Magnesium sulphate therapy in eclampsia: the Sokoto (ultra short) regimen

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.

Intravenous magnesium sulfate in the management of severe pre-eclampsia: A randomized study of 12-hour versus 24-hour maintenance dose

OBJECTIVE

To assess the effectiveness of a 12-hour versus 24-hour intravenous maintenance dose of magnesium sulfate (MgSO₄ ) in women with pre-eclampsia, and the maternal and fetal outcomes.

METHODS

This was a randomized controlled trial conducted at the labor ward complex of University College Hospital, Ibadan, Nigeria between May and August 2014. Pregnant women with severe pre-eclampsia were randomized to receive a 12-hour versus 24-hour maintenance dose of MgSO₄ . Study outcomes were occurrence of seizures, adverse maternal effects, neonatal survival, and admission to the intensive care unit. Data analysis involved descriptive statistics and bivariate analysis using Statistical Package for Social Science (SPSS) version 20.

RESULTS

There were 80 patients randomized to the 12-hour (n=40) and 24-hour (n=40) groups. The participants in the two groups had comparable demographic features. There was no significant difference (P>0.999) between the satisfactory maternal outcome following the 12-hour maintenance dose and the standard 24-hour regimen (95.0% vs 97.5%). Similarly, there was no significant difference (P=0.276) in perinatal mortality in the 12-hour versus 24-hour arm (17.5% vs 12.5%, respectively). No case of eclampsia and maternal death was recorded.

CONCLUSION

A 12-hour maintenance dose of intravenous MgSO₄ in the management of severe pre-eclampsia is effective and safe when compared with the 24-hour maintenance dose.

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).

Single Loading Low Dose MgSo4 Regimen: A Simple, Safe and Effective Alternative to Pritchard's Regimen for Indian Women

INTRODUCTION

Magnesium sulphate is the anticonvulsant of choice in prevention and control of eclamptic convulsions. Pritchard's regimen is the most popular time-tested regimen used. However, owing to concerns of toxicity, several low dose regimens have been introduced considering the lower body mass index of Asian women.

AIM

To compare the efficacy and safety of a single loading low dose MgSo₄ regimen with the Pritchard's regimen.

MATERIALS AND METHODS

Seventy cases of eclampsia and imminent eclampsia were allocated to the control and study groups each. The former received the Pritchard's regimen while the latter was treated with single loading low dose of magnesium sulphate. Recurrent convulsion rates, maternal and perinatal outcomes of both regimens were evaluated and compared using unpaired t-test and Chi-square test for continuous and categorical variables, respectively.

RESULTS

The mean serum magnesium levels were significantly lower in the study group at 30 minutes and 4 hours of initiation of therapy. The single loading low dose regimen was equally efficacious in prevention (96.6% vs 100%, p = 0.934) and control (97.6% vs 97.8%, p = 0.358) of eclamptic fits as compared to the Pritchard's regimen. The feto-maternal outcomes were also comparable.

CONCLUSION

The single loading low dose MgSo₄ regimen is an effective and safe alternative to the Pritchard's regimen, especially tailored to the small built Indian women.

Maternal Outcome with Discontinuation of Magnesium Sulfate immediately Postpartum in Severe Preeclampsia

Objective

To assess the effectiveness of discontinuation of magnesium sulfate (MgSO4) infusion in patients with severe preeclampsia immediately postdelivery.

Materials and methods

In a prospective-randomized study, women with severe preeclampsia attending the Jawaharlal Nehru Medical College, Aligarh, India, between January 2013 and September 2014 were enrolled. The inclusion criteria were blood pressure of at least 160/110 mm Hg after 24 weeks and either of the following: Proteinuria (dipstick value. 1), platelet <100,000, and serum transaminase levels twice as normal. Participants were assigned to control and study groups according to the time of enrollment (6-month blocks). All patients received MgSO4 loading dose (4 gm intravenously), followed by maintenance doses (1 gm/hour) until delivery (study group) and 24 hours (control group). The primary outcome was occurrence of convulsions after completion of MgSO4 therapy. Patients with treatment failure were excluded from analyses.

Results

Analyses included 48 patients in the study group and 43 patients in the control group. No convulsions occurred in either group after the completion of treatment. Conclusion: For women with severe preeclampsia, discontinuing MgSO4 immediately after delivery could effectively prevent convulsions.

How to cite this article

Anjum S, Gade PR, Garg N, Bano I, Alvi Y. Maternal Outcome with Discontinuation of Magnesium Sulfate immediately Postpartum in Severe Preeclampsia. J South Asian Feder Obst Gynae 2017;9(2):78-81.

Factors influencing the use of magnesium sulphate in pre-eclampsia/eclampsia management in health facilities in Northern Nigeria: a mixed methods study

BACKGROUND

Eclampsia remains a major cause of perinatal and maternal morbidity and mortality worldwide. We examined facilitators and barriers to the use of magnesium sulphate (MgSO4) in the management of pre-eclampsia/eclampsia (PE/E) in health facilities in Bauchi and Sokoto States in Nigeria.

METHODS

Data were collected from 80 health facilities using a cross-sectional, mixed method (quantitative and qualitative) design. We assessed health facility readiness to manage PE/E and use MgSO4 as the drug of choice, through provider interviews, in-depth interviews with facility managers and an inventory of equipment and supply in facilities. Bivariate and qualitative data analyses were performed to isolate the principal enabling factors and barriers to the management of PE/E and use of MgSO4.

RESULTS

The majority of health facility providers correctly mentioned MgSO4 as the drug of choice for the prevention and termination of convulsions in severe PE/E (65 %). Sixty-four percent of the health facilities had service registers available. About 45 % of providers had been trained on the use of MgSO4 for the management of PE/E. Regarding providers' practices, 45 % of respondents indicated that MgSO4 was used to prevent and treat convulsions in severe PE/E in their facilities. Barriers to management of PE/E included inadequate numbers of skilled providers, frequent shortages of MgSO4, lack of essential equipment and supplies, irregular supply of electricity and water, and non-availability of guidelines and clinical protocols at the health facilities. Technical support to providers was inadequate.

CONCLUSION

The study revealed that a constellation of factors adversely affect the management of PE/E and especially the use of MgSO4 by service providers. Efforts to improve the management of PE/E in facilities should include integrated programs that substantially improve provider and facility readiness to manage PE/E for better maternal and newborn health outcomes in Northern Nigeria.

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.

Training health workers for magnesium sulfate use reduces case fatality from eclampsia: results from a multicenter trial

OBJECTIVE

To investigate the effectiveness of an intervention aimed at improving the case management of eclampsia.

DESIGN

A multi-center intervention study.

SETTING

Six teaching hospitals in Nigeria.

SAMPLE

Clinical records of cases of eclampsia treated before and 1 year after the intervention.

METHODS

Doctors and midwives in selected hospitals were re-trained to manage eclampsia using magnesium sulfate according to the Pritchard protocol.

MAIN OUTCOME MEASURES

Eclampsia case fatality rates, maternal and perinatal mortality rates before and after the intervention.

RESULTS

A total of 219 cases of eclampsia were managed over a 12-month period. There were seven maternal deaths. The post intervention case fatality rate of 3.2% was significantly less than the pre-intervention rate of 15.1% (p < 0.001). The overall maternal and perinatal mortality ratios and rates respectively in the hospitals declined from 1199.2 to 954 per 100,000 deliveries and 141.5 to 129.8 per 1000 births, respectively (p > 0.05).

CONCLUSION

An intervention to build the capacity of care-providers to use an evidence-based protocol for the treatment of eclampsia in Nigeria was successful in reducing associated case fatality rate. The increased and widespread use of such an intervention in maternity units might contribute to the reduction of maternal mortality in low-income countries.

Predictors of extra care among magnesium sulphate treated eclamptic patients at Muhimbili National Hospital, Tanzania

BACKGROUND

The inclusion of Magnesium Sulphate (MgSO4) as a gold standard in the treatment of eclampsia has substantially reduced incidences of repeated fits, eclamptic morbidity and deaths. However, despite treatment with MgSO4, a proportion of patients need extra medical/nursing attention and prolonged stay in the intensive care unit (ICU). The literature on the underlying factors for the need of extra care in the MgSO4 era is lacking. This study sought to establish predictors of extra care in ICU among eclamptic patients after treatment with MgSO4 at Muhimbili National Hospital (MNH).

METHODS

Data were obtained from hospital records of eclamptic patients who were admitted at MNH and treated with MgSO4 from January 1st to December 31st, 2008. Based on set criteria, patients who needed extra care were identified. Analysis was performed using PASW statistics 18 whereby frequencies, cross-tabulations, bivariate and multiple logistic regressions were performed.

RESULTS

A total of 366 eclamptic patients were admitted and treated with MgSO4 at MNH during a 12 month study period in 2008. Most of these (76%) were referred from district hospitals and 132 (36%) met the criteria for extra care in ICU. After adjusting for other variables, the risk of extra care in ICU for patients who were admitted with altered consciousness was double (OR = 2.3; 95% CI: 1.3-4.0) that of the ones admitted in alert state. The risk or need of extra care increased by increasing time to delivery and was doubled (OR = 2.0; 95% CI:1.1-3.7) if it was between 12 and 24 hours and tenfold elevated (OR = 10.0; 95% CI:4.3-23.6) if beyond 24 hours as compared to when time to delivery was less than 12 hours.Abdominal delivery was also independently associated with increased risk compared to vaginal delivery (OR = 2.5; 95%CI: 1.4-4.5). The type of referral and number of fits were associated with extra care in ICU but this association was wholly explained by the clinical status of the patient on admission to MNH and prolonged time lag to delivery.

CONCLUSION

We concluded that even with MgSO4 used as the gold standard in the treatment of eclampsia, effective pre-referral care and expedited delivery were crucial in minimizing the need for extra care in ICU.