What is the management of eclampsia (a severe complication of preeclampsia)?

From the Guidelines

Management of eclampsia requires immediate intervention with magnesium sulfate as the first-line treatment for seizure control, followed by stabilization of the patient and delivery of the baby if necessary. The first step is to ensure maternal safety by placing the patient in a left lateral position to prevent aspiration and maintain placental perfusion. Magnesium sulfate is administered as a 4-6g IV loading dose over 15-20 minutes, followed by a maintenance infusion of 1-2g/hour for 24 hours after the last seizure or delivery, as recommended by the most recent guidelines 1.

Seizure Control and Stabilization

• Magnesium sulfate is the drug of choice for seizure control in eclampsia, with a loading dose of 4-6g IV over 15-20 minutes, followed by a maintenance infusion of 1-2g/hour for 24 hours after the last seizure or delivery 1.
• Blood pressure should be controlled if severe hypertension is present (≥160/110 mmHg) using IV labetalol (20-40mg every 10-15 minutes) or IV hydralazine (5-10mg every 20 minutes), as these are considered safe and effective for the treatment of severe pre-eclampsia 1.
• Oral nifedipine (10-20mg) can be used as an alternative, but its use should be avoided except in low-resource settings when other drugs are unavailable or until IV access can be obtained and alternative drugs administered 1.

Delivery and Fetal Monitoring

• Once the patient is stabilized, delivery should be planned, as it is the definitive treatment for eclampsia.
• Continuous fetal monitoring should be initiated, and oxygen should be administered to maintain maternal oxygen saturation above 95%.
• Laboratory tests including complete blood count, liver and renal function tests, coagulation profile, and urinalysis should be performed to assess for complications like HELLP syndrome.

Monitoring for Magnesium Toxicity

• Magnesium toxicity should be monitored by checking deep tendon reflexes, respiratory rate, and urine output, with calcium gluconate (1g IV) kept readily available as an antidote.
• Eclampsia is a life-threatening complication of preeclampsia characterized by seizures resulting from cerebral vasospasm, endothelial damage, and cerebral edema, requiring prompt multidisciplinary management to improve maternal and fetal outcomes.

From the FDA Drug Label

In severe pre-eclampsia or eclampsia, the total initial dose is 10 to 14 g of magnesium sulfate. Intravenously, a dose of 4 to 5 g in 250 mL of 5% Dextrose Injection, USP or 0. 9% Sodium Chloride Injection, USP may be infused. Simultaneously, IM doses of up to 10 g (5 g or 10 mL of the undiluted 50% solution in each buttock) are given Alternatively, the initial IV dose of 4 g may be given by diluting the 50% solution to a 10 or 20% concentration; the diluted fluid (40 mL of a 10% solution or 20 mL of a 20% solution) may then be injected IV over a period of three to four minutes Subsequently, 4 to 5 g (8 to 10 mL of the 50% solution) are injected IM into alternate buttocks every four hours as needed, depending on the continuing presence of the patellar reflex and adequate respiratory function. Alternatively, after the initial IV dose, some clinicians administer 1 to 2 g/hour by constant IV infusion. Therapy should continue until paroxysms cease A serum magnesium level of 6 mg/100 mL is considered optimal for control of seizures. A total daily (24 hr) dose of 30 to 40 g should not be exceeded.

The management of eclampsia involves the administration of magnesium sulfate.

• The initial dose is 10 to 14 g, given as an IV dose of 4 to 5 g and an IM dose of up to 10 g.
• The dose is then repeated every 4 hours as needed, with a maximum daily dose of 30 to 40 g.
• The goal is to maintain a serum magnesium level of 6 mg/100 mL to control seizures.
• Therapy should continue until paroxysms cease 2.
• It is essential to monitor serum magnesium levels and the patient's clinical status to avoid the consequences of overdosage in toxemia 2.
• Magnesium sulfate should be used with caution in patients with renal impairment, and the maximum dosage should not exceed 20 grams/48 hours 2.
• Magnesium sulfate can cause fetal abnormalities when administered beyond 5 to 7 days to pregnant women 2.

From the Research

Management of Eclampsia

• Eclampsia is a serious complication of preeclampsia that can be life-threatening for both the mother and the fetus 3.
• Magnesium sulfate is the ideal drug for the prevention and treatment of eclampsia, and its effectiveness has been established in several studies 4, 3, 5, 6, 7.
• The use of magnesium sulfate has been shown to reduce the risk of eclampsia by more than half, with a significant reduction in maternal mortality and morbidity 5, 7.
• A maintenance dose of 1 gram/hour of magnesium sulfate has been found to be as effective as a 2-gram maintenance dose, with fewer side effects 4.
• Magnesium sulfate has also been shown to reduce the risk of placental abruption and increase the risk of caesarean section 7.
• Other anticonvulsants, such as phenytoin and nimodipine, have been compared to magnesium sulfate, and magnesium sulfate has been found to be more effective in reducing the risk of eclampsia 5, 7.
• Side effects of magnesium sulfate are common, but are usually mild, with flushing being the most common side effect 7.
• The use of magnesium sulfate has been recommended as the drug of choice for the prevention and treatment of eclampsia, due to its effectiveness and safety profile 3, 6, 7.