What is the immediate management for an eclamptic female at 31 weeks gestation after having seizures?

Documentation Requirements for Eclamptic Patient at 31 Weeks Gestation Post-Seizure

Your clinical note must document immediate stabilization measures, ongoing magnesium sulfate therapy with toxicity monitoring, blood pressure control targeting <160/105 mmHg, comprehensive maternal-fetal assessment, and delivery planning after maternal stabilization. 1

Immediate Seizure Management Documentation

Document the following acute interventions:

• Magnesium sulfate administration: Record loading dose of 4-5g IV over 5 minutes, followed by maintenance infusion of 1-2g/hour, with plan to continue for 24 hours after last seizure or delivery (whichever is later) 1, 2
• Alternative regimen if used: If IV access was limited, document IM loading dose of 10g (5g in each buttock) with maintenance of 5g IM every 4 hours in alternating buttocks 2
• Airway management: Document positioning (left lateral), airway protection measures, oxygen saturation, and any interventions required during convulsions 3, 4
• Time of seizure onset and duration: Critical for determining magnesium sulfate continuation timeline 1

Blood Pressure Management Documentation

Document aggressive antihypertensive therapy:

• Current blood pressure readings: Record all measurements, noting if BP ≥160/110 mmHg persisted >15 minutes before treatment 1, 5
• Antihypertensive agents administered: First-line IV labetalol (20mg bolus, then 40mg after 10 minutes, then 80mg every 10 minutes to maximum 220mg) or IV nicardipine (5mg/h, increased by 2.5mg/h every 5-15 minutes to maximum 15mg/h) 6, 1
• Target blood pressure: Document goal of systolic 110-140 mmHg and diastolic 85 mmHg (or at minimum <160/105 mmHg) 1, 5
• Avoid documenting use of: Sodium nitroprusside (fetal cyanide toxicity risk) or sublingual nifedipine (uncontrolled hypotension risk when combined with magnesium sulfate) 6, 1

Magnesium Sulfate Toxicity Monitoring

Document hourly assessments to prevent life-threatening toxicity:

• Deep tendon reflexes: Assess patellar reflexes before each dose; loss indicates impending toxicity 1, 2
• Respiratory rate: Document rate every hour; respiratory depression (<12 breaths/minute) is a critical toxicity sign 1, 4
• Urine output: Record hourly via Foley catheter with target ≥100 mL/4 hours (or >35 mL/hour); reduced renal function increases toxicity risk 1, 5
• Oxygen saturation: Continuous monitoring with maternal early warning if <95% 5
• Availability of antidote: Document that injectable calcium gluconate or calcium chloride is immediately available at bedside to counteract magnesium toxicity 1

Comprehensive Maternal Assessment

Document initial and serial laboratory monitoring:

• Initial labs at presentation: Complete blood count (hemoglobin, platelets), comprehensive metabolic panel (creatinine, liver transaminases), peripheral blood smear if HELLP syndrome suspected, uric acid 1, 5
• Specific values to document: Platelet count (thrombocytopenia suggests HELLP), elevated liver enzymes (AST/ALT), creatinine (renal dysfunction), hemoglobin (hemolysis) 6, 5
• Serial monitoring frequency: Repeat labs day after delivery, then every 2 days until stable if abnormal; during expectant management at <34 weeks, repeat at least twice weekly or more frequently with clinical deterioration 1, 5
• Proteinuria quantification: Spot urine protein/creatinine ratio (≥30 mg/mmol confirms significant proteinuria) 5

Document neurological status:

• Ongoing symptoms: Severe headache, visual disturbances (scotomata, blurred vision), altered mental status, confusion, or agitation 1, 5
• Additional seizure activity: Any recurrent convulsions despite magnesium sulfate 1

Document fluid balance:

• Strict intake/output: Total fluid intake restricted to 60-80 mL/hour to prevent pulmonary edema (30 mL/h for insensible losses plus 0.5-1 mL/kg/hour anticipated urinary output) 6, 1
• Rationale: Eclamptic women have capillary leak and are at high risk for pulmonary edema with excessive fluids 1

Fetal Assessment Documentation

Document comprehensive fetal evaluation at 31 weeks:

• Continuous fetal heart rate monitoring: Record baseline rate, variability, accelerations, and any decelerations 1, 5
• Ultrasound findings: Fetal biometry (estimated fetal weight, growth percentile), amniotic fluid volume (AFI or deepest vertical pocket), umbilical artery Doppler (presence of diastolic flow, absent/reversed end-diastolic flow) 6, 1
• Fetal growth restriction: Document if present, as this requires more frequent monitoring 5
• Gestational age confirmation: Critical for delivery timing decisions at 31 weeks 1

Delivery Planning Documentation

Document plan for delivery after maternal stabilization:

• Timing considerations at 31 weeks: This is <34 weeks, requiring conservative expectant management at a center with Maternal-Fetal Medicine expertise if maternal and fetal status stable after stabilization 5
• Absolute indications for immediate delivery (document if any present): Inability to control BP despite ≥3 antihypertensive classes, progressive thrombocytopenia or HELLP syndrome, pulmonary edema, severe intractable headache or repeated visual scotomata, recurrent convulsions, non-reassuring fetal status, maternal pulse oximetry deterioration 1, 5
• Antenatal corticosteroids: Document administration of betamethasone or dexamethasone for fetal lung maturation at 31 weeks gestation (≤34 weeks) 6, 1
• Mode of delivery preference: Vaginal delivery preferred unless cesarean indicated for standard obstetric reasons; induction of labor associated with improved maternal outcomes 6

Anesthesia Considerations

Document anesthesia planning:

• Regional anesthesia eligibility: Can only be used in conscious, seizure-free patients without coagulopathy or HELLP syndrome 3, 4
• Platelet count requirement: Document current platelet count as this determines neuraxial anesthesia safety 4
• General anesthesia preparation: If patient had recent seizure or arrives unstable, document that experienced anesthesia team prepared for difficult intubation 3

Postpartum Management Plan

Document continuation of care:

• Magnesium sulfate duration: Continue for 24 hours after delivery or last seizure, whichever is later (though recent evidence suggests women receiving ≥8g before delivery may not require full 24-hour postpartum continuation, the 24-hour standard remains recommended) 6, 1
• Blood pressure monitoring: Every 4-6 hours for at least 3 days postpartum 6, 1
• Postpartum eclampsia risk: Document that 44% of eclamptic seizures occur postpartum, requiring continued vigilance 7
• Antihypertensive continuation: Restart or continue after delivery, tapering slowly only after days 3-6 postpartum unless BP <110/70 mmHg 6, 1
• Analgesia: Avoid NSAIDs, especially with acute kidney injury; use alternative pain relief 6, 1

Critical Pitfalls to Document Avoidance Of

• Never combine magnesium sulfate with calcium channel blockers: Risk of severe hypotension 1
• Never use diuretics: Plasma volume already reduced in eclampsia 6, 5
• Never allow continuous magnesium sulfate beyond 5-7 days: Can cause fetal abnormalities 2
• Never exceed 30-40g magnesium sulfate in 24 hours: Document total daily dose 2
• Never use sublingual nifedipine with magnesium sulfate: Risk of uncontrolled hypotension and fetal distress 5

Transfer Documentation (if applicable)

If transferring to higher level of care:

• Coordination with receiving facility: Document discussion with obstetric and anesthesia-intensivist teams, including current magnesium sulfate and antihypertensive regimens 5
• Stabilization before transfer: Document that magnesium sulfate initiated and blood pressure controlled prior to transport 5
• Rationale for transfer: At 31 weeks with eclampsia, transfer to center with Maternal-Fetal Medicine expertise and NICU capabilities is appropriate 5