Factors associated with appropriate administration of magnesium sulfate for neuroprotection prior to early preterm birth.

Factors associated with appropriate administration of magnesium sulfate for neuroprotection prior to early preterm birth

Magnesium sulfate and risk of hypoxic-ischemic encephalopathy in a high-risk cohort

The combined maternal administration of magnesium sulfate and aminophylline reduces intraventricular hemorrhage in very preterm neonates

Efecto neuroprotector del sulfato de magnesio en prematuros. Análisis tras instaurar su protocolo de administración antenatal en un hospital terciario

Neuroprotective effect of magnesium sulfate in premature infants. Analysis after establishing an antenatal administration protocol in a tertiary care hospital

To investigate the effects of antenatal magnesium sulfate administration on preterm gastrointestinal feeding intolerance and necrotizing enterocolitis in preterm infants. This observational cohort, single-centre study included preterm infants < 30 weeks gestational age or < 1250 g, who were admitted to the neonatal intensive care unit of a university hospital. These infants were divided into two groups on the basis of having received antenatal magnesium sulfate or not. Overall, 118 preterm infants were enrolled. Fifty-four of these infants had received prenatal magnesium sulfate (Group 1), and 64 (42%) had not (Group 2) before their neonatal intensive care unit (NICU) admission. The number of days to full eneteral feeding and the days of total parenteral nutrition were significantly higher in Group 2 than in Group 1 (p < 0.05). When gestational age, birth weight, and small for gestational age (SGA) were included as factors affecting feeding intolerance, the logistic regression analysis results showed that the administration of magnesium sulfate was an independent risk factor (adjusted OR: 3.5; 95% CI: 1.462-8.615; p < 0.05). Antenatal magnesium sulfate administration was not observed to have an effect on spontaneous intestinal perforation and necrotising enterocolitis. The administration of antenatal magnesium sulfate has proven tocolytic and neuroprotective effects on preterm births. However, it must be taken into consideration that it can cause feeding intolerance in preterm infants without causing intestinal injury.

Commentary on: Rouse DJ, Hirtz DG, Thom E, Varner MW, Spong CY, Mercer BM, Iams JD, Wapner RJ, Sorokin Y, Alexander JM, Harper M, Thorp JM Jr, Ramin SM, Malone FD, Carpenter M, Miodovnik M, Moawad A, O'Sullivan MJ, Peaceman AM, Hankins GD, Langer O, Caritis SN, Roberts JM. Eunice Kennedy Shriver NICHD Maternal-Fetal Medicine Units Networks. A randomized, controlled trial of magnesium sulfate for the prevention of cerebral palsy. N Engl J Med 2008; 359(9):895–905. PMID 18753646. The current American College of Obstetricians and Gynecologists (ACOG) Committee Opinion supports the use of magnesium sulphate for foetal neuroprotection before 32 weeks of gestation 1. The clinical trial reviewed here is the largest and most recent to inform these guidelines 2. This randomised control trial (RCT), aimed to determine if the administration of magnesium sulphate to women at high risk of preterm delivery would reduce the risk of cerebral palsy (CP), found a reduction in moderate/severe CP at two years of age following antenatal magnesium sulphate exposure (RR 0.55, 95% CI 0.32–0.95) 2. These results were consistent with previous RCTs primarily evaluating the neuroprotective benefits of magnesium sulphate on the incidence of CP in preterm infants 3-5. Additionally, a Cochrane review concluded that 63 women were needed to prevent one diagnosis of CP 6. Further investigation is warranted to provide updated and unified guidelines regarding the use of magnesium sulphate for foetal neuroprotection. There was significant heterogeneity in treatment regimens between RCTs with no trial sharing the same loading dose, treatment dose, duration of dosing or retreatment regimen of magnesium sulphate 2-6. Additionally, although no serious maternal complications of antenatal magnesium exposure have been reported, there were several minor complications, including a 50% increase in maternal hypotension, leading to a 3.2-fold increase in cessation of therapy 6. Optimal treatment regimens would likely lead to a refined understanding of treatment effect size, better protocol adherence, and ultimately improved neurodevelopmental outcomes. The results of this trial should be considered in the context of advances in neonatal medicine affecting neurodevelopmental outcomes. Specifically, during the time of this study's enrolment, the American Academy of Pediatrics (AAP) recommended against routine use of postnatal corticosteroids in preterm infants because of its negative effect on neurodevelopmental outcomes 7. This recommendation significantly curtailed the use of early postnatal steroids, potentially altering neurodevelopmental outcomes if differed between treatment groups 7. Additionally, there has been increased survival of infants 22–23 weeks of gestation 8. Currently, there are no RCTs that investigate the neuroprotective benefit of magnesium sulphate in <24 weeks of gestation. It has been 20 years since recruitment started and nearly 10 years since the publication of this landmark trial has influenced the practice of obstetricians in the United States 2. In that same time, there continue to be advances in the care of extremely low birthweight infants impacting changes in survival and neurodevelopmental outcomes. Although many institutions follow ACOG recommendations of administering antenatal magnesium sulphate in preterm delivery, there are no recommendations for magnesium sulphate treatment regimens or gestational age thresholds presumably leading to a variety of clinical practices 1. Perhaps it is time to repeat this clinical trial in a new era to help elucidate both the optimal treatment regimen as well as the effect of antenatal magnesium exposure in the setting of preterm labour and delivery on neurodevelopmental outcomes. In the meantime, this trial remains consistent with available evidence supporting antenatal magnesium sulphate exposure in preterm infants to reduce CP. https://ebneo.org/2017/10/antenatal-magnesium-for-preterm-delivery-reduces-risk-of-cerebral-palsy-among-surviving-very-preterm-infants/ None. None.

BackgroundThe aim of this study was to assess the cost-effectiveness of administering magnesium sulphate to patients in whom preterm birth at < 32+0 weeks gestation is either imminent or threatened for the purpose of fetal neuroprotection.MethodsMultiple decision tree models and probabilistic sensitivity analyses were used to compare the administration of magnesium sulphate with the alternative of no treatment. Two separate cost perspectives were utilized in this series of analyses: a health system and a societal perspective. In addition, two separate measures of effectiveness were utilized: cases of cerebral palsy (CP) averted and quality-adjusted life years (QALYs).ResultsFrom a health system and a societal perspective, respectively, a savings of $2,242 and $112,602 is obtained for each QALY gained and a savings of $30,942 and $1,554,198 is obtained for each case of CP averted when magnesium sulphate is administered to patients in whom preterm birth is imminent. From a health system perspective and a societal perspective, respectively, a cost of $2,083 is incurred and a savings of $108,277 is obtained for each QALY gained and a cost of $28,755 is incurred and a savings of $1,494,500 is obtained for each case of CP averted when magnesium sulphate is administered to patients in whom preterm birth is threatened.ConclusionsAdministration of magnesium sulphate to patients in whom preterm birth is imminent is a dominant (i.e. cost-effective) strategy, no matter what cost perspective or measure of effectiveness is used. Administration of magnesium sulphate to patients in whom preterm birth is threatened is a dominant strategy from a societal perspective and is very likely to be cost-effective from a health system perspective.

Objective To assess the current practice in managing hypertensive disorders of pregnancy (HDP) and provide possible interventions to improve the quality of care. Methods A checklist was developed based on Chinese Medical Association's guideline on HDP. A criteria-based audit was conducted on 66 HDP patients who were admitted to the Intensive Care Unit (ICU) of Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School between January 1, 2014 and December 31, 2016. The quality of care during antepartum and hospitalized period were evaluated, and patient factors were also considered. We also collected data on patients' demographics, complications of HDP, acute physiology and chronic health evaluation (APACHE) Ⅱ score and duration of hospital stay. T or Mann-Whitney U test or Chi-square test was performed. Results (1) From 2014 to 2016, the number of deliveries in Nanjing Drum Tower Hospital was 18 573, with 1 561 cases (8.4%) of HDP. Among the 66 cases being audited, 44 (66.7%) were preeclampsia; 16 (24.2%) were preeclampsia complicated by chronic hypertension; six (9.1%) were eclampsia; no maternal death was reported. (2) Complications of HDP in this study included heart failure (17 cases, 25.8%), hemolysis, elevated liver enzyme levels, low platelet count (HELLP) syndrome (15 cases, 22.7%), anemia and/or thrombopenia requiring transfusion (12 cases, 18.2%), renal dysfunction (seven cases, 10.6%), eclampsia (six cases, 9.1%), pulmonary edema/acute respiratory distress syndrome (five cases, 7.6%), placenta abruption (four cases, 6.1%), cerebral venous and sinus thrombosis (two cases, 3.0%), cerebral hemorrhage (one case, 1.5%) and hepatic rupture (one case, 1.5%). Their APACHEⅡ score was 9.0±3.9. The duration of ICU and hospital stay was 2 (1-30) d and 8 (4-32) d, respectively. (3) Compared with the gravidas who registered during antenatal care, those without registrations were older [(33.0±6.0) vs (29.1±5.4) years old, t=-2.616], having less antenatal visits [2 (0-4) vs 5 (2-10) times, Z=110.000] and higher blood pressure on admission [(177.0±24.1) vs (155.5±24.6) mmHg of systolic blood pressure (t=-3.322), and (116.4±14.6) vs (108.0±18.7) mmHg of diastolic blood pressure (t=-3.013, 1 mmHg=0.133 kPa)], and only a few of them were nulliparas [23.8%(5/21) vs 71.1%(32/45), χ2=13.006] (all P<0.05). (4) Among the 66 cases, seven (10.6%) had preeclampsia history, but none of them received aspirin for HDP prevention; 21 (31.8%) did not have regular testing of blood pressure during antenatal check; 24 (36.4%) did not receive proper antenatal evaluation when hypertension was identified. (5) After excluding 20 cases directly admitted upon the first diagnosis of HDP, the rest 46 were managed in the outpatient department. Eighteen of them (39.1%) did not have blood pressure monitoring and 26 of them (56.5%) did not have a regular test of hemoglobin, platelet, urine protein, liver or renal function. (6) Twenty-nine gravidas (43.9%) suffered a delay in referral or admission. (7) All gravidas received magnesium sulphate administration. Thirty-three cases with severe hypertension (systolic blood pressure≥160 mmHg or diastolic blood pressure≥110 mmHg) were given antihypertensive drugs with satisfactory blood pressure control. Thirty-six cases with living fetus (26-34+6 gestational weeks) received antenatal dexamethasone. Termination of pregnancy was delayed in three cases after admission. Conclusions The management of HDP is not good enough in patients' education, screening for high-risk population, early diagnosis and antenatal care. Quality improvement efforts should be focused on strengthening patient education, training of doctors in primary and secondary hospitals, implementing protocols on antepartum care of preeclampsia and establishing a referral system for patients with severe obstetric complications. Key words: Hypertension, pregnancy-induced; Intensive care units; Clinical audit

Administration of magnesium sulphate before rocuronium: effects on speed of onset and duration of neuromuscular block

Investigation of Intrapartum Parenteral Magnesium Sulfate as an Independent Risk Factor for Postpartum Hemorrhage Using Quantitative Blood Loss Assessment

Introduction: Preeclampsia and eclampsia have remained a major global public health threat in contributing significantly to maternal and perinatal morbidity and mortality with incidence of 2.16% and 0.28% respectively. The treatment modalities of eclampsia and severe pre-eclampsia include initial stabilization, rational use of antihypertensives, anticonvulsants and planning for delivery. Magnesium Sulphate, as anticonvulsant is drug of choice for convulsion prophylaxis but its benefit should always outweigh its adverse effects. Traditionally the use of magnesium sulphate has been recommended for 24 hour postpartum. By reducing the duration of therapy, the frequency of postpartum maternal monitoring may be curtailed and the possibility for the women to ambulate early and care for her newborn may be increased. The purpose of present study is to compare the effectiveness, side effects and maternal outcome of magnesium sulphate administration as single dose and 12 hours postpartum with the conventional 24 hours in the cases of severe preeclampsia. Aims and Objectives: To compare abbreviated regimens of single dose and 12 hours magnesium sulphate administration with the conventional 24 hours postpartum in severe preeclampsia.Material and Methods: A randomized prospective clinical trial was conducted on pregnant women presenting with severe preeclampsia. The patients were randomly allocated into group I (single dose), group II (12hour) and group III (24hour) postpartum MgSO4. The dosage and the route of administration of magnesium sulphate was similar in all three groups before delivery as per Prichard regimen. After delivery, a single maintenance dose of magnesium sulphate was given in group I, 12 hours group II and for 24 hours postpartum in group III. During the study period, the patients were assessed for various outcome parameters such as seizures, clinical outcomes such as time to return to ambulation in hours, duration of indwelling urinary catheter in hours, time until contact with the newborn infant in hour, urine output, adverse effects and evidence of toxicity in mother.Results: All patients in three groups were comparable with regards to demographic as well as obstetric characteristics. None of the patient in group I had any of the signs of MgSO4 toxicity, however in group II, one patient had loss of patellar reflex and in group III, two patients had loss of patellar reflexes and another two had oliguria. None of the patient had respiratory depression or convulsion in any of the three groups. The patients in group I and group II, ambulated much earlier as and had less duration of catheter as compared to group III. However there was no significant difference in the average time until contact with the newborn between the three groups. Conclusion: Magnesium sulphate for 24hrs is the drug of choice for seizure prophylaxis in patients with severe preeclampsia and eclampsia but benefits of magnesium sulphate should outweigh its adverse effects. But there was increase in the feeling of wellbeing in shorter regimens with early ambulation, lesser duration of indwelling catheter and early breastfeeding leading to better capability of the mother to take care of newborn. The present study suggests that the abbreviated postpartum MgSO4 regimens can be effective alternatives to the conventional 24 hours regimen for postpartum seizure prophylaxis in severe preeclampsia.

Unexpected hyperkalemia following succinylcholine administration in prolonged immobilized parturients treated with magnesium and ritodrine.

The impact of risk factors on aspirin's efficacy for the prevention of preterm birth

Objective. To evaluate Doppler velocimetry parameters (resistance index [RI], pulsatility index [PI] and systolic/diastolic [S/D] ratio) of maternal-fetal circulation before and after magnesium sulfate administration in pregnant women with severe preeclampsia. Methods. A prospective observational cohort analysis of 40 women with severe preeclampsia was performed. Doppler ultrasonography scans were performed before and 20 minutes after intravenous administration of magnesium sulfate. Maternal parameters such as heart rate, and systolic, diastolic and mean arterial pressure were recorded. Doppler flow velocity parameters (RI, PI and S/D ratio) were evaluated in the uterine, umbilical and middle cerebral arteries. The different mean values obtained before and after magnesium sulphate were analyzed using the paired t-test. Results. There was a statistically significant increase in mean maternal heart rate and a statistically significant decrease in systolic, diastolic and mean maternal blood pressure before and after administration of magnesium sulphate (p < 0.001). Resistance index decreased in the umbilical (p = 0.003; 95% CI: 0.008 - 0.03) and middle cerebral artery (p = 0.001; 95% CI: 0.01 - 0.05) and in both uterine arteries. Likewise, there was a significant reduction in the PI and S/D ratio in all the arteries assessed. Conclusions. Maternal administration of intravenous magnesium sulfate in preeclampsia leads to an increase in maternal heart rate and a decrease in systolic, diastolic and mean arterial blood pressure. A reduction in the resistance index, pulsatility index and S/D ratio was recorded in the uterine, umbilical and cerebral arteries.