What is the management of eclampsia?

Management of Eclampsia

The management of eclampsia requires immediate administration of intravenous magnesium sulfate for seizure control, along with antihypertensive therapy (labetalol or nicardipine) to maintain blood pressure below 160/105 mmHg, followed by delivery after maternal stabilization. 1

Initial Management

• Airway, Breathing, Circulation: Ensure patient safety during convulsions and maintain adequate oxygenation 2
• Seizure Control: Administer magnesium sulfate as first-line anticonvulsant 1
  • Loading dose: 4-5g IV over 5 minutes, with simultaneous IM doses of up to 10g (5g in each buttock) 3, 4
  • Maintenance dose: 1-2g/hour as continuous IV infusion for 24 hours after the last seizure 3, 4
• Blood Pressure Control: Target BP <160/105 mmHg to prevent maternal complications 1
  • First-line IV antihypertensives: labetalol or nicardipine 1
  • Labetalol: Initial 20mg IV bolus, then 40mg after 10 minutes, followed by 80mg every 10 minutes to maximum 220mg 1
  • Nicardipine: Start at 5mg/h, increase by 2.5mg/h every 5-15 minutes to maximum 15mg/h 1

Monitoring

• Maternal Monitoring 1:
  • Continuous BP monitoring 1
  • Assess deep tendon reflexes before each dose of magnesium (absence indicates potential toxicity) 3
  • Monitor respiratory rate (should be ≥16 breaths/minute) 3
  • Maintain urine output >100mL over 4 hours preceding each dose 3
  • Laboratory tests twice weekly: hemoglobin, platelet count, liver enzymes, creatinine, and uric acid 1
• Fetal Monitoring 1:
  • Continuous fetal heart rate monitoring 1
  • Ultrasound assessment of fetal biometry, amniotic fluid, and umbilical artery Doppler 1

Delivery Considerations

• Timing: Delivery should occur after maternal stabilization 1
• Indications for immediate delivery 1:
  • Inability to control BP despite using ≥3 classes of antihypertensives
  • Progressive deterioration in liver function, creatinine, hemolysis, or platelet count
  • Ongoing neurological features (severe headache, visual disturbances)
  • Placental abruption
  • Abnormal fetal status
  • Gestational age ≥37 weeks
• Mode of delivery: Vaginal delivery is preferred unless cesarean is indicated for obstetric reasons 1
• Antenatal corticosteroids: Administer if gestation is ≤34 weeks to accelerate fetal lung maturation 1

Magnesium Sulfate Administration and Precautions

• Therapeutic serum magnesium levels: 3-6 mg/100mL (2.5-5 mEq/L) 3, 4
• Signs of magnesium toxicity 3:
  • Loss of patellar reflexes (3.5-5 mmol/L)
  • Respiratory depression (5-6.5 mmol/L)
  • Cardiac conduction abnormalities (>7.5 mmol/L)
  • Cardiac arrest (>12.5 mmol/L)
• Antidote: Have injectable calcium salt immediately available to counteract magnesium toxicity 3
• Contraindications/Cautions:
  • Renal impairment (reduce dose and monitor levels closely) 3
  • Avoid combination with calcium channel blockers due to risk of severe hypotension 1
  • Continuous use beyond 5-7 days can cause fetal abnormalities 3

Post-Delivery Management

• Continue magnesium sulfate for 24 hours after delivery or last seizure 4
• Continue antihypertensive therapy during labor and postpartum period 1
• Check BP and urine at 6 weeks postpartum 1
• Assess for secondary causes of hypertension in women under 40 with persistent hypertension 1

Common Pitfalls and Caveats

• Do not use sodium nitroprusside due to risk of fetal cyanide toxicity 1
• Do not attempt to diagnose mild versus severe preeclampsia as all cases may rapidly become emergencies 1
• Do not use diuretics as plasma volume is already reduced in preeclampsia 1
• Do not administer magnesium sulfate too rapidly (maximum 150mg/minute) to avoid hypermagnesemia 3
• Do not exceed total daily dose of 30-40g of magnesium sulfate 3
• Lower maintenance doses of magnesium (1g/hour vs 2g/hour) may be equally effective with fewer side effects 5