Eclampsia / Seizure in Pregnancy

VERSION: 1.0 CREATED: January 31, 2026 STATUS: Approved

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DIAGNOSIS: Eclampsia / Seizure in Pregnancy

ICD-10: O15.0 (Eclampsia complicating pregnancy), O15.1 (Eclampsia complicating labor), O15.2 (Eclampsia complicating the puerperium), O15.9 (Eclampsia, unspecified as to time period), O14.10 (Severe pre-eclampsia, unspecified trimester), O14.12 (Severe pre-eclampsia, second trimester), O14.13 (Severe pre-eclampsia, third trimester), O14.20 (HELLP syndrome, unspecified trimester), G40.909 (Epilepsy in pregnancy — known epilepsy presenting during pregnancy)

CPT CODES: 70450 (CT head), 70553 (MRI brain), 95816 (EEG), 80053 (CMP), 85025 (CBC), 85610 (PT/INR), 82553 (LDH), 84450 (AST), 82040 (albumin), 82728 (ferritin), 83036 (HbA1c), 84703 (hCG), 81003 (urinalysis), 82570 (urine protein/creatinine ratio)

SYNONYMS: Eclampsia, eclamptic seizure, seizure in pregnancy, seizure in preeclampsia, pregnancy-associated seizure, puerperal seizure, postpartum eclampsia, late postpartum eclampsia, hypertensive encephalopathy of pregnancy, PRES in pregnancy, eclamptic encephalopathy, toxemia seizure, gestational seizure

SCOPE: Neurological evaluation and management of seizures occurring during pregnancy and the postpartum period. Covers eclamptic seizures, PRES overlap with eclampsia, management of known epilepsy during pregnancy, acute seizure treatment including magnesium sulfate protocol, blood pressure management, fetal considerations, and postpartum seizure management. Excludes isolated preeclampsia without seizure (obstetric management), non-pregnant seizure evaluation (see New Onset Seizure), and chronic epilepsy management (see Epilepsy Chronic Management).

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PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting

═══════════════════════════════════════════════════════════════ SECTION A: ACTION ITEMS ═══════════════════════════════════════════════════════════════

1. LABORATORY WORKUP

1A. Essential/Core Labs

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
CBC with differential and platelets (CPT 85025)	STAT	STAT	ROUTINE	STAT	HELLP syndrome screening (hemolysis, elevated liver enzymes, low platelets); DIC; infection; baseline for delivery planning	Platelets >100K; <100K → HELLP; schistocytes → microangiopathic hemolysis
CMP (BMP + LFTs) (CPT 80053)	STAT	STAT	ROUTINE	STAT	Hepatic transaminases (HELLP); renal function (preeclampsia with severe features); electrolytes; glucose; uric acid trend	AST/ALT <70 IU/L; elevated → HELLP/severe preeclampsia; creatinine <0.9 mg/dL; elevated → renal involvement
Uric acid (CPT 84550)	STAT	STAT	ROUTINE	STAT	Elevated in preeclampsia; correlates with disease severity; useful trending parameter	<5.5 mg/dL in pregnancy; >6.0 → severe preeclampsia; trend upward concerning
LDH (CPT 82553)	STAT	STAT	ROUTINE	STAT	Hemolysis marker for HELLP; elevated LDH with low haptoglobin and schistocytes confirms hemolysis	<600 IU/L; elevated → hemolysis component of HELLP
PT/INR, PTT, fibrinogen (CPT 85610, 85730, 85384)	STAT	STAT	-	STAT	Coagulopathy screening; DIC in severe preeclampsia/HELLP; baseline before delivery	Normal; fibrinogen <300 mg/dL concerning (normally elevated in pregnancy >400); DIC if fibrinogen <200 + elevated D-dimer
Haptoglobin (CPT 83010)	STAT	STAT	-	STAT	Hemolysis marker; absent or very low in HELLP	Normal; <25 mg/dL → hemolysis
Peripheral blood smear (CPT 85007)	STAT	STAT	-	STAT	Schistocytes confirm microangiopathic hemolysis (HELLP, TTP, HUS)	No schistocytes; present → microangiopathic process
Urinalysis with protein (CPT 81003)	STAT	STAT	ROUTINE	STAT	Proteinuria confirms preeclampsia diagnosis; quantification needed	<300 mg/24h; ≥300 mg → proteinuria (preeclampsia diagnostic criterion)
Urine protein/creatinine ratio (CPT 84156/82570)	STAT	STAT	ROUTINE	STAT	Rapid assessment of proteinuria; correlates with 24h collection; >0.3 diagnostic	<0.3; ≥0.3 → significant proteinuria
Blood glucose (CPT 82947)	STAT	STAT	ROUTINE	STAT	Hypoglycemia as seizure cause; gestational diabetes assessment	60-180 mg/dL; low → treat immediately
Magnesium level (CPT 83735)	STAT	STAT	ROUTINE	STAT	Baseline before MgSO4 therapy; monitor during infusion for toxicity; therapeutic range 4-7 mEq/L for seizure prophylaxis	Baseline 1.5-2.5 mEq/L; therapeutic on MgSO4: 4-7 mEq/L; toxic >7 (loss of reflexes), >10 (respiratory depression), >12 (cardiac arrest)
Calcium, ionized (CPT 82330)	STAT	STAT	-	STAT	Hypocalcemia as seizure cause; MgSO4 can cause hypocalcemia	Normal; low → replete
Type and screen (CPT 86900/86901)	STAT	STAT	-	STAT	Preparation for potential emergent delivery; hemorrhage risk in HELLP/DIC	Type and antibody screen available
ASM levels (if on ASMs for epilepsy) (CPT 80201-80299)	STAT	STAT	ROUTINE	STAT	Pregnancy alters ASM pharmacokinetics (increased clearance, volume distribution, decreased protein binding); levels often subtherapeutic	Compare to pre-pregnancy baseline; lamotrigine drops 50-70%; levetiracetam drops ~60%; free levels preferred

1B. Extended Workup (Second-line)

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
D-dimer (CPT 85379)	STAT	STAT	-	STAT	DIC screening; normally elevated in pregnancy but very high suggests DIC	Mildly elevated (normal in pregnancy); markedly elevated → DIC
Reticulocyte count (CPT 85044)	-	URGENT	-	URGENT	Elevated in hemolytic anemia (HELLP); marrow response to hemolysis	Elevated → active hemolysis; low → marrow suppression
TSH (CPT 84443)	-	ROUTINE	ROUTINE	-	Thyroid storm can cause seizures; postpartum thyroiditis	Normal
Ammonia (CPT 82140)	STAT	STAT	-	STAT	Acute fatty liver of pregnancy (AFLP) can cause seizures; valproate encephalopathy if on VPA	<35 μmol/L; elevated → AFLP or VPA toxicity
Lipase (CPT 83690)	STAT	STAT	-	STAT	Pancreatitis associated with HELLP; severe epigastric pain evaluation	Normal; elevated → pancreatitis
Lactate (CPT 83605)	STAT	STAT	-	STAT	Postictal elevation; persistent elevation → hemodynamic compromise or hepatic dysfunction	Mildly elevated postictal (resolves in 2h); persistent → concerning
Cortisol, AM (CPT 82533)	-	ROUTINE	-	-	Adrenal insufficiency (Sheehan syndrome in postpartum); normally elevated in pregnancy	Normal for pregnancy (elevated baseline)

1C. Rare/Specialized (Refractory or Atypical)

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
ADAMTS13 activity (CPT 85397)	-	URGENT	-	URGENT	Thrombotic thrombocytopenic purpura (TTP) can mimic HELLP/eclampsia; low ADAMTS13 (<10%) diagnostic	>10% (normal); <10% → TTP; requires plasma exchange
Antiphospholipid antibody panel (CPT 86235, 86147)	-	EXT	ROUTINE	-	Antiphospholipid syndrome increases preeclampsia and stroke risk; lupus anticoagulant, anticardiolipin, anti-β2-glycoprotein I	Negative; positive → anticoagulation; thrombophilia workup
Complement levels (C3, C4) (CPT 86160, 86161)	-	EXT	EXT	-	Low in lupus nephritis, atypical HUS, complement-mediated TMA mimicking preeclampsia	Normal; low → autoimmune or complement-mediated process
Autoimmune encephalitis antibody panel	-	EXT	EXT	-	If seizures refractory to MgSO4 and antihypertensives; atypical presentation; postpartum encephalitis	Negative; positive → immunotherapy
Toxicology screen (CPT 80307)	STAT	STAT	-	STAT	Cocaine, methamphetamine → hypertensive crisis and seizures in pregnancy; occult substance use	Negative; positive → specific management
Thrombophilia panel	-	-	EXT	-	If early-onset severe preeclampsia (<34 weeks); recurrent preeclampsia; factor V Leiden, prothrombin mutation, protein C/S, antithrombin III	Normal; positive → hematology referral for future pregnancy planning

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2. DIAGNOSTIC IMAGING & STUDIES

2A. Essential/First-line

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
CT head without contrast (CPT 70450)	STAT	STAT	-	STAT	First-line acute imaging if eclamptic seizure; rule out hemorrhage, edema, herniation; safe in pregnancy (low dose, shield abdomen)	No hemorrhage; may show posterior cerebral edema (PRES pattern); mass effect	None (shield abdomen; benefit outweighs minimal fetal risk)
MRI brain without contrast (CPT 70551)	-	URGENT	ROUTINE	URGENT	Preferred imaging after initial CT; PRES evaluation (T2/FLAIR hyperintensity in posterior cerebral regions); no gadolinium in pregnancy unless absolutely necessary	PRES: bilateral symmetric T2/FLAIR hyperintensity in parieto-occipital regions; may involve frontal, temporal, brainstem, cerebellum; DWI to differentiate vasogenic (PRES) from cytotoxic edema (stroke)	MRI-incompatible implants; avoid gadolinium if possible (crosses placenta)
MRA head and neck (CPT 70544/70547)	-	URGENT	-	URGENT	If concern for cerebral venous thrombosis (CVT), arterial dissection, or vasospasm; CVT risk elevated in pregnancy/postpartum	Normal; CVT (absent flow in sinuses); arterial narrowing → vasospasm (RCVS overlap); dissection	Same as MRI
ECG (12-lead) (CPT 93000)	STAT	STAT	ROUTINE	STAT	Cardiac evaluation; arrhythmia; cardiomyopathy (peripartum); magnesium effects on conduction	Normal; PR prolongation (Mg effect); arrhythmia → cardiology	None
Fetal monitoring (non-stress test / CTG)	STAT	STAT	-	STAT	Fetal heart rate monitoring; assess for fetal distress during/after maternal seizure; placental abruption detection	Reassuring FHR (reactive NST); non-reassuring → emergent delivery planning	None

2B. Extended

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
MRV brain (CPT 70546)	-	URGENT	-	URGENT	Cerebral venous thrombosis (CVT); pregnancy/postpartum is major risk factor; headache + seizure + focal deficit → must exclude	Normal venous sinuses; CVT → anticoagulation	Same as MRI
EEG (routine) (CPT 95816)	-	URGENT	ROUTINE	-	If seizures recur despite MgSO4; diagnostic uncertainty (eclampsia vs epilepsy vs NCSE); persistent altered mental status	Normal background or diffuse slowing (eclampsia); epileptiform discharges → epilepsy; NCSE patterns	None
Continuous EEG (cEEG) (CPT 95700)	-	STAT	-	STAT	Persistent altered mental status after eclamptic seizure; concern for NCSE; refractory seizures	Ictal patterns; NCSE; background assessment	None; resource-dependent
Echocardiogram (CPT 93306)	-	URGENT	-	URGENT	Peripartum cardiomyopathy; pulmonary edema in severe preeclampsia; cardiac function assessment	Normal EF (>55%); reduced EF → peripartum cardiomyopathy; pulmonary hypertension	None
Chest X-ray (CPT 71046)	STAT	STAT	-	STAT	Pulmonary edema (common in severe preeclampsia); aspiration after seizure; ETT position	Clear lungs; bilateral edema → fluid overload/preeclampsia; infiltrate → aspiration	Shield abdomen
Obstetric ultrasound (CPT 76805)	STAT	STAT	-	STAT	Fetal viability and growth; placental abruption evaluation; amniotic fluid assessment	Normal fetal growth; abruption → emergent delivery; oligohydramnios → uteroplacental insufficiency	None

2C. Rare/Specialized

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
CT angiography head (CPT 70496)	-	URGENT	-	URGENT	If concern for vasospasm (RCVS), arterial dissection, or aneurysm; when MRA unavailable or inconclusive	Vasospasm; dissection; aneurysm	Contrast risk to fetus (use only if MRA unavailable and diagnosis critical); iodinated contrast crosses placenta
Conventional angiography (CPT 36224)	-	EXT	-	EXT	Gold standard for cerebral vasospasm if imaging equivocal and clinical suspicion high	Multifocal segmental vasoconstriction (RCVS pattern)	Invasive; radiation; contrast; reserve for equivocal cases

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3. TREATMENT

3A. Acute/Emergent

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Magnesium sulfate (MgSO4) — loading dose	IV	FIRST-LINE for eclamptic seizures and seizure prophylaxis in severe preeclampsia; superior to phenytoin and diazepam for eclampsia	4-6 g IV over 15-20 min :: IV :: q4h :: 4-6 g IV loading dose in 100 mL NS over 15-20 min; Zuspan regimen: 4 g IV load + 1 g/h maintenance; Pritchard regimen: 4 g IV + 10 g IM load (5 g each buttock) + 5 g IM q4h	Myasthenia gravis; severe renal failure (adjust dose); heart block	Magnesium level q4-6h (target 4-7 mEq/L); deep tendon reflexes q1h (FIRST SIGN of toxicity = loss of patellar reflex); respiratory rate q1h (>12/min); urine output q1h (>25 mL/h); have calcium gluconate at bedside	STAT	STAT	-	STAT
Magnesium sulfate (MgSO4) — maintenance	IV	Continued seizure prophylaxis after loading dose; continue for 24-48h postpartum (eclampsia risk persists postpartum)	1-2 g/h continuous infusion :: IV :: continuous :: 1 g/h standard maintenance; increase to 2 g/h if seizure recurs or in severe preeclampsia; continue 24h postpartum (48h if persistent severe features); reduce to 0.5 g/h if CrCl <30	Same as loading; monitor for toxicity	Same as loading; reduce dose if reflexes diminish or urine output drops	STAT	STAT	-	STAT
Calcium gluconate (MgSO4 antidote)	IV	MAGNESIUM TOXICITY RESCUE: Respiratory depression, loss of reflexes, cardiac arrest from Mg toxicity	1 g IV over 3 min :: IV :: once :: 1 g (10 mL of 10% solution) IV over 3 min; may repeat; MUST be at bedside whenever MgSO4 infusing	None in emergency	Cardiac monitoring; respiratory status; repeat Mg level	STAT	STAT	-	STAT
Labetalol	IV	First-line antihypertensive for acute severe hypertension in pregnancy (SBP ≥160 or DBP ≥110); prevents stroke	20 mg IV; 40 mg IV; 80 mg IV :: IV :: continuous :: 20 mg IV push over 2 min; if BP not controlled in 10 min → 40 mg; then 80 mg; max 300 mg total; then start infusion 1-2 mg/min	Asthma; decompensated heart failure; second/third-degree heart block; heart rate <60	BP q5 min during IV bolus; heart rate; fetal monitoring (labetalol safe in pregnancy)	STAT	STAT	-	STAT
Hydralazine	IV	Second-line antihypertensive for acute severe hypertension in pregnancy; alternative when labetalol contraindicated	5 mg IV; 10 mg IV :: IV :: once :: 5 mg IV over 1-2 min; if BP not controlled in 20 min → repeat 5-10 mg; max 20 mg total; then reassess	Coronary artery disease; mitral stenosis; tachycardia	BP q5 min; heart rate (reflex tachycardia common); fetal monitoring	STAT	STAT	-	STAT
Nifedipine (immediate-release)	PO	Oral antihypertensive for severe hypertension when IV access delayed or as transition from IV therapy	10 mg PO; 20 mg PO :: PO :: daily :: 10-20 mg PO; may repeat in 30 min if needed; max 30 mg in acute setting; transition to extended-release 30-60 mg daily	Concurrent MgSO4 (theoretical concern for potentiated hypotension — monitor closely but combination is used); severe aortic stenosis	BP q15 min after first dose; fetal monitoring; avoid sublingual route (unpredictable absorption)	STAT	STAT	-	STAT
Lorazepam	IV	Second-line for eclamptic seizure not responding to MgSO4; or while MgSO4 loading in progress	4 mg IV push :: IV :: once :: 4 mg IV push over 2 min; may repeat x1 in 5 min; max 8 mg; benzodiazepines cross placenta — anticipate neonatal sedation	Severe respiratory depression; use only if MgSO4 inadequate; short-term use only	Respiratory rate; SpO2; neonatal assessment at delivery; have airway equipment ready	STAT	STAT	-	STAT
Levetiracetam	IV, PO	ASM for recurrent seizures after MgSO4 failure; preferred over phenytoin in pregnancy due to better safety profile; for known epilepsy patients needing IV loading	1000 mg IV load; 500 mg IV q12h :: IV :: q12h :: Load 1000-1500 mg IV over 15 min; maintenance 500-1000 mg IV/PO q12h; renal dosing if CrCl <50	Hypersensitivity	Renal function; psychiatric side effects; safe in pregnancy (low teratogenicity); safe in breastfeeding	STAT	STAT	ROUTINE	STAT

3B. Symptomatic Treatments

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Acetaminophen	PO, IV	Headache in eclampsia/preeclampsia; safe in pregnancy; first-line analgesic	650-1000 mg q6h :: PO :: q6h :: 650-1000 mg PO/IV q6h; max 3000 mg/day in pregnancy; avoid in hepatic impairment (HELLP)	Severe hepatic impairment (HELLP with transaminases >5x ULN); allergy	LFTs if HELLP	STAT	STAT	ROUTINE	STAT
Ondansetron	IV, PO	Nausea/vomiting in eclampsia/severe preeclampsia; safe in pregnancy	4 mg IV :: IV :: q8h PRN :: 4 mg IV/PO q8h PRN; max 16 mg/day	QT prolongation; first trimester concern (some data, generally considered safe)	QTc if risk factors	STAT	STAT	ROUTINE	STAT
Labetalol (oral maintenance)	PO	Transition from IV to oral BP control in preeclampsia; maintenance antihypertensive	100 mg BID; 200 mg BID; 300 mg TID :: PO :: TID :: Start 100 mg PO BID; increase by 100 mg q12h as needed; target BP <150/100 antepartum; max 2400 mg/day	Asthma; bradycardia; decompensated CHF	BP; heart rate; fetal monitoring	-	ROUTINE	ROUTINE	-
Nifedipine extended-release	PO	Oral antihypertensive maintenance for preeclampsia; calcium channel blocker safe in pregnancy	30 mg daily; 60 mg daily; 90 mg daily :: PO :: daily :: Start 30 mg daily; increase by 30 mg q3-7d; max 120 mg/day; swallow whole, do not crush	Severe aortic stenosis; hypotension	BP; heart rate; peripheral edema; fetal monitoring	-	ROUTINE	ROUTINE	-

3C. Second-line/Refractory

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Phenytoin (fosphenytoin)	IV	Third-line for eclamptic seizures refractory to MgSO4 + lorazepam; historically used but INFERIOR to MgSO4 for eclampsia	20 mg PE/kg IV :: IV :: once :: 20 mg phenytoin equivalents (PE)/kg IV at ≤150 mg PE/min; maintenance 5 mg PE/kg/day; check free phenytoin level (protein binding altered in pregnancy)	Sinus bradycardia; second/third-degree AV block; Stokes-Adams syndrome; TERATOGENIC (fetal hydantoin syndrome) — use only if no alternative	Cardiac monitoring during infusion; free phenytoin level (not total); BP; fetal monitoring	STAT	STAT	-	STAT
Nicardipine infusion	IV	Refractory severe hypertension not controlled by labetalol + hydralazine; ICU setting	5 mg/h titrated to 15 mg/h :: IV :: continuous :: Start 5 mg/h IV; increase by 2.5 mg/h q5-15min; max 15 mg/h; target SBP 140-155; reduce BP no more than 25% in first hour	Severe aortic stenosis; compensatory hypertension	Arterial line; continuous BP; fetal monitoring	-	-	-	STAT
Sodium nitroprusside	IV	Life-threatening hypertensive emergency refractory to all other agents; LAST RESORT in pregnancy due to cyanide risk to fetus	0.25-0.5 mcg/kg/min :: IV :: q5min :: Start 0.25 mcg/kg/min; titrate by 0.5 mcg/kg/min q5min; max 2 mcg/kg/min; use for shortest duration possible; CYANIDE TOXICITY risk to fetus — LAST RESORT	Compensatory hypertension; hepatic insufficiency; coarctation of aorta	Arterial line mandatory; thiocyanate levels if >24h; FETAL MONITORING — cyanide crosses placenta	-	-	-	STAT
Delivery	Surgical/vaginal	DEFINITIVE TREATMENT for eclampsia: Delivery of fetus and placenta cures eclampsia in most cases	N/A :: Obstetric :: once :: Plan delivery after maternal stabilization (seizure control + BP control); ≥34 weeks: delivery recommended; <34 weeks: consider steroids for fetal lung maturity if maternal condition allows 24-48h delay; emergent C-section if fetal distress	Maternal instability precluding anesthesia (stabilize first)	Continuous fetal monitoring; maternal hemodynamics; postpartum MgSO4 continuation 24-48h	STAT	STAT	-	STAT

3D. ASM Safety in Pregnancy / Postpartum

Treatment	Route	Indication	Dosing	Pre-Treatment Requirements	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Lamotrigine	PO	Preferred ASM in pregnancy for known epilepsy; lowest teratogenicity risk among effective broad-spectrum ASMs; requires dose monitoring	Individualized per levels :: PO :: monthly :: Monitor levels monthly during pregnancy (drops 50-70%); increase dose to maintain pre-pregnancy level; reduce dose by 25% within first 2 weeks postpartum then rapidly taper to pre-pregnancy dose over next 2 weeks	Pre-pregnancy lamotrigine level as target	SJS/TEN with rapid dose changes; do not increase faster than 50 mg q2wk	Monthly lamotrigine levels; postpartum level within 1 week of delivery; toxicity symptoms (diplopia, ataxia) as levels rebound postpartum	-	ROUTINE	ROUTINE	-
Levetiracetam	PO	Preferred ASM in pregnancy; low teratogenicity; safe in breastfeeding; renal elimination (no hepatic interactions)	Individualized per levels :: PO :: per protocol :: Monitor levels each trimester (decreases ~60%); increase dose to maintain seizure control; renal clearance increases in pregnancy; postpartum dose reduction needed	Pre-pregnancy level as target	Hypersensitivity; dose adjust for renal function	Levels each trimester; psychiatric symptoms; renal function; postpartum reduction	-	ROUTINE	ROUTINE	-
Folic acid (high-dose preconception)	PO	Neural tube defect prevention in women with epilepsy; ALL women on ASMs planning pregnancy	4 mg daily :: PO :: daily :: 4 mg daily starting ≥3 months before conception; continue through first trimester; 1 mg daily maintenance after	None	Few	Serum folate	-	ROUTINE	ROUTINE	-
Vitamin K (neonatal)	IM	All neonates born to mothers on enzyme-inducing ASMs; hemorrhagic disease of newborn prevention	1 mg IM at birth :: IM :: once :: 1 mg vitamin K IM to neonate at delivery; standard of care but especially critical with enzyme-inducing maternal ASMs	None	None	Neonatal coagulation studies if clinically indicated	-	ROUTINE	-	-

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4. OTHER RECOMMENDATIONS

4A. Referrals & Consults

Recommendation	ED	HOSP	OPD	ICU
OB/GYN or Maternal-Fetal Medicine (MFM) STAT consultation for all eclamptic seizures for delivery planning and fetal assessment	STAT	STAT	-	STAT
Neurology consultation for eclamptic seizure evaluation; PRES vs CVT vs other neurological cause; ASM management in known epilepsy	STAT	STAT	ROUTINE	STAT
Anesthesiology consultation for delivery planning; epidural/spinal safety; airway assessment if intubated; magnesium-neuromuscular blocker interactions	-	URGENT	-	URGENT
Neonatology or pediatrics notification for delivery; assess neonatal effects of maternal seizure, magnesium, and ASMs	-	URGENT	-	URGENT
Hematology consultation if HELLP with severe thrombocytopenia (<50K), suspected TTP (ADAMTS13 pending), or DIC	-	URGENT	-	URGENT
Nephrology consultation if acute kidney injury (creatinine >1.1 mg/dL in pregnancy) or persistent proteinuria postpartum	-	ROUTINE	ROUTINE	ROUTINE
Postpartum neurology follow-up in 2-4 weeks for MRI review, ASM management, and recurrence risk counseling	-	ROUTINE	ROUTINE	-
Postpartum OB follow-up in 1-2 weeks for BP monitoring, proteinuria resolution, and future pregnancy counseling	-	ROUTINE	ROUTINE	-

4B. Patient Instructions

Recommendation	ED	HOSP	OPD
Return to ED immediately if new seizure, severe headache not responsive to acetaminophen, visual changes (blurring, scotomata, blindness), right upper quadrant pain, or sudden swelling of face/hands (preeclampsia warning signs)	STAT	STAT	ROUTINE
Continue magnesium sulfate monitoring in hospital for 24-48 hours after delivery; do not leave against medical advice during this critical window	-	STAT	-
Postpartum eclampsia can occur up to 6 weeks after delivery; any new seizure, severe headache, or visual changes in the postpartum period requires emergency evaluation	-	ROUTINE	ROUTINE
If on ASMs for epilepsy: do NOT stop medications during pregnancy; benefits of seizure prevention outweigh teratogenicity risk of most ASMs; discuss any changes with neurologist	-	ROUTINE	ROUTINE
Breastfeeding is generally safe with most ASMs (lamotrigine, levetiracetam, valproate, carbamazepine); monitor infant for sedation; discuss with neurologist and pediatrician	-	ROUTINE	ROUTINE
Monitor blood pressure at home daily for 6 weeks postpartum using validated automated cuff; record and bring to follow-up; seek care if SBP ≥150 or DBP ≥100	-	ROUTINE	ROUTINE
Future pregnancies: preeclampsia recurrence risk is 15-25%; eclampsia recurrence ~2%; discuss timing and planning with MFM	-	-	ROUTINE

4C. Lifestyle & Prevention

Recommendation	ED	HOSP	OPD
Low-dose aspirin 81 mg daily starting at 12-16 weeks in future pregnancies for preeclampsia prevention (recommended for women with prior preeclampsia/eclampsia)	-	-	ROUTINE
Blood pressure optimization before future pregnancies; target <130/80; weight management and regular exercise reduce preeclampsia risk	-	-	ROUTINE
Calcium supplementation 1000-2000 mg daily in future pregnancies may reduce preeclampsia risk (especially if baseline dietary calcium is low)	-	-	ROUTINE
Adequate sleep and stress management during pregnancy and postpartum to reduce seizure threshold and support recovery	-	ROUTINE	ROUTINE
Smoking cessation and alcohol avoidance throughout pregnancy and postpartum	-	ROUTINE	ROUTINE

═══════════════════════════════════════════════════════════════ SECTION B: REFERENCE (Expand as Needed) ═══════════════════════════════════════════════════════════════

5. DIFFERENTIAL DIAGNOSIS

Alternative Diagnosis	Key Distinguishing Features	Tests to Differentiate
Eclampsia (primary diagnosis)	New-onset seizure in pregnancy/postpartum with hypertension (≥140/90) and proteinuria; >20 weeks gestation; may occur without preceding preeclampsia diagnosis	BP, urinalysis, preeclampsia labs; clinical diagnosis
PRES (posterior reversible encephalopathy syndrome)	Overlaps heavily with eclampsia; posterior cerebral edema on MRI; may occur with or without eclampsia	MRI (T2/FLAIR posterior predominant edema); DWI (vasogenic not cytotoxic edema); clinical overlap — treat both
Cerebral venous thrombosis (CVT)	Headache, seizures, focal deficits; pregnancy/postpartum is major risk factor; may have hemorrhagic infarct	MRV (absent venous flow); D-dimer (very elevated); CT venogram
Epilepsy (known, during pregnancy)	Pre-existing seizure disorder; may have breakthrough due to decreased ASM levels; no hypertension/proteinuria	ASM levels (subtherapeutic); normal BP; no proteinuria; prior epilepsy history
Ischemic stroke	Sudden focal deficit; may have seizure at onset; pregnancy increases ischemic stroke risk 3-13x	MRI/DWI (restricted diffusion); CTA/MRA (occlusion); onset with focal deficit
Intracerebral hemorrhage	Severe headache; focal deficit; may have seizure; hypertension; coagulopathy (HELLP/DIC)	CT head (hyperdense lesion); coagulation studies; platelet count
RCVS (reversible cerebral vasoconstriction syndrome)	Thunderclap headache; seizures; focal deficits; angiography shows segmental vasoconstriction; overlaps with eclampsia/PRES	CTA/MRA (multifocal narrowing); serial imaging (resolves over weeks)
Thrombotic thrombocytopenic purpura (TTP)	Microangiopathic hemolytic anemia + thrombocytopenia; may mimic HELLP; seizures from TMA	ADAMTS13 <10%; schistocytes; severe thrombocytopenia
Meningoencephalitis	Fever, headache, altered mental status, seizures; may be viral (HSV) or bacterial	CSF analysis; MRI (temporal lobe enhancement in HSV); cultures
Metabolic (hypoglycemia, hyponatremia, hypocalcemia)	Correctable metabolic abnormalities; no hypertension/proteinuria	BMP; glucose; calcium; magnesium
Acute fatty liver of pregnancy (AFLP)	Third trimester; nausea, vomiting, abdominal pain, coagulopathy, hypoglycemia, hyperammonemia	Ammonia (elevated); glucose (low); fibrinogen (low); LFTs (elevated); imaging (fatty liver)

Red Flags for Non-Eclamptic Cause

Red Flag	Concern	Action
Seizure before 20 weeks gestation	Eclampsia rare <20 wks; consider epilepsy, structural lesion, metabolic	Full neurologic workup; MRI; EEG
Normal blood pressure with seizure	Not classic eclampsia (though 20% of eclampsia occurs with "normal" BP)	Consider CVT, epilepsy, metabolic; MRV; ASM levels
Focal neurologic deficit persistent >24h	Stroke (ischemic or hemorrhagic); CVT with infarction	MRI/DWI; MRV; CTA
Fever with seizure	Meningitis, encephalitis; chorioamnionitis	CSF analysis; blood cultures; MRI
Seizure >6 weeks postpartum	Late postpartum eclampsia possible but rare; consider CVT, epilepsy	Full workup as new-onset seizure; MRV

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6. MONITORING PARAMETERS

Parameter	Frequency	Target/Threshold	Action if Abnormal	ED	HOSP	OPD	ICU
Blood pressure	q5 min during acute treatment; q15 min x 2h; then q1h; q4h once stable	<160/110 acute; <150/100 target range; <140/90 postpartum	Persistent ≥160/110 → IV antihypertensive; resistant → ICU	STAT	STAT	ROUTINE	STAT
Magnesium level	q4-6h during infusion; q6h maintenance; PRN if toxicity signs	4-7 mEq/L therapeutic	<4 → increase rate; >7 → decrease rate/hold; >10 → stop + calcium gluconate	STAT	STAT	-	STAT
Deep tendon reflexes (patellar)	q1h during MgSO4 infusion	Present (2+)	Absent/diminished → check Mg level; hold MgSO4 if areflexic; have calcium gluconate ready	STAT	STAT	-	STAT
Respiratory rate	q1h during MgSO4	>12 breaths/min	<12 → hold MgSO4; administer calcium gluconate; prepare for intubation	STAT	STAT	-	STAT
Urine output	q1h (Foley catheter recommended)	>25 mL/h (>0.5 mL/kg/h)	<25 mL/h → reduce MgSO4 (renal excretion); assess volume status; oliguria → fluid bolus vs renal failure	STAT	STAT	-	STAT
Fetal heart rate	Continuous during acute management	110-160 bpm; reactive	Non-reassuring → OB assessment; emergent delivery if persistent fetal distress	STAT	STAT	-	STAT
CBC with platelets	q6-12h if HELLP; daily if preeclampsia	Platelets >100K; stable Hgb	Falling platelets → worsening HELLP; Hgb drop → hemorrhage or hemolysis	STAT	STAT	ROUTINE	STAT
LFTs (AST/ALT)	q6-12h if HELLP; daily if preeclampsia	Trending down after delivery	Rising → worsening HELLP; peak usually 24-48h after delivery then improve	STAT	STAT	ROUTINE	STAT
LDH and haptoglobin	q12-24h if HELLP	LDH trending down; haptoglobin rising	Worsening → ongoing hemolysis; not improving 48-72h → consider TTP/aHUS	-	STAT	-	STAT
ASM levels (if epilepsy)	At admission; monthly during pregnancy; 1 week postpartum	Pre-pregnancy target level	Subtherapeutic → increase dose; postpartum → reduce dose (levels rebound)	STAT	STAT	ROUTINE	STAT
Postpartum BP monitoring	Daily x 72h inpatient; home monitoring daily x 6 weeks	<140/90	Persistent hypertension → continue/escalate antihypertensives; new onset >48h → evaluate late postpartum preeclampsia	-	ROUTINE	ROUTINE	-

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7. DISPOSITION CRITERIA

Disposition	Criteria
Admit to ICU	Eclamptic seizure; refractory hypertension (≥160/110 despite 2 IV agents); HELLP with platelets <50K or DIC; pulmonary edema; renal failure; persistent altered mental status; intubation
Admit to L&D / high-risk antepartum	Severe preeclampsia with controlled BP; stable HELLP (platelets >50K); post-eclamptic seizure now stable; pending delivery planning
Discharge home (postpartum)	Seizure-free ≥24h after MgSO4 completion; BP consistently <150/100 on oral agents; normalizing labs; oral medications tolerated; reliable follow-up arranged; home BP cuff provided
Outpatient follow-up	Neurology 2-4 weeks (MRI review, recurrence risk); OB 1-2 weeks (BP, proteinuria); MFM before future pregnancy for risk counseling
Transfer to tertiary center	If facility lacks MFM, NICU, or neurocritical care capabilities; HELLP with DIC; refractory status epilepticus in pregnancy

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8. EVIDENCE & REFERENCES

Recommendation	Evidence Level	Source
Magnesium sulfate superior to phenytoin and diazepam for eclampsia prevention and treatment	Class I, Level A (large RCTs)	The Magpie Trial. Lancet 2002
MgSO4 reduces eclampsia risk by 58% compared to placebo in severe preeclampsia	Class I, Level A	Altman et al. BJOG 2002 (Magpie follow-up)
Labetalol and nifedipine equally effective for acute severe hypertension in pregnancy	Class I (RCT)	Shekhar et al. Pregnancy Hypertens 2016
PRES is the neuroimaging correlate of eclampsia in majority of cases	Class III evidence (case series)	Brewer et al. AJNR 2013
Low-dose aspirin 81 mg from 12-16 weeks reduces preeclampsia risk in high-risk women	Class I, Level A	Rolnik et al. NEJM 2017 (ASPRE trial)
Lamotrigine and levetiracetam preferred ASMs in pregnancy (lowest teratogenicity)	Class II evidence; Registry data	Tomson et al. Lancet Neurol 2018 (EURAP)
Lamotrigine levels decrease 50-70% during pregnancy; monthly monitoring needed	Class II evidence	Pennell et al. Neurology 2008
Delivery is definitive treatment for eclampsia; timing depends on gestational age and maternal/fetal status	Guideline	ACOG Practice Bulletin 222: Gestational Hypertension and Preeclampsia 2020
Postpartum eclampsia occurs in up to 26% of eclampsia cases; monitoring continues 48h post-delivery	Class III evidence	Al-Safi et al. Am J Obstet Gynecol 2011
CVT risk is 12x higher in pregnancy/postpartum; must be excluded in seizures with headache	Class III evidence	Ferro et al. Stroke 2004

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CHANGE LOG

v1.0 (January 31, 2026) - Initial template creation - Comprehensive eclampsia/seizure in pregnancy management including MgSO4 protocols, PRES overlap, HELLP differentiation, ASM safety in pregnancy, and postpartum management

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APPENDIX A: Magnesium Sulfate Toxicity Levels

Mg Level (mEq/L)	Clinical Effect	Action
1.5-2.5	Normal baseline	No action
4-7	Therapeutic range (seizure prophylaxis)	Maintain infusion; monitor reflexes q1h
7-10	Loss of patellar reflexes; warmth, flushing	Hold infusion; recheck level q2h; resume at lower rate when <7
10-12	Respiratory depression; somnolence	STOP infusion; calcium gluconate 1g IV; prepare for intubation
>12	Respiratory arrest; cardiac arrest	STOP infusion; calcium gluconate 1g IV STAT; intubate; ACLS if cardiac arrest

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APPENDIX B: ASM Safety in Pregnancy Quick Reference

ASM	Pregnancy Category	Major Malformation Rate	Safe in Breastfeeding	Key Risk
Lamotrigine	PREFERRED	2-3%	Yes	Levels drop 50-70%; monthly monitoring
Levetiracetam	PREFERRED	1-2%	Yes	Levels drop ~60%; renal dosing
Oxcarbazepine	Acceptable	2-3%	Yes	Monitor sodium
Carbamazepine	Caution	3-5%	Yes	NTD risk 0.5-1%; enzyme inducer
Topiramate	AVOID	4-9%	Yes	Cleft lip/palate 3x risk
Valproate	CONTRAINDICATED	9-11%	Caution	NTD 1-2%; IQ reduction; DO NOT USE
Phenytoin	AVOID	3-7%	Yes	Fetal hydantoin syndrome
Phenobarbital	AVOID	5-7%	Caution	Cardiac defects; cognitive effects
Lacosamide	Insufficient data	Unknown	Probably yes	Use with caution
Brivaracetam	Insufficient data	Unknown	Unknown	Use with caution