Hypertensive crisis and refractory eclampsia — structured SAQ (15 marks)

(a) Immediate management of seizure and blood pressure (7 marks)

Two marks for the seizure and magnesium, three for the antihypertensive with dose and target, one for oxygen and airway, one for the delivery plan and ongoing magnesium. [1][5]

• Seizure and airway: left lateral position, high-flow oxygen, protect the airway, call for senior help; do not restrain the convulsion.[5]
• Magnesium sulfate: loading dose 4 g intravenously over 20 minutes, then a maintenance infusion of 1 to 2 g per hour, continued for 24 hours after birth or the last seizure, whichever is later. This is the first-line anticonvulsant, superior to diazepam and phenytoin.[1][3]
• Antihypertensive: her pressure is severe-range (186/118). I would use labetalol 200 mg orally, or intravenously 20 mg then 40 to 80 mg every 10 minutes up to a maximum of 300 mg, aiming for a controlled reduction toward a systolic of 140 to 150 and a diastolic of 90 to 100 mmHg, avoiding a fall of more than about 25 percent.[4][5]
• Calcium gluconate 1 g intravenously (10 mL of 10 percent) drawn up and at the bedside before the infusion starts.[5][10]
• Delivery: once the mother is stable, expedite delivery by the route the maternal and fetal condition dictate. Stabilise first, then deliver.[5]

(b) Refractory seizure management (4 marks)

One mark for recognising refractory eclampsia, one for rechecking level and pressure, one for the magnesium bolus and second-line agent with dose, one for intubation and delivery. [6][5]

• This is refractory eclampsia — a recurrent seizure despite an adequate loading dose.[6]
• The blood pressure is now controlled (144/92), so the recurrent seizure is not pressure-driven; check the magnesium level and consider a further 2 g magnesium bolus if the level is low.[5]
• Add a second-line anticonvulsant: levetiracetam 1 to 2 g intravenously is preferred, with phenytoin 15 to 20 mg per kg or diazepam 10 mg intravenously as alternatives. Magnesium remains first-line and is augmented, not abandoned.[1][6]
• Call anaesthetics and intensive care; intubate and ventilate for recurrent or prolonged seizure; deliver once stable.[6]

(c) Postpartum deterioration — diagnosis and management (4 marks)

Two marks for the diagnosis of magnesium toxicity with its signs, two for the management with drug and dose. [10][5]

• Diagnosis: magnesium toxicity. The triad of a respiratory rate under 12, absent deep tendon reflexes (the earliest sign) and a falling conscious level is diagnostic; loss of reflexes precedes respiratory depression.[10]
• Management: stop the magnesium infusion immediately and give calcium gluconate 1 g intravenously (10 mL of a 10 percent solution) over 10 minutes — the specific antidote that reverses magnesium-induced respiratory depression.[5]
• Support the airway and breathing; check a magnesium level and renal function; resume magnesium only if toxicity is excluded and the indication persists, at a lower rate or with level monitoring.[10]