Eclampsia in India: Seizures, Magnesium Sulfate and the 102 Pathway

• Eclampsia is a true emergency. If a pregnant or recently delivered woman has a seizure, call 102 (Janani Express maternal ambulance) or 108 immediately.
• Warning signs can appear hours before a fit: severe headache, blurred or flashing vision, upper-right tummy pain, sudden facial or hand swelling. These need urgent BP checking.
• During a seizure, protect from injury and never put anything in the mouth. Afterwards, turn her onto her left side.
• Magnesium sulfate is the proven, low-cost medicine that stops seizures. It is free at every government facility in India under JSSK.
• Delivery is the only cure. After stabilising the mother, the baby is delivered, usually within hours.
• About 1 in 3 cases happen after delivery, so stay alert to warning signs for up to 6 weeks postpartum.

Eclampsia is a new seizure (convulsion or fit) in a pregnant or recently delivered woman that is caused by hypertensive disease of pregnancy rather than by epilepsy, stroke, infection or any other cause. It is the most severe end of the Preeclampsia in Pregnancy: High BP, Warning Signs and Care spectrum.

A typical eclamptic seizure is generalised tonic-clonic: the woman loses consciousness, her body stiffens for about 30 seconds, then her arms and legs jerk rhythmically for 1 to 2 minutes. She is then drowsy and confused for several minutes to an hour before slowly waking. Seizures may happen once or repeatedly.

The underlying problem is the same as in preeclampsia. The placenta does not embed properly in early pregnancy, which later disturbs blood vessels throughout the mother's body, including the brain. This brain irritation is what tips over into a seizure.

Eclampsia is dangerous for several reasons. The seizure itself can cause injury from a fall, a bitten tongue, or breathing in vomit. It can briefly cut oxygen to the mother and baby. Afterwards there is risk of further seizures, of a brain bleed (stroke) from very high blood pressure, of fluid in the lungs, of HELLP syndrome and bleeding problems, and of the placenta separating early. The reassuring counterpoint is that prompt treatment changes the picture dramatically: with magnesium sulfate and timely delivery, most women recover fully.

Most eclamptic seizures are preceded by warning symptoms in the hours or days beforehand. Recognising them lets you act before a fit happens, which leads to far better outcomes. Every pregnant woman in the second half of pregnancy, and especially anyone with high BP or preeclampsia, should know these signs and so should her family.

The most important warning symptoms are:

Any of the warning signs above in a pregnant or recently delivered woman after 20 weeks needs an urgent blood pressure check and clinical review, even at a primary health centre. A reading of 140/90 or higher means preeclampsia must be ruled out.

Call 102 (Janani Express) or 108 immediately, without waiting, if a pregnant or postpartum woman has any of the following:

If you are with someone having a seizure, call 102 or 108 first. Both are free, run 24 hours a day, and the team will alert the hospital so doctors are ready. Do not wait to see whether the fit stops on its own.

While you wait, a few simple actions protect her. Move sharp objects and furniture out of the way (do not move her unless she is in real danger, for example near fire or water). Cushion her head with a folded cloth. Loosen tight clothing at the neck and waist. If you can, note how long the seizure lasts; most last 1 to 2 minutes, and anything over 5 minutes is more urgent.

Some well-meant actions cause harm. Please do NOT:

Once the jerking stops, gently turn her onto her left side with the upper leg bent for stability and her head turned to one side. This left-lateral position keeps the airway clear if she vomits and takes the weight of the pregnant womb off the main blood vessels, which improves blood flow to her and the baby. Wipe away any vomit or saliva.

Keep watching her breathing. Most women breathe normally between and after seizures. If breathing stops and there is no pulse, basic life support (chest compressions) is needed while help comes. If another seizure starts, repeat the same protective steps.

The ambulance team can give oxygen, monitor her, and in many states carry magnesium sulfate to start treatment on the way. While waiting, one family member should quickly pack her MCP card (with antenatal records), Aadhaar, ABHA number if she has one, and current medicines, but do not delay the ambulance to pack. One adult should travel with her.

On arrival, the emergency team works through a clear sequence, starting with the basics that keep her alive: airway, breathing and circulation (ABC).

The airway is checked and any vomit or secretions are suctioned out. She is kept on her left side, or tilted to the left if she must lie on her back, and given high-flow oxygen by mask. Breathing rate and oxygen levels are watched closely. A breathing tube is used only if she is deeply unconscious or in continuous seizures.

For circulation, two large drips are placed. Blood pressure, pulse and urine output are monitored, and a urinary catheter is inserted. Blood tests (full blood count, liver and kidney function, clotting, and a sample for blood matching) are sent, and the baby's heartbeat is checked continuously with a CTG or NST monitor. An ultrasound assesses the baby and looks for placental separation. The obstetric, anaesthesia, paediatric and ICU teams are all alerted together for an early delivery.

Magnesium sulfate is the single most important treatment in eclampsia, and it is started immediately, before every test is back. Large international trials, including studies that involved Indian hospitals, have shown it prevents and controls seizures far better than older drugs such as diazepam or phenytoin, with better outcomes for mother and baby.

It is also one of medicine's great equalisers. Magnesium sulfate is on the WHO and Indian essential medicines lists, costs only about Rs 50 to 200 a vial, and is stocked free at every government facility from the primary health centre upwards under JSSK.

The Pritchard regimen is the standard Indian protocol because it works even where there are no infusion pumps:

Magnesium is very safe when given carefully, and serious toxicity is rare in trained hands; millions of doses are given each year in India with an excellent record. The nursing team checks three simple things before each maintenance dose:

Alongside magnesium, the blood pressure is brought under control. In eclampsia the BP is often very high (180/110 or more), and the biggest danger is a brain bleed, the most common cause of death after the seizure itself. Lowering the pressure quickly cuts that risk; this is the same emergency that underlies many stroke warning signs in women.

The target is not a normal reading but a safer one, around 140 to 150 over 90 to 100. Dropping it too low can reduce blood flow to the placenta and harm the baby. The first-line medicines are labetalol or hydralazine given into a vein, with immediate-release nifedipine by mouth as an alternative where injections are not available.

Fluids are given carefully and kept restricted (often about 80 ml an hour), because women with eclampsia are prone to fluid building up in the lungs. The urine catheter helps the team judge fluid balance. Once the BP is controlled and seizures are stopped, the focus shifts to the only true cure, delivery. Home blood pressure monitoring becomes important later, in recovery and any future pregnancy.

Once the mother is stable, the baby is delivered, usually within 6 to 12 hours, whatever the stage of pregnancy. Continuing the pregnancy after an eclamptic seizure adds real risk of more seizures, stroke, the placenta separating and worsening organ damage, which almost always outweighs any benefit of waiting for the baby to grow more.

If the baby is between 24 and 34 weeks, a course of steroid injections helps mature the lungs, but delivery is not delayed long if the mother is unwell. This overlaps with the wider care of a preterm birth.

The way of delivering depends on how far along the pregnancy is, whether the cervix is ready, and how mother and baby are doing. If she is near term with a favourable cervix and is stable, induction of labour aiming for a vaginal birth is often best, ideally with an epidural for pain relief and steady BP. A caesarean section is needed when the cervix is unfavourable at an early stage, when the baby is in distress, when there is bleeding from the placenta, or when the mother is too unstable to wait. Because of these factors, caesarean rates in eclampsia are higher than in ordinary pregnancy.

About 30 percent of eclamptic seizures happen after the baby is born, most within the first 24 to 72 hours but occasionally up to 6 weeks later. Sometimes this is the very first sign of unrecognised preeclampsia. This is why the danger does not end at delivery, and the Flo Health library similarly stresses that postpartum preeclampsia is rare but serious and easy to miss once a new mother is home.

For this reason, magnesium is continued for 24 hours after delivery in women who had eclampsia or severe features, BP is watched closely for at least 72 hours, and the warning signs are explained again before discharge. The same red flags apply at home: severe headache, vision changes, upper-tummy pain, sudden swelling, breathlessness, or any fit.

Families should know that the 102 Janani Express ambulance is free for postpartum women for up to 42 days. Treatment is the same as before delivery, and recovery is often quicker because the placenta, the root cause, has already gone. The routine 6-week postpartum check should include a BP and urine check.

After eclampsia, the chance of it recurring in a future pregnancy is low, roughly 1 to 2 percent, though about 20 to 30 percent of women develop preeclampsia again. The odds are higher if the first episode was early or involved HELLP syndrome. Some women choose not to have more pregnancies, which is an entirely valid decision, and contraceptive advice should be offered. For those who do, careful planning makes a big difference, and most go on to have a successful next pregnancy.

Before trying again, doctors look for conditions that raise the risk, such as long-standing high blood pressure, diabetes, thyroid disease, kidney disease, Lupus (SLE) in Indian Women: Diagnosis, Treatment, Pregnancy and antiphospholipid syndrome, and treat anything found. Reaching a healthy weight, eating well and stopping smoking all help.

The most powerful preventive steps for the next pregnancy are:

India has built a system designed so that no family should hesitate over cost in an eclampsia emergency. The 102 Janani Express is a free, dedicated maternal ambulance available across the country, and the 108 service is free for pregnant women too. Both run 24 hours and alert the hospital before arrival.

JSSK (Janani Shishu Suraksha Karyakram) makes maternity care free at every government facility. It covers transport, consultations, tests, medicines (including magnesium sulfate and BP drugs), admission, normal or caesarean delivery, newborn and NICU care, and the trip home. It applies to all pregnant women regardless of income or home state, and to mothers for 42 days after delivery.

The referral chain runs from the ASHA worker and ANM, to the Primary Health Centre, the Community Health Centre, and the District Hospital (the First Referral Unit with full obstetric, caesarean and newborn capability), up to the medical college for the most complex care. A crucial point: a PHC or CHC should give the first magnesium loading dose, control the BP and secure the airway straight away, then transfer, rather than waiting. In the private sector, eclampsia care can cost Rs 1 to 3 lakh, but Ayushman Bharat PMJAY and state schemes (such as Tamil Nadu CMCHIS, Andhra Pradesh Aarogyasri and Rajasthan Chiranjeevi Yojana) bring this within reach. The honest bottom line: never delay calling 102 or 108 over money. A stillbirth or maternal death from delay is the outcome these services exist to prevent.

• WHO recommendations for prevention and treatment of pre-eclampsia and eclampsia
• WHO recommendation on magnesium sulfate for severe pre-eclampsia and eclampsia
• ACOG: Gestational Hypertension and Preeclampsia (Practice Bulletin 222)
• NHS: Pre-eclampsia
• Ministry of Health and Family Welfare (India): Janani Shishu Suraksha Karyakram (JSSK)
• FOGSI Good Clinical Practice Recommendations on Pregnancy Induced Hypertension