Seizures in pregnancy - common cause is pre-existing epilepsy - in the last half of pregnancy or immediate postpartum may be caused by eclampsia
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Pre-eclampsia can only be cured by delivering the baby. If you have pre-eclampsia, you'll be closely monitored until it's possible to deliver the baby. Once diagnosed, you'll be referred to a hospital specialist for further assessment and any necessary treatment. You may be able to return home afterwards and attend regular (possibly daily) follow-up appointments. You may be admitted to hospital for monitoring and treatment if there are any concerns for you or your baby. While you're in hospital, you and your baby will be monitored by: Medicine is recommended to help lower your blood pressure. These medicines reduce the likelihood of serious complications, such as stroke. Some of the medicines used regularly in the UK include labetalol, nifedipine or methyldopa. Of these medicines, only labetalol is specifically licensed for use in pregnant women with high blood pressure. This means the medicine has undergone clinical trials that have found it to be safe and effective for this purpose. But while methyldopa and nifedipine are not licensed for use in pregnancy, they can be used "off-label" (outside their licence) if it's felt the benefits of treatment are likely to outweigh the risks of harm to you or your baby. These medicines have been used by doctors in the UK for many years to treat pregnant women with high blood pressure. They're recommended as possible alternatives to labetalol in guidelines produced by the National Institute for Health and Care Excellence (NICE). Your doctors may recommend one of them if they think it's the most suitable medicine for you. If your doctors recommend treatment with one of these medicines, you should be made aware that the medicine is unlicensed in pregnancy and any risks should be explained before you agree to treatment, unless immediate treatment is needed in an emergency. Anticonvulsant medicine may be prescribed to prevent fits if you have severe pre-eclampsia and your baby is due within 24 hours, or if you have had convulsions (fits).Other medicines
They can also be used to treat fits if they occur.
In most cases of pre-eclampsia, having your baby at about the 37th to 38th week of pregnancy is recommended.
This may mean that labour needs to be started artificially (known as induced labour) or you may need to have a caesarean section.
This is recommended because research suggests there's no benefit in waiting for labour to start by itself after this point.
Delivering the baby early can also reduce the risk of complications from pre-eclampsia.
If your condition becomes more severe before 37 weeks and there are serious concerns about the health of you or your baby, earlier delivery may be necessary.
Deliveries before 37 weeks are known as premature births and babies born before this point may not be fully developed.
You should be given information about the risks of both premature birth and pre-eclampsia so the best decision can be made about your treatment.
After the delivery
Although pre-eclampsia usually improves soon after your baby is born, complications can sometimes develop a few days later.
You may need to stay in hospital after the birth so you can be monitored.
Your blood pressure will be measured regularly and you may be offered medicine if it gets too high, if you are not taking medicine already.
Your baby may also need to be monitored and stay in a hospital neonatal intensive care unit if they're born prematurely.
These units have facilities that can replicate the functions of the womb and allow your baby to develop fully.
Once it's safe to do so, you'll be able to take your baby home.
You'll usually need to have your blood pressure checked regularly after leaving hospital, and you may need to continue taking medicine to lower your blood pressure for several weeks.
If you are still taking medicine, you should be offered an appointment with a doctor 2 weeks after you transfer from hospital care to community midwives. This is to check whether your treatment needs to be changed or stopped.
You should be offered a postnatal appointment 6 to 8 weeks after your baby is born to check your progress and decide if any treatment needs to continue. This appointment will usually be with your GP. This is separate from your 6-week postnatal check.
Page last reviewed: 28 September 2021
Next review due: 28 September 2024
Eclamptic convulsions are life-threatening emergencies and require the proper treatment to decrease maternal morbidity and mortality. Delivery is the only definitive treatment for eclampsia.
The patient should be advised and educated on the course of the disease and any residual problems. She should also be educated on the importance of adequate prenatal care in subsequent pregnancies.
Several organizations have developed screening, treatment, and prevention guidelines for preeclampsia and eclampsia. [22, 23, 24] The American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) continue to support the short-term (usually < 48 hours) use of magnesium sulfate in obstetric care for conditions and treatment durations that include the following [24] :
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For prevention and treatment of seizures in women with preeclampsia or eclampsia
- Recent recommendations suggest that magnesium sulfate be utilized for seizure prophylaxis in severe preeclampsia and for controlling seizures in eclampsia, though magnesium sulfate is not required for preeclampsia without severe features
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For fetal neuroprotection before anticipated early preterm (< 32 weeks of gestation) delivery
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For short-term prolongation of pregnancy (≤48 hours) to allow for the administration of antenatal corticosteroids in pregnant women who are at risk of preterm delivery within 7 days
An experienced obstetrician or maternal-fetal medicine specialist should be consulted. Patients with eclampsia require immediate obstetric consultation and admission to a labor and delivery unit capable of providing intensive care until delivery of the neonate. In the event of premature delivery or fetal compromise, a pediatrician or neonatologist should be consulted.
When initially evaluating a patient with eclampsia, become familiar with the level of care that the medical center can offer the patient, as eclampsia clearly poses a risk of considerable maternal and neonatal morbidity and mortality. Patients with eclampsia may benefit from management at a tertiary care center, a high-risk obstetric facility that provides neonatal and maternal intensive care.
Emergency medical services personnel should (1) secure an intravenous (IV) 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 for eclamptic convulsions includes the following:
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Close monitoring (invasive, if clinically indicated)
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Blood pressure (BP) control
Place the patient in the left lateral position. This positioning decreases the risk of aspiration and will help to improve uterine blood flow by relieving obstruction of the vena cava by the gravid uterus. Protect the patient against injury during the seizure by padding and raising guardrails, using a padded tongue blade between the teeth, and suctioning the oral secretions as needed.
After the seizure has ended, a 16- to 18-gauge IV line should be established for drawing specimens and administering fluids and medications. (Fluid management is critical in patients with eclampsia.) IV fluids should be limited to isotonic solutions to replace urine output plus about 700 mL/d to replace insensible losses.
Pharmacotherapy goals are to reduce morbidity, prevent complications, and correct eclampsia. The drug of choice to treat and prevent eclampsia is magnesium sulfate. [24, 25] Familiarity with second-line medications phenytoin and diazepam/lorazepam is required for cases in which magnesium sulfate may be contraindicated (eg, myasthenia gravis) or ineffective. Control of hypertension is essential to prevent further morbidity or possible mortality. The most commonly used antihypertensive agents are hydralazine, labetalol, and nifedipine.
IV magnesium sulfate is the initial drug administered to terminate seizures. Seizures usually terminate after the loading dose of magnesium. A loading dose of 4-6 g (15-20 min) and a maintenance dose of 1-2 g per hour as a continuous IV solution should be administered. For recurrent seizures or when magnesium is contraindicated, one may use lorazepam (Ativan; 2-4 mg IV over 2-5 minutes) or diazepam (Valium; 5-10 mg IV slowly) can be used to terminate the seizure. While benzodiazepines can be used to treat the seizures due to eclampsia magnesium remains the preferred choice. There exist over 50 years of data and experience using magnesium for this purpose with excellent safety and efficacy. Once the seizures terminate, 85% of patients note improved BP control. [23, 26] Note: Magnesium toxicity can cause coma, and, if mental status changes with these infusion rates, this should be considered. [2]
Benzodiazepines or phenytoin can be used for seizures that are not responsive to magnesium sulfate. Avoid the use of multiple agents to abate eclamptic seizures, unless necessary.
Severe hypertension (>160 mm Hg systolic or > 110 mm Hg diastolic) must be addressed after magnesium infusions. Hydralazine or labetalol can 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. An IV bolus of hydralazine (5-10 mg over 2 minutes) or labetalol (initial dose 20 mg) is recommended. Alternatively, oral nifedipine capsules (10 mg) may be administered. 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 prior to delivery.
Care must be taken not to decrease the BP too drastically; an excessive decrease can cause inadequate uteroplacental perfusion and fetal compromise. [25]
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 × 2 doses) or dexamethasone (6 mg IM q12h × 4 doses) is recommended.
About 10% of women with eclampsia will have an additional seizure after receiving magnesium sulfate. Another 2 g bolus of magnesium may be given in these cases. For the rare patient who continues to have seizure activity while receiving adequate magnesium therapy, seizures may be treated with sodium amobarbital, 250 mg IV over 3-5 minutes. [27] Alternatively, lorazepam or diazepam may be administered (as described above) for status epilepticus. However, these drugs can be associated with prolonged neonatal neurologic depression.
BP should be assessed with the goal of maintaining the diastolic BP at less than 110 mm Hg with administration of antihypertensive medications as needed (eg, hydralazine, labetalol, nifedipine).
Keep nothing by mouth (including medications) until the patient is medically stabilized or delivered, because she is at risk for aspiration when postictal and may have recurrent seizures. Anjum et al reported that following a loading dose of magnesium sulfate, a reduced duration of maintenance doses (12 hours vs 24 hours) for women with eclampsia may be effective for preventing recurrent seizures. [28]
Depending on the clinical course, regularly check the patient’s neurologic status for signs of increased intracranial pressure or bleeding (eg, funduscopic examination, cranial nerves)
Monitor fluid intake and urine output, maternal respiratory rate, and oxygenation, as indicated, and continuously monitor fetal status. Pulmonary arterial pressure monitoring is rarely indicated but may be helpful in patients who have evidence of pulmonary edema or oliguria/anuria.
Once the seizure is controlled and the patient has regained consciousness, the patient’s general medical condition should be assessed to identify any other causes for seizures.
Induction of labor may be initiated when the patient is stable.
Fetal heart rate and uterine contractions should be continuously monitored. Fetal bradycardia is common following the eclamptic seizure and has been reported to last from 30 seconds to 9 minutes. The interval from the onset of the seizure to the fall in the fetal heart rate is typically 5 minutes or less. Transitory fetal tachycardia may occur following the bradycardia. Typically, emergent cesarean delivery is not indicated for this postseizure transient bradycardia; it spontaneously resolves.
After the initial bradycardia, during the recovery phase, the fetal heart rate tracing may reveal a loss of short- and long-term variability and the presence of late decelerations. These abnormalities are most likely due to the decrease in uterine blood flow caused by the intense vasospasm and uterine hyperactivity during the convulsion. If the fetal heart tracing does not improve following a seizure, further evaluation should be undertaken. Growth-restricted and preterm fetuses may take longer to recover following a seizure. Placental abruption may be present if uterine hyperactivity remains and fetal bradycardia persists.
Delivery is the treatment for eclampsia after the patient has been stabilized. No attempt should be made to deliver the infant either vaginally or by cesarean delivery until the acute phase of the seizure or coma has passed. The mode of delivery should be based on obstetric indications but should be chosen with an awareness that vaginal delivery is preferable from a maternal standpoint.
Adequate maternal pain relief for labor and delivery is vital and may be provided with either systemic opioids or epidural anesthesia.
In the absence of fetal malpresentation or fetal distress, oxytocin or prostaglandins may be initiated to induce labor.
Cesarean delivery may be considered in patients with an unfavorable cervix and a gestational age of 30 weeks or less, as induction under these circumstances may result in a prolonged intrapartum course and is frequently unsuccessful in avoiding cesarean delivery, given the high rate of intrapartum complications. When emergent cesarean delivery is indicated, substantiating the absence of coagulopathy before the procedure is important. (See Surgical Therapy.) [29]
Intrapartum complications include the following:
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Fetal growth retardation (30%)
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Nonreassuring fetal heart rate patterns (30%)
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Placental abruption (23%)
Irrespective of gestational age, a prolonged induction with clinically significant worsening of maternal cardiovascular, hematologic, renal, hepatic, and/or neural status is generally an indication for cesarean delivery when the anticipated delivery time is remote.