eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology
Pregnancy, Eclampsia: Treatment & Medication
Updated: Aug 11, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Prehospital Care
- Emergency medical services personnel should (1) secure an intravenous line with a large-bore catheter, (2) initiate cardiac monitoring and administer oxygen, and (3) transport the patient in the left lateral decubitus position.
- Supportive care includes airway support and attempted termination of any ongoing seizure with diazepam.
Emergency Department Care
- Hospitalization, labor followed by delivery. In 1772, De la Motte recognized that prompt delivery of pregnant women with convulsions favored their recovery.9 Delivery is the only definitive treatment.
- The initial step for supportive care is to maintain adequate oxygenation. Supportive care for eclampsia consists of close monitoring, invasive if clinically indicated; airway support; adequate oxygenation; anticonvulsant therapy; and BP control.
- Intravenous magnesium sulfate is the initial drug administered to terminate seizures and lower BP. Seizures usually terminate after the loading dose of magnesium. A loading dose of 6 g (15-20 min) and a maintenance dose of 2 g per hour as a continuous intravenous solution. Once the seizures terminate, 85% of patients note improved blood pressure control.7,2 Note: Magnesium toxicity can cause coma, and, if mental status changes with these infusion rates, this should be considered.2
- Severe hypertension must be addressed after magnesium infusions. Hydralazine or labetalol can then be administered IV for BP control. The goal is to maintain systolic BP between 140 and 160 mm Hg and diastolic BP between 90 and 110 mm Hg. Recommended intravenous bolus of hydralazine (5-10 mg) or labetalol (20-40 mg q15min prn). Other potent antihypertensive medications such as sodium nitroprusside or nitroglycerin can be used but are rarely required.2
- Diuretics are used only in the setting of pulmonary edema.
- Care must be taken not to decrease the BP too drastically; an excessive decrease can cause inadequate uteroplacental perfusion and fetal distress.9
- Benzodiazepine or phenytoin can be used for seizures that are not responsive to magnesium sulfate.
- Maintaining a diastolic BP of 90 mm Hg is the goal of antihypertensive therapy. Oral nifedipine (40-120 mg/d) with or without labetalol (600-2400 mg/d) is given to keep systolic BP between 140 and 155 mm Hg and diastolic pressure between 90 and 105 mm Hg.2
- A dose of antenatal steroids may be administered in anticipation of emergent delivery when gestational age is less than 32 weeks. Betamethasone (12 mg IM q24h X 2 doses) or dexamethasone (6 mg IM q12h X 4 doses) is recommended.9,2
- Several organizations have developed screening, treatment, and prevention guidelines for preeclampsia and eclampsia.10,11,12
Consultations
- Recommend immediate consultation with in-house obstetrician and maternal fetal medicine for emergent delivery. ICU services may also be involved to facilitate close monitoring.
Medication
The goal of therapy is to decrease BP, prevent or control convulsions, and deliver a viable neonate. The antihypertensive agent of choice is hydralazine. Alternative antihypertensives include labetalol, diazoxide, and occasionally, nitroprusside.
Anticonvulsants
Convulsive generalized status epilepticus in pregnancy jeopardizes both the mother and fetus. The anticonvulsant agent of choice is magnesium sulfate. However, when seizures continue after administration of magnesium, benzodiazepines are the drugs of choice.
Magnesium sulfate (MgSO4)
Used to treat and prevent seizures. May cause hyporeflexia, respiratory depression, and bradycardia. Monitor patient's reflexes and discontinue infusion if reflexes are absent or if magnesium level exceeds 6-8 mEq/L. Use IV/IM route for seizure prophylaxis in preeclampsia. When treating true eclampsia, use IV route for quicker action. Calcium gluconate 10% solution 10-20 mL IV can be given as an antidote for clinically significant hypermagnesemia. Discontinue as soon as desired effect is obtained. Repeat doses depend on continuing presence of patellar reflex and adequate respiratory function.
Adult
4 g IV initially, followed by 1-4 g IM q4h prn
Alternatively, 1-4 g/h continuous infusion
Pediatric
20-100 mg/kg/dose IV q4-6h prn; doses as high as 200 mg/kg/dose have been used in severe cases
Concurrent use with nifedipine may cause hypotension and neuromuscular blockade; may increase neuromuscular blockade seen with aminoglycoside use and potentiate neuromuscular blockade produced by tubocurarine, vecuronium, and succinylcholine; may increase CNS effects and toxicity of CNS depressants and betamethasone; may increase 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
May alter cardiac conduction, leading to heart block inpatients taking digitalis; respiratory rate, deep tendon reflex, and renal function should be monitored when electrolyte is administered parenterally; may produce significant hypertension or asystole; in overdose, calcium gluconate 10-20 mL IV of 10% solution can be given as antidote for clinically significant hypermagnesemia; use in eclampsia is reserved for immediate control of life-threatening convulsions
Diazepam (Valium)
For treatment of seizures resistant to magnesium sulfate. Depresses all levels of CNS (eg, limbic and reticular formation), possibly by increasing activity of GABA.
Adult
5-10 mg IV q10-20min; repeat in 2-4 h prn; not to exceed 30 mg in 8 h
Pediatric
0.05-0.3 mg/kg/dose IV over 2-3 min q15-30min; not to exceed 10 mg; repeat in 2-4 h prn
Increases toxicity of benzodiazepines in CNS with coadministration of phenothiazines, barbiturates, alcohols, and MAOIs
Documented hypersensitivity; narrow-angle glaucoma
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution with other CNS depressants, low albumin levels, or hepatic disease (may increase toxicity)
Antihypertensives
A systolic BP of 160-180 mm Hg or greater or a diastolic BP of 110 mm Hg or greater should be treated with IV antihypertensives to prevent cerebral hemorrhage. Hydralazine is the DOC for BP control in eclampsia. However, parenteral hydralazine is provided to pharmacists only through special emergency request. Therefore, be prepared to use other antihypertensive agents when hydralazine is not available immediately. Labetalol has alpha-adrenergic and beta-adrenergic blocking effects and can be used for rapid control of severe hypertension.
Other antihypertensive drugs have significant adverse effects and should not be used as primary agents. Diazoxide may cause hyperglycemia and inhibit labor. Nitroprusside may cause fetal cyanide toxicity. Diuretics should be avoided because of the relative intravascular volume depletion in the patient with eclampsia.
Hydralazine (Hydrea)
Decreases systemic resistance through direct vasodilation of arterioles.
Adult
5 mg IV initially, then 5-10 mg IV q20-30min prn; not to exceed 30 mg
Pediatric
0.1-0.2 mg/kg/dose IV q4-6h prn; not to exceed 20 mg or 1.7-3.5 mg/kg/d divided into 4-6 doses
MAOIs and beta-blockers may increase hydralazine toxicity; pharmacologic effects of hydralazine may be decreased by indomethacin
Documented hypersensitivity; 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
Implicated in myocardial infarction; caution in suspected coronary artery disease
Labetalol (Normodyne)
Used as alternative to hydralazine in eclampsia. It blocks alpha-adrenergic, beta1-adrenergic, and beta2-aderenergic receptor sites.
Adult
20-30 mg IV over 2 min followed by 40-80 mg IV at 10-min intervals; not to exceed 300 mg/dose
Pediatric
Not established
Suggested dose: 0.4-1 mg/kg/h IV; not to exceed 3 mg/kg/h
Decreases effect of diuretics and increases toxicity of methotrexate, lithium, and salicylates; may diminish reflex tachycardia from nitroglycerin use, without interfering with hypotensive effects; cimetidine may increase labetalol blood levels; glutethimide may decrease labetalol effects by inducing microsomal enzymes
Documented hypersensitivity; cardiogenic shock; uncompensated congestive heart failure; bradycardia; pulmonary edema; reactive airway disease; atrioventricular block; severe bradycardia
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
Caution in impaired hepatic function; discontinue therapy with signs of liver dysfunction; in elderly patients, a lower response rate and higher incidence of toxicity may be observed
Diazoxide (Hyperstat)
Produces direct smooth-muscle relaxation of the peripheral arterioles, decreasing BP.
Adult
1-3 mg/kg IV as a single injection, not to exceed 150 mg/dose
Repeat dose in 5-15 min prn until BP is adequately reduced
Pediatric
Administer as in adults
May decrease serum hydantoins, possibly resulting in decreased anticonvulsant effects; thiazide diuretics may potentiate hyperuricemic and antihypertensive effects
Documented hypersensitivity; aortic coarctation; pheochromocytoma; arteriovenous shunts; aortic aneurysm
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
Patients with diabetes mellitus may require treatment for hyperglycemia; when given prior to delivery, may produce fetal or neonatal hyperbilirubinemia, thrombocytopenia, altered carbohydrate metabolism, and other adverse reactions
Nitroprusside (Nitropress)
Used occasionally for treatment of eclampsia. It causes peripheral vasodilation by directly acting on venous and arteriolar smooth muscle, reducing peripheral resistance.
Adult
0.3-0.5 mcg/kg/min IV, increase in increments of 0.5 mcg/kg/min, titrate to desired hemodynamic effect; average dose is 3 mcg/kg/min
Pediatric
Administer as in adults
None reported
Documented hypersensitivity; subaortic stenosis; idiopathic hypertrophic; atrial fibrillation or flutter
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
Caution in increased intracranial pressure, hepatic failure, severe renal impairment, hypothyroidism; in renal or hepatic insufficiency, levels may increase and cause cyanide toxicity; can lower BP and should be used only in patients with mean arterial pressures >70 mm Hg
More on Pregnancy, Eclampsia |
| Overview: Pregnancy, Eclampsia |
| Differential Diagnoses & Workup: Pregnancy, Eclampsia |
 Treatment & Medication: Pregnancy, Eclampsia |
| Follow-up: Pregnancy, Eclampsia |
| References |
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Further Reading
Keywords
eclampsia, hypertension of pregnancy, seizures in pregnancy, toxemia of pregnancy, coma in pregnancy, preeclampsia, hypertensive disorder, proteinuria
