Clinical practice patterns on the use of magnesium sulphate for treatment of pre-eclampsia and eclampsia: a multi-country survey

Population pharmacokinetics and dose optimization of magnesium sulfate in Chinese preeclampsia population

OBJECTIVE

To establish the population pharmacokinetics (PPK) of magnesium sulfate (MgSO4)in women with preeclampsia (PE), and to determine the key covariates having an effect in magnesium pharmacokinetics in Chinese PE.

METHODS

Pregnant women with PE prescribed MgSO4 were enrolled in this prospective study from April 2021 to April 2023. On the initial day of administration, the patients were administered a loading dose of 5 g in conjunction with 10 g of magnesium sulfate as a maintenance dose. On the second day, only the maintenance dose was administration, and maternal blood samples were taken at 0, 4, 5, and 12 h after the second day's 10 g maintenance dose. The software Phoenix was used to estimate PPK parameters of MgSO4, such as clearance (CL) and volume of distribution (V), and to model PPK models with patient demographic, clinical, and laboratory covariates.

RESULTS

A total of 199 blood samples were collected from 51 women with PE and PPK profiles were analyzed. The PPK of MgSO4 is consistent with to a one-compartment model. The base model adequately described the maternal serum magnesium concentrations after magnesium administration. The population parameter estimates were as follows: CL was 2.98 L/h, V was 25.07 L. The model predictions changed significantly with covariates (BMI, creatinine clearance, and furosemide). Furosemide statistically influences V. The creatinine clearance, BMI and furosemide jointly affects CL. Monte Carlo simulation results showed that a loading dose combined with a maintenance dose would need to be administered daily to achieve the therapeutic blood magnesium concentrations. For the non-furosemide group, the optimal dosing regimen was a 5 g loading dose combined with a 10 g maintenance dose of MgSO4. For the furosemide group, the optimal dosing regimen was a 2.5 g loading dose combined with a 10 g maintenance dose of MgSO4.

CONCLUSIONS

The magnesium PPK model was successfully developed and evaluated in Chinese preeclampsia population, and the dose optimization of MgSO4 was completed through Monte Carlo simulation.

A Comprehensive Review of Magnesium Sulfate Infusion: Unveiling the Impact on Hemodynamic Stability During Laryngoscopy and Tracheal Intubation in Ear, Nose, and Throat Surgeries

This comprehensive review explores the potential of magnesium sulfate infusion in mitigating hemodynamic instability during laryngoscopy and tracheal intubation in ear, nose, and throat (ENT) surgeries. Hemodynamic fluctuations during these procedures pose challenges, and magnesium sulfate, with its vasodilatory, antiarrhythmic, and neuroprotective properties, emerges as a promising intervention. The review critically examines existing literature, emphasizing patient selection criteria, dosage protocols, and a comparative analysis with other hemodynamic stabilizers. Safety considerations, including known adverse effects and risk-benefit assessments, and monitoring and management strategies are elucidated. The implications for ENT surgery are discussed, highlighting the potential for enhanced hemodynamic management and individualized approaches. The review concludes with a call for continued research, emphasizing the ongoing evolution of understanding and practice incorporating magnesium sulfate into perioperative care. The insights offered aim to guide clinicians in navigating this dynamic landscape for improved patient outcomes in ENT surgeries.

Comparison of Zuspan regimen and its 12-hour modification in women with severe pre-eclampsia and eclampsia in two hospitals in Abeokuta

BACKGROUND

Hypertensive disorders in pregnancy (HDP) are leading causes of maternal mortality (with severe pre-eclampsia/eclampsia [SPE/EC] being causes of death). Magnesium sulphate (MgSO₄) has proven to be the drug of choice for SPE/EC management. However, its availability and cost remain a drawback to its use in developing countries. This study aimed to compare Zuspan regimen with its 12-hour modification for SPE/EC management in two major hospitals in Abeokuta, Ogun state, South Western Nigeria.

METHODS

A randomized controlled trial of non-inferior parallel design carried out at Federal Medical Centre and Sacred Heart Hospital, Abeokuta involving 148 consenting women who were randomized into two groups A and B. Both groups had 4 g loading dose of MgSO4, but the duration of maintenance was reduced to 12-hours in Group A (intervention) while Group B received the standard Zuspan regimen (control). Outcome measures were the occurrence/recurrence of convulsions (primary), maternal side effects and perinatal outcomes (secondary).

RESULTS

There was no statistically significant difference in the occurrence/recurrence of seizures between the two groups for both SPE/EC. No signs of maternal toxicity were observed in both arm of the study. There were no statistically significant differences in the perinatal/neonatal death and Apgar scores at 1 and 5 min. However, there was a significant increase in the number of days on admission in the control group of those neonates delivered to mothers with eclampsia.

CONCLUSION

A 12-hr modification of Zuspan regimen was found to be non-inferior to the standard Zuspan regimen in the management of SPE/EC.

A randomized controlled trial of loading dose alone versus pritchard regimen of magnesium sulphate, for seizure prophylaxis in severe preeclampsia

Background

Preeclampsia poses a significant risk of maternal and neonatal morbidity and mortality. Magnesium sulfate superiority for seizure prophylaxis in severe preeclampsia has been proven globally. However, the search for the lowest effective dose is an area of continuing research.

Aim

The aim of this study was to compare the effectiveness of loading dose with the Pritchard regimen of magnesium sulfate for seizure prophylaxis in severe preeclampsia.

Materials and Methods

A total of 138 eligible women after 28-week gestation with severe preeclampsia were randomized to either receiving a single loading dose of MgSO₄ (study arm: n = 69) or Pritchard regimen of MgSO₄ (control: n = 69). The effectiveness was assessed by the development of seizure. The results obtained were analyzed using SPSS version 21. Categorical variables were analyzed using the Chi-square test and normally distributed continuous variables were analyzed with t-test and Fisher's exact test. P < 0.05 was considered statistical significance.

Results

There were no significant differences between those who received only the loading dose when compared with those who had Pritchard regimen other than a single recorded convulsion among the control group (P = 0.316). Similarly, except for the duration of hospital stay which was significantly longer in the Pritchard group (P = 0.019), both the arms of the study shared similar maternal and fetal outcomes.

Conclusion

This study suggests the effectiveness of just the loading dose of magnesium sulfate when compared with the standardized Pritchard regimen in the prevention of seizure among women with severe preeclampsia. The study also demonstrated safety and similarity in fetal-maternal outcome. The loading dose only had an added advantage of shorter duration of hospital stay.

A novel 12-hour versus 24-hour magnesium sulfate regimen in the management of eclampsia and preeclampsia in Ghana (MOPEP Study): A randomized controlled trial

OBJECTIVE

We compared the efficacy of a 12-h versus 24-h regimen of intramuscular magnesium sulfate in the management of eclampsia and preeclampsia.

METHODS

This is an open-labeled parallel randomized controlled trial conducted in Accra, Ghana from November 2018 to November 2020. Participants were adult pregnant women admitted to the Korle Bu Teaching Hospital (KBTH) with a diagnosis of antepartum, intrapartum, or postpartum eclampsia or preeclampsia with severe features, having received no more than a loading dose of magnesium sulfate prior to admission at KBTH. Participants in the standard 24-h group received a loading dose of magnesium sulfate 4 g intravenous and 10 g intramuscular (5 g in each buttock) followed by six, 5 g intramuscular maintenance doses over 24 h. Participants in the 12-h intervention group received the same loading dose followed by three, 5 g intramuscular maintenance doses over 12 h. The primary outcome was occurrence of seizure after completion of the assigned magnesium sulfate regimen. Secondary outcomes were magnesium sulfate toxicity, magnesium sulfate side effects, maternal outcomes (mode of delivery, duration of inpatient admission, duration of urethral catheterization), maternal complications (pulmonary edema, acute kidney injury, intensive care unit admission, death), and neonatal outcomes.

RESULTS

Among 1176 total participants, we found no difference in occurrence of seizure after completion of the assigned regimen in the 24-h group (n = 5, 0.9%) versus the 12-h group (n = 2, 0.3%), P = 0.29; RR 0.40, 95% CI 0.08, 2.04), or in occurrence of seizure any time after enrollment (n = 9, 1.5% vs. n = 5, 0.9%, P = 0.28, RR 0.55, 95% CI 0.19-1.64). Participants in the 12-h group had a shorter duration of inpatient admission (9.4 ± 8.8 vs. 7.7 ± 6.5 days, P = 0.0009) and urethral catheterization (2.1 ± 1.0 vs. 1.9 ± 1.3 days, P < 0.0001). Rates of side effects from magnesium sulfate were lower in the 12-h group: pain at the injection site (94.8% (n = 548) vs. 91.5% (n = 540), P = 0.03), inflammation (62.2% (n = 358) vs. 40.0% (n = 237), P < 0.0001), and bleeding or bruising at the injection site (25.1% (n = 144) vs. 14.4% (n = 85), P < 0.0001).

CONCLUSIONS

Compared with 24 h, 12 h of intramuscular magnesium sulfate showed similar rates of seizures, with fewer side effects and shorter inpatient admission.

TRIAL REGISTRATION

Prospective registration was with Pan African Clinical Trial Registry (PACTR201811515303983): https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=4690.

Factors affecting use of magnesium sulphate for pre-eclampsia or eclampsia: a qualitative evidence synthesis

Background

Hypertensive disorders account for 14% of global maternal deaths. Magnesium sulphate (MgSO₄) is recommended for prevention and treatment of pre‐eclampsia/eclampsia. However, MgSO₄ remains underused, particularly in low‐ and middle‐income countries (LMICs).

Objective

This qualitative evidence synthesis explores perceptions and experiences of healthcare providers, administrators and policy‐makers regarding factors affecting use of MgSO₄ to prevent or treat pre‐eclampsia/eclampsia.

Search strategy

We searched MEDLINE, EMBASE, Emcare, CINAHL, Global Health and Global Index Medicus, and grey literature for studies published between January 1995 and June 2021.

Selection criteria

Primary qualitative and mixed‐methods studies on factors affecting use of MgSO₄ in healthcare settings, from the perspectives of healthcare providers, administrators and policy‐makers, were eligible for inclusion.

Data collection and analysis

We applied a thematic synthesis approach to analysis, using COM‐B behaviour change theory to map factors affecting appropriate use of MgSO₄.

Main results

We included 22 studies, predominantly from LMICs. Key themes included provider competence and confidence administering MgSO₄ (attitudes and beliefs, complexities of administering, knowledge and experience), capability of health systems to ensure MgSO₄ availability at point of use (availability, resourcing and pathways to care) and knowledge translation (dissemination of research and recommendations). Within each COM‐B domain, we mapped facilitators and barriers to physical and psychological capability, physical and social opportunity, and how the interplay between these domains influences motivation.

Conclusions

These findings can inform policy and guideline development and improve implementation of MgSO₄ in clinical care. Such action is needed to ensure this life‐saving treatment is widely available and appropriately used.

Tweetable abstract

Global qualitative review identifies factors affecting underutilisation of MgSO₄ for pre‐eclampsia and eclampsia.

Global qualitative review identifies factors affecting underutilisation of MgSO₄ for pre‐eclampsia and eclampsia.

This article includes Author Insights, a video abstract available at https://vimeo.com/manage/videos/623192027

Linked article This article is commented on by LA Magee, p. 392 in this issue. To view this mini commentary visit https://doi.org/10.1111/1471-0528.16971.

Detection of Unknown Pregnancy With Complications Using Point-of-Care Ultrasound

Eclampsia, a condition diagnosed in pre-eclamptic patients who experience seizures, can lead to maternal and fetal death if not treated early. The present case discusses the clinical management of an 18-year-old female who presented to the emergency department (ED) after a generalized tonic-clonic seizure. A physical examination revealed that she was also hypertensive. Based on these symptoms which required urgency due to the patient’s instability, and the suspicion that the patient could be pregnant, point-of-care ultrasound (POCUS) was performed. In this case, a POCUS was a faster more accessible modality than a urine or serum human chorionic gonadotropin test. Although the patient denied that she was pregnant, POCUS identified that she was approximately 22-24 weeks pregnant. The patient was promptly diagnosed with eclampsia and given medication to control her blood pressure and seizures. This case highlights the benefits of using POCUS in the ED to expedite clinical decisions by identifying the etiology of a patient’s condition and lends itself to the discussion of its utility in a critically ill pregnant woman. It also serves to reinforce the importance of keeping eclampsia as part of an emergency physician’s differential when confronted with a potentially pregnant patient with relevant symptoms.

Adverse pregnancy outcomes among mothers with hypertensive disorders in pregnancy: A meta-analysis of cohort studies

BACKGROUND

Presently, the results of studies assessing the association of hypertensive disorders in pregnancy (HDP) with adverse pregnancy outcomes (APOs) in offspring remain inconclusive, and a complete overview is missing. We performed a meta-analysis of cohort studies to review and summarize the association between HDP and risk of APOs in offspring.

METHODS

PubMed, Embase, Web of Science and Chinese databases were searched through May 2019 to identify eligible studies. Outcomes of interest were APOs including perinatal death, fetal death, stillbirth, neonatal death, congenital malformations, preterm birth (PTB), very preterm birth (VPTB), intrauterine growth restriction (IUGR), small for gestational age (SGA), low birth weight (LBW), and very low birth weight (VLBW). Either a fixed- or a random-effects model was used to calculate the overall combined risk estimates. Subgroup analysis was performed to explore potential heterogeneity moderators.

RESULTS

Total 152 cohort studies involving 1,426,742 mothers with HDP and 36,374,542 mothers without HDP were included for analysis. Overall, mothers with HDP compared with those without HDP had a significantly higher risk of perinatal death (OR = 2.86), fetal death (OR = 2.82), stillbirth (OR = 1.93), neonatal death (OR = 1.55), congenital malformations (OR = 2.66), IUGR (OR = 5.48), SGA (OR = 3.39), LBW (OR = 5.02), VLBW (OR = 1.74), PTB (OR = 4.20) and VPTB (OR = 3.26) in offspring. Relevant heterogeneity moderators were identified by subgroup analyses. The sensitivity analysis yielded consistent results. No evidence of publication bias was observed.

CONCLUSION

The present study indicates that HDP significantly increases risk of APOs. Further research is needed to explore efficient management methods to minimize the risk of APOs associated with HDP.

Alternate Dosing Protocol for Magnesium Sulfate in Obese Women With Preeclampsia: A Randomized Controlled Trial

OBJECTIVE

To evaluate whether obese women need greater doses of magnesium sulfate to obtain therapeutic serum concentrations for eclamptic seizure prevention.

METHODS

Women with preeclampsia and a body mass index (BMI) of 35 or higher were randomly allocated to either the Zuspan regimen of magnesium sulfate (4-g intravenous [IV] loading dose, then a 1-g/h infusion) or to alternate dosing (6-g IV loading dose, then a 2-g/h infusion). Women had serum magnesium concentrations obtained at baseline, as well as after administration of magnesium sulfate at 1 hour, 4 hours, and delivery. The primary outcome was the proportion of women who had subtherapeutic serum magnesium concentrations (less than 4.8 mg/dL) 4 hours after administration. A sample size of 18 women per group was planned to compare the proportion of women with subtherapeutic serum magnesium concentrations in each group.

RESULTS

From July 12, 2016, to March 14, 2019, 89 women with preeclampsia were screened and 37 were enrolled: 18 to the Zuspan regimen and 19 to the alternate regimen. A significantly greater proportion of women administered the Zuspan regimen had subtherapeutic serum magnesium concentrations at 4 hours (100% [95% CI 59-100] vs 63% [95% CI 41-81]; P=.01) compared with women administered the alternate higher dose regimen. At 4 hours, mean concentrations were significantly higher in the alternate regimen group (3.53 mg/dL±0.3 [Zuspan regimen] vs 4.41±0.5 [alternate regimen]; P<.01).

CONCLUSION

The alternate dosing regimen of a 6-g IV loading dose followed by a 2-g/h IV maintenance dose more reliably achieves therapeutic serum magnesium concentrations (as defined by a concentration of at least 4.8 mg/dL) in obese women with preeclampsia.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT02835339.

Population Pharmacokinetics of Magnesium Sulfate in Preeclampsia and Associated Factors

Background and Objective

The pharmacokinetic basis of magnesium sulphate (MgSO₄) dosing regimens for preeclampsia (PE) prophylaxis and treatment is not clearly established. The aim of study is to develop a population pharmacokinetic (PK) model of MgSO₄ in PE, and to determine key covariates having an effect in MgSO₄ pharmacokinetics in preeclampsia (PE) and to determine key covariates having an effect in MgSO₄ PK.

Methods

A prospective cohort study was conducted from June 2016 to February 2018 in patients with PE administered MgSO₄ as a 4-g bolus followed by continuous infusion at a rate of 1 g/h. Serum magnesium concentrations were obtained before treatment administration and 2, 6, 12, and 18 h after the initial dose. The software Monolix was used to estimate population PK parameters of MgSO₄ [clearance (CL), volume of distribution (V), half-life] and to develop a PK model with baseline patient demographic, clinical, and laboratory covariates.

Results

The study population consisted of 109 patients. The PK profile of MgSO₄ was adequately described by a one-compartment PK model. The model estimate of the population CL was 1.38 L/h; for V, it was 13.3 L; and the baseline magnesium concentration was 0.77 mmol/L (1.87 mg/dL). The baseline body weight and serum creatinine statistically influenced MgSO₄ CL and V, respectively. The model was parameterized as CL and V.

Conclusion

The PK of MgSO₄ in pregnant women with PE is significantly affected by creatinine and body weight. Pregnant women with PE and higher body weight have a higher V and, consequently, a lower elimination rate of MgSO₄. Pregnant women with PE and a higher serum creatinine value show lower CL and, therefore, lower MgSO₄ elimination rate.

Risk factors and comorbidities associated with magnesium deficiency in pregnant women and women with hormone-related conditions: analysis of a large real-world dataset

BACKGROUND

An accumulating body of literature indicates that magnesium deficiency is associated with a number of hormone-related conditions (HRC) in women, and epidemiological studies are needed to assess its prevalence and risk factors. Here, we present a secondary analysis of data pooled from four large observational studies that assessed magnesium deficiency among pregnant women and women with HRC across the Russian Federation.

METHODS

The main objective of this analysis was to estimate the prevalence of magnesium deficiency in this population and to describe risk factors and comorbidities associated with low serum magnesium. Univariate logistic regression analysis was performed to identify the risk factors and comorbid conditions associated with an increased risk of low serum magnesium level.

RESULTS

A total of 983 pregnant women and 9444 women with HRC were eligible for analysis. Prevalence of hypomagnesemia (magnesium serum level cut-off < 0.66 mmol/L/< 0.8 mmol/L) was 34.0%/78.9% in pregnant women and 21.4%/54.8% in women with HRC. The highest prevalence of magnesium deficiency was observed for osteoporosis and climacteric syndrome. Risk factors included diastolic blood pressure, previous pregnancy complications, infections and edema for pregnant women, and age, body mass index, and various comorbidities for women with HRC.

CONCLUSIONS

These results confirm the high prevalence of hypomagnesemia in pregnant women and women with HRC and underline the importance of routine screening, since risk factors are mostly non-specific.

Comparative risks and predictors of preeclamptic pregnancy in the Eastern, Western and developing world

Preeclampsia (PE) is a complication of pregnancy characterized by hypertension (HTN-Preg), and often proteinuria. If not managed promptly, PE could lead to eclampsia and seizures. PE could also lead to intrauterine growth restriction (IUGR) and prematurity at birth. Although PE is a major cause of maternal and fetal morbidity and mortality, the underlying mechanisms are unclear. Also, there is a wide variability in the incidence of PE, ranging between 2 and 8% of pregnancies in the Eastern, Western and Developing world, suggesting regional differences in the risk factors and predictors of the pregnancy-related disorder. Several demographic, genetic, dietary and environmental factors, as well as maternal circulating biomarkers have been associated with PE. Demographic factors such as maternal race and ethnicity could play a role in PE. Specific genetic polymorphisms have been identified in PE. Maternal age, parity, education and socioeconomic status could be involved in PE. Dietary fat, protein, calcium and vitamins, body weight, and environmental factors including climate changes and air pollutants could also play a role in PE. Several circulating cytoactive factors including anti-angiogenic factors and cytokines have also been associated with PE. Traditional midwifery care is a common practice in local maternity care units, while advanced perinatal care and new diagnostic tools such as uterine artery Doppler velocimetry have been useful in predicting early PE in major medical centers. These PE risk factors, early predictors and diagnostic tools vary vastly in different regions of the Eastern, Western and Developing world. Further understanding of the differences in the demographic, genetic, dietary and environmental factors among pregnant women in different world regions should help in designing a region-specific cluster of risk factors and predictors of PE, and in turn provide better guidance for region-specific tools for early detection and management of PE.

Health facility readiness and provider knowledge as correlates of adequate diagnosis and management of pre-eclampsia in Kinshasa, Democratic Republic of Congo

BACKGROUND

Hypertensive disorders in pregnancy are the second most common cause of maternal mortality in the Democratic Republic of Congo (DRC), accounting for 23% of maternal deaths. This study aimed to assess facility readiness, and providers' knowledge to prevent, diagnose, and treat pre-eclampsia.

METHODS

A facility-based cross-sectional study was conducted in 30 primary health centres (PHCs) and 28 referral facilities (hospitals) randomly selected in Kinshasa, DRC. In each facility, all midwives and physicians involved in maternal care provision (n = 197) were included. Data on facility infrastructure and providers' knowledge about pre-eclampsia were collected using facility checklists and a knowledge questionnaire. Facility readiness score was defined as the sum of 13 health commodities needed to manage pre-eclampsia. A knowledge score was defined as the sum of 24 items about the diagnosis, management, and prevention of pre-eclampsia. The score ranges from 0 to 24, with higher values reflecting a better knowledge. The Mann-Witney U test was used to compare median readiness scores by facility type and ownership; and median knowledge scores between midwives in hospitals and in PHCs, and between physicians in hospitals and in PHCs.

RESULTS

Overall, health facilities had 7 of the 13 commodities, yielding a median readiness score of 53.8%(IQR: 46.2 to 69.2%). Although all provider groups had significant knowledge gaps about pre-eclampsia, providers in hospitals demonstrated slightly more knowledge than those in PHCs. Midwives in public facilities scored higher than those in private facilities (median(IQR): 8(5 to 12) vs 7(4 to 8), p = 0.03). Of the 197 providers, 91.4% correctly diagnosed severe pre-eclampsia. However, 43.9 and 82.2% would administer magnesium sulfate and anti-hypertensive drugs to manage severe pre-eclampsia, respectively. Merely 14.2 and 7.1% of providers were aware of prophylactic use of aspirin and calcium to prevent pre-eclampsia, respectively.

CONCLUSION

Our study showed poor availability of supplies to diagnose, prevent and treat pre-eclampsia in Kinshasa. While providers demonstrated good knowledge regarding the diagnosis of pre-eclampsia, they have poor knowledge regarding its prevention and management. The study highlights the need for strengthening knowledge of providers toward the prevention and management of pre-eclampsia, and enhancing the availability of supplies needed to address this disease.

Pharmacokinetics of magnesium and its effects on clinical variables following experimentally induced hypermagnesemia

The objectives of this study were to describe pharmacokinetic and pharmacodynamic changes as a result of a single intravenous administration of magnesium sulfate (MgSO₄ ) to healthy horses. MgSO₄ is a magnesium salt that has been used to calm horses in equestrian competition and is difficult to regulate because magnesium is an essential constituent of all mammals. Six healthy adult female horses were administered a single intravenous dose of MgSO₄ at 60 mg/kg of body weight over 5 min. Blood, urine, and cerebrospinal fluid (CSF) samples were collected, and cardiovascular parameters were monitored and echocardiograms performed at predetermined times. Noncompartmental pharmacokinetic analysis was applied to plasma concentrations of ionized magnesium (Mg²⁺ ). Objective data were analyzed using the Wilcoxon rank-sum test with p < .05 used as a determination for significance. Plasma concentrations of Mg²⁺ increased nearly fivefold, ionized calcium (Ca²⁺ ) decreased by nearly 10%, and the Ca²⁺ to Mg²⁺ ratio declined more than 3.5-fold and remained different than baseline until 24 hr (p < .05). Significant changes were seen with urinary fractional excretion of electrolytes, cardiovascular parameters, and echocardiographic measurements. No changes were detected in CSF electrolyte concentrations. The decrease in Ca²⁺ result of hypermagnesemia supports the interaction between these cations. Alterations detected in plasma electrolyte concentrations and urinary fractional excretion of electrolytes may serve as biomarkers for regulatory control for the nefarious administration of MgSO₄ .

Perception of Midwives Towards Magnesium Sulfate Use at Chatinkha Maternity Wing in Blantyre, Malawi: A Qualitative Study

Introduction

Globally, magnesium sulfate (MgSO₄) has been recognized as the drug of choice for preventing and controlling fits among women with severe pre-eclampsia and eclampsia, respectively. Improper use of magnesium sulfate has been reported globally. Therefore, actionable findings for improving magnesium sulfate use are needed. This study aims at understanding the views of midwives towards MgSO₄ use to inform an intervention whose objective is to improve MgSO₄ use among the midwives.

Methods

An exploratory qualitative study was conducted from July to September 2018. We conducted 10 in-depth interviews and a focus group discussion with midwives. All the interviews were audio taped and transcribed verbatim. Data were managed by NVivo version 10.0 and analyzed thematically.

Results

We identified one overarching theme: “Inadequate governing approaches on management of clients on MgSO₄” with corresponding subthemes; in adequate preparation on magnesium sulfate administration; inconsistent formula, regimen and guidelines/protocols on magnesium sulfate use and lack of resources.

Conclusion

Midwives perceived MgSO₄ use as a demanding activity due to inadequate training, inconsistent tools, and lack of resources. While periodic in-service training should be intensified to improve MgSO₄ use, necessary resources should be provided, such as blood pressure machines, more midwives, and protocols.

Assessing multidimensional care coverage for pre-eclampsia in the era of universal health coverage: A pre-post evaluation of the Salud Mesoamérica Initiative

Objective

To compare a multidimensional care package for pre‐eclampsia/eclampsia in Central American health facilities, before and after implementation of the Salud Mesoamérica Initiative.

Methods

An evaluation study was conducted at 67 basic‐ and comprehensive‐level health facilities serving the poorest areas in Honduras, Nicaragua, and Belize. Cases of severe pre‐eclampsia or eclampsia were randomly sampled and relevant quality of care data extracted from medical records at baseline (n=111) from January 1, 2011, to March 31, 2013, and at second‐phase follow‐up (n=249) from June 1, 2015, to September 30, 2017. The primary outcome was evidence of the delivery of multidimensional care for the management of pre‐eclampsia/eclampsia.

Results

The care of 360 women with severe pre‐eclampsia or eclampsia was analyzed. Odds of multidimensional care for pre‐eclampsia management (P=0.271) increased (although not significantly) in the second‐phase follow‐up compared to baseline. Multidimensional care was significantly associated with training (P<0.001), basic‐level facilities (P<0.001), and higher in Honduras (P=0.001) and Belize (P=0.024) than the reference country of Nicaragua.

Conclusion

Multidimensional care for pre‐eclampsia management increased across all facility types, countries, and severity of disease. The Salud Mesoamérica Initiative is a promising model for achieving such quality of care interventions in the era of universal health coverage.

Multidimensional care for pre‐eclampsia management increased across all facility types, participating countries, and severity of disease under the Salud Mesoamérica Initiative model in Central America.

Open-labelled randomised controlled trial of 12 hours versus 24 hours modified Pritchard regimen in the management of eclampsia and pre-eclampsia in Ghana (MOPEP Study): study protocol

INTRODUCTION

Hypertensive disorders of pregnancy continue to be a major contributor to maternal and perinatal morbidity and mortality. Magnesium sulfate therapy is the standard of care for seizure prophylaxis and treatment for pre-eclampsia and eclampsia respectively, despite wide disparities in dosing regimens and routes of administration. This study compares the clinical efficacy of magnesium sulfate in the reduction of seizure occurrence or recurrence with the 12 hours versus 24 hours modified Pritchard regimens in the management of severe pre-eclampsia and eclampsia.

METHODS AND ANALYSIS

This study is an open labelled randomised controlled trial. The study participants are patients admitted to the Korle Bu Teaching Hospital (KBTH) in Accra, Ghana with a diagnosis of antepartum, intrapartum or postpartum eclampsia or pre-eclampsia with severe features. All study participants will be administered a loading dose of magnesium sulfate, followed by maintenance dosing. Participants in the control group will receive magnesium sulfate for 24 hours after diagnosis, while those in the treatment group will receive magnesium sulfate for 12 hours after diagnosis. The primary outcome of this study is the occurrence of a seizure any time after the completion of treatment in the assigned group. Secondary outcome measures include maternal health outcomes, magnesium sulfate toxicities and fetal health outcomes. Data collection was started in October 2018 with a target enrolment of 1245 participants with severe pre-eclampsia and 844 participants with eclampsia with a projected study period of 2-3 years.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the KBTH Institutional Review Board (IRB) in Ghana. University of Michigan involvement is limited to protocol development and statistical analysis of de-identified data, and has been granted a Not Regulated Determination by the University of Michigan IRB. Results of the study will be shared at clinical forums at the KBTH and will be submitted for publication in an international peer-reviewed journal.

TRIAL REGISTRATION NUMBER

Pan African Clinical Trial Registry through the South African Medical Research Council (PACTR201811515303983).

Significance of pre-hospital care to reduce the morbidity of eclampsia in rural Zambia

OBJECTIVES

Preeclampsia (PE) is the 2nd leading cause of maternal mortality in developing countries. Maternal deaths caused by PE mainly result from eclampsia. The aim of this study was to survey the current status of PE at a local hospital in Zambia and identify preventive measures against eclampsia.

STUDY DESIGN

The obstetric data of normal pregnant women and patients complicated with gestational hypertension (GH), PE, and eclampsia in 2017 at Zimba Mission Hospital, Zambia were collected from admission and delivery registries and analyzed.

MAIN OUTCOME MEASURES

The mode of delivery, maternal and perinatal mortality.

RESULTS

Among 1704 deliveries, 42 women (2.5%) were complicated with hypertensive disorders of pregnancy (HDP) (GH: 17, PE: 25). There were 2 stillbirths and 1 neonatal death in PE. Magnesium sulfate (MgSO₄) was administered to severe PE patients (11 cases) based on the Pritchard regimen for a resource poor setting. No eclampsia happened after starting MgSO₄. All eclampsia (8 cases) happened out of hospital at the gestational age of 35-40 weeks. All the eclamptic patients were primigravidae aged 15-23 years old. MgSO₄ injection was started on admission. Cesarean section was performed in 7 cases. All the patients of PE including eclampsia were discharged without any sequelae.

CONCLUSION

The Pritchard regimen is considered to be suitable in the setting. However, the morbidity of eclampsia was high out of hospital. We have to educate pregnant women about the risks of PE and encourage the measurement of blood pressure at health facilities.

Alternative Magnesium Sulfate Dosing Regimens for Women With Preeclampsia: A Population Pharmacokinetic Exposure-Response Modeling and Simulation Study

Magnesium sulfate is the anticonvulsant of choice for eclampsia prophylaxis and treatment; however, the recommended dosing regimens are costly and cumbersome and can be administered only by skilled health professionals. The objectives of this study were to develop a robust exposure‐response model for the relationship between serum magnesium exposure and eclampsia using data from large studies of women with preeclampsia who received magnesium sulfate, and to predict eclampsia probabilities for standard and alternative (shorter treatment duration and/or fewer intramuscular injections) regimens. Exposure‐response modeling and simulation were applied to existing data. A total of 10 280 women with preeclampsia who received magnesium sulfate or placebo were evaluated. An existing population pharmacokinetic model was used to estimate individual serum magnesium exposure. Logistic regression was applied to quantify the serum magnesium area under the curve‐eclampsia rate relationship. Our exposure‐response model‐estimated eclampsia rates were comparable to observed rates. Several alternative regimens predicted magnesium peak concentration < 3.5 mmol/L (empiric safety threshold) and eclampsia rate ≤ 0.7% (observed response threshold), including 4 g intravenously plus 10 g intramuscularly followed by either 8 g intramuscularly every 6 hours × 3 doses or 10 g intramuscularly every 8 hours × 2 doses and 10 g intramuscularly every 8 hours × 3 doses. Several alternative magnesium sulfate regimens with comparable model‐predicted efficacy and safety were identified that merit evaluation in confirmatory clinical trials.

Population Pharmacokinetic Modeling to Evaluate Standard Magnesium Sulfate Treatments and Alternative Dosing Regimens for Women With Preeclampsia

Magnesium sulfate is the standard therapy for prevention and treatment of eclampsia. Two standard dosing regimens require either continuous intravenous infusion or frequent, large-volume intramuscular injections, which may preclude patients from receiving optimal care. This project sought to identify alternative, potentially more convenient, but similarly effective dosing regimens that could be used in restrictive clinical settings. A 2-compartment population pharmacokinetic (PK) model was developed to characterize serial PK data from 92 pregnant women with preeclampsia who received magnesium sulfate. Body weight and serum creatinine concentration had a significant impact on magnesium PK. The final PK model was used to simulate magnesium concentration profiles for the 2 standard regimens and several simplified alternative dosing regimens. The simulations suggest that intravenous regimens with loading doses of 8 g over 60 minutes followed by 2 g/h for 10 hours and 12 g over 120 minutes followed by 2 g/h for 8 hours (same total dose as the standard intravenous regimen but shorter treatment duration) would result in magnesium concentrations below the toxic range. For the intramuscular regimens, higher maintenance doses given less frequently (4 g intravenously + 10-g intramuscular loading doses with maintenance doses of 8 g every 6 hours or 10 g every 8 hours for 24 hours) or removal of the intravenous loading dose (eg, 10 g intramusculary every 8 hours for 24 hours) may be reasonable alternatives. In addition, individualized dose adjustments based on body weight and serum creatinine were proposed for the standard regimens.

A retrospective review of on-admission factors on attainment of therapeutic serum concentrations of magnesium sulfate in women treated for a diagnosis of preeclampsia

Introduction: There is little information on the effect of maternal characteristics and on-admission laboratory parameters to the therapeutic serum magnesium sulfate (MgSO₄) levels in women with preeclampsia (PE). We sought to identify factors that may predict timely attainment of therapeutic serum magnesium levels after intravenous administration for seizure prophylaxis.Materials and methods: On-admission factors of 360 women with PE who received intravenous MgSO₄ (4-g loading and 2-g/h maintenance) for seizure prophylaxis were retrospectively reviewed. Parameters of those who attained therapeutic serum concentrations (4.8-8.4 mg/dL) within 2 h (Group A) and those who did not (Group B) were compared.Results: There was no seizure or magnesium toxicity in this cohort. Median (min-max) level of serum magnesium was 4.3 (2.5-8.4) mg/dL. Women in Group A (n = 105) had lower gestational age, body mass index (BMI), and platelets count, higher blood urea nitrogen (BUN), serum creatinine, uric acid, direct bilirubin, aspartate aminotransferase, alanine aminotransferase, lactate dehydrogenase, prothrombin, and partial thromboplastin times than those in Group B (n = 255) (p < .05). Women with mild PE were less likely to attain therapeutic serum magnesium levels compared with those with severe phenotypes (adjusted OR 23.57, 95% CI 8.20-67.76 versus adjusted OR 14.72, 95% CI 3.56-60.89, respectively; p < .05), which may be explained by their significantly lower serum BUN and uric acid (p < .05).Conclusions: On-admission factors, especially BMI and renal clearance indices, of women with PE may affect timely attainment of therapeutic serum magnesium levels. Validation of its clinical impact requires further study focusing on women with severe PE.

Availability and use of magnesium sulphate at health care facilities in two selected districts of North Karnataka, India

BACKGROUND

Pre-eclampsia and eclampsia are major causes of maternal morbidity and mortality. Magnesium sulphate is accepted as the anticonvulsant of choice in these conditions and is present on the WHO essential medicines list and the Indian National List of Essential Medicines, 2015. Despite this, magnesium sulphate is not widely used in India for pre-eclampsia and eclampsia. In addition to other factors, lack of availability may be a reason for sub-optimal usage. This study was undertaken to assess the availability and use of magnesium sulphate at public and private health care facilities in two districts of North Karnataka, India.

METHODS

A facility assessment survey was undertaken as part of the Community Level Interventions for Pre-eclampsia (CLIP) Feasibility Study which was undertaken prior to the CLIP Trials (NCT01911494). This study was undertaken in 12 areas of Belagavi and Bagalkote districts of North Karnataka, India and included a survey of 88 facilities. Data were collected in all facilities by interviewing the health care providers and analysed using Excel.

RESULTS

Of the 88 facilities, 28 were public, and 60 were private. In the public facilities, magnesium sulphate was available in six out of 10 Primary Health Centres (60%), in all eight taluka (sub-district) hospitals (100%), five of eight community health centres (63%) and both district hospitals (100%). Fifty-five of 60 private facilities (92%) reported availability of magnesium sulphate. Stock outs were reported in six facilities in the preceding six months - five public and one private. Twenty-five percent weight/volume and 50% weight/volume concentration formulations were available variably across the public and private facilities. Sixty-eight facilities (77%) used the drug for severe pre-eclampsia and 12 facilities (13.6%) did not use the drug even for eclampsia. Varied dosing schedules were reported from facility to facility.

CONCLUSIONS

Poor availability of magnesium sulphate was identified in many facilities, and stock outs in some. Individual differences in usage were identified. Ensuring a reliable supply of magnesium sulphate, standard formulations and recommendations of dosage schedules and training may help improve use; and decrease morbidity and mortality due to pre-eclampsia/ eclampsia.

TRIAL REGISTRATION

The CLIP trial was registered with ClinicalTrials.gov ( NCT01911494 ).

Neonatal Effects of Maternal Magnesium Sulphate in Late Preterm and Term Pregnancies

Aim

To compare the clinical, obstetric and neonatal parameters between patients with > 34-week gestation having severe preeclampsia receiving magnesium sulphate and those with > 34-week gestation with preeclampsia but not receiving magnesium sulphate.

Materials and Methods

Single-centre prospective study studied 60 patients in each of the two groups. Magnesium sulphate was administered by Pritchard regimen as per standard protocol. Standard obstetric management was followed for both groups. In the severe preeclampsia/eclampsia group, maternal blood sample was analysed for serum magnesium levels. The duration of exposure, the amount of magnesium sulphate received and time elapsed between last dose of magnesium sulphate and delivery were all noted. Neonatal assessment was done. The various parameters including age, parity, blood pressure, mode of termination of pregnancy, NICU admission rate, incidence of hypotonia in the newborn and other neonatal parameters were tabulated and compared.

Results

The two groups were comparable with respect to age and parity. Need for induction of labour was higher in the group with severe preeclampsia/eclampsia. Rate of LSCS and birth weights were comparable between the two groups. NICU admission rate and incidence of hypotonia were higher in those who received magnesium sulphate. Amount of magnesium sulphate received and total duration of magnesium sulphate did not correlate with NICU admission rates.

Conclusions

Neonatal morbidity, in terms of higher NICU admission rates and hypotonia, is higher in patients receiving magnesium sulphate.

The comparison of anti-seizure and tocolytic effects of phenytoin and magnesium sulphate in the treatment of eclampsia and preeclampsia: A randomised clinical trial

Background: To date, magnesium sulphate (MgSO₄) is the treatment of choice for prevention of seizure in eclampsia and preeclampsia. However, there are some limitations in the administration of MgSO₄ due to its tocolytic effects. The aim of this study was to compare the anticonvulsant and tocolytic effects of MgSO₄ and another drug, phenytoin, in patients with eclampsia and preeclampsia. Methods: This clinical trial was conducted on pregnant women hospitalised with eclampsia or preeclampsia, during 2014-2016. The subjects were randomly assigned to two treatment groups using blocking method based on disease (eclampsia or mild and severe preeclampsia). One group received MgSO₄ (group M) and another group received phenytoin (group P) as treatment. Each group consisted of 110 and 65 women with mild and severe preeclampsia, respectively (subgroup A), and 25 women with eclampsia (subgroup B). Duration of labor, the number of cesarean sections, convulsions and Apgar scores of infants were compared between the two groups and were considered as treatment outcomes. Results: Convulsion rate was significantly lower with MgSO₄ than phenytoin (P = 0.001). No seizure occurred in patients with mild preeclampsia in group P. Duration of stage one of labor (P < 0.001) and the number of cesarean sections (P = 0.040) were significantly higher in group M. However, one-minute Apgar scores for newborns were higher in women treated with MgSO₄ compared to that of phenytoin (P = 0.001). Five-minute Apgar was not significantly different. Conclusion: Although MgSO₄ is more effective than phenytoin for prevention of convulsion in eclampsia and severe preeclampsia, phenytoin may be considered for treatment of special conditions such as mild preeclampsia. Due to the tocolytic effects of MgSO₄ on increasing the duration of labor, the increased risk of cesarean section and the potential for toxicity, physicians should critically consider the best drug according to the condition of the patient.

Obstetrician's risk perception on the prescription of magnesium sulfate in severe preeclampsia and eclampsia: A qualitative study in Brazil

Introduction

Magnesium sulfate (MgSO₄) is the drug of choice for the prevention and control of seizures in the management of severe preeclampsia/eclampsia. Several barriers have been identified in the use of MgSO₄, especially in low and middle-income settings.

Objective

To describe the obstetrician’s perception on possible reasons for underutilizing magnesium sulfate to treat preeclampsia/eclampsia.

Method

A qualitative clinical study, based on phenomenological reference by semi-structured interviews and open-ended discussions with obstetricians of the public healthcare system in primary care units (PCU) and referral maternity hospitals (RMH), in a southeastern Brazilian city.

Results

Fear of drug toxicity was the major cause for not prescribing the medication in PCU. Fear was justified by insufficient technical, structural and organizational resources of healthcare facilities and by a shortage of physicians properly trained for adequate drug use.

Conclusion

Fear of toxicity of magnesium sulfate was the main barrier towards timely and proper drug use. Periodic skill development and training of obstetricians, along with integration of the medical team in the work environment may contribute to decrease fear, ensuring safety of drug prescription and thus possibly reducing adverse outcomes related to PE.

Clinical practice patterns on the use of magnesium sulphate for treatment of pre-eclampsia and eclampsia: a multi-country survey

Objective

To characterise the current clinical practice patterns regarding the use of magnesium sulphate (MgSO₄) for eclampsia prevention and treatment in a multi‐country network of health facilities and compare with international recommendations.

Design

Cross‐sectional survey.

Setting

A total of 147 health facilities in 15 countries across Africa, Latin America and Asia.

Population

Heads of obstetric departments or maternity units.

Methods

Anonymous online and paper‐based survey conducted in 2015.

Main outcome measures

Availability and use of MgSO₄; availability of a formal clinical protocol for MgSO₄ administration; and MgSO₄ dosing regimens for eclampsia prevention and treatment.

Results

Magnesium sulphate and a formal protocol for its administration were reported to be always available in 87.4% and 86.4% of all facilities, respectively. MgSO₄ was used for the treatment of mild pre‐eclampsia, severe pre‐eclampsia and eclampsia in 24.3%, 93.5% and 96.4% of all facilities, respectively. Regarding the treatment of severe pre‐eclampsia, 26.4% and 7.0% of all facilities reported using dosing regimens that were consistent with Zuspan and Pritchard regimens, respectively. Across regions, intramuscular maintenance regimens were more commonly used in the African region (45.7%) than in the Latin American (3.0%) and Asian (22.9%) regions, whereas intravenous maintenance regimens were more often used in the Latin American (94.0%) and Asian (60.0%) regions than in the African region (21.7%). Similar patterns were found for the treatment of eclampsia across regions.

Conclusions

The reported clinical use of MgSO₄ for eclampsia prevention and treatment varied widely, and was largely inconsistent with current international recommendations.

Tweetable abstract

MgSO₄ regimens for eclampsia prevention and treatment in many hospitals are inconsistent with international recommendations.

MgSO₄ regimens for eclampsia prevention and treatment in many hospitals are inconsistent with international recommendations.