamethasone, are listed in over 90% of EMLs in LMICs 7.