What is the immediate treatment for a patient with eclampsia?

Immediate Treatment for Eclampsia

Administer intravenous magnesium sulfate immediately as first-line anticonvulsant therapy, with a loading dose of 4-5 grams IV over 5 minutes, followed by a maintenance infusion of 1-2 grams/hour for 24 hours after the last seizure, while simultaneously controlling blood pressure to maintain levels below 160/105 mmHg using IV labetalol or nicardipine. 1, 2, 3

Immediate Seizure Management

Magnesium Sulfate Administration

Loading Dose:

• Give 4-5 grams IV over 5 minutes (diluted in 250 mL of 5% dextrose or 0.9% sodium chloride) 1, 2, 3
• Alternatively, use the Pritchard regimen: 4 grams IV combined with 10 grams IM (5 grams in each buttock) for a total loading dose of 14 grams when IV infusion pumps are unavailable 2, 3
• If IV access is unavailable, give 5 grams IM in each buttock (10 grams total) and arrange immediate transfer 2

Maintenance Dose:

• Continue 1-2 grams/hour as continuous IV infusion for 24 hours after the last seizure 1, 2, 3
• The 1 gram/hour maintenance dose is as effective as 2 grams/hour with fewer side effects 4
• If using IM route, give 5 grams IM into alternate buttocks every 4 hours 3

Critical Safety Monitoring:

• Check patellar reflexes before each dose—if absent, withhold magnesium 3
• Monitor respiratory rate (must be ≥16 breaths/minute) 3, 5
• Maintain urine output >100 mL over 4 hours preceding each dose 2, 3
• Target therapeutic serum magnesium level: 1.8-3.0 mmol/L (3-6 mg/100 mL) 3, 5
• Have injectable calcium salt immediately available to counteract magnesium toxicity 1, 2, 3

Magnesium Toxicity Recognition

Warning signs occur at specific serum levels:

• Loss of patellar reflexes: 3.5-5 mmol/L 5
• Respiratory paralysis: 5-6.5 mmol/L 5
• Altered cardiac conduction: >7.5 mmol/L 5
• Cardiac arrest: >12.5 mmol/L 5

Blood Pressure Control

Target BP: <160/105 mmHg 1, 2

First-Line IV Antihypertensives

Labetalol:

• Initial dose: 20 mg IV bolus 2
• If inadequate response after 10 minutes: 40 mg IV 2
• Then 80 mg IV every 10 minutes to maximum 220 mg 2

Nicardipine:

• Start at 5 mg/hour IV 2
• Increase by 2.5 mg/hour every 5-15 minutes to maximum 15 mg/hour 2

Alternative oral agents when IV unavailable:

• Oral nifedipine or oral methyldopa 2
• Critical caveat: Risk of severe hypotension when combining nifedipine with magnesium sulfate—use with extreme caution 1, 2

Avoid:

• Sodium nitroprusside (risk of fetal cyanide toxicity) 2
• Diuretics (plasma volume already reduced in eclampsia) 1, 2

Airway, Breathing, and Circulation During Seizure

• Position patient on left side to prevent aspiration 6
• Ensure airway patency and adequate oxygenation 6
• Provide supplemental oxygen 6
• Protect patient from injury during convulsions 6
• Establish IV access if not already present 6

Monitoring Requirements

Maternal:

• Continuous blood pressure monitoring 2
• Deep tendon reflexes before each magnesium dose 2, 3
• Respiratory rate continuously 2, 3
• Urine output hourly (maintain >100 mL/4 hours) 2, 3
• Serum magnesium levels if available 3, 5

Fetal:

• Continuous fetal heart rate monitoring 2
• Ultrasound assessment of fetal biometry, amniotic fluid, and umbilical artery Doppler 2

Delivery Planning

Deliver after maternal stabilization 2, 6

Immediate delivery indications:

• Inability to control blood pressure despite two medications within 360 minutes 1
• Progressive deterioration in liver function, creatinine, hemolysis, or platelet count 2
• Ongoing neurological features 2
• Placental abruption 2
• Abnormal fetal status 2
• Gestational age ≥37 weeks 2

Mode of delivery:

• Vaginal delivery preferred unless cesarean indicated for obstetric reasons 2
• Neuraxial anesthesia is preferred for cesarean section in conscious, seizure-free women with stable vital signs 6

Corticosteroids:

• Administer antenatal corticosteroids if gestational age ≤34 weeks to accelerate fetal lung maturation 2

Critical Pitfalls to Avoid

• Never exceed 5-7 days of continuous magnesium sulfate administration—prolonged use causes fetal hypocalcemia, skeletal demineralization, osteopenia, and fractures 3
• Avoid rapid or excessive blood pressure reduction—can cause fetal bradycardia from reduced uteroplacental perfusion 7
• Do not combine magnesium with calcium channel blockers without extreme caution—risk of severe hypotension 1, 2
• Maximum total daily dose: 30-40 grams magnesium sulfate 3
• In severe renal insufficiency: maximum 20 grams/48 hours with frequent serum magnesium monitoring 3
• Watch for pulmonary edema, especially with hemoconcentration—use conservative fluid administration 7

Post-Seizure Management

• Continue magnesium sulfate for 24 hours after delivery or last seizure 2
• Continue antihypertensive therapy during labor and postpartum period 2
• Monitor hourly for first 12 hours postpartum for blood pressure control and pulmonary edema 7
• Check blood pressure and urine at 6 weeks postpartum 2
• Assess for secondary causes of hypertension in women under 40 with persistent hypertension 2