Occurrence of generalised tonic-clonic seizures after 20 weeks of pregnancy, associated with hypertension
and proteinuria, without any other neurological cause of seizures.
Clinical features
- Patient may or may not have had previous clinical features of severe pre-eclampsia
- Headache that is usually frontal, blurring of vision, aura (flickering lights)
- Generalized tonic-clonic seizures
- Right upper quadrant abdominal pain with nausea
- BP raised >140/90 mmHg
- Oedema of legs and sometimes face and body
- Unconsciousness if condition not treated
- Amnesia and other mental changes
Differential diagnosis
- Other causes of fits, e.g. cerebral malaria, meningitis, epilepsy, poisoning
Investigations
- Urine for Protein
- CBC, LFT, RFT
- Malaria parasites
- Urea, electrolytes
- Clotting time if platelet count <100×109
- Fibrinogen levels
PRINCIPLES OF MANAGEMENT
Eclampsia is a medical emergency and should be referred to hospital urgently, after first aid measures as available.
Goals of treatment are:
- Controlling/preventing convulsions
- Controlling blood pressure
- Delivering the baby as soon as possible
First aid
- Protect the airway by placing the patient on her left side
- Prevent patient from hurting herself
- Place padded tongue blade between her teeth to prevent tongue bite, and secure it to prevent
aspiration – DO NOT attempt this during a convulsion - Do not restrict/restrain the patient while fitting
- Refer to hospital as soon as possible
Stop and control convulsions
- Give IV loading dose of magnesium sulphate injection (4 g of MgSO4)
- Draw 8 mL of a 50% MgSO4 and add 12 mL of water for injection or Normal saline: this is equal
to 4 g of 20% MgSO4 - Give the solution as slow IV bolus over 20 minutes (the 20-20-20 rule)
- Then give 5 g of magnesium sulphate (10 mL of MgSO4 50% solution, undiluted) in each buttock
deep IM (total 10 g) with 1 mL of 2% lignocaine in the same syringe - Give IV fluids (Normal saline) very slowly (1 L in 6-8 hours max)
- Monitor BP, pulse, and respiration every 30 minutes; pass indwelling Foley’s catheter for
continuous bladder drainage - Monitor fluid balance
If the facility has capacity, continue with maintenance dose after 4 hours from the loading
dose, ONLY IF:
- Urine output >100 mL in 4 hours
- Respiratory rate is >16 per minute
- Patellar reflexes (knee jerk) are present
Signs of magnesium sulphate toxicity
- Respiratory depression, rate <16 breaths per minute
- Urine output <30 mL/hour
- Depressed patellar reflexes
Antidote for magnesium sulphate
- Give calcium gluconate 1 g (10 mL of 10%) slow IV, not exceeding 5 mL per minute. Repeat prn
until respiratoty rate gets back to normal (rate >16 breaths per minute)
Maintenance dose
- Magnesium sulphate 5 g IM (10 mL of MgSO4 50% solution) every 4 hours in alternate buttocks
for 24 hours from the time of loading dose or after the last convulsion; whichever comes first. Add 1
mL of lignocaine 2% in the same syringe
If there are further convulsions
- Repeat ½ of the loading dose of magnesium sulphate (2 g of 20% solution given IV, slowly)
ONLY IF magnesium sulphate is not available use - Diazepam 10 mg slow IV over 2 minutes loading dose, (repeat once if convulsions recur)
- Diazepam 40 mg in 500 mL of normal saline IV infusion to run slowly, keeping the patient sedated
but rousable
Note
Notify the person who will resuscitate the newborn that a benzodiazepine and/or magnesium sulphate has been given to the mother
Control blood pressure: if BP is >110 mmHg diastolic or >170 mmHg systolic
- Give hydralazine 5 mg IV bolus every 30 minutes until diastolic is BP is down to <100 mmHg
- Alternative, if hydralazine not available: Nifedipine 20 mg orally every 12 hours until
delivery - Or Labetalol 20 mg IV over 2 minutes, double the dose every 30 minutes until diastolic is <100
mmHg (total dose not to exceed 160 mg/hour) - Maintenance antihypertensive therapy is necessary after controlling the BP. Maintain the
patient on Nifedipine retard 20 mg 12 hourly until delivery - Monitor BP every 15 minutes until stable (when systolic BP <170 and Diastolic <100 mmHg)
Deliver the baby by the safest and fastest means available within 6-12 hours
- Augment labour if mother is approaching second stage with nor contraindication to vaginal
delivery and theatre is nearby - Perform vacuum extraction if mother is in second stage and there is no contraindication
- Deliver by emergency caesarian section if facilities are available
Post delivery care
- Monitor BP every 15 minutes for 2 hours
- Continue to monitor vital signs (BP, urine protein, etc) very carefully for at least 48 hours
- Continue antihypertensive to mantain BP diastolic <90 mmHg
- Send home when BP is stable and no urine protein
- Continue antihypertensive according to clinical monitoring
Note
- Hypertension usually resolves with birth of the baby, but may persist (e.g. in case of undiagnosed
pre existent hypertension)
Prevention
- Regular attendance of good antenatal care with a skilled birth attendant, and checking of blood pressure and urine protein.