Postictal at 36 Weeks: Eclampsia in a Walk-Up Apartment
At 22:15, you are called to a third-floor apartment for a 33-year-old woman, 36 weeks pregnant by dates, who had a generalized seizure lasting about 90 seconds. She has no prenatal care and no known seizure history. She is postictal, moaning, with facial edema and a bitten tongue. Vital signs: BP 176/112, HR 112, RR 24, SpO2 89% on room air, temperature 37.0°C. Capillary glucose is 6.8 mmol/L. She localizes to pain but does not follow commands. The apartment has a narrow staircase and no elevator. The obstetric unit is 38 minutes away; the nearest hospital is 12 minutes away and has an emergency department but no obstetrics or neonatal ICU. Your protocol permits magnesium sulfate for eclampsia if on-line medical control approves; you also carry midazolam and labetalol.
1. What is the diagnosis and what are your immediate priorities?
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The diagnosis is eclampsia until proven otherwise: late pregnancy, generalized seizure, severe hypertension, facial edema, and a postictal state. Priorities are airway, oxygenation, prevention of aspiration, and seizure control. Position her left lateral to reduce aortocaval compression, suction the mouth, give oxygen to keep SpO2 at least 94%, and do not force anything between her teeth. Check glucose and treat hypoglycemia if present. Magnesium sulfate is the definitive anticonvulsant: 4 g IV over 10 minutes, or 6 g IM if no IV, per medical control, followed by an infusion. If magnesium is unavailable or not approved, midazolam 5 mg IV or IM may terminate the seizure. Treat BP of 160/110 or higher with labetalol or hydralazine per protocol, but avoid dropping pressure precipitously. Monitor reflexes, respiratory rate, urine output, and fetal heart tones if equipped.
2. How do you choose the destination and move her safely?
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Transport to the obstetric unit 38 minutes away rather than the nearest ED 12 minutes away, provided the airway is protected and seizures are controlled. Eclampsia needs magnesium, blood pressure control, fetal monitoring, and usually delivery by cesarean; a hospital without obstetrics or neonatal ICU cannot provide definitive care and may simply delay it. If she has recurrent seizures, airway compromise, or shock, go to the nearest ED for stabilization and immediate transfer. Use a scoop stretcher for the narrow staircase, keep her left lateral, and pre-notify the obstetric team. Do not delay transport for multiple IV attempts.
3. What are the signs of magnesium toxicity and how would you manage them?
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Magnesium toxicity presents as loss of deep tendon reflexes, respiratory depression, oliguria, flushing, and eventually cardiac arrest. Monitor respiratory rate, reflexes, and urine output. If toxicity is suspected, stop the magnesium infusion, support ventilation with BVM, give calcium gluconate 1 g IV over 10 minutes if available, and transport urgently. Reassure that magnesium remains first-line and the benefit outweighs the risk when monitored.