What is the management for a patient with eclampsia and Posterior Reversible Encephalopathy Syndrome (PRES) in the postpartum period?

Management of Eclampsia with PRES in the Postpartum Period

Magnesium sulfate is the first-line treatment for postpartum eclampsia with PRES, administered as a 4-5g IV loading dose followed by continuous infusion for 24 hours postpartum, combined with aggressive blood pressure control targeting systolic <160 mmHg and diastolic <110 mmHg using IV labetalol, oral nifedipine, or IV hydralazine. 1

Immediate Seizure Management

• Administer magnesium sulfate immediately using the dosing regimen from the Eclampsia and MAGPIE trials: 4-5g IV loading dose over 5-10 minutes, followed by 1-2g/hour continuous infusion 2, 1
• Continue magnesium sulfate for 24 hours postpartum, as this is the standard duration recommended despite some controversy about shorter durations 2
• Magnesium sulfate is superior to mannitol for treating PRES in eclamptic women, with significantly shorter treatment duration and better neurological recovery 3
• PRES occurs in approximately 98% of eclampsia cases, making it essentially a constant component of the disease process 4

Critical Blood Pressure Control

• Treat blood pressure ≥160/110 mmHg lasting >15 minutes immediately to prevent cerebrovascular complications 2, 1
• First-line IV agents for acute severe hypertension:
  • IV labetalol: 20mg bolus, then 40mg after 10 minutes, then 80mg every 10 minutes for 2 additional doses (maximum 220mg) 2
  • Oral nifedipine: 10-20mg, repeat in 30 minutes if needed 2
  • IV hydralazine: 5mg bolus, then 10mg every 20-30 minutes to maximum 25mg 2
• Maintain systolic BP <160 mmHg and diastolic BP <110 mmHg throughout the postpartum period 2, 1

Monitoring Protocol

• Monitor blood pressure every 4-6 hours while awake for minimum 3 days postpartum, as eclampsia may develop de novo or persist during this period 2, 5, 1
• Monitor neurological status continuously for headache, visual disturbances, altered mental status, and signs of worsening cerebral edema 5, 1
• Repeat laboratory tests daily until stable: hemoglobin, platelets, creatinine, and liver transaminases if any were abnormal before delivery 2, 5, 1
• Monitor for magnesium toxicity: check deep tendon reflexes, respiratory rate (should be >12/min), and urine output (should be >25-30 mL/hour) 6

Critical Pitfalls to Avoid

• Do not use NSAIDs for pain control in women with preeclampsia/eclampsia, especially with acute kidney injury, as they can worsen hypertension and renal function 2, 1
• Avoid prolonged magnesium sulfate beyond 5-7 days as continuous administration can cause fetal hypocalcemia and bone abnormalities if still pregnant, though this is less relevant postpartum 6
• Do not discharge before 24 hours postpartum or until vital signs are stable and neurological symptoms have resolved 1
• Limit total fluid intake to 60-80 mL/hour to avoid pulmonary edema, as preeclamptic women have capillary leak 2

Transition to Oral Antihypertensives

• Continue or restart antihypertensive medications postpartum and taper slowly only after days 3-6, unless BP becomes low (<110/70 mmHg) or patient becomes symptomatic 2, 5
• Preferred oral agents for breastfeeding mothers:
  • Labetalol (first-line beta-blocker) 2
  • Nifedipine (calcium channel blocker) 2, 5
  • Methyldopa (if longer-term control needed) 2

Discharge Planning

• Most women can be discharged by day 5 postpartum if blood pressure is controlled and they can monitor BP at home 2, 5
• Ensure patient has home blood pressure monitoring capability and clear instructions on when to seek emergency care 5
• Mandatory follow-up at 6 weeks postpartum to confirm normalization of BP, urinalysis, and laboratory tests 2, 5

Long-Term Follow-Up

• Review all women at 3 months postpartum to ensure complete resolution of hypertension and proteinuria 2, 5, 1
• Refer to specialist if hypertension or proteinuria persists at 6 weeks, as this may indicate underlying renal disease or secondary hypertension requiring further workup 2, 5
• Counsel about future pregnancy risks: 15% recurrence risk for preeclampsia and 15% risk for gestational hypertension in subsequent pregnancies 5
• Counsel about long-term cardiovascular risks: increased lifetime risk of cardiovascular disease, stroke, diabetes mellitus, venous thromboembolism, and chronic kidney disease 5