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Eclampsia in the ED: Presentation, Differential Diagnosis, and Treatment

The mainstay of treatment for eclampsia is magnesium sulfate, both as seizure prophylaxis in patients with preeclampsia and as a first line antiepileptic when seizures occur...

The most recent ACOG guidelines recommend initial dosing in any patient suspected to have eclampsia includes a loading dose of 4 or 6 grams over 15-20 minutes, followed by maintenance with continuous infusion at a rate of 2 g/hr. If IV magnesium sulfate is not available or IV access cannot be established, administer a 10g loading dose IM (5g IM in each buttock) followed by 5g IM every 4 hours.

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 Preeclampsia and Eclampsia: Common Pitfalls in Diagnosis and Management

The first line medication for this is magnesium sulfate. Magnesium is given IM if necessary while IV access is being obtained. Magnesium is provided at 4-6 g IV load over 15 minutes, followed by 2-3 g/hr. The IM route includes up to 10 g. Benzodiazepines can be given in refractory situations, or if magnesium is not readily available. A gravid-appearing woman having seizures should be presumed to have eclampsia until proven otherwise.

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A burst of light on postpartum seizure

Eclampsia can occur in the post-partum period. 90% of post-partum eclamptic seizures occur within 1 week of delivery.

All Seizures Stop...Eventually (Magnesium and Eclampsia)

Delivery of the baby is the only definitive treatment for pre-eclampsia or eclampsia. However, giving magnesium sulphate 4g IV loading dose followed by 1gm/hr infusion for 24hrs saves lives and prevents further seizures in women with eclampsia.

Case of eclampsia in your resus bay

If need to consider intubation... Induction - consider propofol (category B). You want to avoid: Etomidate - lowers seizure threshold and Ketamine - worsens HTN.

Eclampsia

This is a life threatening situation for the mother and baby.

Eclampsia and hypertensive emergency in pre-eclampsia

The first eclamptic seizure is usually self-limiting. Intravenous magnesium sulphate should be initiated in patients with eclampsia as a first-line therapy and for prevention of recurrent seizures. If intravenous access is not established, magnesium sulphate (4g) or midazolam (5–10mg) can be given intramuscularly in the immediate setting, though access must be subsequently established. If the seizure is prolonged, benzodiazepines may be required. It is important to exercise a great degree of caution with co-administration of magnesium sulphate and benzodiazepines as this increases the risk of respiratory arrest.

Efficacy of Magnesium Sulfate on Maternal Mortality in Eclampsia

Unfortunately, the use of MgSO4 is constrained in developing countries by the high costs associated with the infusion pump required to administer the drug as well as the intensive monitoring for signs of toxicity. Given that preeclampsia/eclampsia remains one of the most common causes of maternal mortality in low- and middle-income countries, solutions have been proposed to improve the cost-effectiveness of MgSO4, such as limiting its use to severe preeclampsia/eclampsia along with using the IM route and employing alternative low-cost methods of drug delivery.

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TeachMe ObGyn

Eclampsia is defined as the occurrence of one or more convulsions in a pre-eclamptic woman in the absence of any other neurological or metabolic causes. The majority of seizures occur in the post-natal period (44%), but they can also occur in the antepartum (38%) or intrapartum (18%) settings.