What are the steps for managing eclampsia in a pregnant woman?

Management of Eclampsia

Magnesium sulfate must be administered immediately as the definitive first-line anticonvulsant for eclamptic seizures, followed by urgent blood pressure control and delivery planning after maternal stabilization. 1

Immediate Seizure Management

Administer magnesium sulfate immediately using the following protocol 1, 2:

• Loading dose: 4-5 g IV over 5 minutes (diluted in 250 mL of 5% dextrose or 0.9% normal saline) 2
• Simultaneous IM loading: Up to 10 g IM (5 g in each buttock) can be given concurrently 2
• Maintenance infusion: 1-2 g/hour continuous IV infusion 1, 2
• Alternative maintenance: 4-5 g IM into alternate buttocks every 4 hours as needed, depending on presence of patellar reflex and adequate respiratory function 2
• Continue for 24 hours postpartum 3

During the acute seizure, provide supportive care to prevent maternal injury while preparing magnesium sulfate 4:

• Protect the airway and ensure adequate oxygenation 5
• Position patient on left side to prevent aspiration 5
• Avoid placing objects in the mouth 5
• Provide supplemental oxygen 5

Monitor for magnesium toxicity by checking 2:

• Patellar reflexes (loss indicates toxicity) 2
• Respiratory rate (should be >12 breaths/minute) 2
• Urine output (should be >30 mL/hour) 2
• Serum magnesium levels (therapeutic range 4-8 mg/dL; target 6 mg/100 mL for seizure control) 2

Critical warning: Do not exceed 30-40 g total daily dose of magnesium sulfate, and in severe renal insufficiency, maximum is 20 g/48 hours 2

Urgent Blood Pressure Control

Treat severe hypertension (≥160/110 mmHg) immediately within 15 minutes to prevent maternal cerebral hemorrhage 1:

First-line antihypertensive options 3, 1:

• Oral nifedipine (preferred first-line agent) 1
• IV labetalol: 20 mg IV bolus, then 40 mg after 10 minutes, then 80 mg every 10 minutes (maximum cumulative dose 220 mg) 6
• IV hydralazine: 5-10 mg IV every 20 minutes as needed 6

Target blood pressure: Systolic 110-140 mmHg and diastolic 85 mmHg 1, 6

Important caveat: Avoid rapid or excessive blood pressure reduction, as this can compromise uteroplacental perfusion and cause fetal bradycardia 7. Do not reduce diastolic BP below 80 mmHg 6.

Comprehensive Laboratory Assessment

Obtain immediately 1:

• Complete blood count with hemoglobin and platelet count (assess for thrombocytopenia <100,000/μL) 1
• Comprehensive metabolic panel: AST/ALT, creatinine, uric acid (evaluate for HELLP syndrome and renal dysfunction) 1
• Coagulation studies if platelets are low or bleeding is suspected 4

Repeat laboratory tests at least twice weekly or more frequently if clinical deterioration occurs 6

Maternal Monitoring Protocol

Continuous monitoring includes 1:

• Blood pressure every 4 hours or continuously 1
• Neurological status assessment: visual disturbances, headache severity, mental status 1
• Respiratory status and oxygen saturation 1
• Deep tendon reflexes and clonus 3
• Fluid balance: limit total fluid intake to 60-80 mL/hour to avoid pulmonary edema 3
• Urine output monitoring (target 0.5-1 mL/kg/hour) 3

Watch for pulmonary edema, as preeclamptic women have capillary leak and are at high risk 3. Avoid fluid overload by replacing only insensible losses (30 mL/hour) plus anticipated urinary losses 3.

Fetal Assessment

Perform electronic fetal heart rate monitoring to assess fetal well-being 1:

• Continuous monitoring during acute management 1
• Fetal bradycardia may occur during or immediately after seizure but typically resolves 7
• Non-reassuring fetal status is an absolute indication for immediate delivery 1

Delivery Planning

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

Timing of delivery 1, 6:

• At ≥37 weeks: Deliver immediately after maternal stabilization 1, 6
• At 34-37 weeks: Deliver after maternal stabilization 6
• At <34 weeks: Deliver after maternal stabilization, as eclampsia itself is an absolute indication regardless of gestational age 6

Absolute indications for immediate delivery (any gestational age) 6:

• Eclamptic seizure (the diagnosis itself mandates delivery after stabilization) 4
• Inability to control BP despite ≥3 classes of antihypertensives 6
• Progressive thrombocytopenia 6
• Progressively abnormal liver or renal function tests 6
• Pulmonary edema 6
• Placental abruption 6
• Non-reassuring fetal status 6

Mode of delivery: Vaginal delivery is preferred if obstetric conditions are favorable; cesarean section is reserved for standard obstetric indications 5, 8. Neuraxial anesthesia is the anesthesia of choice for conscious, seizure-free women with stable vital signs undergoing cesarean section 5.

Postpartum Management

Continue magnesium sulfate for 24 hours postpartum, as eclampsia can occur in the postpartum period 3:

• Monitor BP at least every 4-6 hours for at least 3 days postpartum 3
• Continue neurological monitoring, as postpartum eclampsia remains a risk 3
• Repeat laboratory tests (hemoglobin, platelets, creatinine, liver enzymes) the day after delivery and then every other day until stable 3

Avoid NSAIDs for postpartum analgesia in women with eclampsia, especially in the setting of renal dysfunction, as they can worsen hypertension and renal function 3, 6

Critical Pitfalls to Avoid

Do not underestimate disease severity: All eclampsia can rapidly progress to life-threatening complications including cerebral hemorrhage, placental abruption, pulmonary edema, aspiration pneumonia, and acute renal failure 1, 4

Do not rely on blood pressure alone: Serious organ dysfunction develops at relatively mild BP elevations in eclampsia 1, 6

Do not delay magnesium sulfate: It is superior to phenytoin and other anticonvulsants for preventing recurrent eclamptic seizures (0.6% recurrence rate with magnesium vs 2% without) 9, 8

Do not continue magnesium sulfate beyond 5-7 days total (antepartum plus postpartum combined), as prolonged use causes fetal skeletal demineralization, osteopenia, and neonatal fractures 2

Do not perform routine cerebral imaging unless there are signs of intracranial hemorrhage, infarction, or ongoing neurologic deficit beyond the immediate post-seizure period 4

Special Considerations for HELLP Syndrome

HELLP syndrome carries 3.4% maternal mortality and is part of the eclampsia/preeclampsia spectrum 1, 6:

• Hallmark symptom: Epigastric or right upper quadrant pain 1
• Monitor glucose intraoperatively: Severe hypoglycemia can occur 6
• Manage as severe preeclampsia with all features sought and addressed 6