Eclampsia with pulmonary oedema — FFICM MCQ

Correct answer: E — Give magnesium sulphate and control severe hypertension with obstetric involvement

The correct answer is E, give magnesium sulphate and control severe hypertension with obstetric involvement. This woman has eclampsia (seizure plus severe pre-eclampsia features: BP 178/112 mmHg, proteinuria 3+) with superimposed pulmonary oedema (bibasal crackles, hypoxia despite high-flow oxygen). NICE NG133 identifies magnesium sulphate as the anticonvulsant of choice for treating eclamptic seizures and preventing further seizures, alongside urgent antihypertensive treatment for severe hypertension and immediate multidisciplinary obstetric, anaesthetic and critical care input. The hypoxia and crackles signal pulmonary oedema, a recognised complication of severe pre-eclampsia, which further mandates senior obstetric and critical care involvement rather than isolated seizure management. Why the other options are wrong: B. Phenytoin as first-line seizure prophylaxis: Trial evidence consistently shows magnesium sulphate is superior to phenytoin for eclamptic seizure prevention and treatment; phenytoin is not recommended first-line in UK obstetric practice. D. Delay treatment until delivery suite transfer: Eclampsia and pulmonary oedema are immediately life-threatening; treatment (magnesium sulphate, antihypertensives, oxygen, monitoring) must start at the point of care, with transfer arranged in parallel, not deferred. A. Give large-volume crystalloid resuscitation: This woman already has pulmonary oedema and hypoxia; aggressive fluid loading risks worsening pulmonary oedema and is specifically cautioned against in severe pre-eclampsia, where fluid restriction is used. C. Use ACE inhibitor immediately: ACE inhibitors are teratogenic and contraindicated in pregnancy; they have no role in acute severe hypertension management antenatally. Key point: In eclampsia with pulmonary oedema, magnesium sulphate for seizure control plus urgent BP treatment and senior obstetric/critical care involvement takes priority over fluid resuscitation or alternative anticonvulsants.

Reference: NICE Guideline NG133, Hypertension in pregnancy: diagnosis and management (2019, updated), sections on magnesium sulphate for eclampsia and severe pre-eclampsia and management of severe hypertension in a critical care setting. https://www.nice.org.uk/guidance/ng133