Magnesium Sulfate Seizure Prophylaxis Research Articles

Impact of free maternity services on outcomes related to hypertensive disorders of pregnancy at Moi Teaching and Referral Hospital in Kenya: a retrospective analysis

BackgroundPreeclampsia is a major contributor to maternal and neonatal mortality worldwide. Ninety-nine percent of these deaths occur in resource limited settings. One of the greatest barriers to women seeking medical attention remains the cost of care. Kenya implemented a nation-wide policy change in 2013, offering free inpatient maternity services to all women to address this concern. Here, we explore the impact of this policy change on maternal and neonatal outcomes specific to the hypertensive disorders of pregnancy.MethodsWe conducted a retrospective cross-sectional chart review of patients discharged or deceased with a diagnosis of gestational hypertension, preeclampsia, eclampsia or HELLP syndrome at a tertiary referral center in western Kenya one year before (June 1, 2012-May 31, 2013) and one year after (June 1, 2013-May 31, 2014) free maternity services were introduced at public facilities across the country. Demographic information, obstetric history, medical history, details of the current pregnancy, diagnosis on admission and at discharge, antepartum treatment, maternal outcomes, and neonatal outcomes were collected and comparisons were made between the time points.ResultsThere were more in hospital births after policy change was introduced. The proportion of women diagnosed with a hypertensive disorder of pregnancy was higher in the year before free maternity care although there was a statistically significant increase in the proportion of women diagnosed with gestational hypertension after policy change. Among those diagnosed with hypertensive disorders, there was no difference in the proportion who developed obstetric or medical complications. Of concern, there was a statistically significant increase in the proportion of women dying as a result of their condition. There was a statistically significant increase in the use of magnesium sulfate for seizure prophylaxis. There was no overall difference in the use of anti-hypertensives between groups and no overall difference in the proportion of women who received dexamethasone for fetal lung maturity.ConclusionsFree maternity services, however necessary, are insufficient to improve maternal and neonatal outcomes related to the hypertensive disorders of pregnancy at a tertiary referral center in western Kenya. Multiple complementary strategies acting in unison are urgently needed.

Is peripartum magnesium sulfate associated with a reduction in postpartum depressive symptoms?

The prevention of postpartum depression is an important area of investigation given its association with major maternal and neonatal sequelae, yet few evidence-based treatments to reduce the frequency of postpartum depression are used. Recent data suggest that N-methyl-D-aspartate receptor antagonists may lead to rapid improvement of depressive symptoms lasting up to 2 weeks. We hypothesized that the N-methyl-D-aspartate receptor antagonist magnesium sulfate would elicit antidepressant effects subsequent to its receipt by women receiving peripartum seizure prophylaxis for a hypertensive disorder of pregnancy. This study aimed to compare the frequency of depressive symptoms at 2 weeks and 6 weeks after delivery between women who did and did not receive peripartum magnesium sulfate for a hypertensive disorder of pregnancy. This prospective cohort study included women with a hypertensive disorder of pregnancy at ≥34 weeks' gestation with singleton gestations. Magnesium sulfate for seizure prophylaxis was administered at the obstetrician's discretion. The Quick Inventory of Depressive Symptomatology survey was administered before hospital discharge and again at 2 weeks and 6 weeks after delivery to assess for postpartum depressive symptoms. The primary outcome for this study was the change in Quick Inventory of Depressive Symptomatology score from baseline to 2 weeks after delivery, which was analyzed both continuously and categorically (any symptom worsening vs stability or improvement). Secondary outcomes included the change in Quick Inventory of Depressive Symptomatology score from baseline to 6 weeks after delivery and the proportion of women who experienced an increase in Quick Inventory of Depressive Symptomatology score at 6 weeks after delivery. Of the 342 women enrolled, 39% (n=134) received magnesium sulfate. Compared with women who did not receive magnesium, women who received magnesium had a significantly smaller change in their mean Quick Inventory of Depressive Symptomatology score (0.6±3.4 vs 1.6±3.0; P=.015) and also were less likely to have an increase in Quick Inventory of Depressive Symptomatology score at 2 weeks after delivery (52% vs 67%; P=.022). These differences were not present at 6 weeks after delivery. After controlling for potential confounders, women who received magnesium continued to have a lower odds of having an increased Quick Inventory of Depressive Symptomatology score from baseline at 2 weeks after delivery than women who did not receive magnesium (adjusted odds ratio, 0.88; 95% confidence interval, 0.78-0.98). Peripartum magnesium was associated with less of an exacerbation in depressive symptoms in the immediate postpartum period. Given the implications of postpartum depression on maternal and child health and the lack of existing prophylaxis, randomized trials should examine this novel potential prophylactic therapy.

Improving compliance with guidelines for hypertensive disorders of pregnancy through an electronic health record alert: A retrospective chart review.

Improve appropriate and timely administration of rapid acting antihypertensive medication for the management of hypertensive emergency in pregnancy with utilization of an automated electronic health record (EHR) alert in an academic birthplace. An automated alert was incorporated into an existing EHR that notified providers of a documented severe range blood pressure, defined as systolic blood pressure (SBP)≥160mmHg or diastolic blood pressure (DBP)≥110mmHg. Retrospective chart review was utilized to evaluate appropriate intervention before and after implementation of the alert (referred to as pre-implementation and post-implementation cohorts). The primary outcome was appropriate administration of rapid-acting antihypertensive medication for the management of hypertensive emergency. Secondary outcomes included: appropriate administration of intravenous (IV) magnesium sulfate for seizure prophylaxis, initiation of oral antihypertensive medication postpartum, and appropriate timing of follow up for blood pressure evaluation following discharge. Of 98 patients identified as having hypertensive emergency in the pre-implementation cohort, 34 (35%) received treatment with a rapid acting antihypertensive medication within one hour compared with 54 of 104 (55%) of patients in the post-implementation cohort (35% vs 55%, RR 1.40 95% CI 1.07-1.82). Significantly more patients followed up for a blood pressure check within one week of discharge (41% vs 31%; p=0.02). There was not a significant effect on the administration of IV magnesium sulfate or initiation of oral medications postpartum. An automated EHR alert improved timely administration of rapid-acting antihypertensive medications for hypertensive emergency and has the potential to improve compliance with national preeclampsia guidelines.

Association between Receipt of Intrapartum Magnesium Sulfate and Postpartum Hemorrhage.

Objective The aim of the study is to investigate the association between intrapartum administration of magnesium sulfate in women with hypertensive disorders of pregnancy and postpartum hemorrhage. Study Design This was a retrospective cohort study of women diagnosed with a hypertensive disorder of pregnancy who delivered singleton gestations >32 weeks at a single, large volume tertiary care center between January 2006 and February 2015. Women who received intrapartum magnesium sulfate for seizure prophylaxis were compared with women who did not receive intrapartum magnesium sulfate. The primary outcome was frequency of postpartum hemorrhage. Secondary outcomes included estimated blood loss, uterine atony, and transfusion of packed red blood cells. Bivariable analyses were used to compare the frequencies of each outcome. Multivariable logistic regression models examined the independent associations of magnesium sulfate with outcomes. Results Of 2,970 women who met inclusion criteria, 1,072 (36%) received intrapartum magnesium sulfate. Women who received magnesium sulfate were more likely to be nulliparous, publicly insured, of minority race or ethnicity, earlier gestational age at delivery, and undergo labor induction. The frequency of postpartum hemorrhage was significantly higher among women who received magnesium sulfate compared with those who did not (12.4 vs. 9.3%, p = 0.008), which persisted after controlling for potential confounders. Of secondary outcomes, there was no difference in estimated blood loss between women who did and did not receive magnesium sulfate (250 mL [interquartile range 250–750] vs. 250 mL [interquartile range 250–750], p = 0.446). However, compared with women who did not receive magnesium sulfate, women who received magnesium sulfate had a greater frequency of uterine atony (8.9 vs 4.9%, p < 0.001) and transfusion of packed red blood cells (2.0 vs. 0.8%, p = 0.008). These differences persisted after controlling for potential confounders. Conclusion Intrapartum magnesium sulfate administration to women with hypertensive disorders of pregnancy is associated with increased odds of postpartum hemorrhage, uterine atony, and red blood cell transfusion.

Neuropathophysiology of preeclampsia and eclampsia: A review of cerebral hemodynamic principles in hypertensive disorders of pregnancy.

Preeclampsia and eclampsia are hypertensive disorders of pregnancy associated with abnormal placental vascular development. The systemic angiogenic imbalance, endothelial dysfunction and proinflammatory state caused by abnormal placental development results in abnormalities in renal, hepatic, pulmonary and neurologic function. Neurosensory symptoms related to pregnancy induced hypertension (PIH), the most devastating of which are intracranial hemorrhage and seizure, are among the leading causes of maternal and perinatal morbidity and mortality globally, yet risk stratification strategies and targeted therapies remain elusive. Current treatment for preeclampsia with severe features is limited to delivery, antihypertensive therapy, and magnesium sulfate seizure prophylaxis. Magnesium sulfate reduces seizure rates among severe preeclamptics, but predisposes patients to weakness, uterine atony, pulmonary edema and respiratory depression. Therefore, this drug should ideally be administered only to the subset of preeclamptics who are at increased risk for neurologic complications. While there are no objective methods validated to predict eclampsia, we hypothesize that measurement of optic nerve sheath diameters, optic disc height and middle cerebral artery transcranial doppler resistance indices may be useful in identifying subclinical cerebral edema, potentially allowing us to recognize those patients at highest risk for seizures. This summary of the current literature provides an initial framework for developing more sophisticated and noninvasive methods for identifying, monitoring and treating parturients who are at highest risk for neurologic complications from preeclampsia.

Prediction Model for Vaginal Birth After Induction of Labor in Women With Hypertensive Disorders of Pregnancy.

To identify characteristics associated with vaginal delivery compared with cesarean delivery after labor induction among women with hypertensive disorders of pregnancy and to develop and validate a prediction model to assist in clinical care. We studied a retrospective cohort of women with singleton pregnancies who had hypertensive disorders of pregnancy and who underwent induction of labor at 34 weeks of gestation or more from January 1, 2002, to March 31, 2013. Exclusion criteria included spontaneous labor, prelabor cesarean delivery, and known fetal anomalies. The study cohort was randomly divided into two groups; 70% of pregnancies were used to identify characteristics associated with vaginal delivery and develop a prediction model, and 30% were used to internally validate the model. Candidate predictors were limited to those associated with cesarean delivery and were available to a practitioner at time of induction. Stepwise backward logistic regression was used to build the most parsimonious model predicting cesarean delivery. Hosmer-Lemeshow test was used to assess goodness-of-fit. Model discrimination was evaluated using the concordance index and displayed through the area under the receiver operating characteristic curve (AUC). Of the 1,357 women meeting study criteria, 974 (71.8%) had a vaginal delivery. The final model consisted of eight variables: maternal age, body mass index, gestational age, intrapartum magnesium sulfate for seizure prophylaxis, need for cervical ripening, prior cesarean delivery and cervical dilation, and effacement. Model calibration and discrimination were satisfactory with Hosmer-Lemeshow test P=.35 and with a 95% CI, an AUC of 0.76 (0.73-0.79). Among those with predicted probability of cesarean delivery of 20% or less, 89.5% had a vaginal delivery. Internal validation demonstrated similar discriminatory ability. Using information available before labor induction, and contingent on future external validation, our model can help women better understand their likelihood of vaginal delivery success when undergoing induction of labor for hypertensive disorders of pregnancy.

Pancreatic carcinoma underlying a complex presentation in late pregnancy: a case report

BackgroundGestational diabetes mellitus is strongly related to the risk of pancreatic cancer in pregnant women, but gestational diabetes can precede a diagnosis of pancreatic cancer by many years. Women with a history of gestational diabetes showed a relative risk of pancreatic cancer of 7.1. Pancreatic adenocarcinoma is one of the most common malignancies associated with thromboembolic events. A clinical study showed that thromboembolic events were detected in 36% of patients diagnosed as having pancreatic cancer. Studies showed that gestational diabetes mellitus could be one of the important risk factors for pancreatic cancer.Case presentationGestational diabetes mellitus is associated with increased risk of breast and pancreatic cancer. This case report describes a 29-year-old Chinese woman who presented with: gestational diabetes mellitus; International Society on Thrombosis and Haemostasis criteria suggested disseminated intravascular coagulation with a score of 5; hemolysis, elevated liver enzymes, low platelet count syndrome; and pulmonary hypertension. After an intravenous injection of fibrinogen, she gave birth to a normal baby and following delivery, her blood pressure reached 180/110 mmHg. Laboratory analysis results showed elevated lactic dehydrogenase, decreased platelets and fibrinogen, and urine protein was positive. She was transfused with fresh frozen plasma, blood coagulation factor, and fibrinogen. Subsequently, she was transferred to a maternity intensive care unit, where magnesium sulfate seizure prophylaxis was continued for 24 hours to keep her magnesium level at a low therapeutic range. However, continuous oxygen therapy was needed to maintain her oxygenation. Further laboratory investigations revealed elevated carcinoembryonic antigen, carbohydrate antigen 19-9, and carbohydrate antigen 72-4. Positron emission tomography-computed tomography showed malignant carcinoma in the head of her pancreas with lymph node involvement along with bone, peritoneal, and left adrenal metastasis, as well as double lung lymphangitic carcinomatosis.ConclusionA differential diagnosis of digestive system neoplasm should be considered when a pregnant patient presents with gestational diabetes mellitus and disseminated intravascular coagulation, where the disseminated intravascular coagulation has no specific cause and cannot be readily resolved.

Effect of Maternal Body Mass Index on Serum Magnesium Levels Given for Seizure Prophylaxis

To estimate the effect of body mass index (BMI) on magnesium levels for eclampsia prophylaxis. This is a retrospective study from 2004 to 2011, examining magnesium levels in women receiving seizure prophylaxis. Women received 6 g and then 2 g/h. Women had 4-hour and 12-hour levels drawn. Levels were considered subtherapeutic at less than 4.9 mg/dL, therapeutic from 4.9 to 8.4 mg/dL, and supratherapeutic at 8.5 mg/dL or more. If the 4-hour value was not therapeutic, the dose was adjusted and a 12-hour level was drawn. Levels at 4 and 12 hours were compared among the women with different BMI classifications and clinical characteristics. During the study period,106,265 women delivered, and 7,799 (7.4%) had preeclampsia diagnosed and received magnesium sulfate for seizure prophylaxis. A total of 5,304 (68%) of these women had a recorded BMI. At 4 hours, 2,698 (51%) were subtherapeutic. These women were more likely to be older, parous, undergo cesarean delivery, have a higher systolic blood pressure, and have central nervous system manifestations. At 12 hours, 2,342 (90%) of therapeutic women remained therapeutic, and 5% became subtherapeutic (n=118) or supratherapeutic (n=140). Using logistic regression, we were able to predict being subtherapeutic in women with greater BMI and to predict being supratherapeutic if women had labor longer than 12 hours and worsening severity of preeclampsia. Women receiving seizure prophylaxis with a BMI of more than 30 may benefit from routine serum magnesium evaluation 4 hours after the loading dose. III.

Postpartum Cerebral Venous Thrombosis

Cerebral venous thrombosis is a rare entity in pregnancy and the postpartum period, with an incidence of 1:10,000 to 1:25,000. A 19-year-old woman, gravida 1, para 1, presented to the emergency department on postpartum day 7, having experienced seizures. Severe preeclampsia had been diagnosed during the antepartum period. The patient initially was diagnosed with postpartum eclampsia and started on magnesium sulfate for seizure prophylaxis. Magnetic resonance imaging later showed cerebral venous thrombosis of the left transverse sinus and right frontal and left frontoparietal cortical veins. Cerebral venous thrombosis and eclampsia may manifest in a similar manner. Physicians can optimize the care of patients presenting with seizures by considering etiologies rarer than eclampsia and pursuing tests that may distinguish them.

Hello, Trauma Team? HELLP! Our OB Patient's Liver Ruptured!

Although hepatic rupture in pregnant women occurs in only 1 in 250,000 cases, the results are life threatening for mother and newborn. Only 41% of mothers and 59% of newborns survive a maternal hepatic rupture. Our patient beat these grim odds thanks to the dedicated, skillful, and immediate interventions by the obstetric (OB) and surgical critical care trauma teams that responded to her emergency. The patient presented to our OB triage with excruciating right upper quadrant pain. Lab results confirmed the diagnosis of HELLP syndrome. She was admitted for labor induction and magnesium sulfate seizure prophylaxis. Shortly after her arrival to Labor and Delivery, she became profoundly hypotensive and increasingly lethargic, with resulting fetal bradycardia. She was immediately taken to the OB operating room for Cesarean delivery.

Systemic Lupus Erythematosus Presenting with Leukocytoclastic Vasculitis and Seizure during Pregnancy

Systemic lupus erythematosus (SLE) is a rare multisystem disease with a wide array of presentation and is a diagnostic challenge during pregnancy. A 20-year-old gravida 1 at 39 weeks' gestation was referred to our hospital for elevated blood pressure, headache, and history of seizure. She was admitted with the impression of severe preeclampsia. Intravenous magnesium sulfate for seizure prophylaxis and oxytocin for induction of labor were started. Primary lower-segment cesarean section was performed for nonreassuring fetal heart tracing. The postoperative course was complicated with fever requiring prolonged intravenous antibiotic therapy, appearance of violaceous skin lesions on the periungual areas of fingers and toes, recurrent seizures, and altered sensorium. Biopsy of the lesions revealed leukocytoclastic vasculitis (LCV) with thrombi. Laboratory workup confirmed SLE with a dramatic improvement of the patient's condition upon initiating intravenous steroid therapy. LCV and neuropsychiatric SLE are rare presentations of SLE during pregnancy, and obstetricians should be aware of them. Workup for SLE is warranted in cases with atypical presentation of preeclampsia that does not resolve with delivery.

Can postgraduate courses in Maternal-Fetal Medicine change clinical attitude?

Objective. To investigate the effect of structured didactic lectures by leaders in the field of Maternal-Fetal Medicine on reported clinical decision-making.Methods. An interactive survey of obstetric management was performed as part of a postgraduate course at the 2004 Annual Meeting of the Society for Maternal-Fetal Medicine. Seven controversial topics were addressed, including tocolytic therapy, progesterone supplementation for the prevention of preterm birth, screening for inherited thrombophilia, cervical cerclage for a shortened cervix, the management of preterm premature rupture of membranes, magnesium sulfate seizure prophylaxis, and dexamethasone therapy for hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome. The survey was carried out before and after a series of structured didactic lectures, thereby allowing for analysis of the effect of the lectures on reported clinical decision-making.Results. A total of 298 obstetric care providers attended the postgraduate course. By report, the majority of attendees were Maternal-Fetal Medicine specialists (60.7%), less than 10 years out from specialty training (56.3%), and practicing in a university-based setting (52.9%). An average of 233 practitioners (range 157–298) answered each question. Comparison of responses to the survey given before and after the lectures demonstrated significant differences, especially in the areas of tocolytic therapy and inherited thrombophilias.Conclusions. Postgraduate lectures by leaders in the field of Maternal-Fetal Medicine have significant immediate impact on reported clinical decision-making.

Defining standards of care in maternal-fetal medicine

The purpose of this study was to describe current practice patterns for 7 controversial topics in Maternal-Fetal Medicine. An interactive survey of obstetric treatment was performed as part of a postgraduate course at the 2004 Annual Meeting of the Society for Maternal-Fetal Medicine. Seven controversial topics were addressed, which included tocolytic therapy, progesterone supplementation for the prevention of preterm birth, screening for inherited thrombophilia, cervical cerclage for a shortened cervix, treatment of preterm premature rupture of membranes, magnesium sulfate seizure prophylaxis, and dexamethasone therapy for HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome. A total of 298 obstetric care providers attended the postgraduate course. By report, most attendees were maternal-fetal medicine specialists (60.7% of respondents) who were >10 years out from specialty training (56.3% of respondents) and who were practicing in a university-based setting (52.9% of respondents). An average of 233 practitioners (range, 157-298 practitioners) answered each question. An analysis of the responses allowed for the determination of current practice patterns in the 7 controversial areas addressed. Contemporary practice patterns for 7 controversial topics in obstetric medicine are described. Such surveys may be useful in defining standards of care in maternal-fetal medicine.

Magnesium sulfate prophylaxis in preeclampsia: lessons learned from recent trials

In the US, the routine use of magnesium sulfate for seizure prophylaxis in women with preeclampsia is an ingrained obstetric practice. During the past decade, several observational studies and randomized trials have described the use of various regimens of magnesium sulfate to prevent or reduce the rate of seizures and complications in women with preeclampsia. There are only 2 double-blind, placebo-controlled trials evaluating the use of magnesium sulfate in mild preeclampsia. There were no instances of eclampsia among 181 women assigned to placebo, and there were no differences in the percentage of women who progressed to severe preeclampsia (12.5% in magnesium group vs 13.8% in the placebo group, relative risk [RR] 0.90; 95% CI 0.52-1.54). However, the number of women enrolled in these trials is too limited to draw any valid conclusions. There are 4 randomized controlled trials that compare the use of no magnesium sulfate, or a placebo vs magnesium sulfate, to prevent convulsions in patients with severe preeclampsia. The rate of eclampsia was 0.6% among 6343 patients assigned to magnesium sulfate vs 2.0 % among 6330 patients assigned to a placebo or control (RR 0.39; 95% CI 0.28-0.55). However, the reduction in the rate of eclampsia was not associated with a significant benefit in either maternal or perinatal outcome. In addition, there was a higher rate of maternal respiratory depression among those assigned magnesium sulfate (RR 2.06; 95% CI 1.33-3.18). The evidence to date confirms the efficacy of magnesium sulfate in reduction of seizures in women with eclampsia and severe preeclampsia; however, this benefit does not affect overall maternal and perinatal mortality and morbidities. The evidence regarding the benefit-to-risk ratio of magnesium sulfate prophylaxis in mild preeclampsia remains uncertain, and does not justify its routine use for that purpose.

Eclampsia in Southern Alberta: Is There a Role for Seizure Prophylaxis in All Women with Gestational Hypertension?

Objective: To evaluate the predictability of eclampsia and explore the role for seizure prophylaxis in a population with a low frequency of seizure prophylaxis.Methods: A retrospective review was conducted of all women with eclampsia registered at the Foothills Hospital in Calgary, Alberta, between 1991 and 2000. The data collected included timing of seizure in relation to diagnosis of gestational hypertension (GHTN) and delivery, method of seizure prophylaxis (if any), and maternal characteristics.Results: During the study period, 3075 of 38 577 women (8.0%) were diagnosed with GHTN, with or without proteinuria or adverse conditions. Three percent had received magnesium sulfate for seizure prophylaxis. Of these 3075 women, 17 (0.6%) developed eclampsia, none of whom was receiving magnesium sulfate for seizure prophylaxis at the time. Of these, 10 women (59%) exhibited GHTN prior to their first seizure, including 6 women with GHTN with adverse conditions, 3 with GHTN with proteinuria but without adverse conditions, and 1 with GHTN without proteinuria or adverse conditions. Five of the 17 women had seizures that occurred prior to labour, 6 were intrapartum, and 6 were postpartum. Nine (53%) of the 17 women with eclampsia had their initial seizure after the diagnosis of GHTN and before 24 hours postpartum.Conclusion: Seizure prophylaxis for all the women with GHTN, from the time of diagnosis through 24 hours postpartum, may have been able to prevent as many as 53% of eclamptic episodes. Three hundred and seven women with GTHN would have to receive seizure prophylaxis to prevent one seizure.

Postpartum seizure prophylaxis: using maternal clinical parameters to guide therapy

OBJECTIVE: To use individual patient clinical parameters to signal cessation of postpartum magnesium sulfate seizure prophylaxis for the spectrum of pregnancy-related hypertensive disorders. METHODS: This was a prospective study using clinical symptoms (absence of headache, visual changes, epigastric pain) and signs (sustained blood pressure less than 150/100 without need for acute antihypertensive therapy, spontaneous diuresis more than 100 mL per hour for no less than 2 hours) to signal cessation of intravenous magnesium sulfate postpartum in gravidas diagnosed with preeclampsia, eclampsia, and hemolysis, elevated liver enzymes, low platelets syndrome. Laboratory assessments (including proteinuria) were not used as criteria for drug discontinuation. RESULTS: Five hundred three patients were enrolled and classified according to American College of Obstetricians and Gynecologists criteria (mild preeclampsia, severe preeclampsia, chronic hypertension with superimposed preeclampsia, eclampsia, and hemolysis, elevated liver enzymes, low platelets syndrome). Maternal age, gestational age, and hours of magnesium therapy before delivery were not statistically different among groups. There was no significant difference in the duration of postpartum magnesium sulfate therapy among groups with the median duration of therapy 4 hours (range 2–77 hours). No eclamptic seizures occurred after magnesium discontinuation. Thirty-eight patients (7.6%) required reinstitution of magnesium therapy for 24 hours because of exacerbation of blood pressure (sustained blood pressure more than 160/110) associated with headache or visual changes. CONCLUSION: Clinical criteria, when compared with arbitrary protocols, can be used successfully to shorten the duration of postpartum magnesium sulfate administration for seizure prophylaxis in patients with pregnancy-related hypertensive disorders.

Postpartum Seizure Prophylaxis: Using Maternal Clinical Parameters to Guide Therapy

OBJECTIVE: To use individual patient clinical parameters to signal cessation of postpartum magnesium sulfate seizure prophylaxis for the spectrum of pregnancy-related hypertensive disorders. METHODS: This was a prospective study using clinical symptoms (absence of headache, visual changes, epigastric pain) and signs (sustained blood pressure less than 150/100 without need for acute antihypertensive therapy, spontaneous diuresis more than 100 mL per hour for no less than 2 hours) to signal cessation of intravenous magnesium sulfate postpartum in gravidas diagnosed with preeclampsia, eclampsia, and hemolysis, elevated liver enzymes, low platelets syndrome. Laboratory assessments (including proteinuria) were not used as criteria for drug discontinuation. RESULTS: Five hundred three patients were enrolled and classified according to American College of Obstetricians and Gynecologists criteria (mild preeclampsia, severe preeclampsia, chronic hypertension with superimposed preeclampsia, eclampsia, and hemolysis, elevated liver enzymes, low platelets syndrome). Maternal age, gestational age, and hours of magnesium therapy before delivery were not statistically different among groups. There was no significant difference in the duration of postpartum magnesium sulfate therapy among groups with the median duration of therapy 4 hours (range 2-77 hours). No eclamptic seizures occurred after magnesium discontinuation. Thirty-eight patients (7.6%) required reinstitution of magnesium therapy for 24 hours because of exacerbation of blood pressure (sustained blood pressure more than 160/110) associated with headache or visual changes. CONCLUSION: Clinical criteria, when compared with arbitrary protocols, can be used successfully to shorten the duration of postpartum magnesium sulfate administration for seizure prophylaxis in patients with pregnancy-related hypertensive disorders. (Obstet Gynecol 2003;101:66-9. © 2003 by The American College of Obstetricians and Gynecologists.)

Repeat postpartum magnesium sulfate administration for seizure prophylaxis: is there a patient profile predictive of need for additional therapy?

Objective: To profile patients with hypertensive disorders of pregnancy who require reinstitution of magnesium sulfate therapy for disease exacerbation. Study design: A prospective clinical trial enrolling gravidas with pre-eclampsia. The length of postpartum magnesium sulfate seizure prophylaxis was determined by individual patient characteristics. Patients with exacerbation of their disease after discontinuation of magnesium sulfate received a second course of magnesium sulfate lasting 24 h. Results: Of a total of 503 patients, 38 (7.6%) required reinstitution of postpartum magnesium sulfate therapy for an additional 24-h period. Patients with chronic hypertension complicated by superimposed pre-eclampsia were most likely to require further therapy (11/61, 18.0%), when compared with other hypertensive disorders. Additionally, patients who required reinstitution of magnesium therapy had significantly shorter gestations (32.4 ± 4.2 weeks versus 36.3 ± 4.2 weeks, respectively; p < 0.001), and higher mean arterial pressure during the initial magnesium course (113.2 ± 11.2 versus 105.6 ± 11.3 mmHg; p < 0.001). Conclusion: Patients with chronic hypertension complicated by superimposed pre-eclampsia, patients delivered prior to 35 weeks' gestation and patients requiring a longer initial magnesium prophylaxis are at higher risk for the need of reinstitution of seizure prophylaxis postpartum.

Repeat postpartum magnesium sulfate administration for seizure prophylaxis: is there a patient profile predictive of need for additional therapy?

Objective: To profile patients with hypertensive disorders of pregnancy who require reinstitution of magnesium sulfate therapy for disease exacerbation.Study design: A prospective clinicaltrial enrolling gravidas with pre-eclampsia. The length of postpartum magnesium sulfate seizure prophylaxis was determined by individual patient characteristics. Patients with exacerbation of their diseaseafter discontinuation of magnesium sulfate received a second course of magnesium sulfate lasting 24 h.Results: Of a total of 503 patients, 38 (7.6%) required reinstitution of postpartum magnesiumsulfate therapy for an additional 24-h period. Patients with chronic hypertension complicated by superimposed pre-eclampsia were most likely to require further therapy (11/61, 18.0%), when compared withother hypertensive disorders. Additionally, patients who required reinstitution of magnesium therapy had significantly shorter gestations (32.4 ± 4.2 weeks versus 36.3 ± 4.2 weeks, respectively;p < 0.001), and higher mean arterial pressure during the initial magnesium course (113.2 ± 11.2 versus 105.6 ± 11.3 mmHg; p < 0.001).Conclusion: Patients withchronic hypertension complicated by superimposed pre-eclampsia, patients delivered prior to 35 weeks' gestation and patients requiring a longer initial magnesium prophylaxis are at higher risk for the needof reinstitution of seizure prophylaxis postpartum.

A randomized trial of labor analgesia in women with pregnancy-induced hypertension

Objective: The purpose of this study was to compare the peripartum and perinatal effects of epidural with intravenous labor analgesia in women with pregnancy-induced hypertension. Study Design: Women with pregnancy-induced hypertension who had consented to participate were randomized to receive either epidural or intravenous analgesia for labor pain. Both methods were given according to standardized protocols. All women received magnesium sulfate seizure prophylaxis. Obstetric and neonatal outcomes were compared according to intent-to-treat allocation. Results: Seven hundred thirty-eight women were randomized: 372 women were given epidural analgesia, and 366 women were given intravenous analgesia. Maternal characteristics were similar, including the severity of hypertension. Epidural analgesia was associated with a significantly prolonged second-stage labor, an increase in forceps deliveries, and an increase in chorioamnionitis. Cesarean delivery rates and neonatal outcomes were similar. Pain relief was superior with the epidural method. Hypotension required treatment in 11% of women in the epidural group. Conclusion: Epidural labor analgesia provides superior pain relief but no additional therapeutic benefit to women with pregnancy-induced hypertension. (Am J Obstet Gynecol 2001;185: 970-5.)