ECLAMPSIA

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.