An integrative review of the side effects related to the use of magnesium sulfate for pre-eclampsia and eclampsia management

Magnesium sulphate for the management of preeclampsia and eclampsia in low and middle income countries: a systematic review of tested dosing regimens

OBJECTIVE

To review systematically the magnesium sulphate (MgSO4) dosing regimens tested in low and middle income countries (LMICs) for women with preeclampsia (prevention) and/or eclampsia (treatment).

DATA SOURCES

We searched Medline, EMBASE, IPA, CINAHL, CDSR, and CENTRAL databases for relevant English language publications.

STUDY SELECTION

Our search yielded 753 publications, of which 26 (10 randomized controlled trials and 16 observational studies) evaluated MgSO4 for preeclampsia and/or eclampsia in World Bank-classified LMICs.

DATA EXTRACTION

Independent, by two authors.

DATA SYNTHESIS

Twenty-five studies were conducted in hospital settings and one in the community. Rates of eclampsia were usually < 5% (median 3.0%, range 0.0% to 26.5%) even when MgSO4 was administered for eclampsia. When dosage varied from the standard Pritchard or Zuspan regimens, almost all (n = 22) reduced the dose or duration of treatment, most commonly because of concerns about maternal safety, cost, or resource availability. Four trials of a loading dose only (4 g IV + 10 g IM) versus loading plus maintenance dosing of 5 g/4 hr IM found no difference in eclampsia recurrence (RR 1.64; 95% CI 0.48 to 5.65, n = 396). One study documented less eclampsia recurrence associated with community administration of a MgSO4 loading dose before referral to a care facility versus treatment in a care facility (RR 0.23; 95% CI 0.11 to 0.49, n = 265).

CONCLUSION

Use of MgSO4 for eclampsia treatment and prevention has been well-studied in LMICs, but concern remains about potential toxicity. Further studies are needed to identify the minimum effective dosage of MgSO4 for management of preeclampsia and eclampsia and whether MgSO4 loading can be safely administered in the community.

Contemporary clinical management of the cerebral complications of preeclampsia

The neurological complications of preeclampsia and eclampsia are responsible for a major proportion of the morbidity and mortality arising from these conditions, for women and their infants alike. This paper outlines the evidence base for contemporary management principles pertaining to the neurological sequelae of preeclampsia, primarily from the maternal perspective, but with consideration of fetal and neonatal aspects as well. It concludes with a discussion regarding future directions in the management of this potentially lethal condition.

Prevention and management of severe pre-eclampsia/eclampsia in Afghanistan

Background

An evidence-based strategy exists to reduce maternal morbidity and mortality associated with severe pre-eclampsia/eclampsia (PE/E), but it may be difficult to implement in low-resource settings. This study examines whether facilities that provide emergency obstetric and newborn care (EmONC) in Afghanistan have the capacity to manage severe PE/E cases.

Methods

A further analysis was conducted of the 2009–10 Afghanistan EmONC Needs Assessment. Assessors observed equipment and supplies available, and services provided at 78 of the 127 facilities offering comprehensive EmONC services and interviewed 224 providers. The providers also completed a written case scenario on severe PE/E. Descriptive statistics were used to summarize facility and provider characteristics. Student t-test, one-way ANOVA, and chi-square tests were performed to determine whether there were significant differences between facility types, doctors and midwives, and trained and untrained providers.

Results

The median number of severe PE/E cases in the past year was just 5 (range 0–42) at comprehensive health centers (CHCs) and district hospitals, compared with 44 (range 0–130) at provincial hospitals and 108 (range 32–540) at regional and specialized hospitals (p < 0.001). Most facilities had the drugs and supplies needed to treat severe PE/E, including the preferred anticonvulsant, magnesium sulfate (MgSO₄). One-third of the smallest facilities and half of larger facilities reported administering a second-line drug, diazepam, in some cases. In the case scenario, 96% of doctors and 89% of midwives recognized that MgSO₄ should be used to manage severe PE/E, but 42% of doctors and 58% of midwives also thought diazepam had a role to play. Providers who were trained on the use of MgSO₄ scored significantly higher than untrained providers on six of 20 items in the case scenario. Providers at larger facilities significantly outscored those at smaller facilities on five items. There was a significant difference between doctors and midwives on only one item: continued use of anti-hypertensives after convulsions are controlled.

Conclusions

Drugs and supplies needed to treat severe PE/E are widely available at EmONC facilities in Afghanistan, but providers lack knowledge in some areas, especially concerning the use of MgSO₄ and diazepam. Providers who have specialized training or work at larger facilities are better at managing cases of severe PE/E. The findings suggest a need to clarify service delivery guidelines, offer refresher training, and reinforce best practices with supervision and reinforcement.

Magnesium sulphate versus phenytoin in eclampsia - Maternal and foetal outcome - A comparative study

BACKGROUND

Eclampsia manifests as seizures and is unique to the pregnant state. It remains an important cause of maternal mortality especially in resource-challenged countries that lack access to prenatal care.

AIMS

The aim of our study was to compare maternal and foetal outcomes in mothers with eclampsia with the administration of either magnesium sulphate or phenytoin in a resource- challenged situation.

METHOD

The work was conducted from January 2012 to December 2012. A total of 80 patients were assigned alternately to two groups - one group was treated with magnesium sulphate (Group-M; n=40), and the other treated with phenytoin (Group-P; n=40) (Figure 1). The magnesium sulphate was administered according to Pritchard's regimen; phenytoin administered according to Ryan's regimen. With either regimen, anticonvulsant therapy was continued for 24 hours postpartum or 24 hours after the last convulsion, whichever was later.

RESULTS

Fifty-four per cent of patients regained consciousness within eight hours of treatment onset in Group-P compared to 5.3 per cent in Group-M (p=0.0001, χ(2)=19.24). Seven patients in Group-P had recurrence of convulsions as compared to none of the 40 women assigned to Group-M (p=0.032, χ(2)=4.62). The incidence of Caesarean section was greater (62.5 per cent) in Group-M compared to Group-P (25 per cent; p=0.001, χ(2)= 9.96). No statistically significant differences were found in the foetal outcomes between the two groups.

CONCLUSION

Phenytoin use may be reconsidered in selective cases in low and middle income countries (LMIC) as it has been found simpler to use, has several benefits and also curtails treatment cost. Magnesium sulphate is substantially more effective than phenytoin with regard to recurrence of convulsions. Proper training in the management of eclampsia should be given to all health care workers to ensure appropriate management of eclamptic mothers. Thus, the treatment of this disease calls for more research especially in resource-challenged settings.