Eclampsia Management

Clinical assessment

New onset of generalized tonic-clonic seizures in a woman >20 weeks pregnant, during labour, or postpartum (usually within 48h, but can occur later) PLUS evidence of pre-eclampsia (hypertension +/- proteinuria or other signs like HELLP). Diagnosis requires exclusion of other causes of seizures.

Investigations

• Blood Pressure measurement (essential)
• Urine dipstick for Proteinuria (essential)
• Rule out other causes: Point-of-care Blood Glucose (hypoglycaemia), Malaria parasites test (cerebral malaria).
• Hospital level investigations (for severity assessment / HELLP syndrome / complications):
• - Full Blood Count (CBC) - check Platelet count, signs of Haemolysis.
• - Liver Function Tests (LFTs) - check AST, ALT.
• - Renal Function Tests (RFTs) - Urea, Creatinine.
• - Electrolytes.
• - Coagulation profile (if platelets low or surgery planned).

Diagnostic criteria

Generalized tonic-clonic seizure(s) in the setting of pre-eclampsia (hypertension after 20 weeks gestation with proteinuria OR hypertension with signs of severe features like low platelets, high LFTs, high creatinine, pulmonary oedema, cerebral/visual symptoms) after excluding other neurological or metabolic causes.

Non-pharmacological management

• Call for Help! (Obstetric emergency).
• Positioning: Place patient in left lateral position to prevent aspiration and improve uteroplacental blood flow.
• Airway Management: Ensure patent airway, suction if necessary. Prevent injury during seizure (protect head, padded tongue blade *between* teeth *after* seizure to prevent bite - DO NOT force during convulsion). Do not restrain.
• Oxygen Therapy: Administer high-flow oxygen via face mask.
• Urinary Catheterization: Insert Foley catheter to monitor urine output accurately (essential for MgSO4 safety and fluid balance).
• Prepare for Delivery: Definitive treatment is delivery of baby and placenta, planned once mother is stabilized (usually within 6-12 hours).

Pharmacological treatment

• Anticonvulsant Therapy (FIRST LINE):
• - Magnesium Sulphate (MgSO4): Loading Dose: 4 grams IV slowly over 20 minutes (e.g., 8 mL of 50% MgSO4 diluted with 12 mL water for injection/NS) PLUS 10 grams IM (5g = 10mL of 50% MgSO4 undiluted, deep IM in each buttock, mixed with 1mL of 2% Lignocaine).
• - Maintenance Dose: 5 grams IM (10mL of 50% MgSO4 undiluted with 1mL Lignocaine 2%) every 4 hours into alternate buttocks. Continue for 24 hours after the last seizure or delivery, whichever is later.
• - Recurrent Seizure: Give additional 2 grams MgSO4 IV slowly (4mL of 50% solution diluted) over 5-10 minutes.
• - MgSO4 Monitoring (BEFORE each maintenance dose): Check Respiratory Rate (>16/min), Urine Output (>100 mL in past 4 hours), Patellar Reflexes (must be present). Withhold dose if signs of toxicity present.
• - MgSO4 Antidote: Calcium Gluconate 1 gram (10 mL of 10% solution) IV slowly over 5-10 minutes if signs of toxicity (especially respiratory depression <12/min).
• Anticonvulsant Therapy (SECOND LINE - if MgSO4 unavailable):
• - Diazepam: 10 mg slow IV over 2 minutes (loading). Repeat once if seizure recurs. Follow with infusion: 40 mg in 500 mL Normal Saline IV, run slowly to keep patient sedated but rousable. (Note: Less effective than MgSO4 and causes more sedation).
• Antihypertensive Therapy (if BP severely elevated: SBP ≥160-170 mmHg or DBP ≥110 mmHg):
• - Hydralazine: 5 mg IV bolus slowly. Repeat every 20-30 minutes until target BP reached (aim DBP 90-100 mmHg).
• - Labetalol: 20 mg IV slowly over 2 minutes. Can repeat with increasing doses (40mg, 80mg) every 10-20 mins (max total dose ~300mg).
• - Nifedipine (oral): 10-20 mg capsule (bite and swallow, or just swallow). Repeat after 30 mins if needed. Then use sustained-release Nifedipine 20mg PO q12h for maintenance.
• - Maintain BP control (DBP 90-100 mmHg) until delivery and postpartum.
• IV Fluids: Use cautiously to avoid pulmonary oedema. Isotonic crystalloids (NS or RL) at maintenance rate (e.g., ~1 L over 8-12 hours or ~80-125 ml/hr), unless significant fluid loss.
• Follow specific Ugandan treatment algorithms/guidelines.

Monitoring

Continuous or frequent monitoring of: Vital signs (BP, HR, RR, SpO2) - e.g., q15min during stabilization, then q30-60min. Neurological status (level of consciousness, seizure activity). Fetal heart rate (continuous EFM if available). Urine output (hourly). Signs of MgSO4 toxicity (RR, reflexes, urine output) before each dose. Fluid balance.