Prevention Of Eclampsia Research Articles

Program evaluation and early outcomes of a severe preeclampsia and eclampsia maternal safety bundle in a single institution in the Philippines

BACKGROUND: To reduce maternal morbidity and mortality associated with hypertension, standards for maternal safety and efforts to implement a structured team approach have been undertaken. Following the formulation of a policy document, a maternal safety bundle was developed. The implementation of bundle components including eclampsia kits, clinical pathways, and educational module occurred in phases due to pandemic restrictions. An eclampsia kit and clinical pathways were implemented in 2020. An online lecture was launched in 2021 followed by in-person eclampsia simulation workshop beginning 2022. OBJECTIVES: This paper aims to report the early outcomes of a severe preeclampsia and eclampsia maternal safety bundle implementation in a private hospital between 2020 to 2023. MATERIALS AND METHODS: Demographic information, posttest knowledge assessment and pre- and post- eclampsia workshop confidence scores were recorded. Structure, process, and outcome measures were determined. Descriptive statistics were used for participant demographics and score percentages. Paired t-Test with a significance level of P<0.05 was used to compare the pre- and post-simulation confidence scores. Summary data for outcome and process metrics were manually calculated. Summary categorical data was used for structure metrics. RESULTS: Two hundred eighty-eight (288) participants completed the online didactic lecture. Average posttest knowledge assessment score was 88.1%, 88.88%, and 82.6% from 2020 to 2023. Ninety-nine participants completed the eclampsia simulation workshops. Mean post-simulation confidence scores were greater than mean pre-simulation confidence scores (42.3 vs. 39, p=0.0259 in 2022 and 41.975 vs 36.65, P=0.0035 in 2023). There is 100% compliance with timely management of severe hypertension and eclampsia prevention and a decreasing trend in hypertension related severe maternal morbidity rates. CONCLUSION: A severe preeclampsia and eclampsia maternal safety bundle is a feasible quality improvement initiative that promotes peer learning, strengthens clinical competencies, and improves access to emergency resuscitation supplies. The results of this program evaluation may serve as a framework for implementing quality improvement initiatives on maternal safety.

STUDY OF MATERNAL AND FETAL OUTCOME IN PATIENTS OF ECLAMPSIA

Background: Eclampsia is still a major cause of maternal morbidity and mortality in India and across the globe. Material & Methods: This was a descriptive cross-sectional study conducted at Government Medical College, LaturMaharashtra in 240 eclamptic patients admitted from 1st January 2019 to 30th June 2020, included after permission from the Institutional Ethics Committee & were evaluated regarding eclampsia, its sociodemographic presentation, risk factors, and fetomaternal complications. Epi- info 7.2.5 & SPSS version 2.0 was used for statistical analysis. The incidence Results: of eclampsia in the study was 1.64%. The mean age of eclampsia cases was 21.25 ± 2.47 years. 71.66% of cases were primiparous, 61.25% of cases of eclampsia had no education at all, and 13.33% of cases had a family history of preeclampsia.70% of patients were unbooked, 68.33% of cases were from rural residence while 78.34% cases were referred from different hospitals. 87.50% cases had antepartum eclampsia, 66.98% presented at gestational age less than 37 weeks, and 65.84% presented with severe hypertension with blood pressure >160/110 mm Hg on admission. 63.75% of cases had 2-4 convulsions before the start of anticonvulsant therapy. 67.91% of cases were delivered by lower segment cesarean section while 32.09% of cases had delivered vaginally. 9.17% of cases had HELLP syndrome, 7.5% cases had PRES, 5% cases required ventilatory support, and 2.92% cases developed pulmonary edema. Maternal death occurred in 9 cases. Pulmonary edema was the commonest cause of death in 44.44% of cases of eclampsia. 56.67% of cases of eclampsia had LBW babies, 85% of babies were born alive and there were 15% perinatal deaths. Eclampsia is still major Conclusion: contributor for maternal and perinatal mortality and morbidity. The incidence of eclampsia and maternal deaths are higher in developing countries due to lack of education and lack of antenatal care. Proper antenatal care, early detection of pre-eclampsia, health education about imminent symptoms to patients, and proper management of pre-eclampsia are essential steps for the prevention of eclampsia. The maternal and fetal outcomes can be improved by the better provision of health care facilities, antenatal care, and improvement of socioeconomic conditions.

Role of the Family Members in the Prevention of Eclampsia

Preeclampsia is a global cause of maternal death. Maternal mortality due to eclampsia in Indonesia is 33.07%. Various interventions have been carried out, but until now maternal mortality due to preeclampsia has not been able to be controlled. Current interventions are more focused on medical interventions, but the involvement of the family members in the preeclampsia treatment is not optimal. The aim of this study is to explore the experience of family members in caring treatment woman with preeclampsia during pregnancy to prevent eclampsia. This is a qualitative study with a phenomenological approach. Data collection using in-depth interviews. The informants in this study are 5 family members who have meet a inclusion criteria. The result this study found 2 themes, namely (1) family support, (2) family mentoring. The family support and family mentoring are necessary to prevent eclampsia in pregnant woman. Suggestions for the family members to involve in caring pregnant woman to prevent eclampsia.

Developing shared understanding of pre-eclampsia in Haiti and Zimbabwe using Theory of Change.

Pre-eclampsia, a complex and multi-system disorder specific to pregnancy, is a leading cause of preventable maternal and perinatal deaths in low-resource settings. Early detection and appropriate intervention with management of hypertension, prevention of eclampsia and timely delivery are effective at reducing mortality and morbidity. Outcomes can be greatly improved with the provision and uptake of good quality care. Cultural contexts of maternal care, social practices and expectations around pregnancy and childbirth profoundly shape understanding and prioritisation when it comes to seeking out care. Few studies have addressed health education specifically targeting pre-eclampsia in low resource settings. The existing literature has limited descriptions of contextual barriers to care or of the intervention development processes employed. More engaging, holistic approaches to pre-eclampsia education for women and families that recognise the challenges they face and that support a shared understanding of the disorder, are needed. We describe our experience of developing a Theory of Change (ToC) as part of the co-production of educational resources for pre-eclampsia in Haiti and Zimbabwe.

Neonatal magnesium levels are safe after maternal MgSO4 administration: a comparison between unexposed preterm neonates and neonates exposed for fetal neuroprotection or maternal eclampsia prevention-a cohort study.

We found mean differences in neonatal magnesemia between children not exposed to MgSO4 antenatally, children exposed for fetal neuroprotection, and children exposed for maternal eclampsia prevention. A 4-g loading and 1-g/h maintenance doses, for fetal neuroprotection and eclampsia prevention, appear to be safe on the short term for the neonate. •Magnesium sulphate is a valuable medicine in obstetrics. The main indications are prevention of eclampsia and fetal neuroprotection. The most used dosage is a 4- or 6-g loading dose and a 1- or 2-g per h maintenance dose. It reduces neuromotor disabilities in extreme-to-moderate preterm born children. •Maternal concentrations are supraphysiological and the maternal total dose can be high. Concentrations in neonates appear to remain in safe ranges. A dosage of 4-g loading and 1 g/h seems safe for the preterm neonate on the short term.

Duration of Postpartum Magnesium Sulphate for the Prevention of Eclampsia

OBJECTIVE: To estimate the optimal duration of postpartum magnesium sulphate to prevent eclampsia. DATA SOURCES: MEDLINE, EMBASE, CINAHL, the Cochrane Database of Systematic Reviews, and ClinicalTrials.gov databases were searched from inception until January 2020 and limited to English-language human randomized controlled trials. Search strategy included the key works “eclampsia,” “magnesium sulphate,” and “postpartum.” METHODS OF STUDY SELECTION: Title, abstract, and full-text review was performed using Covidence data-management software. Of the 3,629 articles screened, 10 studies were included in the final review. Studies were included if they compared two different time points of magnesium sulphate postpartum in women with either preeclampsia or eclampsia. TABULATION, INTEGRATION AND RESULTS: Two authors reviewed studies independently. RevMan software was used to calculate risk difference (RD) for categorical outcomes and mean difference for continuous outcomes. Shorter duration of magnesium sulphate (12 hours or less) was not associated with increased risk of eclampsia compared with 24-hour postpartum regimens (RD −0.01, 95% CI −0.02 to 0.01, I2 70%). Studies randomizing women with preeclampsia did not show increased risk of eclampsia with shorter regimens (RD 0, 95% CI −0.01 to 0.01, I2 0%), nor did trials randomizing those with eclampsia (RD −0.04, 95% CI −0.14 to 0.07, I2 87%). Secondary outcomes, including flushing, duration of Foley catheter insertion, time to ambulation, and duration of hospital stay, were all reduced with shorter-duration magnesium sulphate. CONCLUSION: This systematic review and meta-analysis suggests that a shorter duration of postpartum magnesium sulphate does not increase the risk for eclamptic seizure; however, data remain underpowered to render firm conclusions. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42020182432.

Refreshing our magnesium sulphate strategy.

Eddy and colleagues are to be commended on this comprehensive, global synthesis of qualitative evidence (22 studies), reporting on barriers and facilitators of magnesium sulphate use for eclampsia prevention and treatment. Almost all of the 22 studies were from low-and-middle-income countries that bear most of the burden of pre-eclampsia-related morbidity and mortality. The analysis accounted for the perspectives of healthcare providers, facilitator administrators, and policy-makers, all organised according to the COM-B model of behaviour change theory, according to stakeholders' capability, opportunity, and motivation to use magnesium sulphate appropriately.

Gestational Hypertension and Preeclampsia: An Overview of National and International Guidelines.

Gestational hypertension and preeclampsia are leading causes of maternal and perinatal morbidity and mortality worldwide. Τhe lack of effective screening and management policies appears to be one of the main reasons. The aim of this study was to review and compare recommendations from published guidelines on these common pregnancy complications. A descriptive review of guidelines from the National Institute for Health and Care Excellence, the Society of Obstetric Medicine of Australia and New Zealand, the International Society of Hypertension, the International Society for the Study of Hypertension in Pregnancy, the European Society of Cardiology, the International Federation of Gynecology and Obstetrics, the Society of Obstetricians and Gynaecologists of Canada, the American College of Obstetricians and Gynecologists, the International Society of Ultrasound in Obstetrics and Gynecology, the World Health Organization, and the US Preventive Services Task Force on gestational hypertension and preeclampsia was carried out. There is an overall agreement that, in case of suspected preeclampsia or new-onset hypertension, blood and urine tests should be carried out, including dipstick test for proteinuria, whereas placental growth factor-based testing is only recommended by the National Institute for Health and Care Excellence and the European Society of Cardiology. In addition, there is a consensus on the recommendations for the medical treatment of severe and nonsevere hypertension, the management of preeclampsia, the appropriate timing of delivery, the optimal method of anesthesia and the mode of delivery, the administration of antenatal corticosteroids and the use of magnesium sulfate for the treatment of eclamptic seizures, the prevention of eclampsia in cases of severe preeclampsia, and the neuroprotection of preterm neonates. The reviewed guidelines also state that, based on maternal risk factors, pregnant women identified to be at high risk for preeclampsia should receive low-dose aspirin starting ideally in the first trimester until labor or 36 to 37 weeks of gestation, although the recommended dose varies between 75 and 162 mg/d. Moreover, most guidelines recommend calcium supplementation for the prevention of preeclampsia and discourage the use of other agents. However, controversy exists regarding the definition and the optimal screening method for preeclampsia, the need for treating mild hypertension, the blood pressure treatment targets, and the postnatal blood pressure monitoring. The development and implementation of consistent international protocols will allow clinicians to adopt effective universal screening, as well as preventive and management strategies with the intention of improving maternal and neonatal outcomes.

For the prevention of eclampsia. Wiеlosh (Munch, med. Woch., 1926, No. 7)

Wieloch (Munch, med. Woch., 1926, No. 7) with mild edema prohibits pregnant women from performing heavy work and restricts the introduction of liquid and NaCl. With increased edema - bed keeping, the introduction of colloids per os (gelatins 15.0, raspberry syrup 20.0 and water up to 200.0).

A literature review and best practice advice for second and third trimester risk stratification, monitoring, and management of pre‐eclampsia

A literature review and best practice advice for second and third trimester risk stratification, monitoring, and management of pre‐eclampsia

Interrupted versus continuous magnesium sulfate and blood loss at cesarean delivery

Objective Magnesium sulfate is standard of care for prevention of eclampsia in women with preeclampsia with severe features. The American College of Obstetrics and Gynecology endorses its use throughout labor, delivery and the immediate postpartum period. Some providers pause magnesium sulfate infusion preoperatively due to concern for increased risk of uterine atony and postpartum hemorrhage. Using a non-inferiority analysis, we investigated the effect of interrupted versus continuous infusion of magnesium sulfate on postpartum hemorrhage in women with preeclampsia with severe features undergoing cesarean delivery. Study design Retrospective non-inferiority cohort study of women with preeclampsia with severe features treated with magnesium sulfate undergoing cesarean delivery with singleton pregnancies at tertiary care hospital from 2013 to 2018. The primary outcome was postpartum hemorrhage. Secondary outcomes included estimated blood loss, change in hematocrit and a composite of postpartum hemorrhage severity, including transfusion of blood products, use of more than one uterotonic and additional surgical interventions. Results Of 249 women, magnesium sulfate infusion was interrupted in 171 (69%) and continued in 78 (31%). Women with interrupted magnesium sulfate infusion were more likely to be Caucasian (73% vs 67%, p = .024), have chronic hypertension (23% vs 1%, p < .001), labor prior to cesarean delivery (84% vs 55%, p < .001), undergo primary cesarean delivery (86% vs 67%, p = .005), and experience shorter surgical time (50 vs 55 min, p = .026). The rate of postpartum hemorrhage for those receiving interrupted magnesium sulfate infusion (9.9%) and continuous magnesium sulfate infusion (10.2%) was similar, falling within the non-inferiority margin (absolute difference 0.3%, 95% CI -7.8 to 8.4%, p = .88). There were no significant differences in the secondary outcomes. Conclusion Interrupted magnesium sulfate infusion is non-inferior to continued magnesium sulfate infusion for rates of postpartum hemorrhage in women with preeclampsia with severe features undergoing cesarean delivery.

Provider practices for the prevention of eclampsia and attitudes toward magnesium sulfate: results of a nationwide survey

Objective To survey OB-GYNs regarding their practice patterns and perspectives when it comes to using magnesium sulfate (magnesium) in the prevention of eclampsia. Study Design We conducted a cross-sectional web-based 18-item survey given to 564 practicing OB-GYNs in the Pregnancy-Related Care Research Network. The survey used clinical scenarios to look at provider practices for preventing eclampsia in patients who have preeclampsia and relative contraindications to magnesium. Next, we assessed provider attitudes toward magnesium and inquired about their experiences with complications related to its use. The survey also contained an embedded educational component that addressed the signs and symptoms of magnesium toxicity followed by a 2-item quiz for those providers who self-identified as having never treated magnesium toxicity. Results Nearly 30% of OB-GYNs contacted completed the survey. For patients with preeclampsia and a contraindication to magnesium such as myasthenia gravis, 44.4% of respondents would administer an alternative antiepileptic and 42.5% of them would administer no antiepileptic at all. For patients with pulmonary edema complicating preeclampsia, 32.5% would give magnesium at the usual dose, 33.1% would give magnesium at less than the usual dose, 12.3% would give an alternative antiepileptic and 22.1% would give no antiepileptic at all. For patients with laboratory evidence of renal compromise complicating preeclampsia, most respondents (89.6%) said they would give magnesium at less than the usual dose. Regarding complications of magnesium that clinicians have encountered, over one-third of respondents have administered calcium gluconate for magnesium toxicity in patients with preeclampsia. For those providers who have not treated magnesium toxicity and were prompted to receive the educational component and quiz, all knew the correct initial bolus dosing of magnesium and the majority were able to identify symptoms of toxicity. The majority (81.8%) of respondents said that continuous magnesium infusions cause an increased demand for dedicated personnel to care for the patients on them. Almost 57% of respondents endorsed the need for an alternative antiepileptic to magnesium in the prevention of eclampsia. Most write-in responses supporting this need cited a concern with magnesium’s safety and side effects. Conclusion There is wide variation among OB-GYNs regarding the prevention of eclampsia and complications of magnesium are not uncommon. The survey revealed that OB-GYNs are using alternative antiepileptics in scenarios where there is concern for magnesium’s safety profile. In addition, over half of those surveyed believe there is a need for validated antiepileptics other than magnesium for the prevention of eclampsia in patients with preeclampsia. These findings suggest that OB-GYNs would support further research into alternative antiepileptics in the prevention of eclampsia.

A RETROSPECTIVE STUDY OF FETOMATERNAL OUTCOME IN ECLAMPSIA

In India the perinatal and maternal outcome in eclampsia cases is still poor due to inadequate antenatal care in rural areas, financial restraints and non-availability of transportation facilities, and social taboos causing delay in management resulting in poor maternal and neonatal outcome. Aim of the study was to evaluate fetomaternal outcome in patients with eclampsia. This retrospective study was conducted over a period of 2 years from May 2018 to April 2020 at department of obstetrics and gynaecology of Government medical college and Sir T General hospital, Bhavnagar , Gujarat , India. During the review period total 50 cases of eclampsia reported.Incidence in our study is 0.43%.Results showed 86 % of eclampsia patients were of age less than 25 years. 82% of patients had antepartum eclampsia , 14 % had postpartum eclampsia and 4% had intrapartum eclampsia . 90% patients had 1 episodes of convulsion. 8% patients had 2 episodes of convulsions.2% pateint had 5 episode of convulsion. Out of 50 patients 36 patients were delivered by C-section and 14 patients by vaginal delivery.1 patient had twin pregnancy.Out of 51 newborn, 5 were stillbirth and 1 early neonatal death.Maternal mortility was 2 % .Eclampsia is still one of the important and common obstetric emergencies, which has a significant role in maternal and perinatal outcome. Regular Antenatal Care (ANC), proper health education, improvements of socioeconomic conditions and spreading of awareness in the community has major roles in prevention of eclampsia. Timely and appropriate intervention including primary management, early referral and judicious termination of pregnancy help in reducing morbidity and mortality of both mother and fetus.&#x0D; Keywords: Eclampsia, Fetomaternal outcome.

Ssociated Factors of Subtherapeutic Serum Magnesium Level for Prevention of Eclampsia in Term Pregnant Women with Severe Pre-eclampsia

Objective: To investigate the factors associated with subtherapeutic serum magnesium levels in order to prevent eclampsia in term pregnant women with severe pre-eclampsia. Methods : This case-control study included 200 term pregnant women with severe pre-eclampsia who received magnesium sulfate for eclampsia prophylaxis. These patients were randomly allocated into case and control groups. Experimental cases included 100 women whose serum magnesium level did not reach the therapeutic level (&lt;4.8 mg/dL) at 2 hours after initial administration, whereas the controls were 100 women whose serum magnesium levels reached therapeutic levels (4.8-8.4 mg/dL). Data from the medical records, including baseline characteristics, sign and symptoms, laboratory findings and pregnancy outcomes, were extracted for univariate and multivariate analyses. Results: Only two factors, pre-pregnancy body mass index (BMI) and serum creatinine level, showed significant differences between the two groups. Pre-pregnancy BMI greater than 25 kg/m 2 increased the risk of subtherapeutic serum magnesium level by 56% compared with normal pre-pregnancy BMI (adjusted OR 1.56, p=0.019), whereas pre-pregnancy BMI less than 18 kg/m 2 decreased the risk by 80% (adjusted OR 0.2, p=0.02). Also, serum creatinine levels greater than 0.9 mg/dl decreased the risk by 98.7% (adjusted OR 0.013, p&lt;0.001). No significant difference in pregnancy outcomes was noted in either group. Conclusion: Pre-pregnancy BMI greater than 25 kg/m 2 increased the risk, whereas pre-pregnancy BMI less than 18 kg/m 2 decreased the risk of subtherapeutic serum magnesium levels. A serum creatinine level greater than 0.9 mg/dl was another factor that decreased the risk.

DIFFERENT REGIMENS OF MAGNESIUM SULFATE FOR MANAGEMENT OF WOMEN WITH SEVERE PREECLAMPSIA

Background: Preeclampsia is serious syndrome that can affect human pregnancy causing serious complications. Preeclampsia is pregnancy-specific syndrome of reduced organ perfusion secondary to vasospasm and endothelial activation. Objective: To assess the comparative effects of three regimens for the administration of the magnesium sulfate when used for the care of women with severe preeclampsia to determine the minimal effective dose of magnesium sulfate in controlling cases with severe preeclampsia and prevention of eclampsia and to determine whether only loading dose of magnesium sulfate is effective in prevention of eclampsia or not. Patients and Methods: 240 patients were recruited and divided into three groups. Each group contains 80 patients, the first group received only the loading dose of MgSO4 and the second group received loading dose plus 12 hours maintenance dose while the last group received the loading dose and the full maintenance dose of MgSo4 for 24 hours. Results: Although strong evidence supports the use of magnesium sulfate for prevention and treatment of eclampsia, there was no significant difference between occurrence of eclampsia in the three groups after either administration of loading dose of MgSO4 only or administration of loading dose with maintenance dose for 12 hours or maintenance dose for 24 hours in the studied patients. Conclusion: Magnesium sulfate proved to cause many hemodynamic changes as it has vasodilator effect on maternal and fetal blood vessels; however, magnesium sulfate should be given to all patients with severe preeclampsia.

Preeclampsia: The Need for a Biological Definition and Diagnosis.

The centuries-old approach to the prevention of eclampsia and its associated maternal morbidity and mortality is based on the recognition of the presence of premonitory signs and symptoms such as hypertension and proteinuria. The spectrum of preceding signs and symptoms came to be known as preeclampsia, which is debatably considered to be an early stage on a clinical continuum possibly leading to eclampsia. The premonitory signs and symptoms were then construed as diagnostic criteria for the poorly understood syndrome of preeclampsia, and this led to a perpetual debate that remains subject to wide disagreement and periodic updates. In this commentary, we will draw attention to the fact that the criteria for preeclampsia should be viewed from the prism of a screening test rather than as diagnostic of a condition in itself. Focusing research on developing better diagnostic and screening methods for what is clinically important, namely maternal and perinatal morbidity and mortality from hypertensive disorders of pregnancy, a long overdue upgrade from what was possible centuries ago, will ultimately lead to better management approaches to what really matters.

529: Continuous versus interrupted magnesium for preeclampsia with severe features and blood loss during cesarean delivery

Magnesium sulfate is the standard of care for the prevention of eclampsia in women with preeclampsia with severe features. ACOG endorses its use throughout labor, delivery and the immediate postpartum period, even during cesarean delivery (CD). Some providers pause magnesium sulfate infusion during CD due to concern for increased risk of operative blood loss and postpartum hemorrhage. We sought to assess the effect of continuous versus interrupted infusion of magnesium sulfate on operative blood loss and postpartum hemorrhage for women with preeclampsia with severe features. Retrospective cohort study of women undergoing CD with singleton pregnancies and preeclampsia with severe features treated with magnesium sulfate infusion at a tertiary care hospital from 2013-2018. The primary outcome was a composite of postpartum hemorrhage (EBL > 1000mL), transfusion of blood products, use of other uterotonics, or additional surgical interventions. These outcomes were compared between women who received continuous versus interrupted magnesium sulfate infusion during CD. Multivariable analysis controlled for factors found to be statistically significant from baseline and delivery characteristics. Of 249 women, magnesium sulfate infusion was continuous in 78 (31%) and interrupted in 171 (69%) during CD. Women with continuous magnesium sulfate infusion were more likely to be African American (22% vs 13%, p = 0.02), experience prolonged surgical time (55 vs 50 min, p= < 0.01), have a prior cesarean delivery (28% vs 11%, p = < 0.01), and use anticoagulants prior to delivery (19% vs 6%, p < 0.01) (Table 1). There was no difference in the primary outcome (17% vs 14%, p= 0.78). Additionally, there were no significant differences for postpartum hemorrhage (10% vs 10%, p = 0.49), need for transfusion (5% vs 1%, p=0.42) or use of other uterotonics (6% vs 4%, p=0.49) (Table 2). Continuing intraoperative magnesium sulfate infusion for eclampsia prevention does not appear to be an independent risk factor for increased operative blood loss or postpartum hemorrhage.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

832: Comparison of magnesium sulfate regimens for prevention of eclampsia: A network meta-analysis

To compare the efficacy and safety profile of different magnesium sulfate regimens administered to patients with preeclampsia with severe features for eclampsia prophylaxis A search was conducted on PubMed, Scopus, Web of Science and the Cochrane Library databases from database inception through February 1st, 2019. Search includes clinical trials, comparative prospective and retrospective studies comparing 2 or more magnesium sulfate regimens administered for eclampsia prophylaxis. Primary outcome was treatment efficacy in preventing eclampsia. Secondary outcomes were maternal complications and side effects. Fixed effects models were used to pool odds ratios (OR) and 95% confidence interval (CI) Out of 5414 articles retrieved on initial search, 20 studies were eligible for network meta-analysis and met our inclusion criteria. Comparing Pritchard regimen to Dhaka, low dose, Pritchard with shortened maintenance, standard dose (25 g), Zuspan, and loading dose only regimens, there were no significant differences in the risk of seizures. Similarly, the risk of maternal and neonatal mortality was not significantly different among these regimens. Although loading dose only (OR 0.01, 95% CI 0.00; 0.26), and low dose regimens (OR 0.14, 95% CI 0.06; 0.38) were associated with lower risk of loss of tendon reflexes compared to Pritchard regimen, the risk of respiratory depression with Pritchard regimen was comparable to low dose, Dhaka and Zuspan regimens. Loading dose only and low dose regimens were associated with lower APGAR scores at 5 minutes but there was no significant difference in the incidence of APGAR scores < 7. Cesarean delivery rates associated with Pritchard, low dose, standard dose, loading dose only regimen and Pritchard with shortened maintenance were not significantly different. Dhaka regimen is associated with shorter hospital stay compared to Pritchard regimen (MD −0.92, 95% CI −1.24; −0.60) Efficacy and safety profile of Pritchard, Dhaka, low dose, Pritchard with shortened maintenance, standard dose, Zuspan, and loading dose only regimens are comparableView Large Image Figure ViewerDownload Hi-res image Download (PPT)

Unexpected complication of a common therapy in a pregnant patient

Background: Pre-eclampsia/eclampsia is a life-threatening disease with considerable risks on maternal and neonatal health. Globally, it affects between 2–8% of all pregnancies. Worldwide, approximately 63,000 pregnant women die each year due to pre-eclampsia/eclampsia. The MAGPIE (Magnesium sulphate for Prevention of Eclampsia) trial stated that the risk of developing convulsions was lowered significantly (58%) in severe pre-eclampsia patients who received magnesium sulfate in comparison to the placebo group.1 The exact mechanism of action of magnesium sulfate (MgSO4) is not completely understood, blocking calcium channels and decreasing availability of calcium for smooth muscle contractions has been suggested. Pritchard advocated that therapeutic concentration of MgSO4 should be between 2-4 mmol/l.2 Despite strong evidence of the effectiveness of MgSO4, concerns have been expressed about the risk of hypocalcemia to the patient when used alone or concomitantly with nifedipine as both of them affect calcium metabolism.3 Hypermagnesemia causes hypocalcemia by inhibiting parathyroid hormone secretion and increases urinary excretion of calcium. Severe hypocalcemia is a life-threatening condition and may lead to focal or generalized tonic muscle cramps, convulsions, arrhythmia, and laryngospasm and stridor which is common in the pediatric population but has also been reported in adults.4 A case of symptomatic hypocalcemia secondary to hypermagnesemia is extremely rare, and to the best of our knowledge, only a few cases have been reported.5 We believe this is the only case in the literature with stridor and potential airway obstruction. Case: A 30-year old black South African woman, gravida 5, para 3+1, presented with severe preeclampsia (BP 215/145 mmHg, proteinuria +2), and preterm premature rupture of membrane at 33 weeks of gestation. General and obstetric examinations were unremarkable. Laboratory parameters on admission showed acute kidney injury, anemia and elevated lactate dehydrogenase and alkaline phosphatase. Other investigations were normal (Table 1). She was admitted to the high dependent unit and received 10 grams of intramuscular MgSO4, followed by continuous intravenous infusion at a rate of 2 g/hour for 24 hours. Her blood pressure dropped to 145/95 mmHg. Three hours post-admission, her blood pressure raised to 186/124 mmHg and was controlled with a labetalol intravenous infusion and nifedipine 10 mg orally. Her blood pressure then dropped to 150/90 mmHg. Six hours post-admission, the patient had an uneventful emergency caesarean section under spinal anesthesia for fetal distress. Nine hours post-admission, the patient had dyspnea, respiratory distress, and inspiratory stridor, and chest examination was unremarkable. While checking her blood pressure, the patient had carpopedal spasm (Trousseau's sign) and masseter muscle spasm (Chvostek's sign). MgSO4 infusion was stopped. She received 10 ml of 10% calcium chloride over 10 minutes and responded dramatically to resuscitation and calcium chloride. Investigations (arterial blood gas, FBC, urea and electrolytes) were performed and showed low ionized calcium 0.89 mmol/l and her magnesium level was 2.74 mmol/l. Conclusion: Although MgSO4 is considered as the treatment of choice for the prevention of convulsions in pre-eclampsia/eclampsia patients, concerns have been raised regarding the risk of severe hypocalcemia, especially when used concomitantly with calcium channel blockers. Prospective studies designed in a controlled fashion are needed to assess the safe combination of magnesium sulfate and nifedipine.

Serum magnesium levels during magnesium sulfate infusion at 1 gram/hour versus 2 grams/hour as a maintenance dose to prevent eclampsia in women with severe preeclampsia: A randomized clinical trial.

Background:Magnesium sulfate is the ideal drug for the prevention and treatment of eclampsia. Nevertheless, the best regimen for protection against eclampsia with minimal side effects remains to be established. This study aimed to compare serum magnesium levels during intravenous infusion of magnesium sulfate at 1 gram/hour versus 2 grams/hour as a maintenance dose to prevent eclampsia in pregnant and postpartum women with severe preeclampsia.Methods:A randomized, triple-blind clinical trial was conducted, comparing serum magnesium levels during the intravenous infusion of magnesium sulfate at 1 gram/hour versus 2 grams/hour as a maintenance dose for the prevention of eclampsia in 62 pregnant and postpartum women with severe preeclampsia, 31 in each group. An intravenous loading dose of 6 grams of magnesium sulfate was administered over 30 minutes in both groups. The patients were then randomized to receive a maintenance dose of either 1 or 2 grams/hour for 24 hours. Primary outcomes consisted of serum magnesium levels at the following time points: baseline, 30 minutes, every 2 hours until the end of the first 6 hours, and every 6 hours thereafter until the termination of magnesium sulfate infusion. Side effects, maternal complications, and neonatal outcomes were the secondary outcomes.Results:Serum magnesium levels were higher in the 2-gram/hour group, with a statistically significant difference from 2 hours after the beginning of the magnesium sulfate infusion (P <.05). Oliguria was the most common complication recorded in both groups, with no significant difference between the 2 regimens (RR 0.88; 95% CI: 0.49–1.56; P = .65). No cases of eclampsia occurred. Side effects were more common in the 2-gram/hour group (RR 1.89; 95% CI: 1.04–3.41; P = .02); however, all were mild. There were no differences between the 2 groups regarding neonatal outcomes, except for admission to neonatal intensive care, which was more frequent in the 1-gram/hour group (25% vs 6.3%; P = .04).Conclusion:Magnesium sulfate therapy at the maintenance dose of 1 gram/hour was just as effective as the 2-gram maintenance dose, with fewer side effects.