Experience of low dose magnesium
Sulphate for the management of Eclampsia and its comparison with
Pritchard regime
Suman S 1, Jain P 2, Mishra
M.G 3
1Dr Supriya Suman, Junior Resident, Department of Obstetrics
Gynecology, F.H. Medical College Hospital, Tundla, Firozabad
(U.P.), 2Dr Prerna Jain, Assistant Professor, Department of Obstetrics
& Gynecology, F.H. Medical College Hospital, Tundla,
Firozabad, (U.P.), 3Dr Manju Gita Mishra, Chief Consultant, M.G.M
Hospital & Research Center, Patna, Bihar, India
Address for
Correspondence: Dr Prerna Jain, Email: drpjaiims@gmail.com
Abstract
Objectives:
To study the effectiveness, side effects, maternal and perinatal
outcome, using low dose Magnesium sulphate and to compare the results
with Pritchard regime. Methods:
Thirty women with eclampsia aged between 25 to 35 years were
prospectively studied over two years at M.G.M hospital &
research center, Patna, Bihar. Study was designed into Group A who
received low dose magnesium sulphate regime (n=15) and Group B who
received standard Pritchard regime (n=15). Results: Groups were
compared with respect to type of eclampsia, amount of dose of Magnesium
sulphate and Signs of Toxicity of Magnesium sulphate. Magnesium
sulphate received was 23gm in Group A and 44 gms in Group B and dose
related toxicity was less in Group A. Perinatal morbidity and mortality
was higher with Pritchard regime compared to low dose Magnesium
sulphate regime. Conclusion:
Low dose Magnesium sulphate is as effective as conventional full dose
Pritchard regime with lesser side effects with equally good perinatal
outcome.
Key words:
Pritchard regime, Eclampsia, Magnesium sulphate
Manuscript received:
4th August 2016, Reviewed:
14th August 2016
Author Corrected: 25th
August 2016, Accepted for
Publication: 12th September 2016
Introduction
Eclampsia remains a significant cause of maternal mortality and
morbidity, worldwide [1], with studies indicating that it accounts for
more than 50,000 maternal deaths, each year [1,2]. Because eclamptic
convulsions are grave emergencies requiring proper medical treatment
[2,3], the vast majority of these deaths occur in developing countries
wherein the quality of maternity care can be inadequate [4].
The incidence of Eclampsia in India varies from 0.5 to 1.8% [5].
Magnesium sulphate is the anti-convulsant drug of choice for both
prevention and treatment of eclampsia, but its dose-relative toxicity
is of great concern [6,7]. Potential hazards include maternal
hypotension, respiratory depression, and respiratory arrest (with
cardiac arrest as a rare outcome) [8, 9]. Undue apprehension concerning
these hazards results in limited use of the drug in many low-income
countries [10, 11].
Varying magnesium sulphate dose protocols have been implemented to
treat eclampsia, amongst which the Pritchard regime is most widely used
[12]. Flower et al adjusted doses of magnesium sulphate according to
body weight, plasma level and urinary excretion of magnesium sulphate
[13], while Sardesai Suman et al employed a low-dose magnesium sulphate
regime in eclampsia in Indian woman, finding it to be both safe and
very effective [14].
The lower dosage had been chosen primarily because of the relatively
small size of Indian women and concerns about toxicity in circumstances
wherein there is no facility for measuring of serum levels of
magnesium. It is appropriate to consider the body weight of Asian
women, whose body weight is usually less than 70kg [15], and if a woman
is or appears to be small or of low body weight, the dose may need to
be limited [15]. Therefore, the low dose magnesium sulphate regime that
has been proposed in this study is justified.
The aim of the present study was to evaluate the efficacy of low dose
magnesium sulphate in the control of convulsions in eclampsia, to
assess the magnesium related toxicity, to analyze the maternal and
perinatal outcomes, and to compare the results with those of the
standard Pritchard regime.
Material
and Methods
This study was carried out over a period of two years in the department
of obstetrics and gynecology at M.G.M hospital & research
center, Patna. Thirty cases of eclampsia, either antepartum or
intrapartum, were selected randomly. Patients who presented
with complications like cerebro-vascular accident, renal failure,
aspiration pneumonitis and HELLP syndrome; those who were deeply
unconscious with cerebro-vascular accident, renal failure, associated
pulmonary edema, disseminated intravascular coagulation, shock and post
partum eclampsia and those who had received anticonvulsant treatment
before admission to the hospital were excluded from the
study.
Written informed consent was obtained for every case included in the
study. As informed written consent requires a sound mind, in cases
where patients were unconscious or confused, consent was obtained from
the next of kin, usually the husband. The standard principles of
managing eclampsia were followed. All patients in the study were
sub-divided into two groups.
Group A: consisted
of fifteen women with eclampia who received a low dose magnesium
sulphate regime between March 2014 and February 2015, aged between
25-35 years, with a mean height of 151+ 7cms, mean weight of 41.7+
1.5kg, and a body mass index of 21. Ninety percent of these patients
were primigravid. The low dose regime consisted of the following: a
loading dose of 3gm magnesium sulphate intravenously plus
2.5gms magnesium sulphate injection in each buttock (for a total of 8gm
of intravenous magnesium sulphate), followed by a maintainance dose of
2.5gm administered intramuscularly every four hours, alternately in
each buttock, over the 24 hours that followed the last seizure. (Total
dose- 23gms of magnesium sulphate).
Group B:
consisted of fifteen women with eclampsia who received the standard
Pritchard regime between March, 2013 to February, 2014, aged 25-35 with
an average body mass index of 21.5. The Pritchard regime consisted of a
loading dose of 4g magnesium sulphate intravenously plus 5gms
intramuscular injection in each buttock (for a total of 14gm of
intravenous magnesium sulphate), followed by a maintenance dose of 5gms
intramuscular injection every 4 hours, alternately in each buttock,
over the 24 hours that followed the last seizure (Total dose - 44gms of
magnesium sulphate).
Patients were monitored every hour for vitals, knee jerks and urinary
output. For each dose of magnesium sulphate, knee jerks should be
present, respiratory rate should be more than 16 per minute, and
urinary output should be more than 30ml/hr. If there was recurrence of
convulsions 30 minutes after the initial loading dose, an additional
2gms of magnesium sulphate was given intra-muscularly. The efficacy of
the low dose magnesium sulphate regime was assessed by the control of
convulsions with a low dose protocol and by noting the total quantity
of magnesium sulphate required for control of convulsions. A structured
form was filled out for each patient with eclampsia, and maternal and
perinatal events included in the form were the frequency of seizures,
onset of labour, mode of delivery and perinatal outcome. Each
patient’s records were followed up on throughout the course
of treatment.
Results
It was observed that 90% of cases of eclampsia were unbooked, aged
between 25 and 35 years, and that 90% of patients were primigravida.
During this prospective study, following results were
found:
Table
1: Incidence of Eclampsia
| Type of eclampsia |
Group A |
Group B |
|
(cases) |
% |
(control) |
% |
| Ante-partum |
11 |
70% |
12 |
80% |
| Intra-partum |
4 |
30% |
3 |
20% |
| Total |
15 |
100% |
15 |
100% |
The incidence of antepartum eclampsia in group A was 70%, while in
group B, it was 80%, and the remaining patients had intra-partum onset
of eclampsia (Table I).
Table 2: Complications
during Magnesium Sulphate Therapy
| Type of
complication |
Group A |
Group B |
|
No. of Patient |
(%) |
No. of Patient |
(%) |
| Loss of knee jerk |
1
|
(6.67%) |
3 |
(20%) |
| Respiratory depression |
1
|
(6.67%) |
2 |
(6.67%) |
| Recurrence of fit |
0
|
(0%) |
1 |
(13.33%) |
In the present study, we also observed that complications during
magnesium sulphate therapy were fewer in Group A than Group B, and that
there was no evidence of recurrence of seizures in Group A patients
(Table II).
Table 3: Perinatal
Outcome
| Perinatal
outcome |
Group A |
Group B |
| Still birth |
1 (6.67%) |
2 (13.33%) |
| Apgar score |
7-8
|
6-7 |
| Deceleration in CTG |
1(6.67%) |
3 (20%) |
| Cesarean section |
7(46.67%) |
12 (80%) |
| Vaginal delivery |
8 (53.33%) |
3 (20%) |
It was observed that the incidence of still birth was 6.67% in Group A
compared to 13.33% in Group B. One patient showed deceleration on CTG
in Group A while three patients showed deceleration in Group B. The
incidence of cesarean section and vaginal delivery was 46.67% and
53.33%, respectively, in Group A compared to 80% cesarean section and
20% vaginal delivery in Group B. In Group A, the incidence of still
birth, deceleration on CTG, and cesarean deliveries were comparatively
fewer than in Group B, which received the standard Pritchard Regime
(Table III).
The serum magnesium levels were monitored in all cases for evidence of
toxicity. The mean serum magnesium value ranged between 2.78 and
3.05meq/lit during a low dose regime. There was no evidence of toxicity
in any case. In the present study, the total dose of magnesium sulphate
was 23gms, which is 52% less than what is required in the Pritchard
regime.
Thus, it was observed that a low dose magnesium sulphate regime was
sufficient to control eclamptic convulsions, and there was no maternal
mortality due to eclampsia or its complications in the present study.
Discussion
Antenatal care has been recognized as a way to improve health outcomes
for pregnant women and their babies. In the present study, it was seen
that 90% of the patients were not booked. In 1952, Helmin reported that
eclampsia would be scarcity if good and regular antenatal care were
made available [16], whereas Mudaliar & Menon [17] and Dawn
[18] stated that 75% of the cases were seen among primigravidas.
Similar observations were made in our present study. 90% of the
patients with convulsions were controlled with the use of low dose
magnesium sulphate in their large study done by Sardesai et al [14].
Rashida Begum et al reported that 98% of the cases were controlled with
the modified low dose Dhaka regime of magnesium sulphate [10]. The
results of the study made, were comparable with these studies regarding
low dose regime for the control of eclamptic convulsions.
Maternal mortality in the present study was Nil. Saedesai Suman [14]
reported that maternal mortality was 2.63% with low dose regime,
whereas with the Pritchard regime maternal mortality was 3.8% and 5.2%
by the collaborative eclampsia trial [6]. The adverse effects of
magnesium sulphate were almost rubbed out and seizure recurrence and
maternal mortality were satisfying. The dose adjustment stems from the
simple course of thought that the weight of Indian women is
approximately 2/3rd that of their US counterparts (45 kg v/s 65kg)
[17], thus require a dose modification.
We received a large number of patients at M.G.M hospital &
research center who had not been administered magnesium sulphate and
were sent to us directly from a referral hospital. The reasons for
referral and general difficulty in managing eclampsia at referring
hospitals in rural areas are often the lack of a full time
obstetrician, blood bank, emergency operating room, essential life
saving drugs, intravenous fluids, plasma expanders and ultrasonograms.
The study result has 3 major considerations. First is that magnesium
toxicity was effectively eliminated and thus safety of the drug was
increased, second is that overall cost of treatment was lowered as the
lower drug dose was given to the patient [18, 19] and Magnesium
sulphate is likely to become acceptable at peripheral health centre
where risk of toxicity with the drug act as impediment and proves to be
stumbling block.
Magnesium is a prototypical drug, with rapid onset of action, non
sedative effects on the mother and baby, with good safety margin and
promptly available antidote in the form of calcium gluconate. Magnesium
curtails the risk of recurrent seizures compared to the other
recognized drugs like diazepam and phenytoin [6]. Furthermore,
Magnesium sulphate does not appear to have any prejudicial effects on
the neonate [20, 21]. Mean serum magnesium levels were taken into
consideration and it was seen that level of serum magnesium remained
below the therapeutic range of magnesium; which account to control
convulsions. The mean serum magnesium level was ranging between
2.78-3.05 meq/lit during the low dose regime. Thus, it can be stated
that low dose regime as seen in present study, was found to be free
from the hazards of hypermagnesemia.
Low rate of fatality can be accredited to various factors, including
the development of integrated clearly written guidelines that was first
made available and then enforced. Education and training were given to
all grades of staff which included hospital interns and feedback was
requested. The instructions and various protocols were followed
strictly and regularly clinical audits of maternal death were carried
out.
Conclusion
Low dose magnesium sulphate was efficient in the control of eclamptic
convulsions. The dose needed for the control of convulsion with our low
dose regime was 52% less than that of Pritchard regime. It is
privileged to state that there was no magnesium related toxicity; so
this low dose magnesium sulphate regime as taken in our studies, suits
low income and developing countries like India with both constrained
and limited resources and women of lower body weight.
Funding:
Nil, Conflict of
interest: None initiated.
Permission from IRB:
Yes
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How to cite this article?
Suman S, Jain P, Mishra M.G. Experience of low dose magnesium Sulphate
for the management of Eclampsia and its comparison with Pritchard
regime. Int J Med Res Rev 2016;4(11):1935-1939.doi:10.17511/ijmrr.
2016.i11.04.