What is the management of eclampsia in pregnant women?

Management of Eclampsia

Eclampsia requires immediate administration of magnesium sulfate to control seizures, urgent blood pressure control if severely elevated, and delivery planning after maternal stabilization. 1, 2

Immediate Seizure Management

Magnesium sulfate is the definitive first-line anticonvulsant for eclamptic seizures and must be administered immediately. 3, 1, 2, 4

Magnesium Sulfate Dosing Protocol

• Loading dose: 4-5 g IV over 5 minutes (diluted in 250 mL of 5% dextrose or 0.9% normal saline) 1, 2
• Maintenance infusion: 1-2 g/hour continuous IV 1, 2
• Alternative regimen: 4 g IV loading dose plus simultaneous IM administration of 10 g (5 g in each buttock), followed by 4-5 g IM into alternate buttocks every 4 hours as needed 2
• Target therapeutic level: 6 mg/100 mL serum magnesium for seizure control 2
• Maximum daily dose: 30-40 g per 24 hours (20 g/48 hours in severe renal insufficiency) 2

Critical Monitoring During Magnesium Administration

• Continuously assess patellar reflexes (discontinue if absent) 2
• Monitor respiratory rate (must remain adequate) 2
• Obtain frequent serum magnesium concentrations in renal insufficiency 2
• Critical warning: Do not continue magnesium sulfate beyond 5-7 days as it causes fetal skeletal demineralization, osteopenia, and neonatal fractures 2

Acute Seizure Care

• Maintain airway, breathing, and circulation during convulsions 4
• Position patient in left lateral decubitus to prevent aspiration and optimize uteroplacental perfusion 5, 4
• Provide supplemental oxygen and monitor oxygen saturation 6
• Protect patient from physical injury during seizure activity 4

Urgent Blood Pressure Control

Severe hypertension (≥160/110 mmHg) requires immediate treatment within 15 minutes to prevent maternal cerebral hemorrhage. 1, 6

First-Line Antihypertensive Options

• Oral nifedipine: Preferred first-line agent 3, 7
• IV labetalol: 20 mg IV bolus, then 40 mg after 10 minutes, then 80 mg every 10 minutes (maximum cumulative dose 220 mg) 1
• IV hydralazine: 5-10 mg IV every 20 minutes as needed (use cautiously—can cause rapid BP drops leading to fetal bradycardia from reduced uteroplacental perfusion) 1, 8

Blood Pressure Targets

• Target systolic: 110-140 mmHg 3, 1, 6
• Target diastolic: 85 mmHg 3, 1, 6
• Minimum acceptable: <160/105 mmHg 1
• Critical pitfall: Avoid reducing diastolic BP below 80 mmHg 1

Comprehensive Laboratory Assessment

• Complete blood count with hemoglobin and platelet count (assess for thrombocytopenia <100,000/μL) 1, 6
• Comprehensive metabolic panel: AST/ALT (evaluate for HELLP syndrome), creatinine (assess for renal dysfunction >1.1 mg/dL), uric acid 1, 6
• Coagulation studies if HELLP syndrome suspected 5
• Spot urine protein/creatinine ratio 1, 6

Maternal Monitoring Protocol

• Continuous or every 4-hour blood pressure monitoring 7
• Assess for visual disturbances (scotomata, cortical blindness) 1
• Evaluate for epigastric or right upper quadrant pain (hallmark of HELLP syndrome) 1
• Monitor for pulmonary edema (use IV nitroglycerin starting at 5 mcg/min if develops, NOT plasma volume expansion) 1
• Assess deep tendon reflexes and clonus 3, 6, 7
• Monitor oxygen saturation continuously 6

Fetal Assessment

• Perform electronic fetal heart rate monitoring to assess fetal well-being 6, 7
• Obtain ultrasound for fetal biometry, amniotic fluid volume, and umbilical artery Doppler 6, 7
• Important: Non-reassuring fetal status is an absolute indication for immediate delivery 1

Delivery Planning: The Definitive Treatment

Delivery is the definitive treatment for eclampsia and should occur after maternal stabilization. 1, 5, 4

Timing of Delivery

• ≥37 weeks gestation: Immediate delivery after maternal stabilization 3, 1, 6
• 34-37 weeks without severe features: Expectant management with close monitoring 1, 6
• 34-37 weeks with severe features: Deliver after maternal stabilization 1
• <34 weeks: Individualize based on maternal and fetal status 4

Absolute Indications for Immediate Delivery (Any Gestational Age)

• Inability to control BP despite ≥3 classes of antihypertensives 3, 1
• Progressive thrombocytopenia 3, 1
• Progressively abnormal liver or renal function tests 3, 1, 7
• Pulmonary edema 3, 1
• Recurrent eclamptic seizures 7
• Placental abruption 1
• Non-reassuring fetal status 3, 1, 7
• Maternal oxygen saturation deterioration (<90%) 1

Mode of Delivery

• Cesarean section is most often recommended for eclampsia due to urgency and maternal instability 5
• Vaginal delivery can be attempted only exceptionally if rapid completion is possible with stable maternal and fetal status 5
• Maintain left lateral positioning during cesarean section 5

Anesthesia Considerations

• Regional anesthesia (neuraxial): Preferred for conscious, seizure-free patients without coagulopathy or HELLP syndrome 5, 4
• General anesthesia: Required for sudden interventions, patients arriving with active seizures, or those with coagulopathy; must be performed by experienced team prepared for difficult intubation 5, 4

Critical Pitfalls to Avoid

• Do not underestimate disease severity—all eclampsia can rapidly progress to life-threatening complications 1, 6
• Do not rely on blood pressure alone to determine severity—serious organ dysfunction develops at relatively mild BP elevations 1, 6, 7
• Do not use serum uric acid or proteinuria level as indications for delivery 1, 6, 7
• Do not use diuretics routinely—they further reduce already contracted plasma volume in preeclampsia 1, 7
• Do not delay delivery at ≥37 weeks based on non-reactive NST—delivery is indicated regardless 1
• Do not administer hydralazine too frequently—this causes dangerous rapid BP drops and fetal bradycardia from reduced uteroplacental perfusion 8
• Do not use plasma volume expansion routinely—increases risk of pulmonary edema 1, 6
• Do not administer NSAIDs for analgesia—they worsen renal function in eclampsia 7

Special Considerations for HELLP Syndrome

• HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) carries 3.4% maternal mortality 1
• Epigastric or right upper quadrant pain is the hallmark symptom 1
• Monitor glucose intraoperatively as severe hypoglycemia can occur 1
• Regional anesthesia is contraindicated due to coagulopathy 5

Postpartum Management

• Continue magnesium sulfate for 24-48 hours postpartum to prevent late postpartum eclampsia (44% of eclamptic seizures occur postpartum) 9, 10
• Monitor hourly for first 12 hours postpartum for blood pressure control and pulmonary edema 8
• Watch for massive diuresis as hemoconcentration resolves 8
• Important: Rare cases of eclampsia occur over a week after delivery, requiring extended vigilance 9

Prognosis and Counseling

• Maternal mortality: approximately 2% in developed countries 9
• Major maternal complications occur in 23-35% (ventilation requirement, pulmonary edema, renal failure, DIC, stroke, cardiac arrest) 9
• Stillbirth or neonatal death occurs in approximately 7% of cases 9
• Recurrence risk in subsequent pregnancies: 1-2% for eclampsia, 22-35% for preeclampsia 10