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

Abstract

ObjectiveTo characterise the current clinical practice patterns regarding the use of magnesium sulphate (MgSO 4) for eclampsia prevention and treatment in a multi‐country network of health facilities and compare with international recommendations.DesignCross‐sectional survey.SettingA total of 147 health facilities in 15 countries across Africa, Latin America and Asia.PopulationHeads of obstetric departments or maternity units.MethodsAnonymous online and paper‐based survey conducted in 2015.Main outcome measuresAvailability and use of MgSO 4; availability of a formal clinical protocol for MgSO 4 administration; and MgSO 4 dosing regimens for eclampsia prevention and treatment.ResultsMagnesium sulphate and a formal protocol for its administration were reported to be always available in 87.4% and 86.4% of all facilities, respectively. MgSO 4 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.ConclusionsThe reported clinical use of MgSO 4 for eclampsia prevention and treatment varied widely, and was largely inconsistent with current international recommendations.Tweetable abstractMgSO 4 regimens for eclampsia prevention and treatment in many hospitals are inconsistent with international recommendations.

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

“…Moreover, regimens with lower total daily dose and/or shorter treatment duration that might be easier to implement compared with the standard Zuspan and Pritchard regimens have been reported in these regions. 10 The need for trained healthcare providers to handle the logistics of the standard regimens (continuous intravenous or intravenous combined with intramuscular administration) with different loading and maintenance doses likely contributes to the use of these variations from the standard regimens. 7 Recently, concerns about adverse events with the use of standard regimens and coverage limitations posed by health resource requirements in low-income settings have renewed interest in identifying the minimum effective dose of magnesium sulfate for preventing and treating eclampsia.…”

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

“…The probability of eclampsia occurrence was predicted for 27 different types of women with all possible combinations of age (20, 30, and 40 years), maternal body weight (60, 85, and 110 kg), and serum creatinine concentrations (0.5, 0.8, and 1.2 mg/dL). The alternative regimens were selected (in part) based on the findings of an international survey on clinical practice patterns of MgSO 4 or their previous application in research contexts for eclampsia prophylaxis, tocolysis, or fetal neuroprotection and were prespecified by the study authors prior to the simulation analysis . Supplemental describes the features of each regimen.…”

“…The alternative regimens were selected (in part) based on the findings of an international survey on clinical practice patterns of MgSO 4 or their previous application in research contexts for eclampsia prophylaxis, tocolysis, or fetal neuroprotection and were prespecified by the study authors prior to the simulation analysis. 8,9 Supplemental Table S4 describes the features of each regimen.…”

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

“…Approximately 17% of Indian women with eclampsia receive a low-dose magnesium sulphate regimen (National Eclampsia Registry report, 2015), which is similar to the Asian wing of the current report. 1 In Asia and more frequently in Africa, a lower dose of magnesium sulphate is used in a sizable proportion of cases.…”

“…What is the right balance between reassurance regarding a rare risk of stillbirth and pathologising a normal life event for the vast majority? The commentary 1 rightly exhorts a focus on more readily preventable errors. Hence, equally pertinently the birth attendants should scrutinise and amend the obvious fundamental scientific anomalies in cardiotocography interpretation and intermittent auscultation to substantially reduce the morbidity and mortality from intrapartum asphyxia for all babies.…”