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Postpartum eclampsia — MRCEM SBA MCQ

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HardResuscitation and critical illnessPostpartum eclampsiaMRCEM SBA

A 31-year-old woman presents to the emergency department five days after giving birth. She reports a worsening headache and flashing lights, then has a generalised tonic–clonic seizure lasting one minute. She is now alert, protecting her airway and has no focal neurological deficit. Her blood pressure is 184/118 mmHg on repeat measurement and capillary glucose is 5.3 mmol/L. Intravenous access and monitoring are established. A urine protein result is pending. What is the most appropriate immediate treatment and disposition?

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Correct answer: D — Start intravenous magnesium sulfate and labetalol now, and arrange level 2 care.

A seizure after childbirth, preceded by headache and visual disturbance and accompanied by severe hypertension, requires immediate management as eclampsia. The fit has ended, but intravenous magnesium sulfate is still indicated to prevent further seizures. NICE recommends a 4 g intravenous loading dose over 5–15 minutes, followed by 1 g/hour for 24 hours after the last fit. Her severe hypertension also needs immediate treatment; intravenous labetalol is a recommended choice. Arrange urgent obstetric involvement and level 2 critical care: eclampsia meets NICE’s level 2 criteria even when ventilation is unnecessary. A correctly addresses the blood pressure but delays magnesium sulfate for a proteinuria result that does not alter treatment of this presentation. B uses a familiar antiseizure medicine, but NICE advises against substituting another anticonvulsant for magnesium sulfate in eclampsia. C recognises both treatments but incorrectly makes CT a prerequisite; investigation for another intracranial cause can follow initial stabilisation if indicated. E selects the appropriate drugs but underestimates the care level required after an eclamptic fit. Level 1 care may be appropriate for less complicated hypertensive disease or subsequent step-down, not this immediate disposition.

Reference: NICE NG133, recommendations 1.8.1 and 1.8.4–1.8.5: anticonvulsants (Last updated 17 April 2023) — https://www.nice.org.uk/guidance/ng133/chapter/recommendations NICE NG133, recommendation 1.8.6: antihypertensives (Last updated 17 April 2023) — https://www.nice.org.uk/guidance/ng133/chapter/recommendations NICE NG133, recommendation 1.8.14, table 4: critical care referral (Last updated 17 April 2023) — https://www.nice.org.uk/guidance/ng133/chapter/recommendations