Anticonvulsant therapy for eclampsia

RHL practical aspects by Atallah AN

FIRST CONTACT (PRIMARY CARE) LEVEL

Educate all pregnant women to contact a health facility immediately if any of the following occur:

  • oedema developing rapidly (within few days)
  • headache that is persistent and severe
  • upper abdominal pain
  • blurred vision

Blood pressure measurement and urine testing for proteinuria should be performed in women attending health centres with these complaints.

Convulsions

If a woman with eclampsia is seen at a primary care clinic;

1. airway should be maintained,

2. the woman should be positioned sideway (left lateral) to avoid aspiration of vomit or other secretions,

3. intravenous line should be established if possible,

4. magnesium sulphate.

  • once magnesium sulphate treatment is initiated and the woman's condition is stable she should be transferred to higher level of care
  • magnesium sulphate regimens (see the link to "Magnesium sulphate regimens for women with pre-eclampsia and eclampsia" under "Related documents"): There are two magnesium sulphate regimens, the intravenous (IV) and intramuscular (IM). Both regimens have the same IV loading dose but the maintenance schemes are different. The IM regimen is more suited to primary care settings where close monitoring of the patient's condition and possible overdose may be difficult.

- Loading dose: Slow intravenous injection of 4 g (20 ml of 20 % solution in saline) at a rate of 1g/5 minutes over 20 minutes.

- Maintenance regimen (IM): Immediately after the loading dose administer 5g of 50% solution to each buttock (10g total IM dose) as deep IM injection. This should be followed by 5 g of 50% solution every 4 hours to alternate buttocks. Magnesium sulphate treatment should be continued for 24 hours after delivery or the last convulsion whichever occurs last. IM injections should preferably be given with 1 ml of 2% lignocaine in the same syringe to make them less painful.

- Maintenance regimen (IV): After the loading dose give 1-2 g/hour in 100 ml of maintenance solution.

- Monitoring of magnesium sulphate administration: During magnesium sulphate treatment the following should be checked at least every 4 hourly for their presence: Patellar reflex, respiratory rate >16/minute, urine output during the previous 4 h>100 ml.

- Magnesium sulphate overdose: In any setting where magnesium sulphate is used, an ampoule of calcium gluconate (1 g) should be available as antidote for magnesium sulphate overdose. Magnesium sulphate overdose should be suspected if the criteria listed in the previous paragraph on monitoring are not met.

  • Blood pressure should be measured and antihypertensives used accordingly.
  • Recurrent convulsions: For both the IM and IV regimens, a further 2-4 g of magnesium sulphate is given IV over 5 minutes, the dose decided upon according to the weight of the woman in case of recurrent convulsions.

REFERRAL HOSPITAL (SECONDARY CARE) LEVEL

When the diagnosis of convulsion due to eclampsia is made, the patient should receive magnesium sulphate loading dose, the emergency measures mentioned above and then transferred to a referral hospital as soon as possible.

Additional suggestions

  • Both regimens suggested here have been used in the Collaborative Eclampsia Trial (1), found to be feasible. An additional practical measure to ensure administration of quick and efficient anticonvulsant treatment to women with eclampsia is to use 'eclampsia boxes' (see the link to "Magnesium sulphate regimens for women with pre-eclampsia and eclampsia" under "Related documents") (2).Shoe-box sized boxes containing everything needed to initiate and maintain treatment for 24 hours used in the Collaborative Eclampsia Trial were found to be very useful by the routine staff. These boxes contained magnesium sulphate for bolus and maintenance, syringes, infusion sets, swabs and calcium gluconate in case of overdose.
  • Keep in mind that the definitive treatment of eclampsia is delivery.
  • Take into account the chances of fetal survival in the hospital where the delivery occurs.
  • Consider that epidural anaesthesia will reduce the maternal arterial blood pressure by itself and may preclude the use of rapid acting drugs for hypertension.

References

  • The Eclampsia Trial Collaborative Group. Which anticonvulsant for women with eclampsia? Evidence from the Collaborative Eclampsia Trial. The lancet 1995;345:1455-1463.
  • Duley L. Magnesium sulphate regimens for women with eclampsia. Messages from the Collaborative Eclampsia Trial. British journal of obstetrics and gynaecology 1996;103:103-105.

This document should be cited as: Atallah AN. Anticonvulsant therapy for eclampsia: RHL practical aspects (last revised: 14 November 2003). The WHO Reproductive Health Library; Geneva: World Health Organization.