Prophylactic magnesium sulphate in prevention of eclampsia in women with severe preeclampsia: randomised controlled trial (PIPES trial)

Alternative magnesium sulphate regimens for women with pre-eclampsia and eclampsia

BACKGROUND

Magnesium sulphate is the drug of choice for the prevention and treatment of women with eclampsia. Regimens for administration of this drug have evolved over the years, but there is no clarity on the comparative benefits or harm of alternative regimens. This is an update of a review first published in 2010.

OBJECTIVES

To assess if one magnesium sulphate regimen is better than another when used for the care of women with pre-eclampsia or eclampsia, or both, to reduce the risk of severe morbidity and mortality for the woman and her baby.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (29 April 2022), and reference lists of retrieved studies.

SELECTION CRITERIA

We included randomised trials and cluster-randomised trials comparing different regimens for administration of magnesium sulphate used in women with pre-eclampsia or eclampsia, or both. Comparisons included different dose regimens, intramuscular versus intravenous route for maintenance therapy, and different durations of therapy. We excluded studies with quasi-random or cross-over designs. We included abstracts of conference proceedings if compliant with the trustworthiness assessment.

DATA COLLECTION AND ANALYSIS

For this update, two review authors assessed trials for inclusion, performed risk of bias assessment, and extracted data. We checked data for accuracy. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

For this update, a total of 16 trials (3020 women) met our inclusion criteria: four trials (409 women) compared regimens for women with eclampsia, and 12 trials (2611 women) compared regimens for women with pre-eclampsia. Most of the included trials had small sample sizes and were conducted in low- and middle-income countries. Eleven trials reported adequate randomisation and allocation concealment. Blinding of participants and clinicians was not possible in most trials. The included studies were for the most part at low risk of attrition and reporting bias. Treatment of women with eclampsia (four comparisons) One trial compared a loading dose-alone regimen with a loading dose plus maintenance dose regimen (80 women). It is uncertain whether either regimen has an effect on the risk of recurrence of convulsions or maternal death (very low-certainty evidence). One trial compared a lower-dose regimen with standard-dose regimen over 24 hours (72 women). It is uncertain whether either regimen has an effect on the risk of recurrence of convulsion, severe morbidity, perinatal death, or maternal death (very low-certainty evidence). One trial (137 women) compared intravenous (IV) versus standard intramuscular (IM) maintenance regimen. It is uncertain whether either route has an effect on recurrence of convulsions, death of the baby before discharge (stillbirth and neonatal death), or maternal death (very low-certainty evidence). One trial (120 women) compared a short maintenance regimen with a standard (24 hours after birth) maintenance regimen. It is uncertain whether the duration of the maintenance regimen has an effect on recurrence of convulsions, severe morbidity, or side effects such as nausea and respiratory failure. A short maintenance regimen may reduce the risk of flushing when compared to a standard 24 hours maintenance regimen (risk ratio (RR) 0.27, 95% confidence interval (CI) 0.08 to 0.93; 1 trial, 120 women; low-certainty evidence). Many of our prespecified critical outcomes were not reported in the included trials. Prevention of eclampsia for women with pre-eclampsia (five comparisons) Two trials (462 women) compared loading dose alone with loading dose plus maintenance therapy. Low-certainty evidence suggests an uncertain effect with either regimen on the risk of eclampsia (RR 2.00, 95% CI 0.61 to 6.54; 2 trials, 462 women) or perinatal death (RR 0.50, 95% CI 0.19 to 1.36; 2 trials, 462 women). One small trial (17 women) compared an IV versus IM maintenance regimen for 24 hours. It is uncertain whether IV or IM maintenance regimen has an effect on eclampsia or stillbirth (very low-certainty evidence). Four trials (1713 women) compared short postpartum maintenance regimens with continuing for 24 hours after birth. Low-certainty evidence suggests there may be a wide range of benefit or harm between groups regarding eclampsia (RR 1.99, 95% CI 0.18 to 21.87; 4 trials, 1713 women). Low-certainty evidence suggests there may be little or no effect on severe morbidity (RR 0.96, 95% CI 0.71 to 1.29; 2 trials, 1233 women) or side effects such as respiratory depression (RR 0.80, 95% CI 0.25 to 2.61; 2 trials, 1424 women). Three trials (185 women) compared a higher-dose maintenance regimen versus a lower-dose maintenance regimen. It is uncertain whether either regimen has an effect on eclampsia (very low-certainty evidence). Low-certainty evidence suggests that a higher-dose maintenance regimen has little or no effect on side effects when compared to a lower-dose regimen (RR 0.79, 95% CI 0.61 to 1.01; 1 trial 62 women). One trial (200 women) compared a maintenance regimen by continuous infusion versus a serial IV bolus regimen. It is uncertain whether the duration of the maintenance regimen has an effect on eclampsia, side effects, perinatal death, maternal death, or other neonatal morbidity (very low-certainty evidence). Many of our prespecified critical outcomes were not reported in the included trials.

AUTHORS' CONCLUSIONS

Despite the number of trials evaluating various magnesium sulphate regimens for eclampsia prophylaxis and treatment, there is still no compelling evidence that one particular regimen is more effective than another. Well-designed randomised controlled trials are needed to answer this question.

Eclampsia in the 21st century

The reported incidence of eclampsia is 1.6 to 10 per 10,000 deliveries in developed countries, whereas it is 50 to 151 per 10,000 deliveries in developing countries. In addition, low-resource countries have substantially higher rates of maternal and perinatal mortalities and morbidities. This disparity in incidence and pregnancy outcomes may be related to universal access to prenatal care, early detection of preeclampsia, timely delivery, and availability of healthcare resources in developed countries compared to developing countries. Because of its infrequency in developed countries, many obstetrical providers and maternity units have minimal to no experience in the acute management of eclampsia and its complications. Therefore, clear protocols for prevention of eclampsia in those with severe preeclampsia and acute treatment of eclamptic seizures at all levels of healthcare are required for better maternal and neonatal outcomes. Eclamptic seizure will occur in 2% of women with preeclampsia with severe features who are not receiving magnesium sulfate and in <0.6% in those receiving magnesium sulfate. The pathogenesis of an eclamptic seizure is not well understood; however, the blood-brain barrier disruption with the passage of fluid, ions, and plasma protein into the brain parenchyma remains the leading theory. New data suggest that blood-brain barrier permeability may increase by circulating factors found in preeclamptic women plasma, such as vascular endothelial growth factor and placental growth factor. The management of an eclamptic seizure will include supportive care to prevent serious maternal injury, magnesium sulfate for prevention of recurrent seizures, and promoting delivery. Although routine imagining following an eclamptic seizure is not recommended, the classic finding is referred to as the posterior reversible encephalopathy syndrome. Most patients with posterior reversible encephalopathy syndrome will show complete resolution of the imaging finding within 1 to 2 weeks, but routine imaging follow-up is unnecessary unless there are findings of intracranial hemorrhage, infraction, or ongoing neurologic deficit. Eclampsia is associated with increased risk of maternal mortality and morbidity, such as placental abruption, disseminated intravascular coagulation, pulmonary edema, aspiration pneumonia, cardiopulmonary arrest, and acute renal failure. Furthermore, a history of eclamptic seizures may be related to long-term cardiovascular risk and cognitive difficulties related to memory and concentration years after the index pregnancy. Finally, limited data suggest that placental growth factor levels in women with preeclampsia are superior to clinical markers in prediction of adverse pregnancy outcomes. This data may be extrapolated to the prediction of eclampsia in future studies. This summary of available evidence provides data and expert opinion on possible pathogenesis of eclampsia, imaging findings, differential diagnosis, and stepwise approach regarding the management of eclampsia before delivery and after delivery as well as current recommendations for the prevention of eclamptic seizures in women with preeclampsia.

Serum Biomarkers of Maternal Morbidity and Adverse Outcome in Severe Pre-Eclampsia

OBJECTIVE

To evaluate the association of maternal serum biomarkers of myocardial damage, oxidative stress and angiogenic imbalance with maternal adverse outcomes in women with severe pre-eclampsia.

METHODS

This was a prospective cohort study, where maternal serum biomarkers were evaluated in women admitted with severe pre-eclampsia to a tertiary care centre between March 2019 and February 2020. Serum markers included brain naturetic peptide (BNP), cardiac troponin-T (cTnT), cystatin-C (cys-C), soluble fms-like tyrosine kinase-1 (sFlt-1), placental growth factor (PlGF), Total Anti-Oxidant status (TAO) and malondialdehyde (MAO). Main outcome measures were adverse maternal outcomes defined as eclampsia, pulmonary oedema, acute kidney injury, placental abruption and HELLP syndrome.

RESULTS

Adverse maternal outcomes occurred in 93(37.2%, 95% CI: 31.2%-43.6%) of the 250 women with severe pre-eclampsia included in the study, including 21 with pulmonary oedema, 25 with acute kidney injury and 36 with eclampsia. BNP levels were higher among women who developed pulmonary oedema (55.4 pg/mL vs 42.0 pg/mL, p = 0.008). TAO levels were higher in women who developed eclampsia (4.6 mM, IQR 3.1-5.7, p < 0.001) and acute kidney injury (4.1 mM, IQR 3.2-6.3, p = 0.002) compared to those who did not develop any complications (2.93 mM, IQR 2.3-4.1).

CONCLUSIONS

Even though the endothelial dysfunction and oxidative stress biomarkers were associated with development of preeclampsia, it may have limited utility in identifying women who might develop adverse outcomes.

Efficacy of Magnesium Sulfate on Maternal Mortality in Eclampsia

Eclampsia is a common complication of preeclampsia patients and can be life-threatening for both the mother and the fetus. Hence, timely intervention and appropriate management of this detrimental condition are extremely crucial. Eclampsia is described as the occurrence of generalized convulsions in patients with preeclampsia. Magnesium sulfate (MgSO₄) is the drug of choice for treating and preventing eclampsia. This review aims to study and analyze the available literature on the pathogenesis of eclampsia, the pharmacology of MgSO₄, and its effectiveness in the management of eclampsia. Other proposed treatments and their comparative study with MgSO₄ are also discussed. Additionally, we examine the data regarding the impact of eclampsia, its public health burden, and the cost-effectiveness of MgSO₄. One of the major drawbacks associated with the use of MgSO₄ in low-income countries has been the cost of treatment and the lack of resources. We have analyzed the trials that have proposed alternate treatment regimens which could shape new guidelines to resolve these issues. For this review, we extensively studied abstract and full-text articles from multiple databases. This article discusses the pathophysiology of eclampsia, the pharmacology of MgSO₄, the issues surrounding eclampsia management, and how MgSO₄ benefits these patients.

Generating evidence on screening, diagnosis and management of non-communicable diseases during pregnancy; a scoping review of current gap and practice in India with a comparison of Asian context

Background

Children born to high-risk pregnancies are more likely to experience adverse health outcomes later in life. As estimated, 15% of all pregnancies are at risk of various life-threatening conditions leading to adverse maternal and foetal outcomes. Millennium Development Goal resulted in the global reduction of maternal death from 390,000 to 275000 in 1990–2015). Similarly, to keep this momentum, the current United Nations Sustainable Development Goal (SDG: 3.1) aims at reducing the global maternal mortality ratio to less than 70 per 100,000 live births by 2030, and this can be achieved by addressing high-risk pregnancy contributing to significant mortality and morbidity. In India, gestational diabetes, gestational hypertension, and gestational hypothyroidism were identified as factors contributing to the high-risk pregnancy. This review summarises the commonly used approach for screening, diagnosis, and management of these conditions in the Asian population. It draws a comparison with the current protocols and guidelines in the Indian setting.

Methods

Electronic search in PubMed and Google Scholar, reference snowballing, and review of current guidelines and protocols were done between January 2010 to October 2019. Published studies reporting Screening, diagnosis, and management of these conditions were included. Articles selected were then screened, appraised for quality, extract relevant data, and synthesised.

Results

Screening, diagnosis, and management of these three conditions vary and no single universally accepted criteria for diagnosis and management exist to date. In India, national guidelines available have not been evaluated for feasibility of implementation at the community level. There are no national guidelines for PIH diagnosis and management despite the increasing burden and contribution to maternal and perinatal morbidity and mortality. Criteria for diagnosis and management of gestational diabetes, gestational hypertension, and gestational hypothyroidism varies but overall early screening for predicting risk, as reported from majority of the articles, were effective in minimizing maternal and foetal outcome.

Conclusion

Existing National guidelines for Screening, Diagnosis, and Management of Gestational Diabetes Mellitus (2018) and Gestational Hypothyroidism (2014) need to be contextualized and modified based on the need of the local population for effective treatment. Findings from this review show that early screening for predicting risk to be an effective preventive strategy. However, reports related to a definitive diagnosis and medical management were heterogeneous.

Neuroprotective magnesium sulfate administration increases maternal Neutrophil-to-Lymphocyte Ratio, Platelet-to-Lymphocyte Ratio and Systemic Immune-Inflammation Index

PURPOSE

We aimed to analyze the linear changes of Neutrophil-to-Lymphocyte Ratio (NLR), Platelet-to-Lymphocyte Ratio (PLR) and Systemic Immune-Inflammation Index (SII) levels in pregnant women who administrated magnesium sulfate for fetal neuroprotection.

METHODS

This retrospective study included 63 pregnant women who underwent neuroprotective magnesium sulfate administration during January 2015 and July 2020. Women with co-existing diseases or obstetric complications such as preeclampsia, gestational diabetes mellitus, suspicion of chorioamnionitis etc. excluded. The laboratory test results were obtained for each participant. Three results were compared; (1) Before magnesium sulfate-0th hour, (2) 6 h and (3) 12 h after starting loading dose.

RESULTS

The mean NLR was 7.18 ± 5.14 in patients before treatment. The mean NLR increased to 10.09 ± 4.77 and 10.04 ± 4.35 at 6th and 12th hour of magnesium sulfate treatment. The mean PLR was also increased after starting neuroprotective magnesium sulfate (170.35 ± 89.09 at the beginning; 209.85 ± 88.77 at 6th hour and 209.24 ± 76.66 at 12th hour). The mean SII was found to be increased from 1783.33 ± 1367.29 to 2517.15 ± 1325.77 with magnesium sulfate treatment. However, no statistically significant difference was observed in terms of SII between 6 and 12th hours of treatment (p = 0.752). Maternal serum magnesium levels at 6th and 12th hour were found to be not correlated with NLR, PLR and SII.

CONCLUSION

We demonstrated that values of NLR, PLR and SII at 6th hour were all increased after starting magnesium sulfate. Levels of these systemic inflammatory indices were similar at 6th and 12th hour of therapy.

Antenatal magnesium sulphate and adverse neonatal outcomes: A systematic review and meta-analysis

BACKGROUND

There is widespread, increasing use of magnesium sulphate in obstetric practice for pre-eclampsia, eclampsia, and preterm fetal neuroprotection; benefit for preventing preterm labour and birth (tocolysis) is unproven. We conducted a systematic review and meta-analysis to assess whether antenatal magnesium sulphate is associated with unintended adverse neonatal outcomes.

METHODS AND FINDINGS

CINAHL, Cochrane Library, LILACS, MEDLINE, Embase, TOXLINE, and Web of Science, were searched (inceptions to 3 September 2019). Randomised, quasi-randomised, and non-randomised trials, cohort and case-control studies, and case reports assessing antenatal magnesium sulphate for pre-eclampsia, eclampsia, fetal neuroprotection, or tocolysis, compared with placebo/no treatment or a different magnesium sulphate regimen, were included. The primary outcome was perinatal death. Secondary outcomes included pre-specified and non-pre-specified adverse neonatal outcomes. Two reviewers screened 5,890 articles, extracted data, and assessed risk of bias following Cochrane Handbook and RTI Item Bank guidance. For randomised trials, pooled risk ratios (RRs) or mean differences, with 95% confidence intervals (CIs), were calculated using fixed- or random-effects meta-analysis. Non-randomised data were tabulated and narratively summarised. We included 197 studies (40 randomised trials, 138 non-randomised studies, and 19 case reports), of mixed quality. The 40 trials (randomising 19,265 women and their babies) were conducted from 1987 to 2018 across high- (16 trials) and low/middle-income countries (23 trials) (1 mixed). Indications included pre-eclampsia/eclampsia (24 trials), fetal neuroprotection (7 trials), and tocolysis (9 trials); 18 trials compared magnesium sulphate with placebo/no treatment, and 22 compared different regimens. For perinatal death, no clear difference in randomised trials was observed between magnesium sulphate and placebo/no treatment (RR 1.01; 95% CI 0.92 to 1.10; 8 trials, 13,654 babies), nor between regimens. Eleven of 138 non-randomised studies reported on perinatal death. Only 1 cohort (127 babies; moderate to high risk of bias) observed an increased risk of perinatal death with >48 versus ≤48 grams magnesium sulphate exposure for tocolysis. No clear secondary adverse neonatal outcomes were observed in randomised trials, and a very limited number of possible adverse outcomes warranting further consideration were identified in non-randomised studies. Where non-randomised studies observed possible harms, often no or few confounders were controlled for (moderate to high risk of bias), samples were small (200 babies or fewer), and/or results were from subgroup analyses. Limitations include missing data for important outcomes across most studies, heterogeneity of included studies, and inclusion of published data only.

CONCLUSIONS

Our findings do not support clear associations between antenatal magnesium sulphate for beneficial indications and adverse neonatal outcomes. Further large, high-quality studies (prospective cohorts or individual participant data meta-analyses) assessing specific outcomes, or the impact of regimen, pregnancy, or birth characteristics on these outcomes, would further inform safety recommendations. PROSPERO: CRD42013004451.

Long-term impact of intrauterine neuroinflammation and treatment with magnesium sulphate and betamethasone: Sex-specific differences in a preterm labor murine model

Preterm infants are at significantly increased risk for lifelong neurodevelopmental disability with male offspring disproportionately affected. Corticosteroids (such as betamethasone) and magnesium sulphate (MgSO₄) are administered to women in preterm labor to reduce neurologic morbidity. Despite widespread use of MgSO₄ in clinical practice, its effects on adult offspring are not well known nor have sex-specific differences in therapeutic response been explored. The objective of our study was to examine the long-term effects of perinatal neuroinflammation and the effectiveness of prenatal MgSO₄/betamethasone treatments between males and females in a murine model via histologic and expression analyses. Our results demonstrate that male but not female offspring exposed to intrauterine inflammation demonstrated impaired performance in neurodevelopmental testing in early life assessed via negative geotaxis, while those exposed to injury plus treatment fared better. Histologic analysis of adult male brains identified a significant reduction in hippocampal neural density in the injured group compared to controls. Evaluation of key neural markers via qRT-PCR demonstrated more profound differences in gene expression in adult males exposed to injury and treatment compared to female offspring, which largely showed resistance to injury. Prenatal treatment with MgSO₄/betamethasone confers long-term benefits beyond cerebral palsy prevention with sex-specific differences in response.