What is the management approach for a pregnant woman with eclampsia?

Management of Eclampsia

Eclampsia requires immediate seizure control with magnesium sulfate, urgent blood pressure management if ≥160/110 mmHg, and delivery as the definitive treatment once maternal stabilization is achieved. 1, 2, 3

Immediate Seizure Management

Acute Seizure Care

• Ensure airway patency, adequate breathing, and circulation during convulsions 3
• Position the patient on her left side to prevent aspiration and optimize uteroplacental perfusion 3
• Administer supplemental oxygen and prepare for potential intubation if airway protection is compromised 3

Magnesium Sulfate Administration

• Give an initial IV loading dose of 4-5 g magnesium sulfate diluted in 250 mL of 5% dextrose or 0.9% sodium chloride, infused over 3-4 minutes 2
• Simultaneously administer 10 g IM (5 g in each buttock using undiluted 50% solution) if IV access is limited 2
• Continue maintenance therapy with 1-2 g/hour by constant IV infusion or 4-5 g IM every 4 hours into alternate buttocks 2
• Target serum magnesium level of 6 mg/100 mL for optimal seizure control 2
• Continue magnesium sulfate for 24 hours postpartum 1

Magnesium Toxicity Monitoring

• Check patellar reflexes hourly—absent reflexes indicate impending toxicity 2
• Monitor respiratory rate (must be >12 breaths/minute) and urine output (>25-30 mL/hour) 2
• Have calcium gluconate 1 g IV available as antidote for magnesium toxicity 3
• Do not exceed 30-40 g total daily dose; in severe renal insufficiency, maximum is 20 g/48 hours 2
• Never continue magnesium sulfate beyond 5-7 days as it causes fetal skeletal demineralization, osteopenia, and neonatal fractures 2

Blood Pressure Management

Severe Hypertension (≥160/110 mmHg)

• Initiate urgent treatment within 15 minutes to prevent maternal stroke 1, 4
• First-line: Oral nifedipine 10 mg, repeat every 20 minutes to maximum 30 mg 1
• Alternative: IV labetalol 20 mg bolus, then 40 mg after 10 minutes if needed, followed by 80 mg every 10 minutes to maximum 220 mg 1
• Target systolic BP 110-140 mmHg and diastolic BP 85 mmHg 1, 4

Critical Blood Pressure Pitfalls

• Never use sublingual nifedipine—causes precipitous drops leading to myocardial infarction or fetal distress 5, 1
• Never combine IV magnesium with calcium channel blockers—causes myocardial depression 5, 1
• Absolutely contraindicated: ACE inhibitors, ARBs, direct renin inhibitors (cause fetal renal dysgenesis) 5, 1, 4

Maternal Monitoring

• Monitor blood pressure continuously or every 4 hours while awake for at least 3 days postpartum 5, 1
• Assess deep tendon reflexes and clonus hourly while on magnesium sulfate 1
• Obtain laboratory tests at least twice weekly: complete blood count (hemoglobin, platelets), liver enzymes (AST/ALT), creatinine, uric acid 1, 4
• Evaluate for pulmonary edema, severe persistent headache, visual disturbances, or epigastric/right upper quadrant pain 1, 4

Fluid Management

• Strictly limit total fluid intake to 60-80 mL/hour to prevent pulmonary edema 1, 4
• Aim for euvolemia; avoid "running dry" as this increases acute kidney injury risk 1
• Diuretics are absolutely contraindicated—they further reduce plasma volume already compromised in eclampsia and worsen uteroplacental perfusion 5, 1

Fetal Surveillance

• Perform continuous electronic fetal heart rate monitoring to assess for non-reassuring fetal status 1, 6
• Obtain ultrasound for fetal biometry, amniotic fluid volume, and umbilical artery Doppler 1, 4
• Assess biophysical profile including fetal breathing movements, body movements, and tone 6

Timing and Mode of Delivery

Delivery Indications

• Delivery is the only definitive treatment for eclampsia 5, 1
• Deliver immediately after maternal stabilization if any of the following occur: 1, 4
  • Repeated eclamptic seizures despite magnesium sulfate
  • Repeated episodes of severe hypertension despite treatment with 3 antihypertensive classes
  • Progressive thrombocytopenia or abnormal liver/renal function
  • Pulmonary edema
  • Placental abruption
  • Non-reassuring fetal status

Gestational Age Considerations

• If gestational age <34 weeks and maternal/fetal status permits brief delay, administer corticosteroids for 48 hours to accelerate fetal lung maturation 5, 1
• At ≥37 weeks, proceed with delivery after maternal stabilization 6

Mode of Delivery

• Vaginal delivery is preferred unless cesarean is indicated for standard obstetric reasons 6
• Neuraxial anesthesia is the anesthesia of choice for conscious, seizure-free women with stable vital signs undergoing cesarean section 3

Postpartum Management

• Continue close monitoring for at least 3 days postpartum as eclampsia can develop de novo in the postpartum period 5, 1
• Continue antihypertensives and taper slowly after days 3-6 postpartum; never cease abruptly 5
• Avoid NSAIDs for postpartum analgesia—they worsen renal function in eclampsia, especially with known renal disease, placental abruption, acute kidney injury, sepsis, or postpartum hemorrhage 5, 4
• Review at 3 months postpartum to ensure blood pressure, urinalysis, and laboratory abnormalities have normalized 5

Long-Term Counseling

• Women with eclampsia have significantly increased lifetime cardiovascular disease risk 5, 1
• Recommend annual medical review lifelong with healthy lifestyle including exercise, ideal body weight, and healthy eating 5
• Aim to achieve prepregnancy weight by 12 months and limit interpregnancy weight gain 5