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10 practical, evidence-based recommendations to improve outcomes in women who have eclampsia

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Both maternal and perinatal outcomes will improve if you follow these data-driven strategies for managing eclampsia and stabilizing the mother


 

Because eclampsia occurs but rarely during pregnancy and the postpartum period, most health-care providers have little to no personal experience with management of this life-threatening obstetric emergency. Knowledge about maternal resuscitation during and after an eclamptic seizure is critical for improving maternal and perinatal outcomes.

In this round-up, I present 10 practical recommendations for prompt diagnosis and management of women who have eclampsia. Immediate implementation of these recommendations can lead to improved maternal and perinatal outcomes (both acute and long-term).

1. Practice. Practice again.

Implement regular monthly simulation training sessions

Fisher N, Bernstein PS, Satin A, et al. Resident training for eclampsia and magnesium toxicity management: simulation or traditional lecture? Am J Obstet Gynecol. 2010;203(4):379.e1–5.

Eclampsia is unpredictable and can develop rapidly at home, in labor and delivery, on the antepartum/postpartum ward, and in the emergency room. Therefore, it is prudent that all health-care providers who treat pregnant or postpartum women on a daily basis be trained and knowledgeable about early detection and management of eclampsia. This goal can be achieved by developing drills for rehearsal and by testing the response and skills of all providers.

2. Preventive: Magnesium sulfate

Do not attempt to arrest the seizure. Use MgSO4 to prevent recurrent convulsions.

Duley L, Henderson-Smart DJ, Walker GJ, Chou D. Magnesium sulfate versus diazepam for eclampsia. Cochrane Database Syst Rev. 2010;(12):CD000127.

Most eclamptic seizures are self-limiting. Therefore, there is no need to administer bolus drugs such as diazepam or midazolam. These drugs are usually used in the emergency room, but they inhibit maternal laryngeal reflexes and may lead to aspiration. They also suppress the central nervous system respiratory centers and can cause apnea, requiring intubation.

When used in the management of eclampsia, magnesium sulfate is associated with a lower rate of recurrent seizures and maternal death than is diazepam.

3. FHR changes? Be patient.

Do not rush the patient to emergent cesarean section because of an abnormal FHR tracing

Sibai BM. Diagnosis, prevention, and management of eclampsia. Obstet Gynecol. 2005;105(2):402–410.

During an eclamptic convulsion, there is usually prolonged fetal heart rate (FHR) deceleration or even bradycardia—with or without an increase in both frequency and uterine tone. After the convulsion, as a result of maternal hypoxia and hypercarbia, the FHR tracing can show tachycardia, reduced beat-to-beat variability, and transient recurrent decelerations. When this happens, concern about fetal status can distract the obstetric provider from resuscitation of the mother. However, these FHR changes usually return to normal after maternal resuscitation. If the FHR changes persist for longer than 15 minutes, consider abruptio placentae and move to delivery.

4. Target: Lower BP

Reduce maternal blood pressure to a safe level to prevent stroke, but without compromising uteroplacental perfusion

Zwart JJ, Richters A, Ory F, de Vries JI, Bloemenkamp KW, van Roosmalen J. Eclampsia in the Netherlands. Obstet Gynecol. 2008;112(4):820–827.

In this nationwide review of complications from eclampsia in the Netherlands, the authors found that failure to treat persistent severe hypertension was associated with hypertensive encephalopathy, cerebral infarction, bleeding, or congestive heart failure. They also found that 35.2% of women had systolic or diastolic blood pressure at or above 170/110 mm Hg at admission, but fewer than half were given antihypertensive drugs at that time. Among the cases deemed to have received substandard care, one third involved inadequate treatment of hypertension.

5. Know your antihypertensives

Learn which agents are best to control severe hypertension in eclampsia

Sibai BM. Hypertensive Emergencies. In: Foley MR, Strong TH, Garite TJ, eds. Obstetric Intensive Care Manual. 3rd ed. New York, NY: The McGraw-Hill Companies; 2010.

It is critical to familiarize oneself with the mechanism of action, dose, and potential side effects of agents used to control hypertension. For example, neither hydralazine nor nifedipine should be used in patients who have severe headache and persistent tachycardia (pulse, >100 bpm). Labetalol should be avoided in women who have persistent bradycardia (pulse, <60 bpm), asthma, or congestive heart failure.

For women who have persistent headache and tachycardia, I suggest intravenous (IV) labetalol, starting at a dose of 20 mg, 40 mg, or 80 mg every 10 minutes as needed to keep systolic blood pressure below 160 mm Hg and diastolic blood pressure below 105 mm Hg. The maximum dose of labetalol should not exceed 300 mg in 1 hour.

For patients who have bradycardia and severe asthma, I suggest oral, rapid-acting nifedipine, starting at 10 mg to 20 mg, to be repeated in 20 to 30 minutes as needed, up to a maximum of 50 mg to 60 mg in 1 hour. Oral nifedipine can be used with magnesium sulfate. An alternative is an IV bolus injection of hydralazine, starting at a dose of 5 mg to 10 mg, to be repeated every 15 minutes, up to a maximum dose of 25 mg.

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