What is the management of eclampsia?

Management of Eclampsia

Immediate Seizure Management and Stabilization

Administer magnesium sulfate immediately as the first-line anticonvulsant for eclamptic seizures, with a loading dose of 4-5g IV over 5 minutes, followed by a maintenance infusion of 1-2g/hour for 24 hours after the last seizure or delivery. 1, 2

Magnesium Sulfate Administration Protocols

Loading Dose Options:

• IV route (preferred): 4-5g diluted in 250mL of 5% dextrose or 0.9% saline, infused over 5 minutes for immediate therapeutic levels 1, 2
• Combined IV/IM route: 4g IV plus 10g IM (5g in each buttock) for total loading dose of 14g, used when continuous IV infusion pumps unavailable 1, 2
• IM-only route (Pritchard regimen): If IV access unavailable, give 10g IM (5g in each buttock) and arrange immediate transfer 1

Maintenance Dose:

• Standard regimen: 1-2g/hour continuous IV infusion for 24 hours after last seizure or delivery 1, 2
• Alternative IM regimen: 5g IM every 4 hours in alternating buttocks 3, 2
• Duration controversy: Recent evidence suggests women receiving ≥8g MgSO4 before delivery may not require full 24-hour postpartum continuation, though 24-hour postpartum continuation remains the standard recommendation until further validation 3

Critical Monitoring During Magnesium Therapy

Before each dose, assess the following to prevent toxicity:

• Patellar reflexes: Must be present; absence indicates magnesium level >4 mEq/L and impending toxicity—hold next dose 1, 2
• Respiratory rate: Must be ≥16 breaths/minute; respiratory depression occurs at 5-6.5 mmol/L 1, 2, 4
• Urine output: Must be ≥100mL over preceding 4 hours; magnesium is renally excreted and accumulates with oliguria 1, 2
• Serum magnesium levels: Therapeutic range 1.8-3.0 mmol/L (4.8-7.2 mg/dL); levels >3.5 mmol/L cause loss of reflexes, >5 mmol/L cause respiratory paralysis, >7.5 mmol/L alter cardiac conduction, >12.5 mmol/L cause cardiac arrest 4, 5

Have calcium gluconate 1g (10mL of 10% solution) immediately available at bedside to reverse magnesium toxicity if respiratory depression or cardiac complications occur. 1, 2

Blood Pressure Management

Target blood pressure <160/105 mmHg urgently to prevent maternal cerebral hemorrhage while maintaining uteroplacental perfusion. 1, 6

First-Line IV Antihypertensive Options

When BP ≥160/110 mmHg persisting >15 minutes:

• Labetalol: 20mg IV bolus, then 40mg after 10 minutes, then 80mg every 10 minutes to maximum 220mg 1
• Nicardipine: Start 5mg/hour, increase by 2.5mg/hour every 5-15 minutes to maximum 15mg/hour 1
• Hydralazine: Alternative IV agent when labetalol/nicardipine unavailable 3, 1

Avoid sodium nitroprusside due to fetal cyanide toxicity risk. 1

Avoid combining magnesium sulfate with calcium channel blockers (nifedipine) due to severe hypotension risk; however, oral nifedipine can be used for non-urgent BP control when IV agents unavailable. 1

Fluid Management

Restrict total fluid intake to 60-80mL/hour to prevent pulmonary edema, replacing insensible losses (30mL/hour) plus anticipated urinary output (0.5-1mL/kg/hour). 3

• Preeclamptic/eclamptic women have capillary leak and are at high risk for pulmonary edema with excessive fluids 3
• Do not "run dry"—maintain euvolemia as women are already at risk for acute kidney injury 3
• Avoid diuretics as plasma volume is already reduced 1, 6

Airway and Supportive Care During Seizure

During active seizure:

• Position patient on left side to prevent aspiration 5
• Maintain airway patency and provide supplemental oxygen 5
• Protect from injury during convulsions 5
• Do not attempt to restrain or place objects in mouth 5
• Monitor oxygen saturation continuously 6

Delivery Planning

Delivery is the definitive treatment for eclampsia and should occur after maternal stabilization with magnesium sulfate and blood pressure control. 1, 6

Indications for Immediate Delivery (Regardless of Gestational Age)

• Inability to control blood pressure despite 3 antihypertensive classes 3
• Progressive thrombocytopenia or HELLP syndrome 3
• Progressive renal dysfunction (rising creatinine) or liver enzyme abnormalities 3
• Pulmonary edema 3
• Recurrent seizures despite magnesium therapy 3
• Placental abruption 3, 6
• Non-reassuring fetal status 3
• Gestational age ≥37 weeks 3

Mode of Delivery

Vaginal delivery is preferred unless cesarean section indicated for standard obstetric reasons. 1

• Neuraxial anesthesia is preferred for cesarean section in seizure-free women with stable vital signs 5

Corticosteroids for Fetal Lung Maturation

Administer antenatal corticosteroids if gestational age 24-34 weeks, may consider up to 38 weeks for elective cesarean. 3, 1

• Multiple steroid courses not recommended 1

Laboratory Monitoring

Initial assessment:

• Complete blood count (hemoglobin, platelets) 1, 6
• Comprehensive metabolic panel (creatinine, liver enzymes) 1, 6
• Uric acid 3
• Peripheral blood smear if HELLP syndrome suspected 6

Repeat labs:

• Day after delivery, then every 2 days until stable if abnormal before delivery 3
• Twice weekly during expectant management <34 weeks 3, 6

Postpartum Management

Continue magnesium sulfate for 24 hours after delivery or last seizure (whichever is later). 3, 1

Monitor:

• Blood pressure every 4-6 hours for at least 3 days postpartum 3
• Neurological status—eclampsia can occur postpartum 3
• General well-being and symptoms 3

Restart or continue antihypertensives after delivery, taper slowly only after days 3-6 postpartum unless BP <110/70 mmHg. 3

Avoid NSAIDs in women with eclampsia/preeclampsia, especially with acute kidney injury—use alternative analgesia. 3

Common Pitfalls and Critical Warnings

Fetal harm with prolonged magnesium: Continuous maternal administration beyond 5-7 days causes fetal hypocalcemia, skeletal demineralization, osteopenia, and neonatal fractures—use shortest duration necessary 2

Magnesium toxicity progression: Loss of patellar reflexes → respiratory depression → altered cardiac conduction → cardiac arrest; monitor reflexes, respiratory rate, and urine output before each dose 2, 4

Renal insufficiency: Maximum dose 20g/48 hours in severe renal impairment with frequent serum magnesium monitoring 2

Drug interactions: Magnesium potentiates neuromuscular blocking agents and CNS depressants; adjust doses accordingly 2

Postpartum eclampsia: 25-30% of eclamptic seizures occur postpartum; maintain vigilance and continue prophylaxis 3