Alternative regimens of magnesium sulfate for treatment of preeclampsia and eclampsia: a systematic review of non‐randomized studies

Abstract

Introduction The optimal dosing regimen of magnesium sulfate for treating preeclampsia and eclampsia is unclear. Evidence from the Cochrane review of randomized controlled trials (RCTs) was inconclusive due to lack of relevant data. Material and methods To complement the evidence from the Cochrane review, we assessed available data from non‐randomized studies on the comparative efficacy and safety of alternative magnesium sulfate regimens for the management of preeclampsia and eclampsia. Sources included Medline, EMBASE, Popline, CINAHL, Global Health Library, African Index Medicus, Biological abstract, BIOSIS and reference lists of eligible studies. We selected non‐randomized study designs including quasi‐RCTs, cohort, case‐control and cross‐sectional studies that compared magnesium sulfate regimens in women with preeclampsia or eclampsia. Results Of 6178 citations identified, 248 were reviewed in full text and five studies of low to very low quality were included. Compared with standard regimens, lower‐dose regimens appeared equally as good in terms of preventing seizures [odds ratio (OR) 1.02, 95% confidence interval (CI) 0.46–2.28, 899 women, four studies], maternal morbidity (OR 0.47, 95%CI 0.32–0.71, 796 women, three studies), and fetal and/or neonatal mortality (OR 0.87, 95%CI 0.38–2.00, 800 women, four studies). Comparison of loading dose only with maintenance dose regimens showed no differences in seizure rates (OR 0.99, 95%CI 0.22–4.50, 146 women, two studies), maternal morbidity (OR 0.53, 95%CI 0.15–1.93, 146 women, two studies), maternal mortality (OR 0.63, 95%CI 0.05–7.50, 146 women, two studies), and fetal and/or neonatal mortality (OR 0.49, 95%CI 0.23–1.03, 146 women, two studies). Conclusion Lower‐dose and loading dose‐only regimens could be as safe and efficacious as standard regimens; however, this evidence comes from low to very low quality studies and further high quality studies are needed.

Immunology of hepatic diseases during pregnancy

“…MgSO 4 treatment was shown to be highly effective, enabling a prolonged pregnancy and the prevention of platelet count decrease. Nevertheless there is still some debate on the dosage [125,126]. Oral calcium supplementation to reduce the risk of PE has been currently reviewed and found to be beneficial [127].…”

Author's reply re: Should we implement universal screening with late pregnancy ultrasound to prevent stillbirth?

“…No magnesium sulphate regimen -not even the 'gold standard' (Pritchard or Zuspan regimen) -has been subjected to 'standard exposureresponse pharmacological studies.' 4 Therefore, the lowest effective dose for magnesium sulphate is still unknown. 3 Variation of regimen worldwide should be viewed as an opportunity to resynthesize the knowledge base so that a more rational use of magnesium sulphate can be recommended.…”

“…Although this is partially based on a view that these measurements are more likely to characterise accurately the underlying pathological processes, I also feel that it might be less difficult to generate standardised clinical screening tools using ultrasonic and biochemical measurements than using measurements based on clinical examination. & [2][3][4] Despite the availability of international guidelines, concerns for magnesium sulphate toxicity, narrow therapeutic range, complexities of regimen, arbitrariness of its dose, and duration of schedule create doubt, if not confusion in the mind of clinicians. [2][3][4] Although drug dose depends on body weight, which is more relevant for a potentially toxic drug such as magnesium sulphate, there are many more known and unknown considerations.…”

“…& [2][3][4] Despite the availability of international guidelines, concerns for magnesium sulphate toxicity, narrow therapeutic range, complexities of regimen, arbitrariness of its dose, and duration of schedule create doubt, if not confusion in the mind of clinicians. [2][3][4] Although drug dose depends on body weight, which is more relevant for a potentially toxic drug such as magnesium sulphate, there are many more known and unknown considerations. [2][3][4] Attempts have been successfully made to reduce magnesium sulphate dose in Indian women since the late 1980s.…”

“…[2][3][4] Although drug dose depends on body weight, which is more relevant for a potentially toxic drug such as magnesium sulphate, there are many more known and unknown considerations. [2][3][4] Attempts have been successfully made to reduce magnesium sulphate dose in Indian women since the late 1980s.…”