Management of Eclampsia

Initial Management

The European Society of Cardiology recommends immediate administration of intravenous magnesium sulfate for seizure control, along with antihypertensive therapy to maintain blood pressure below 160/105 mmHg, followed by delivery after maternal stabilization 1, 2
The American Heart Association suggests administering magnesium sulfate as first-line anticonvulsant, with a loading dose of 4-5g IV over 5 minutes, and maintenance dose of 1-2g/hour as continuous IV infusion for 24 hours after the last seizure 1, 3
The European Society of Cardiology recommends targeting blood pressure <160/105 mmHg to prevent maternal complications, using first-line IV antihypertensives such as labetalol or nicardipine 1, 3, 4, 5
Labetalol can be administered with an initial 20mg IV bolus, then 40mg after 10 minutes, followed by 80mg every 10 minutes to maximum 220mg 6
Nicardipine can be started at 5mg/h, increased by 2.5mg/h every 5-15 minutes to maximum 15mg/h 3

The American College of Cardiology recommends continuous blood pressure monitoring, assessing deep tendon reflexes, monitoring respiratory rate, and maintaining urine output >100mL over 4 hours preceding each dose 2, 7
The European Society of Cardiology suggests performing laboratory tests twice weekly, including hemoglobin, platelet count, liver enzymes, creatinine, and uric acid 2
Continuous fetal heart rate monitoring and ultrasound assessment of fetal biometry, amniotic fluid, and umbilical artery Doppler are recommended 2, 4, 7

The American College of Obstetricians and Gynecologists recommends delivery after maternal stabilization 2, 3
Indications for immediate delivery include inability to control blood pressure, progressive deterioration in liver function, creatinine, hemolysis, or platelet count, ongoing neurological features, placental abruption, abnormal fetal status, and gestational age ≥37 weeks 2, 7
Vaginal delivery is preferred unless cesarean is indicated for obstetric reasons 3
Antenatal corticosteroids can be administered if gestation is ≤34 weeks to accelerate fetal lung maturation 2, 3

The European Society of Cardiology recommends avoiding combination of magnesium sulfate with calcium channel blockers due to risk of severe hypotension 3, 7
Signs of magnesium toxicity include loss of patellar reflexes, respiratory depression, cardiac conduction abnormalities, and cardiac arrest 6, 7
Injectable calcium salt should be available to counteract magnesium toxicity 7

The American College of Cardiology recommends continuing magnesium sulfate for 24 hours after delivery or last seizure, and continuing antihypertensive therapy during labor and postpartum period 3
Blood pressure and urine should be checked at 6 weeks postpartum, and secondary causes of hypertension should be assessed in women under 40 with persistent hypertension 3

The European Society of Cardiology recommends avoiding sodium nitroprusside due to risk of fetal cyanide toxicity 4, 5
Diuretics should not be used as plasma volume is already reduced in preeclampsia 1, 3

Administer 4g IV combined with 10g IM (5g in each buttock) for a total loading dose of 14g, as an alternative to IV loading dose, according to the American College of Obstetricians and Gynecologists 8
Administer antenatal corticosteroids if gestational age is ≤34 weeks, and may be given up to 38 weeks for elective cesarean section, as recommended by the American College of Obstetricians and Gynecologists 8
Multiple steroid courses are not recommended, as stated by the American College of Obstetricians and Gynecologists 8
If IV access unavailable, give IM loading dose of 5g magnesium sulfate in each buttock (10g total) and refer, according to the World Health Organization 8
Methyldopa and nifedipine are acceptable oral antihypertensives when IV agents unavailable, as recommended by the American Heart Association 8
The Pritchard regimen (IM administration) can be used when IV infusion pumps are not available, according to the American College of Obstetricians and Gynecologists 8
Task-shifting allows lower-level providers to initiate loading dose and refer, as stated by the World Health Organization 8

The American College of Cardiology recommends alternative IM regimen of 5g IM every 4 hours in alternating buttocks for magnesium sulfate administration 9
Recent evidence suggests women receiving ≥8g MgSO4 before delivery may not require full 24-hour postpartum continuation, though 24-hour postpartum continuation remains the standard recommendation until further validation 10

The American Heart Association recommends restricting total fluid intake to 60-80mL/hour to prevent pulmonary edema, replacing insensible losses (30mL/hour) plus anticipated urinary output (0.5-1mL/kg/hour) 10
Preeclamptic/eclamptic women have capillary leak and are at high risk for pulmonary edema with excessive fluids 10
Hydralazine can be used as an alternative IV agent when labetalol/nicardipine are unavailable 10

The American College of Obstetricians and Gynecologists recommends delivery after maternal stabilization with magnesium sulfate and blood pressure control, with indications for immediate delivery including inability to control blood pressure despite 3 antihypertensive classes, progressive thrombocytopenia or HELLP syndrome, and others 9

Initial assessment should include uric acid levels 10
Repeat labs should be done day after delivery, then every 2 days until stable if abnormal before delivery, and twice weekly during expectant management <34 weeks 10

The American College of Obstetricians and Gynecologists recommends continuing magnesium sulfate for 24 hours after delivery or last seizure (whichever is later) 10
Blood pressure should be monitored every 4-6 hours for at least 3 days postpartum, and antihypertensives should be restarted or continued after delivery, tapering slowly only after days 3-6 postpartum unless BP <110/70 mmHg 10
NSAIDs should be avoided in women with eclampsia/preeclampsia, especially with acute kidney injury, and alternative analgesia should be used 10
Postpartum eclampsia can occur in 25-30% of cases, and vigilance should be maintained with continued prophylaxis 10