Eclampsia management

Eclampsia is a condition peculiar to pregnancy and the postpartum period, characterized by elevated blood pressure and tonic-clonic convulsions that are not caused by epilepsy, severe malaria, meningitis, hypoglycaemia, or other causes of seizures. Approximately 50% of cases occur before term. Eclampsia may occur without prior elevation of blood pressure.

Diagnostic Criteria

• Features of severe pre-eclampsia (BP ≥160/110 mmHg)

• Loss of consciousness

• Tonic-clonic seizures

• Coma

Investigations

• Full blood count and blood crossmatch

• Obstetric ultrasound for gestational age and fetal viability

• Urea, creatinine and electrolytes

• Liver function tests

• 24-hour urine collection for proteinuria

• Clotting profile

• Blood smear to exclude malaria

• Blood glucose estimation to exclude hypoglycaemia

• Lumbar puncture when indicated to exclude meningitis

Pharmacological Treatment

Antihypertensive Therapy

Manage hypertension as for severe pre-eclampsia.

Magnesium Sulfate

Loading Dose

• Magnesium sulfate 4 g IV of 20% solution administered slowly over 5 minutes.

If only 50% magnesium sulfate is available:

• Draw 8 mL of 50% magnesium sulfate.

• Add 12 mL of water for injection.

• This produces 20 mL of 20% magnesium sulfate solution.

OR

• Draw 10 mL (5 g) of 50% magnesium sulfate into each syringe.

• Add 1 mL of 2% lignocaine into each syringe.

• Administer deep IM injection into each buttock.

Maintenance Dose

Continue until 24 hours after delivery or 24 hours after the last convulsion, whichever is later.

Options include:

• Magnesium sulfate infusion 1 g/hour in 200–300 mL Ringer’s Lactate

OR

• Magnesium sulfate 5 g undiluted 50% solution plus 1 mL of 2% lignocaine, administered as a deep IM injection into alternating buttocks every 4 hours

Recurrent convulsions management

If convulsions recur within 15 minutes:

• Magnesium sulfate 2 g IV slowly over 5 minutes

Preparation:

• Draw 4 mL of 50% magnesium sulfate (2 g)

• Add 6 mL water for injection

• This yields 10 mL of 20% magnesium sulfate solution

Monitoring During Magnesium Sulfate Therapy

Magnesium sulfate should only be continued if:

• Patellar reflexes are present

• Respiratory rate is ≥12 breaths per minute

• Urine output is >100 mL over 4 hours

Features of Magnesium Sulfate toxicity

• Respiratory depression (<16 breaths/minute)

• Reduced urine output (<30 mL/hour)

• Loss of deep tendon reflexes

Management of magnesium Sulfate toxicity

• Stop magnesium sulfate administration immediately

• Administer calcium gluconate 1 g IV slowly over 2–3 minutes

Obstetrical management

• Deliver within 12 hours of onset of seizures, even if the fetus is premature.

• Expectant management is contraindicated.

If the patient is not in labour and there are no contraindications:

Misoprostol

• 50 micrograms orally every 4 hours

OR

• 25 micrograms vaginally every 8 hours

Maximum: 4 doses

If induction fails or vaginal delivery is contraindicated:

• Perform immediate Caesarean section.

Prevention of pre-eclampsia and eclampsia

• Ensure effective antenatal care

• Calcium supplementation 1.5–2.0 g elemental calcium daily for women at high risk of developing pre-eclampsia

• Low-dose aspirin 75 mg daily for women at high risk of developing pre-eclampsia