Individually determined postpartum magnesium sulfate therapy with clinical parameters to safely and cost-effectively shorten treatment for pre-eclampsia

Shortened postpartum magnesium sulfate treatment vs traditional 24h for severe preeclampsia: a systematic review and meta-analysis of randomized trials

Objectives: This meta-analysis aimed to compare the benefits and risks of shortened magnesium sulfate with traditional 24 h for severe postpartum preeclampsia.Methods: We systematically searched the Cochrane, Embase, Web of science and Pubmed database from inception till May 15 2019. Studies included type is limited to randomized controlled trial (RCT). Pooled risks difference (RDs), odds risks (ORs), mean difference (MD), standard mean difference (SMD) and 95% confifidence intervals (CIs) were used to summarize the effect sizes.Results: Totally studies included are 7 randomized controlled trials (RCTs). Shortened magnesium sulfate treatment has the same risk as eclampsia (RD 0.00, 95%CI-0.01-0.01) and total complications (OR 0.78, 95% CI 0.53-1.15), however, significant difference was observed in both groups pertaining to flushing (OR 0.40, 95% CI 0.20-0.82), and the need for prolonged treatment (RD 0.05, 95% CI 0.01 - 0.1), Others factors,namely the benefits of shortened magnesium sulfate treatment,showed differences in both groups.Conclusions: Shortened postpartum magnesium sulfate treatment was as effective as traditional 24 h magnesium sulfate in seizure prevention and total complications. But flushing and needed for prolonged treatment in the shortened groups warrants further research.

Ibuprofen and Postpartum Blood Pressure in Women With Hypertensive Disorders of Pregnancy: A Randomized Controlled Trial

OBJECTIVE

To evaluate the effect of ibuprofen on blood pressure in women with a diagnosis of hypertensive disorders of pregnancy and mild hypertension during the immediate postpartum period.

METHODS

In this double-blind controlled trial, we randomly assigned women with a diagnosis of hypertensive disorders of pregnancy and mild hypertension to receive a postpartum analgesic regimen with either ibuprofen or acetaminophen. The primary outcome was average mean arterial pressure during the postpartum hospital stay. Prespecified secondary outcomes included use of breakthrough opioid pain medications, length of hospital stay, and postpartum diuresis, defined as urine output of at least 200 mL/hour for 4 hours. A sample size of 56 participants was needed to detect a difference of 6 mm Hg in average mean arterial pressure between the study groups.

RESULTS

From January 17, 2017, to February 24, 2018, 61 participants were randomized and completed the trial, 31 participants in the ibuprofen group and 30 in the control group. Baseline characteristics were similar between groups. Postpartum average arterial pressure did not differ between study groups (93±8 mm Hg for those in the ibuprofen group vs 93±7 mm Hg in the control group, P=.93). Breakthrough opioid medications were requested by 24% of the participants in the ibuprofen group compared with 30% in the control group (P=.62). The ibuprofen group did not have a longer length of stay (48 hours vs 43 hours in the control group) or decreased rate of postpartum diuresis (61% in ibuprofen group vs 77% in the control group, P=.2).

CONCLUSION

In women with hypertensive disorders of pregnancy and mild hypertension, ibuprofen did not increase postpartum blood pressure compared with women not receiving nonsteroidal antiinflammatory drugs.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov NCT03011567.

Clinical and laboratory markers in the recovery from severe preeclampsia

OBJECTIVE

To examine the recovery from severe Preeclampsia toxemia (PET) in women treated with magnesium sulfate (MgSO₄) during the first 24h postpartum as reflected by the changes in various clinical and laboratory markers.

STUDY DESIGN

The study population included all women diagnosed with severe PET that gave birth at the Soroka University Medical center between 2013 and 2014, and were treated with MgSO₄ in the first 24h postpartum. Data were collected from the institutional computerized records. The different parameters were examined in 6h intervals and were compared using appropriate statistical tests.

MAIN OUTCOMES MEASURES

Change in various postpartum laboratory and clinical parameters.

RESULTS

During the study period there were 132 singleton deliveries with severe PET treated with a 24-hours postpartum MgSO₄ regimen. Most of the women were primigravida and delivered vaginally. Both mean systolic and mean diastolic blood pressure values have shown recovery to normal values after the first 6h of treatment (P<0.001). Urine output and proteinuria have demonstrated later recovery (after 12h).

CONCLUSIONS

When assessing the natural recovery of severe PET features, the earliest parameter to recover during the first 24h postpartum is hypertension followed by urine output and the proteinuria. Further larger studies are needed in order to confirm these results. Moreover, the use of these parameters may allow using shorter MgSO₄ treatment regimens for appropriate women showing earlier recovery and facilitating quicker mother-baby bonding and emotional recovery.

Factors influencing the postpartum length of hospital stay in eclamptic women

OBJECTIVE

To determine which variables are associated with postpartum length of hospital stay in eclamptic patients.

MATERIALS AND METHODS

The study sample comprised 98 eclamptic patients who were admitted to our perinatology unit during the period between January 1998 and May 2003. The study sample was divided into two postpartum length-of-stay groups: the short-stay group (1-3 days) consisted of 33 patients and the long-stay group (4 days and longer) consisted of 65 patients. The groups were compared with respect to the demographic characteristics, clinical and laboratory variables, and complications.

RESULTS

The mean hospitalization periods for the short-stay and long-stay groups were 2.48 +/- 0.79 and 5.60 +/- 2.12 days, respectively ( p = 0.010). The mean prepartum follow-up period after the onset of eclampsia was longer in the long-stay group than in the short-stay group (12.11 +/- 27.63 vs. 5.08 +/- 6.08 hours). The proportion of patients receiving magnesium sulfate therapy longer than 12 hours was higher in the long-stay group ( p = 0.014). The long-stay group had higher diastolic arterial blood pressure than that of the short-stay group ( p = 0.006). The total cesarean delivery rate for the short-stay group was 48.5%, compared with 67.7% in the long-stay group ( p = 0.081).

CONCLUSION

The duration of magnesium therapy, the timing, and the mode of delivery should be individualized to reduce the length of hospital stay in eclamptic patients.

Abbreviated Postpartum Magnesium Sulfate Therapy for Women With Mild Preeclampsia

OBJECTIVE

To determine whether women receiving 12-hour and 24-hour postpartum magnesium sulfate (MgSO4) therapy for mild preeclampsia have differing clinical courses.

METHODS

Consenting women with suspected mild preeclampsia were randomly assigned to 12 hours or 24 hours of MgSO4 postpartum therapy. Treatment was continued after the assigned time period if there was evidence of severe preeclampsia. The frequency of progression to severe disease and other outcomes were compared between study groups using the Fisher exact, chi2, and Student t tests where appropriate.

RESULTS

Between January 2001 and August 2004, 200 women were enrolled. The 12-hour and 24-hour groups were similar in age, parity, delivered gestational age, anesthesia, and mode of delivery, as well as for proteinuria and blood pressure. In the 12-hour group, MgSO4 treatment was extended in seven women (6.9%) for progression to severe disease versus one (1.1%) in the 24-hour group (P = .07). Women who developed severe disease had higher blood pressures at the first prenatal visit (140/78 versus 122/69, P < or = .02 for systolic and diastolic pressures), at the time of randomization (152/88 versus 135/78, P < or = .03 for systolic and diastolic pressures), and were more likely to have insulin-requiring diabetes (27.3% versus 4.4%, P = .03). No 12-hour patients required treatment beyond 24 hours postpartum. There were no seizures, MgSO4 toxicity, or intolerance in either group.

CONCLUSION

Twelve hours of postpartum MgSO4 therapy for mild preeclampsia is associated with infrequent disease progression and a clinical course similar to that with 24-hour therapy. Patients with chronic hypertension and insulin-requiring diabetes are at risk for progression to severe disease postpartum.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT00344058

LEVEL OF EVIDENCE

I.

A prospective randomized trial of magnesium sulfate in severe preeclampsia: use of diuresis as a clinical parameter to determine the duration of postpartum therapy

OBJECTIVE

The purpose of this study was to assess the use of the onset of diuresis in the determination of the duration of postpartum magnesium sulfate therapy among patients with severe preeclampsia.

STUDY DESIGN

A prospective randomized trial of postpartum therapy with magnesium sulfate was conducted. The control group received 24 hours of therapy, and the study group received therapy until the onset of diuresis (urine output >100 mL/hr for 2 consecutive hours). The Student t test, chi 2 test, and Fisher's exact test were used for analysis of data; a probability value of <.05 was considered statistically significant.

RESULTS

There were 50 patients in the control group and 48 patients in the study group. There was no difference in maternal demographic data, severe disease criteria, blood pressure, 24-hour postpartum urine output, or need for antihypertensive therapy. The study group had a significantly shorter duration of therapy, and no patient had eclampsia or required the re-initiation of therapy.

CONCLUSION

The use of the onset of diuresis in the postpartum period as the determinant clinical parameter for the discontinuation of magnesium sulfate in patients with severe preeclampsia was associated with no untoward outcomes or need for the re-initiation of treatment.

Postpartum Preeclampsia Management With Furosemide: A Randomized Clinical Trial

OBJECTIVE

This investigation was undertaken to estimate whether a brief postpartum course of furosemide for patients with preeclampsia benefits recovery and shortens hospitalization by enhancing diuresis, lessening severe hypertension, and reducing the need for antihypertensive therapy.

METHODS

Two hundred sixty-four patients with preeclampsia were enrolled. After spontaneous onset of postpartum diuresis and discontinuation of intravenous magnesium sulfate, patients were randomly assigned to receive either no therapy or 20 mg oral furosemide daily for 5 days with oral potassium supplementation. Patient outcomes were compared between treatment groups with regard to classification of hypertensive disease.

RESULTS

Only postpartum patients with severe preeclampsia (n = 70) who received furosemide compared with controls had significantly lower systolic blood pressure by postpartum day 2 (142 +/- 13 mm Hg compared with 153 +/- 19 mm Hg, P < .004) and required less antihypertensive therapy during hospitalization (14% compared with 26%, P = .371) and at discharge (6% compared with 26%, P = .045). No benefit was shown for patients with mild preeclampsia (n = 169) or superimposed preeclampsia (n = 25). Neither length of hospitalization nor frequency of delayed postpartum complications was positively affected by the intervention.

CONCLUSION

Brief postpartum furosemide therapy for patients with severe preeclampsia seems to enhance recovery by normalizing blood pressure more rapidly and reducing the need for antihypertensive therapy. Shortening of hospitalization and reduction of delayed postpartum complications were not benefitted.

Preeclampsia. Part 1: clinical and pathophysiologic considerations

Preeclampsia-eclampsia is still one of the leading causes of maternal and fetal morbidity and mortality. Despite active research for many years, the etiology of this disorder exclusive to human pregnancy is an enigma. Recent evidence suggests there may be several underlying causes or predispositions leading to the signs of hypertension, proteinuria, and edema, findings that allow us to make the diagnosis of the "syndrome" of preeclampsia. Despite improved prenatal care, severe preeclampsia and eclampsia still occur. Although understanding of the pathophysiology of these disorders has improved, treatment has not changed significantly in over 50 years. Although postponement of delivery in selected women with severe preeclampsia improves fetal outcome to a degree, this is not done without risk to the mother. In the United States, magnesium sulfate and hydralazine are the most commonly used medications for seizure prophylaxis and hypertension in the intrapartum period. The search for the underlying cause of this disorder and for a clinical marker to predict those women who will develop preeclampsia-eclampsia is ongoing, with its prevention the ultimate goal. This review begins with the clinical and pathophysiologic aspects of preeclampsia-eclampsia (Part 1). In Part 2, the experimental observations, the search for predictive factors, and the genetics of this disorder will be reviewed.

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.

Preeclampsia into eclampsia: toward a new paradigm

OBJECTIVE

This study was undertaken to characterize aspects of the natural history of eclampsia.

STUDY DESIGN

A retrospective analysis was performed on the records of patients with eclampsia who were delivered at two tertiary care hospitals.

RESULTS

Fifty-three pregnancies complicated by eclampsia were identified. Thirty-seven of the women were nulliparous. The mean age was 22 years (range, 15-38 years). Mean gestational age at the time of seizures was 34.2 weeks' gestation (range, 22-43 weeks' gestation). Twenty-eight women had antepartum seizures (53%); 23 of the 28 had seizures at home. Nineteen women had intrapartum seizures (36%). Eight of these women had seizures while receiving magnesium sulfate, and 7 had therapeutic magnesium levels. Six women had postpartum seizures (11%), 4 >24 hours after delivery. Headache preceded seizures in 34 cases. Visual disturbance preceded seizures in 16 cases. The uric acid level was elevated to >6 mg/dL in 43 women. There were no maternal deaths or permanent morbidities. There were 4 perinatal deaths. Two patients had intrauterine fetal deaths at 28 and 36 weeks' gestation. These mothers had seizures at home. One infant died of complications of prematurity at 22 weeks' gestation and one died of respiratory complications at 26 weeks' gestation. There were 4 cases of abruptio placentae, 1 of which resulted in fetal death. Of the 53 cases of eclampsia, only 9 were potentially preventable. One of these was that of a woman who was being observed at home. The other 8 women were hospitalized and had hypertension and proteinuria. Only 7 women could be considered to have severe preeclampsia before seizure (13%), and 4 of these 7 women were receiving magnesium sulfate.

CONCLUSIONS

Eclampsia was not found to be a progression from severe preeclampsia. In 32 of 53 cases (60%) seizures were the first signs of preeclampsia. In this series eclampsia appeared to be more of a subset of preeclampsia. Only 9 cases of eclampsia were potentially preventable with current standards of practice. Our paradigm for this disease, as well as our approach to seizure prophylaxis, should be reevaluated.