Discuss the management of antepartum eclampsia in a 25-year-old primigravida with 32 weeks of pregnancy.

The management of antepartum eclampsia in a 25-year-old primigravida at 32 weeks of gestation is a medical emergency demanding a systematic, multidisciplinary approach focused on stabilizing the mother, controlling seizures, managing hypertension, assessing fetal well-being, and planning for timely delivery.

Immediate Stabilization and Initial Management

• Airway, Breathing, Circulation (ABC):
  • Ensure a patent airway: Position the patient on her side to prevent aspiration, especially during and after a seizure. Remove any oral secretions.
  • Administer oxygen: Provide oxygen via face mask at 8-10 L/min to optimize maternal and fetal oxygenation.
  • Establish intravenous access: Insert two large-bore intravenous cannulas for fluid administration and medication delivery.
  • Monitor vital signs: Continuously monitor blood pressure, pulse, respiratory rate, and oxygen saturation.
• Seizure Management (Anticonvulsant Therapy):
  • Magnesium Sulfate: This is the drug of choice for controlling eclamptic seizures and preventing recurrence.
    • Loading Dose: 4-6 g of magnesium sulfate intravenously (IV) administered over 15-20 minutes using a controlled infusion device.
    • Maintenance Dose: 1-2 g per hour as a continuous IV infusion, continued for at least 24 hours after the last seizure or delivery, whichever is later.
    • Recurrent Seizures: If seizures recur despite adequate magnesium sulfate levels, an additional bolus of 2-4 g of magnesium sulfate can be given IV over 5 minutes. If seizures persist, second-line anticonvulsants like lorazepam (2-4 mg IV) or diazepam (5-10 mg IV slowly) may be considered.
• Monitoring for Magnesium Toxicity:
  • Regularly assess deep tendon reflexes (patellar reflex): Absent reflexes indicate rising magnesium levels.
  • Monitor respiratory rate: Respiratory depression (<12 breaths/minute) is a sign of toxicity.
  • Measure urine output: Oliguria can lead to toxic magnesium levels as magnesium is primarily excreted renally.
  • If toxicity is suspected, discontinue magnesium infusion and administer calcium gluconate (10 mL of 10% solution IV over 3 minutes) as an antidote.

Blood Pressure Control (Antihypertensive Therapy)

Severe hypertension (systolic BP ≥ 160 mmHg or diastolic BP ≥ 110 mmHg) must be managed to prevent cerebral hemorrhage and other maternal complications. The goal is to maintain systolic BP between 140-160 mmHg and diastolic BP between 90-110 mmHg, avoiding drastic drops that could compromise uteroplacental perfusion.

• First-line agents:
  • Labetalol: Initial dose of 20 mg IV, followed by 20-80 mg IV every 10-30 minutes, or a continuous infusion.
  • Hydralazine: 5-10 mg IV over 2 minutes, repeated every 20 minutes as needed, up to a maximum total of 20 mg.
  • Nifedipine (oral): 10-20 mg immediate-release tablet orally, repeated after 45 minutes, maximum dose 80 mg.
• Fluid Management: Maintain strict fluid balance. In uncomplicated pre-eclampsia, total fluids should be restricted. A fluid challenge may be appropriate in specific situations like severe oliguria or prior to regional anesthesia.

Maternal and Fetal Assessment

• Maternal Investigations:
  • Complete Blood Count (CBC) including platelet count.
  • Liver Function Tests (LFTs): AST, ALT, LDH.
  • Renal Function Tests: Serum creatinine, blood urea, uric acid.
  • Urine analysis: For proteinuria.
  • Coagulation profile.
  • Consider imaging (e.g., CT head) if neurological deficits persist or other causes of seizures are suspected, but not routinely.
• Fetal Monitoring:
  • Continuous Cardiotocography (CTG) to assess fetal heart rate and uterine contractions. Eclamptic seizures can cause fetal distress, including bradycardia.
  • Ultrasound to assess fetal growth, amniotic fluid volume, and placental location. At 32 weeks, evaluate for Intrauterine Growth Restriction (IUGR) and placental abruption.
  • Administer antenatal corticosteroids (Betamethasone 12 mg IM q24h × 2 doses or Dexamethasone 6 mg IM q12h × 4 doses) to promote fetal lung maturity, given the preterm gestation. Delivery should not be delayed to complete the steroid course if maternal or fetal condition deteriorates.

Timing and Mode of Delivery

Delivery is the definitive treatment for eclampsia. However, maternal stabilization (seizure control, blood pressure management, and correction of hypoxia) should precede delivery, regardless of fetal compromise.

• Decision to Deliver: Once the mother is stabilized, delivery should be planned. At 32 weeks, the benefits of delivery for maternal health must be weighed against the risks of prematurity for the fetus.
• Mode of Delivery:
  • A Caesarean section is often the preferred mode in antepartum eclampsia, especially if the maternal or fetal condition warrants rapid delivery, or if the cervix is unfavorable.
  • Vaginal delivery may be considered if labor is already established and progressing rapidly, and the mother remains stable.

Postpartum Management

• Continued Monitoring: Close monitoring of blood pressure, urine output, and magnesium sulfate levels (if still infusing) for at least 24-48 hours postpartum.
• Antihypertensive Management: Gradually reduce antihypertensive medications as blood pressure stabilizes.
• Counselling: Provide comprehensive counseling regarding future pregnancies, contraception, and the long-term health implications of eclampsia.

The management of antepartum eclampsia at 32 weeks necessitates a rapid and coordinated response from a multidisciplinary team, including obstetricians, anesthetists, neonatologists, and critical care specialists, to optimize outcomes for both the mother and the baby.