Eclampsia at a District Hospital Two Hours From Maternity Intensive Care

This is eclampsia until proven otherwise: seizure plus hypertension plus proteinuria at 35 weeks. The first hour determines both maternal and fetal outcome; do magnesium and blood pressure control simultaneously, not sequentially.

1. Airway and environment. Left lateral position, oxygen to keep SpO2 above 95%, suction, padded bed, minimise noise and stimulation, continuous pulse oximetry and ECG, insert two large-bore cannulas, catheterise to measure urine output.

2. Magnesium sulphate - seizure prophylaxis and treatment.

• Loading dose 4 g intravenously over 5–10 minutes (some protocols use 4–6 g, or the Pritchard regimen of 4 g IV plus 10 g intramuscularly if no infusion pump).
• Maintenance 1 g/hour by infusion pump.
• Recurrent seizure: a further 2 g IV bolus over 5 minutes.
• Before each dose and hourly: deep tendon reflexes, respiratory rate, urine output, and oxygen saturation. Reflexes disappear around 9–12 mEq/L, respiratory depression around 12–15, cardiac arrest above 15.

3. Blood pressure control. Target 140–150/90–100 mmHg; do not drop it precipitously because placental perfusion falls with it. Hydralazine 5–10 mg IV every 20–30 minutes, or labetalol 20 mg IV then 40–80 mg every 10–20 minutes (avoid in asthma), or nifedipine orally. Persistent above 160/110 mmHg is the threshold for treating urgently to prevent maternal intracranial haemorrhage.

4. Fluids. Restrict to about 80 mL/hour; pre-eclampsia causes endothelial leak and pulmonary oedema is easily produced by over-resuscitation.

5. Fetal monitoring where possible, and steroids for fetal lung maturity if delivery is not immediate and the gestation is under 36 weeks - but do not delay necessary delivery for steroids in eclampsia.

6. Document a magnesium chart and ensure the midwife and the doctor both know the toxicity signs and where the calcium gluconate is kept.

Frame the decision properly. Delivery is the only definitive treatment for eclampsia. The real question is not 'deliver or transfer' but 'where and when can delivery be done most safely'. At 35 weeks the fetus is preterm; there is no neonatal intensive care here, no blood bank, and no obstetrician, so a caesarean section in this hospital is a major risk for both patients. Against that, a 2-hour road journey in a woman who has just seized carries a substantial risk of recurrent seizure, abruption, aspiration and fetal compromise.

The deciding factors:

• Maternal stability. She must be seizure-free, with blood pressure below 160/110 and a magnesium load on board, before any transfer.
• Imminent vaginal delivery. If the cervix is fully dilated and delivery is imminent, deliver locally - transferring a woman in advanced labour is more dangerous than delivering with a midwife and a doctor present. Assess cervical dilatation before deciding; do not assume.
• Fetal condition. A non-reassuring fetal heart rate with abruption or severe growth restriction changes the urgency and argues for delivery at a facility with neonatal support.
• Recurrent seizures or uncontrolled blood pressure mean she cannot travel yet.

Before the ambulance leaves: magnesium loading dose given and infusion running; blood pressure controlled; airway equipment, suction and oxygen on the vehicle; a doctor or experienced nurse escort with a seizure plan and a further 2 g magnesium bolus drawn up; intravenous access secured; the receiving unit has accepted the patient by direct telephone conversation and knows she is eclamptic; the husband is told the plan and the risks in plain language, with the reasons for each step.

Answer to the family: her seizure is being treated and she will be transferred as soon as it is safe - usually within 30–60 minutes - because the drugs must be working first. Say this with the midwife present so the team gives one message.

This is magnesium toxicity until proven otherwise. The progression is predictable: loss of deep tendon reflexes at roughly 9–12 mEq/L, respiratory depression at 12–15, and cardiac arrest above 15. Oliguria is the precipitant because magnesium is cleared renally - with pre-eclampsia, a falling urine output and possible renal impairment, the standard 1 g/hour maintenance dose accumulates. Other contributors to a low respiratory rate in this patient include the postictal state, opioids given for pain, and a developing intracranial event; but in a woman on magnesium with absent reflexes, magnesium is the diagnosis until the level returns.

Immediate actions:

1. Stop the magnesium infusion.
2. Airway and breathing: oxygen, monitor, suction at the bedside, and prepare to support ventilation. If she is not breathing adequately, bag-mask ventilate and intubate - do not wait for the calcium to work.
3. Give the antidote: calcium gluconate 1 g (10 mL of 10%) intravenously over 10 minutes. This antagonises the neuromuscular and cardiac effects but does not lower the serum magnesium; it buys time for excretion.
4. Send serum magnesium, urea, creatinine, electrolytes and a full blood count, and monitor urine output hourly with a catheter.
5. Reassess blood pressure and seizure risk. Stopping magnesium removes seizure prophylaxis; if she seizes again, treat with a small bolus (2 g) rather than restarting the full maintenance rate, and control blood pressure with hydralazine or labetalol.
6. Restart magnesium only when reflexes have returned and the respiratory rate is above 12–16/min, at a reduced rate (0.5 g/hour) in renal impairment, with more frequent monitoring.
7. Re-open the transfer question. A woman who has had magnesium toxicity and is oliguric needs a facility with renal support and obstetric intensive care; if she is stable after resuscitation, this strengthens the case for transfer rather than weakening it. Document the event, the dose given, the timing and the response.