Eclampsia and Role of Magnesium Sulfate

SUMMARY:  

Eclampsia is a severe, life-threatening manifestation of preeclampsia.  While long-term neurologic damage is rare, there is risk of maternal hypoxia and death. Most women will experience signs such as headaches or visual changes prior to a seizure.

Eclampsia

• Defined as convulsions during pregnancy and/or postpartum
  • Tonic-clonic, focal, or multifocal
  • New onset
  • Unexplained by other neurologic pathology
• Consider other underlying cerebral conditions when
  • Seizures occur 2 to 3 days postpartum
  • Patient on magnesium sulfate

Note: Not all women will demonstrate classic features of preeclampsia (hypertension, proteinuria)

Magnesium Sulfate – Seizure Prophylaxis  

• Magnesium sulfate is the treatment of choice for seizure prophylaxis (ACOG recommended dosing) 
  • Loading dose of 4–6 g of magnesium sulfate administered per infusion pump over 20–30 minutes (i.e., slowly) followed by a maintenance dose of 1-2 g per hour as a continuous intravenous infusion  
  • Continue 24 hours postpartum
• Recurrent seizures
  • Additional dose of 2-4 g can be infused over 5 minutes
• Refractory seizures
  • Sodium amobarbital: 250 mg IV in 3 minutes
  • Thiopental or phenytoin: 1,250 mg IV at a rate of 50 mg/minute
  • Patient should be managed in ICU
  • Consider neuroimaging
• IM option
  • 10 g initially as a loading dose (5 g IM in each buttock) followed by 5 g every 4 hours
  • Use if IV access limited
  • Mix with 1 mL xylocaine 2% to alleviate pain

Note: Magnesium sulfate should not be considered an antihypertensive agent

Magnesium Sulfate – When to Use

• Severe features of preeclampsia 
  • Administer to all women 
• No severe features of preeclampsia and systolic BP > 140 and < 160 mm Hg or diastolic BP > 90 and < 110 mm Hg 
  • There is no consensus on this matter as prophylaxis will reduce eclampsia but 1 in 100 to 129 women need to be treated and side effects (although not life threatening) will increase
  • ACOG states that the decision to use magnesium sulfate when severe features are not present should be the decision of the “physician or institution, considering patient values or preferences, and the unique risk-benefit trade-off of each strategy” 

Delivery and Postpartum 

• Vaginal delivery
  • Continue infusion 24 hours postpartum
• Cesarean
  • Begin infusion (if not yet running) before surgery and continue 24 hours postpartum
  • Discontinuing prior to operative vaginal birth or cesarean section to avoid uterine atony or anesthetic drug interactions is not recommended

 Prevention of Magnesium Sulfate toxicity 

• Place Foley to monitor renal function (hourly output)  
• Confirm normal serum creatinine  
• Serial evaluation of patellar deep tendon reflexes 
• Monitor respiratory rate  
• Serum magnesium levels not routinely required
  • Monitor serum magnesium levels in setting of renal dysfunction and/or absence of patellar reflexes 
  • Maintain serum concentrations 5 to 9 mg/dL (4–7 mEq/L) range  
• Predictive symptoms of magnesium sulfate toxicity  
  • Loss of deep tendon reflexes >9 mg/dL (greater than 7 mEq/L)  
  • Respiratory depression >12 mg/dL (greater than 10 mEq/L) 
  • Cardiac arrest >30 mg/dL (greater than 25 mEq/L) 

Pending toxicity 

• Notify appropriate health care provider  
• Discontinue magnesium infusion  
• Administer supplemental oxygen  
• Obtain a serum magnesium level  
• Reverse magnesium 
  • 10 mL of 10% calcium gluconate IV (1 g total) and over 3 min (i.e., slowly) to avoid hypotension and/or bradycardia 
  • Calcium effect (competitively inhibits magnesium at neuromuscular junction) can wear off if magnesium level stays high 
  • Furosemide may help increase urinary excretion
• Respiratory arrest: Intubation and assisted ventilation as indicated

Other Prophylactic Agents

• Magnesium sulfate is superior to diazepam, phenytoin and lytic cocktail (chlorpromazine, promethazine, pethidine) in reducing significantly the risk of seizure recurrence  
  • Cochrane Review 2010: Magnesium sulfate reduced eclampsia compared to phenytoin (relative risk 0.08, 95% CI 0.01 to 0.60)   
• Morbidity related to pneumonia, mechanical ventilation and admission to an intensive care unit are significantly reduced with the use of magnesium sulfate compared with phenytoin  
• Magnesium sulfate does not cause maternal or newborn CNS depression 
  • Diazepam or lorazepam does stop or shorten seizures, but risk of maternal apnea and/or cardiac arrest
• Diazepam and phenytoin may be considered if
  • Patient on these medications to treat epilepsy
  • Magnesium sulfate is contraindicated
    • Myasthenia gravis | Hypocalcemia | Moderate-to-severe renal failure | Cardiac ischemia | Heart block | Myocarditis

Learn More – Primary Sources:

National Partnership for Maternal Safety: Consensus Bundle on Severe Hypertension During Pregnancy and the Postpartum Period 

ACOG Practice Bulletin 222: Gestational Hypertension and Preeclampsia

Management of pre-eclampsia: issues for anaesthetists 

Acute pulmonary oedema in pregnant women 

Cochrane Review: Magnesium sulphate and other anticonvulsants for women with pre-eclampsia 

Compliance Findings in Blood Pressure Treatment for Preeclampsia

PURPOSE:

Multiple guidelines have been released to decrease severe morbidity and mortality associated with preeclampsia but data remains limited as to impact of these recommendations on adverse events. This study by Shields et al. (AJOG, 2017) aimed to determine if standardized guideline-based protocols to treat severe hypertension/preeclampsia are associated with improved outcomes.

METHODS:

Multicentered, Prospective Quality Improvement Project. The standardized protocol included IV anti-hypertensive medication and magnesium sulfate when systolic BP ≥160 mm Hg and/or diastolic BP was ≥110 mm Hg. The study was designed to compare 6 months of data prior to establishing the standardized protocol to data collected in the year following implementation.

RESULTS:

During the study (including baseline and later data), there were 69,449 births, 2,034 of which had critically elevated blood pressure, preeclampsia, or superimposed preeclampsia. Compliance steadily increased over the year of the study interval.  Rates of eclampsia decreased by 42.6% (1.15 ± 0.15/1000 to 0.62 ± 0.09/1000 births) and severe maternal morbidity decreased by 16.7% (2.4 ± 0.10% to 2.0 ± 0.15%) with P < .01. The authors conclude that (1) preeclampsia guideline compliance outside of studies may be low; (2) compliance can be improved quickly; (3) standardization of protocols using professional guidelines can positively impact adverse outcomes in the setting of severe preeclampsia.

Learn More – Primary Sources:

Early standardized treatment of critical blood pressure elevations is associated with a reduction in eclampsia and severe maternal morbidity