The ABCDEFG of Eclampsia: Advanced Life Support in Eclampsia (ALSE)

Amorim, Melania Maria Ramos de; Cunha, Anna Catharina Carneiro da; Albuquerque, Marina Amorim; Brito, Josikwylkson Costa; Souza, Alex Sandro Rolland; Katz, Leila

doi:10.1590/1806-9304202520250347-en

person Melania Maria Ramos de Amorim

approved the final version of the article · declare no conflicts of interest · conceptualization · methodology · project administration · supervision · manuscript writing · review · and editing

schoolPrograma de Pós-graduação Stricto Sensu em Saúde Integral. Instituto de Medicina Integral Prof. Fernando Figueira. Rua dos Coelhos, 300. Boa Vista. Recife, PE, Brazil. CEP: 50.070-902schoolCentro de Atenção à Mulher. Instituto de Medicina Integral Prof. Fernando Figueira. Recife, PE, Brazil

0000-0003-1047-2514

person Anna Catharina Carneiro da Cunha

approved the final version of the article · declare no conflicts of interest · visualization · writing · review · and editing

schoolPrograma de Pós-graduação Stricto Sensu em Saúde Integral. Instituto de Medicina Integral Prof. Fernando Figueira. Rua dos Coelhos, 300. Boa Vista. Recife, PE, Brazil. CEP: 50.070-902

0000-0003-1281-192X

person Marina Amorim Albuquerque

approved the final version of the article · declare no conflicts of interest · data curation · investigation · visualization · manuscript writing

schoolUniversidade Federal de Campina Grande. Campina Grande, PB, Brazil

0000-0003-3853-1344

person Josikwylkson Costa Brito

approved the final version of the article · declare no conflicts of interest · investigation · validation · writing · review · and manuscript editing

schoolFaculdade de Medicina do ABC (FMABC). Santo André, SP, Brazil

0000-0002-5936-9043

person Alex Sandro Rolland Souza

approved the final version of the article · declare no conflicts of interest · visualization · writing · review · and editing

schoolCentro de Atenção à Mulher. Instituto de Medicina Integral Prof. Fernando Figueira. Recife, PE, BrazilschoolEscola de Saúde e Ciências da Vida. Universidade Católica de Pernambuco. Recife, PE, BrazilschoolÁrea acadêmica de Ginecologia e Obstetrícia. Universidade Federal de Pernambuco. Recife, PE, Brazil

0000-0001-7039-2052

person Leila Katz

approved the final version of the article · declare no conflicts of interest · conceptualization · validation · supervision · writing · review · and editing of the manuscript

schoolCentro de Atenção à Mulher. Instituto de Medicina Integral Prof. Fernando Figueira. Recife, PE, BrazilschoolEscola de Saúde e Ciências da Vida. Universidade Católica de Pernambuco. Recife, PE, Brazil

0000-0001-9854-7917

Associated Editor:

Lygia Vanderlei

Concept / Criterion	Definition	Operationalization
Preeclampsia	Hypertension (SBP ≥140 mmHg and/or DBP ≥90 mmHg) after 20 weeks of gestation + proteinuria or signs of organ dysfunction.	Confirm elevated BP in two measurements ≥4 h apart; protein/creatinine ratio ≥0.3 or ≥300 mg/24 h; assess renal/liver function and platelet count.
Severe hypertension	SBP ≥160 mmHg and/or DBP ≥110 mmHg.	Treat immediately, without waiting 4 h interval; reduce by 15-25% (SBP 130-150 mmHg, DBP 80-100 mmHg).
Eclampsia	Generalized tonic-clonic seizure in a patient with preeclampsia and no other identifiable cause.	Clinical diagnosis; initiate MgSO₄ immediately, without waiting for additional exams.
Neurological warning signs	Severe headache, scotomas, amaurosis, seizures, and altered consciousness.	Indicate imminent risk of eclampsia/complications; reinforce need for MgSO₄ and consider neuroimaging
Respiratory warning signs	Dyspnea, diffuse crackles, SpO₂ <95%, RR >30 or <10 bpm.	Suggest complications (acute pulmonary edema, MgSO₄-induced depression); assess need for ventilatory support escalation.
Blood pressure targets	Gradual reduction of 15-25% in the first hours (SBP 130-150, DBP 80-100 mmHg).	Avoid abrupt drops that compromise cerebral/uteroplacental perfusion; reassess every 10-30 min.
Oxygenation targets	SpO₂ ≥95%.	If SpO₂ <90% with supplemental O₂, consider advanced airway management.
Indication for neuroimaging	Atypical presentations or neurological alarming signs.	Prolonged coma (>30 min), focal deficits, thunderclap headache, persistent amaurosis, recurrent seizures under MgSO₄, suspected intracranial hemorrhage or cerebral venous thrombosis.

Ampoule concentration	Dose*	Example label
MgSO₄ 10% (1 g/10 mL)	Loading: withdraw 60 mL (6 g) + dilute in 100 mL 0.9% NaCl; infuse over 20-30 min. Maintenance: withdraw 100 mL (10 g) + dilute in 500 mL 0.9% NaCl; infuse at 100 mL/h (2 g/h).	MgSO₄ 10% - 10 g/500 mL 0.9% NaCl - 100 mL/h = 2 g/h
MgSO₄ 50% (5 g/10 mL)	Loading: withdraw 12 mL (6 g) + dilute in 100 mL 0.9% NaCl; infuse over 20-30 min. Maintenance: withdraw 20 mL (10 g) + dilute in 500 mL 0.9% NaCl; infuse at 100 mL/h (2 g/h).	MgSO₄ 50% - 10 g/500 mL 0.9% NaCl - 100 mL/h = 2 g/h

Drug	Preparation	Initial dose	Re-evaluation / Repeat interval	Errors to avoid
Nifedipine (PO, immediate-release)	10 mg tablet/capsule PO, intact (do not crush or chew).	10 mg VO.	Reassess in 20-30 min; repeat if SBP ≥160 and/or DBP >110 mmHg. After 2-3 doses without response, consider IV hydralazine.	Never administer sublingually; never crush or chew the capsule; do not repeat in <20 min.
Hydralazine (IV)	20 mg/1 mL ampoule + dilute in 9 mL 0.9% NaCl → 2 mg/mL	5 mg IV slowly (2 min)	Reassess in 20-30 min; repeat 5 mg if needed. Maximum: 20 mg/24 h. After 2-3 doses without response, consider PO nifedipine (if feasible)	Never apply as rapid bolus; never use without proper dilution; do not repeat in <20 min.

Exam	Objective	Interpretation
Hemogram	Assess anemia, infection, and thrombocytopenia.	Platelets <100,000/mm³ indicate bleeding risk; <70,000/mm³ contraindicates neuraxial anestesia.
AST/ALT	Liver function; detect enzymatic elevation.	Increase >2× upper limit may indicate HELLP syndrome
LDH and bilirubin	Hemolysis indicators.	LDH >600 U/L or bilirubin >1.2 mg/dL suggest active hemolysis.
Haptoglobin	Complementary hemolysis marker	Low values support hemolysis diagnosis in HELLP syndrome.
Urea and creatinine	Assess renal function.	Creatinine ≥1.2 mg/dL indicates renal dysfunction; ≥2.5 mg/dL contraindicates MgSO₄ maintenance.
Electrolytes	Investigate metabolic disturbances.	Hyponatremia or hyperkalemia may worsen clinical instability.
Uric acid	Marker of severity and endothelial dysfunction.	Elevated levels are associated with severe pre-eclampsia.
Proteinuria (protein/creatinine ratio)	Confirm preeclampsia diagnosis.	Ratio ≥0.3 indicates significant proteinúria.

[1] MgSO₄ = magnesium sulfate; NaCl = normal saline (0.9%);

[TFN1] ^*
Always use an exclusive line for MgSO₄; maintain antidote (10% calcium gluconate) at the bedside; double-check preparation and complete labeling (drug, concentration, dose in g/h and mL/h, start time, responsible clinician).

The ABCDEFG of Eclampsia: Advanced Life Support in Eclampsia (ALSE)

Abstract