eMedicine Specialties > Neurology > Seizures and Epilepsy
Preeclampsia and Eclampsia: Treatment & Medication
Updated: Jun 18, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
Considering the significant morbidity and even deaths associated with the condition, aggressive treatment of eclampsia is warranted. Close observation of the blood pressure of pregnant women is very important. Admission to an intensive care unit is justified. Eclampsia also adversely affects the fetus; therefore, when possible, labor should be promptly induced. If fetal lung maturity is a question, expeditious administration of corticosteroid is warranted. If induction and rapid vaginal delivery is not possible, abdominal delivery should be considered. Prevention of any subsequent seizures is another goal. In the past, the choice of anticonvulsant was controversial; however, 2 large multicenter randomized trials have put an end to the controversy—magnesium sulfate is now the drug of choice.22
- Magnesium sulfate (MgSO4) is superior to phenytoin sodium and diazepam in controlling recurrent seizures and is associated with lower neonatal morbidity and mortality rates.23,24 Magnesium sulfate should be administered as soon as possible after diagnosis of preeclampsia is confirmed. It should be administered immediately after a seizure, if not administered before. In case of recurrent seizure after magnesium sulfate administration, a bolus of 2 g of additional magnesium sulfate is useful.
- Control of hypertension is very important. If administration of magnesium sulfate does not reduce the blood pressure adequately, other antihypertensive agents should be used. Some of the commonly used agents are hydralazine, labetalol, nifedipine, and sodium nitroprusside.1 Nifedipine has the advantage of ease of administration via the sublingual route; the other 2 agents can be administered intravenously. In developing countries, a lower cost antihypertensive medication alpha methyldopa is used widely.
Surgical Care
Evaluation for retained products of conception and their removal may be helpful in cases of postpartum eclampsia. In case of antepartum eclampsia, cesarean delivery is useful if immediate vaginal delivery is not feasible.
Consultations
Consulting an ophthalmologist is recommended for evaluation of papilledema or retinal pathology.
Diet
No specific dietary restriction or supplementation is needed for the treatment of eclampsia. With increasing gestational age, serum ionized and total magnesium levels decrease significantly; however, dietary supplementation of magnesium is not known to have any advantages. Several studies evaluating effects of exercise and diet, including aerobic exercise, protein restriction, protein supplementation, increasing or decreasing salt intake, magnesium supplementation, and zinc supplementation, have not produced any clear answers.
Various trials of supplementation with fish oil or oil of evening primrose, which are rich sources of long-chain fatty acids, have not shown preventative effects consistently. Early studies of dietary calcium supplementation suggest that it may be helpful in preventing toxemia in women who are at highest risk and in women with a low dietary intake of calcium. However, in a large National Institutes of Health trial with healthy nulliparous women randomly assigned at 13-21 weeks’ gestation, calcium supplementation neither reduced the incidence or severity of preeclampsia nor delayed its onset.25 One of the several hypotheses of the pathogenesis of preeclampsia focuses on the oxidative stress caused by the imbalance in prooxidant and antioxidant forces.
Although preliminary findings on vitamin E and vitamin C supplementation in preeclamptic women were originally encouraging26 , a recent study may prove otherwise.
In a multicenter, randomized, controlled trial, Villar et al studied the effect of vitamin C and E supplementation in high-risk pregnant women with low nutritional status to determine if this intervention reduced preeclampsia. There were 687 women randomized to receive vitamin C (1000 mg) and vitamin E (400 IU) and 678 women who received placebo daily until delivery. At the doses used for supplementation, vitamins C and E were not associated with a reduction of preeclampsia, eclampsia, gestational hypertension, or any other maternal outcome. Low birthweight, small for gestational age, and perinatal deaths were also unaffected.27
Activity
Patients with eclampsia are usually monitored in an intensive care setting, so activity is limited. Once they recover from eclampsia, normal activity can be resumed, depending on whether abdominal delivery was performed.
Medication
The goals of pharmacotherapy are to reduce morbidity and prevent complications.
Mineral supplements
Magnesium sulfate is effective in the treatment of eclampsia. It is superior to phenytoin sodium and diazepam in controlling recurrent seizures and is useful for prevention of seizures in women with preeclampsia. Magnesium sulfate also has favorable effects on neonatal mortality and morbidity rates.
Magnesium sulfate, MgSO4
Was used in treatment of eclampsia as early as 1906. Over the years was popular in the United States and many other countries worldwide; however, conventional antiepileptic drugs and diazepam were used as treatment of eclampsia in the UK and many other centers. This changed after 2 different trials were published in 1990s showing clear superiority of MgSO4 over phenytoin and diazepam in prevention of recurrent seizures in eclampsia and prevention of seizures in women with preeclampsia. Dosing schedules described below were used in 2 studies mentioned above.
Adult
10 g (50% solution of MgSO4) IM in upper outer quadrant of each buttock in divided dose, followed by 5 g (50% solution) in alternate buttocks q4h if patellar reflex present (respiration rate exceeded 12/min in the trials, and urine output during preceding 4 h exceeded 100 mL)
Severe preeclampsia: 4 g (20% solution of MgSO4) IV initial loading dose before IM doses
Prevention of recurrent seizures in eclampsia: 4 g IV as loading dose, followed by 5 g into each buttock IM q4h if respiratory rate >16/min and urine output >25 mL/h, with knee jerks present; continue IV for 24 h, with loading dose of 4 or 5 g also used, followed by infusion of 1 g/h for 24 h; administer additional 2-4 g IV over 5 min if convulsions recur
Pediatric
Not established
Nifedipine may cause hypotension and neuromuscular blockade; may increase neuromuscular blockade observed with aminoglycosides and potentiate neuromuscular blockade produced by tubocurarine, vecuronium, and succinylcholine; may increase CNS effects and toxicity of CNS depressants and betamethasone and cardiotoxicity of ritodrine
Documented hypersensitivity; heart block; Addison disease; myocardial damage; severe hepatitis
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Magnesium may alter cardiac conduction, leading to heart block in digitalized patients; respiratory rate, deep tendon reflexes, and renal function should be monitored when electrolyte administered parenterally; caution when administering magnesium dose because it may produce significant hypertension or asystole; in overdose, calcium gluconate, 10-20 mL IV of 10% solution, can be administered as antidote for clinically significant hypermagnesemia
Antihypertensives
Aggressive use of antihypertensive medications is necessary if blood pressure remains high after administration of magnesium sulfate. Continued elevation of blood pressure in the setting of eclampsia may cause further cerebral edema or cerebral hemorrhage.
Hydralazine (Apresoline)
Peripheral vasodilator that can be used in hypertensive emergency to quickly lower blood pressure.
Adult
5-10 mg IV repeated at 15- to 20-min intervals until satisfactory response achieved
Pediatric
Not established
MAOIs and beta-blockers may increase toxicity; indomethacin decreases pharmacologic effects
Documented hypersensitivity; coronary artery disease; mitral valve rheumatic heart disease
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Has been implicated in myocardial infarction; caution in suspected coronary artery disease
Labetalol (Normodyne, Trandate)
Alpha1-nonselective beta-blocker that can be used effectively in hypertensive emergency via IV route.
Adult
10 mg IV bolus administered initially, followed by 20 mg in 10 min if response not adequate; later, incremental doses of 40 mg and 80 mg can be used if necessary
Pediatric
Not established
Decreases effect of diuretics; increases toxicity of methotrexate, lithium, and salicylates; may diminish reflex tachycardia resulting from nitroglycerin use without interfering with hypotensive effects; cimetidine may increase blood levels; glutethimide may decrease effects by inducing microsomal enzymes
Documented hypersensitivity; bronchial asthma; overt cardiac failure; cardiogenic shock; severe bradycardia; second- or third-degree AV block
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May exacerbate cardiac failure; abrupt withdrawal may precipitate angina; severe hepatocellular injury can occur with short- or long-term therapy; caution in impaired hepatic function; discontinue therapy if signs of liver dysfunction occur; in elderly patients, lower response rate and higher incidence of toxicity may be observed
Antiplatelet agents
Toxemia of pregnancy is associated with deficiency of prostaglandins (potent vasodilators) and excess of thromboxane (vasoconstrictor). This leads to the belief that low-dose aspirin with its effects on synthesis of these agents may be useful in preventing toxemia of pregnancy. Antiplatelet agents were associated with a 19% reduction in the risk of preeclampsia when a metaanalysis of 43 trials was performed. This benefit was present in trials where all women or only women at high risk of developing preeclampsia were included.
Aspirin (Ascriptin, Anacin, Bayer Aspirin, Bayer Buffered Aspirin)
Inhibits prostaglandin synthesis, preventing formation of platelet-aggregating thromboxane A2. May be used in low dose to inhibit platelet aggregation and improve complications of venous stases and thrombosis.
Adult
Low dose: 75-81 mg/d PO for antiplatelet effect
Pediatric
Not established
Effects may decrease with antacids and urinary alkalinizers; corticosteroids decrease salicylate serum levels; additive hypoprothrombinemic effects and increased bleeding time may occur with coadministration of anticoagulants; may antagonize uricosuric effects of probenecid and increase toxicity of phenytoin and valproic acid; doses >2 g/d may potentiate glucose-lowering effect of sulfonylurea drugs
Documented hypersensitivity; liver damage; hypoprothrombinemia; vitamin K deficiency; bleeding disorders; asthma; use in children (<16 y) with flu because of association of aspirin with Reye syndrome
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
May cause transient decrease in renal function and aggravate chronic kidney disease; avoid use in patients with severe anemia, with history of blood coagulation defects, or taking anticoagulants
More on Preeclampsia and Eclampsia |
| Overview: Preeclampsia and Eclampsia |
| Differential Diagnoses & Workup: Preeclampsia and Eclampsia |
 Treatment & Medication: Preeclampsia and Eclampsia |
| Follow-up: Preeclampsia and Eclampsia |
| Multimedia: Preeclampsia and Eclampsia |
| References |
| « Previous Page | Next Page » |
References
Report of the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy. Am J Obstet Gynecol. Jul 2000;183(1):S1-S22. [Medline].
Shah AK, Nikhar NK, Watson CR. New-onset peripartum seizures - Insight into a common disorder. Neurology. 1998;50 (suppl 4):A253.
Redman CW, Sargent IL. Latest advances in understanding preeclampsia. Science. Jun 10 2005;308(5728):1592-4. [Medline].
Noris M, Perico N, Remuzzi G. Mechanisms of disease: Pre-eclampsia. Nat Clin Pract Nephrol. Dec 2005;1(2):98-114; quiz 120. [Medline].
Conrad KP, Lindheimer MD. Renal and cardiovascular alterations. In: Lindheimer MD, Roberts JM, Cunningham FG, eds. Hypertensive Disorders in Pregnancy. Stamford, CT: Appleton; 1999:263-326.
Fitzgerald DJ, Rocki W, Murray R, Mayo G, FitzGerald GA. Thromboxane A2 synthesis in pregnancy-induced hypertension. Lancet. Mar 31 1990;335(8692):751-4. [Medline].
Seligman SP, Buyon JP, Clancy RM, Young BK, Abramson SB. The role of nitric oxide in the pathogenesis of preeclampsia. Am J Obstet Gynecol. Oct 1994;171(4):944-8. [Medline].
Shah AK, Rajamani K, Whitty JE. Eclampsia: A neurological perspective. J Neurol Sci. Aug 15 2008;271(1-2):158-67. [Medline].
Shah AK, Whitty JE. Characteristics of headache in women with eclampsia. Neurology. 1999;52 (suppl 2):A285-86.
Shah AK. Non-aneurysmal primary subarachnoid hemorrhage in pregnancy-induced hypertension and eclampsia. Neurology. Jul 8 2003;61(1):117-20. [Medline].
Lubarsky SL, Barton JR, Friedman SA, et al. Late postpartum eclampsia revisited. Obstet Gynecol. Apr 1994;83(4):502-5. [Medline].
Cunningham FG, Fernandez CO, Hernandez C. Blindness associated with preeclampsia and eclampsia. Am J Obstet Gynecol. Apr 1995;172(4 Pt 1):1291-8. [Medline].
Rahman I, Saleemi G, Semple D, Stanga P. Pre-eclampsia resulting in central retinal vein occlusion. Eye. Aug 5 2005;[Medline].
Duley L. Pre-eclampsia and the hypertensive disorders of pregnancy. Br Med Bull. 2003;67:161-76. [Medline].
Cunningham FG, Fernandez CO, Hernandez C. Blindness associated with preeclampsia and eclampsia. Am J Obstet Gynecol. Apr 1995;172(4 Pt 1):1291-8. [Medline].
Hoffmann M, Keiseb J, Moodley J, Corr P. Appropriate neurological evaluation and multimodality magnetic resonance imaging in eclampsia. Acta Neurol Scand. Sep 2002;106(3):159-67. [Medline].
Brown CE, Purdy P, Cunningham FG. Head computed tomographic scans in women with eclampsia. Am J Obstet Gynecol. Oct 1988;159(4):915-20. [Medline].
Shah AK, Whitty JE. Brain MRI in peripartum seizures: usefulness of combined T2 and diffusion weighted MR imaging. J Neurol Sci. Jul 1 1999;166(2):122-5. [Medline].
Sengar AR, Gupta RK, Dhanuka AK, et al. MR imaging, MR angiography, and MR spectroscopy of the brain in eclampsia. AJNR Am J Neuroradiol. Sep 1997;18(8):1485-90. [Medline].
Williams K, Galerneau F. Maternal transcranial Doppler in pre-eclampsia and eclampsia. Ultrasound Obstet Gynecol. May 2003;21(5):507-13. [Medline].
Sheehan HL, Lynch JB. Cerebral lesions. In: Pathology of Toxemia of Pregnancy. 1973. London, England: Churchill-Livingstone; 524-53.
Moodley J, Kalane G. A review of the management of eclampsia: practical issues. Hypertens Pregnancy. 2006;25(2):47-62. [Medline].
Lucas MJ, Leveno KJ, Cunningham FG. A comparison of magnesium sulfate with phenytoin for the prevention of eclampsia. N Engl J Med. Jul 27 1995;333(4):201-5. [Medline].
Eclampsia Trial Collaborative Group. Which anticonvulsant for women with eclampsia? Evidence from the Collaborative Eclampsia Trial. Lancet. Jun 10 1995;345(8963):1455-63. [Medline].
Levine RJ, Hauth JC, Curet LB, Sibai BM, Catalano PM, Morris CD, et al. Trial of calcium to prevent preeclampsia. N Engl J Med. Jul 10 1997;337(2):69-76. [Medline].
Chappell LC, Seed PT, Briley AL, Kelly FJ, Lee R, Hunt BJ, et al. Effect of antioxidants on the occurrence of pre-eclampsia in women at increased risk: a randomised trial. Lancet. Sep 4 1999;354(9181):810-6. [Medline].
[Best Evidence] Villar J, Purwar M, Merialdi M, Zavaleta N, Thi Nhu Ngoc N, Anthony J, et al. World Health Organisation multicentre randomised trial of supplementation with vitamins C and E among pregnant women at high risk for pre-eclampsia in populations of low nutritional status from developing countries. BJOG. May 2009;116(6):780-8. [Medline].
Further Reading
Keywords
eclampsia, preeclampsia, toxemia of pregnancy, hypertension in pregnancy, pregnancy-induced hypertension, PIH, seizures, convulsions, pre-eclampsia, hypertensive disorder
