How do you manage eclampsia?

Management of Eclampsia

Immediate administration of magnesium sulfate is the cornerstone of eclampsia management, along with blood pressure control, delivery planning, and close maternal-fetal monitoring. 1

Initial Stabilization and Assessment

• Ensure airway patency and adequate oxygenation
• Position patient in left lateral position to improve uteroplacental perfusion
• Establish IV access
• Monitor vital signs continuously
• Assess neurological status including deep tendon reflexes
• Obtain baseline laboratory tests: complete blood count, liver enzymes, creatinine, platelets

Seizure Control with Magnesium Sulfate

Loading Dose

• Administer 4-6 grams IV magnesium sulfate over 20-30 minutes 1, 2
• Simultaneously, may give 5 grams IM in each buttock (total 10g) if using combined IV/IM protocol 2

Maintenance Dose

• Continue with 1-2 grams/hour IV infusion for 24 hours after delivery 1, 2
• The 1 gram/hour maintenance dose is as effective as 2 grams/hour with fewer side effects 3
• For overweight patients (BMI ≥25 kg/m²), consider 2 grams/hour to achieve therapeutic levels 4

Monitoring During MgSO₄ Therapy

• Check deep tendon reflexes hourly (first sign of toxicity when lost at levels 3.5-5 mmol/L)
• Monitor respiratory rate (should be >12/min)
• Ensure urine output >30 mL/hour
• Therapeutic serum magnesium level: 1.8-3.0 mmol/L (4.8-8.4 mg/dL) 5
• Consider serum magnesium level monitoring if available

MgSO₄ Toxicity Management

• If respiratory depression occurs (respiratory rate <12/min), hold MgSO₄
• For severe toxicity, administer calcium gluconate 1g IV over 3-5 minutes

Blood Pressure Management

• Treat severe hypertension urgently if BP ≥160/110 mmHg 1
• First-line agents:
  • IV labetalol: 20-40 mg IV every 10-15 minutes (maximum 300 mg)
  • IV hydralazine: 5-10 mg every 20 minutes
  • Oral nifedipine: 10-20 mg every 30 minutes
• Target BP: 140-150/90-100 mmHg (avoid excessive lowering which may compromise uteroplacental perfusion)

Fluid Management

• Limit total fluid intake to 60-80 mL/hour to avoid pulmonary edema 1
• Aim for euvolemia - replace insensible losses (30 mL/h) plus anticipated urinary losses (0.5-1 mL/kg/h)
• Monitor for signs of pulmonary edema
• Avoid fluid overload as preeclamptic women have capillary leak

Delivery Planning

• Eclampsia is an indication for delivery regardless of gestational age
• Stabilize the mother first before proceeding with delivery
• Mode of delivery should be based on obstetric indications
• Vaginal delivery is preferred if feasible and maternal condition is stable
• For gestational age <34 weeks, administer corticosteroids for fetal lung maturity if time permits

Postpartum Management

• Continue magnesium sulfate for 24 hours after delivery 1
• Monitor BP at least every 4-6 hours for at least 3 days postpartum
• Continue neurological assessment as eclampsia can occur postpartum
• Check laboratory tests (Hb, platelets, creatinine, liver enzymes) the day after delivery and then every second day until stable 1
• Avoid NSAIDs for pain relief if possible, especially with renal impairment 1
• Continue antihypertensives and taper slowly after days 3-6 postpartum unless BP <110/70 mmHg

Follow-up

• Review within one week if still requiring antihypertensives at discharge
• All women should be reviewed at 3 months postpartum to ensure BP, urinalysis, and laboratory tests have normalized 1
• Assess for depression, anxiety, or post-traumatic stress disorder
• Counsel regarding increased cardiovascular risk and recurrence risk in future pregnancies

Common Pitfalls to Avoid

1. Delaying magnesium sulfate administration - it should be given immediately upon diagnosis
2. Using diazepam or phenytoin instead of magnesium sulfate - MgSO₄ is superior for preventing recurrent seizures 6
3. Aggressive fluid administration - can precipitate pulmonary edema
4. Rapid or excessive BP lowering - may compromise uteroplacental perfusion
5. Discontinuing magnesium sulfate too early - continue for full 24 hours postpartum
6. Failing to monitor for magnesium toxicity - check reflexes, respiratory rate, and urine output regularly

Remember that eclampsia is a life-threatening emergency requiring prompt intervention to reduce maternal and fetal morbidity and mortality.