What is the management approach for a pregnant woman experiencing seizures and hypotension?

Management of Seizures and Hypotension in Pregnant Women

For pregnant women experiencing seizures with hypotension, immediate administration of magnesium sulfate is the first-line treatment for seizure control, while simultaneously addressing hypotension through left lateral positioning, IV fluid resuscitation, and careful monitoring of both maternal and fetal status. 1, 2, 3

Initial Assessment and Stabilization

• Ensure airway, breathing, and circulation while positioning the patient in left lateral decubitus position to relieve inferior vena cava compression and improve venous return 4, 5
• Administer oxygen and establish IV access immediately 3
• Monitor vital signs continuously, including blood pressure, heart rate, respiratory rate, and oxygen saturation 1
• Assess for early maternal warning signs such as tachycardia and oliguria that may indicate worsening condition 1

Seizure Management

• Administer magnesium sulfate as the first-line treatment for eclamptic seizures:
  • Initial dose: 4-5g IV in 250mL of 5% Dextrose or 0.9% Sodium Chloride over 3-4 minutes 2
  • Simultaneously, give up to 10g IM (5g in each buttock) 2
  • Maintenance: 1-2g/hour by continuous IV infusion or 4-5g IM every 4 hours 2, 3
  • Continue therapy until seizures cease; optimal serum magnesium level is 6 mg/100mL 2
• Monitor for magnesium toxicity by checking patellar reflexes, respiratory function, and urine output 2
• If seizures persist despite magnesium sulfate, consider benzodiazepines as second-line treatment 6

Hypotension Management

• Position patient in left lateral decubitus position to relieve inferior vena cava compression 4, 5
• Administer IV fluid boluses (crystalloids) to treat acute symptomatic hypotension 4
• Monitor response to fluid resuscitation closely 4
• If hypotension persists despite fluid administration, vasopressors may be considered with caution 4
• Identify and address potential causes of hypotension:
  • Excessive antihypertensive therapy in women with hypertensive disorders 4
  • Position-related hypotension (supine hypotensive syndrome) 4
  • Magnesium sulfate administration (which can cause vasodilation) 2

Monitoring and Ongoing Management

• Continuously monitor maternal vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation 1, 3
• Perform regular neurological assessments, including level of consciousness and reflexes 1
• Monitor fetal heart rate continuously 5, 3
• Obtain laboratory tests to assess for complications:
  • Complete blood count (focusing on platelet count)
  • Liver function tests
  • Renal function tests
  • Coagulation studies 1, 7

Delivery Considerations

• Delivery is the definitive treatment for eclampsia 7, 3
• The timing and mode of delivery depend on:
  • Maternal condition stability
  • Gestational age
  • Fetal status 5, 3
• Cesarean section is often recommended for immediate delivery in unstable patients 5
• Maintain left lateral positioning during cesarean section to prevent further hypotension 5
• Regional anesthesia can be used only in conscious patients who are free from coagulopathy and HELLP syndrome 5

Important Precautions

• Do not administer magnesium sulfate concomitantly with calcium channel blockers due to risk of severe hypotension 1
• Total daily dose of magnesium sulfate should not exceed 30-40g/24 hours 2
• In severe renal insufficiency, maximum dosage of magnesium sulfate is 20g/48 hours with frequent monitoring of serum magnesium levels 2
• Continuous use of magnesium sulfate beyond 5-7 days can cause fetal abnormalities 2
• Have calcium gluconate readily available to reverse magnesium toxicity if needed 2