Eclampsia at 32 Weeks – PLAB/UKMLA Clinical Scenario (Seizure in Pregnancy)
Clinical Scenario 📖
A 32-year-old woman, 32 weeks pregnant, is brought to the emergency department after a generalized tonic-clonic seizure. Prior to the seizure, she complained of a severe headache and blurred vision. On examination, her blood pressure is 160/100 mmHg and urinalysis shows 3+ protein. After the convulsion, she is drowsy but responsive. What is the most appropriate immediate management?
A. IV Diazepam
B. IV Labetalol
C. IV Magnesium sulfate
D. Immediate delivery of the baby
E. IV Phenytoin
Clinical Reasoning 🩺
This scenario is highly suggestive of eclampsia, a life-threatening obstetric emergency. Eclampsia is essentially the occurrence of **seizures in a pregnant woman with preeclampsia (Eclampsia: Causes, Symptoms, Diagnosis & Treatment). In this case, the patient’s markedly elevated blood pressure (160/100) and proteinuria (3+ protein) indicate preeclampsia, and the tonic-clonic seizure confirms that she has progressed to eclampsia. Key prodromal features like headache and visual disturbances (blurred vision) often precede eclamptic seizures due to severe hypertension and cerebral edema.
Recognizing eclampsia is critical for anyone preparing for the PLAB 1 exam or tackling UKMLA exam questions on obstetric emergencies. Prompt management is required to prevent maternal and fetal complications such as intracerebral hemorrhage, placental abruption, or even maternal death. The cornerstone of eclampsia management is to stop the seizure and prevent recurrent convulsions, while also controlling the blood pressure and planning for delivery once the patient is stabilized.
According to the NICE Hypertension in Pregnancy Guidelines, intravenous magnesium sulfate (MgSO₄) is the first-line treatment for an eclamptic seizu (Recommendations | Hypertension in pregnancy: diagnosis and management | Guidance | NICE). Magnesium sulfate directly controls the convulsions and dramatically reduces the risk of further seizures. It is considered the gold-standard therapy, superior to other anti-epileptic drugs in the context of eclamps (Eclampsia - StatPearls - NCBI Bookshelf). In addition, supportive care (airway protection, oxygen, left lateral position to improve uteroplacental blood flow) should be provided during and after the seizure.
Controlling the blood pressure is also crucial in eclampsia to reduce the risk of stroke. Once the seizure is addressed, antihypertensive therapy (for example, IV labetalol or hydralazine) should be given to bring the severe hypertension under control (Recommendations | Hypertension in pregnancy: diagnosis and management | Guidance | NICE). Definitive treatment of eclampsia involves delivery of the baby (usually after stabilizing the mother with magnesium sulfate and blood pressure control). In this patient at 32 weeks, that means planning for induction of labor or Caesarean section after initial stabilization. However, the immediate step is to manage the seizure and prevent another one – which brings us to the correct answer.
Answer and Explanation ✅
The correct answer is C. IV Magnesium sulfate. This is the most appropriate immediate management for an eclamptic seizure in a pregnant patient.
IV Magnesium Sulfate (MgSO₄) – First-line Treatment: Magnesium sulfate is the anticonvulsant of choice for eclampsia. It halts the current seizure and prevents recurrent seizures by reducing neuronal excitability. Clinical guidelines strongly endorse MgSO₄ in eclampsia; in fact, NICE explicitly states that if a woman has an eclamptic fit, give IV magnesium sulfate without del (Recommendations | Hypertension in pregnancy: diagnosis and management | Guidance | NICE). Magnesium not only treats the seizure but also has mild anti-hypertensive effects and neuroprotective benefits for the mother. The standard regimen (from the Collaborative Eclampsia Trial) is a loading dose (often 4 g IV over 5–15 minutes) followed by a maintenance infusion (1 g/hour for 24 hour (Recommendations | Hypertension in pregnancy: diagnosis and management | Guidance | NICE). Magnesium therapy has been proven to reduce the risk of recurrent seizures and maternal complications. (Notably, one should monitor the patellar reflexes, respiratory rate, and urine output during magnesium infusion, as magnesium toxicity can cause respiratory depression – and calcium gluconate should be available as an antidote. However, in the exam setting, the key point is recognizing magnesium sulfate as the initial management.) Importantly, no other anticonvulsant is recommended in place of magnesium for eclamps (Recommendations | Hypertension in pregnancy: diagnosis and management | Guidance | NICE). Thus, IV magnesium sulfate is the correct and lifesaving intervention in this scenario.
Why Other Options are Less Suitable:
A. IV Diazepam: Benzodiazepines like diazepam are not first-line for eclamptic seizures. While diazepam can stop seizures, it is less effective than magnesium sulfate in preventing further convulsions in eclampsia. Guidelines specifically advise against using diazepam or other anticonvulsants as alternatives to magnesium sulfate in eclamptic patien (Recommendations | Hypertension in pregnancy: diagnosis and management | Guidance | NICE). Diazepam may also cause neonatal and maternal respiratory depression. In summary, diazepam is appropriate for many seizure conditions (e.g., status epilepticus), but in pregnancy-related eclampsia, magnesium sulfate is superior.
B. IV Labetalol: Labetalol is an antihypertensive, commonly used to manage severe blood pressure in preeclampsia/eclampsia. Here, the patient’s BP is 160/100, which does warrant treatment – and **labetalol IV is indeed a recommended drug to lower severe hypertension in pregnancy (Recommendations | Hypertension in pregnancy: diagnosis and management | Guidance | NICE). However, during an eclamptic emergency, controlling the seizure takes priority. The question asks for the most appropriate immediate management. While you would certainly begin addressing her hypertension soon (to reduce stroke risk), the first step is to stop and prevent seizures with magnesium. Initiating IV labetalol before securing the airway and stopping the convulsion would be inappropriate. Thus, labetalol is important in management, but not the first step in this scenario.
D. Immediate delivery of the baby: Definitive treatment for eclampsia is to deliver the fetus and placenta, since that will ultimately resolve the preeclampsia/eclampsia syndrome. However, an immediate delivery (e.g., emergent C-section) during or right after a seizure is dangerous. The mother needs to be stabilized first. Performing an urgent delivery without controlling the seizure and blood pressure could lead to trauma, poor maternal perfusion, or cardiac arrest. Obstetric protocol is to stabilize the mother (with magnesium sulfate, blood pressure control, and supportive care) before initiating delivery. In a 32-week pregnancy, you would expedite delivery once the mother is stable (and often give corticosteroids if time allows to help fetal lungs mature). But delivery is not the very first step in acute management of eclampsia. Therefore, this option is incorrect as the immediate action.
E. IV Phenytoin: Phenytoin is an anticonvulsant that in the past was sometimes used for eclampsia, but evidence has shown it to be inferior to magnesium sulfate. Like diazepam, phenytoin is **not recommended for first-line use in eclamptic seizures (Recommendations | Hypertension in pregnancy: diagnosis and management | Guidance | NICE). Magnesium sulfate has better outcomes in preventing recurrent seizures and reducing morbidity. Phenytoin might be considered only if magnesium sulfate is contraindicated or ineffective (which is rare). Examples of contraindications could be severe maternal myasthenia gravis or cardiac conduction blocks – but these are uncommon scenarios. In almost all cases, especially in exams, phenytoin is not the correct choice for seizures in pregnancy when eclampsia is present.
Clinical Pearl: Eclampsia is a high-yield topic for both PLAB 1 and UKMLA. Remember that magnesium sulfate is the drug of choice for seizure in pregnancy due to eclampsia – a classic fact tested in many exam questions. Also be aware of the supportive measures and NICE guidelines: stabilize the mother first (ABCs, MgSO₄, blood pressure control) then proceed to delivery once safe. Any alternative answer that deviates from magnesium for an eclamptic seizure is likely incorrect on exams.
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References (Guidelines)
NICE, Hypertension in Pregnancy (2019 update) – recommends IV magnesium sulfate for any woman who has an eclamptic f (Recommendations | Hypertension in pregnancy: diagnosis and management | Guidance | NICE), and explicitly says **do not use diazepam or phenytoin as alternatives (Recommendations | Hypertension in pregnancy: diagnosis and management | Guidance | NICE). It also advises urgent treatment of severe hypertension (e.g. with labetalol) in these patien (Recommendations | Hypertension in pregnancy: diagnosis and management | Guidance | NICE).
Cleveland Clinic – defines eclampsia as seizures in a pregnant woman with preeclamps (Eclampsia: Causes, Symptoms, Diagnosis & Treatment)7】, underlining that this condition is a serious obstetric emergency typically occurring in the second half of pregnancy.
StatPearls (NIH) – confirms that magnesium sulfate is the first-line treatment to prevent and control seizures in eclamps (Eclampsia - StatPearls - NCBI Bookshelf)1】, reflecting its universal acceptance in obstetric practice.
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