What is the management for a pregnant patient with hypertension (high blood pressure), headache, and seizure?

Management of Eclampsia in Pregnancy

This patient has eclampsia (seizure in the setting of severe preeclampsia) and requires immediate administration of magnesium sulfate for seizure control, urgent IV antihypertensive therapy to reduce blood pressure to safe levels (systolic 110-140 mmHg, diastolic 85 mmHg), and expedited delivery after maternal stabilization. 1

Immediate Seizure Management

Administer magnesium sulfate immediately - this is the definitive treatment for eclamptic seizures and prevention of recurrent seizures. 2, 1, 3

• Loading dose: 4-5g IV over 5 minutes 1
• Maintenance dose: 1-2g/hour continuous IV infusion 1
• Magnesium sulfate is superior to other anticonvulsants (including phenytoin and diazepam) for both treatment and prevention of eclamptic seizures 4, 3

During active seizure:

• Position patient on left side to prevent aspiration 5
• Ensure airway patency and administer oxygen 5
• Do not attempt to restrain or place objects in mouth 4

Urgent Blood Pressure Control

Initiate IV antihypertensive therapy immediately when BP ≥160/110 mmHg persists for more than 15 minutes. 2, 1

First-line IV antihypertensive options: 2, 1

• IV Labetalol: 20mg IV bolus, then 40mg after 10 minutes, followed by 80mg every 10 minutes to maximum 220mg 1
• IV Hydralazine: Alternative option, though associated with more perinatal adverse effects than labetalol 2
• Oral nifedipine: 10mg orally can be used for non-severe hypertension 2, 5

Target blood pressure: Systolic 110-140 mmHg and diastolic 85 mmHg (or at minimum <160/105 mmHg) 2, 1

Critical warning: Avoid short-acting oral nifedipine when combined with magnesium sulfate due to risk of uncontrolled hypotension and fetal compromise. 1, 6 Careful blood pressure monitoring is essential when using this combination. 6

Diagnostic Workup

Immediate laboratory assessment: 2, 1

• Complete blood count (hemoglobin, platelet count) - assess for HELLP syndrome
• Comprehensive metabolic panel (creatinine, liver enzymes including ALT and LDH)
• Coagulation studies (fibrinogen, D-dimer, PT)
• Urine protein-to-creatinine ratio or 24-hour urine collection
• Serum uric acid

Look for signs of HELLP syndrome: 2, 7

• Hemolysis (elevated LDH, decreased haptoglobin)
• Elevated liver enzymes (ALT, AST)
• Low platelet count (<100 × 10⁹/L)
• Right upper quadrant or epigastric pain

Critical Monitoring Requirements

Continuous maternal monitoring: 1

• Blood pressure every 15 minutes until stable, then hourly
• Deep tendon reflexes before each magnesium dose (to detect toxicity)
• Respiratory rate (magnesium toxicity causes respiratory depression)
• Hourly urine output via Foley catheter (target ≥100 mL/4 hours or >35 mL/hour)
• Oxygen saturation (maintain >95%)
• Level of consciousness (assess for confusion, agitation, unresponsiveness)

Fetal monitoring: 1

• Continuous fetal heart rate monitoring
• Ultrasound assessment of fetal status, biometry, and amniotic fluid

Delivery Planning

Delivery is the definitive cure and should be expedited after maternal stabilization. 2, 1, 8

Absolute indications for immediate delivery (after stabilization): 1

• Eclampsia (this patient)
• Inability to control BP despite ≥3 classes of antihypertensives
• Progressive thrombocytopenia or worsening liver/renal function
• Pulmonary edema
• Non-reassuring fetal status
• Gestational age ≥34 weeks

Before delivery at <35 weeks: 2

• Administer corticosteroids (betamethasone or dexamethasone) for fetal lung maturity per national guidance
• Magnesium sulfate also provides neuroprotection if delivery required before 32 weeks

Mode of delivery: 1

• Vaginal delivery is preferred unless cesarean indicated for obstetric reasons
• Induction of labor is associated with improved maternal outcomes

Special Considerations and Pitfalls

Magnesium sulfate toxicity monitoring: 1

• Loss of deep tendon reflexes is the first sign of toxicity
• Respiratory depression occurs at higher levels
• Have calcium gluconate 1g IV available as antidote

Avoid these medications: 1

• Sodium nitroprusside (except extreme emergencies - risk of fetal cyanide poisoning)
• ACE inhibitors, ARBs, direct renin inhibitors (absolutely contraindicated - severe fetotoxicity)
• Diuretics (worsen plasma volume depletion)

For pulmonary edema: 1

• IV nitroglycerin is drug of choice (starting 5 mcg/min, titrate to maximum 100 mcg/min)
• Do not use routine plasma volume expansion

Postpartum care: 2, 7

• Continue magnesium sulfate for 24-48 hours postpartum
• Eclampsia can occur up to 1 month postpartum (late postpartum eclampsia) 3
• Monitor blood pressure closely - most resolve within 42 days but some require continued antihypertensive therapy

Transfer considerations: 1

• If not at a facility with maternal-fetal medicine expertise and level 2/3 care capability, initiate magnesium sulfate and blood pressure control prior to medicalized transport
• Coordinate with receiving obstetric and anesthesia teams before transfer