Facility and personnel factors influencing magnesium sulfate use for eclampsia and pre-eclampsia in 3 Indian hospitals

Objective

To identify factors at the health facility and health professional levels that might hinder or facilitate the appropriate use of magnesium sulfate for the treatment of pre-eclampsia and eclampsia.

Methods

Seven focus group discussions were conducted with a purposively sampled group of obstetricians/gynecologists, medical residents, and nurses at 3 hospitals in Nagpur, India. Data were collected on facility and drug availability, criteria for diagnosis and management of pre-eclampsia and eclampsia, attitudes about magnesium sulfate use, and perceived barriers to the treatment of pre-eclampsia and eclampsia.

Results

Senior gynecologists seemed to encourage the use of magnesium sulfate, especially management prior to transfer to a higher facility. However, clinicians noted a lack of specific institutional guidelines on dose, timing, and indications, particularly in cases in which delivery was not imminent. In all facilities, service providers noted that their clinical care decisions were sometimes influenced by political and social factors, making management of eclampsia and pre-eclampsia cases difficult. Care was further challenged by limited drug availability, particularly at the tertiary-care center.

Conclusion

Limited drug supply and lack of specific institutional guidelines, equipment, and trained staff hinder the translation of evidence-based policy on magnesium sulfate into practice.     

An audit of the use of magnesium sulphate in severe pre-eclampsia and eclampsia.

Over the last decade there has been an increase in the use of MgSO4 for the prevention of seizures in women with severe pre-eclampsia or eclampsia. At the Rotunda Hospital it is regularly used for this purpose. The aim of this study was to audit the use of MgSO4 at the hospital, to determine whether the drug was being used according to the hospital's protocol and to observe its effectiveness in the prevention of eclampsia in our population. A retrospective chart review over the two years from 1/1/2000 to 31/12/2001 was undertaken. Outcome measures assessed were; Patient selection, Administration of the drug - whether recommended protocols were adhered, Effectiveness of therapy for seizure prophylaxis, Maternal and neonatal outcomes. There were 12,910 deliveries at the Rotunda hospital over this period of time. Fifty of these women were treated with MgSO4 (0.4%). Patient selection was appropriate in all cases. The correct loading dose of MgSO4 was administered in all cases, however MgSO4 levels were recorded in only 30 (60%) of women. There were no seizures in the treated group. Two women presented with seizures (one was antenatal the other post-natal period), both were treated with MgSO4. There were no maternal or neonatal mortality. Seventy two percent (36) of these women were delivered by lower segment caesarean section. The mean gestation at delivery was 36 weeks (range 28-41 weeks). Thirty eight percent (13) of babies required admission to the neonatal intensive care unit. The mean birth weight at delivery was 2.54 kg (range 1.11-3.68 kg). MgSO4 use in the Rotunda hospital appears to be safe and effective for the prevention of seizures in women with severe pre-eclampsia or eclampsia. Serum MgSO4 levels were only recorded in 60% of patients and the hospital's protocol was not adhered to regarding monitoring of patients on treatment. This needs to be addressed.     

The effects of maternal weight and age on pre-eclampsia and eclampsia in Haiti

Objective: Patient data from Maison de Naissance (MN), a rural maternity clinic in Haiti, were analyzed to determine the prevalence of pregnancy-related hypertensive disorders and the extent to which maternal weight and age are associated with these disorders in the MN population.

Methods: A case-control study design was used with cases defined as pregnant women who were presented at MN with pregnancy-related hypertensive disorders (pregnancy-induced hypertension, pre-eclampsia or eclampsia) and controls defined as those women who delivered babies at MN and were not diagnosed with a pregnancy-related hypertensive disorder. The final cohort size was 622 controls and 67 cases. Odds ratios were calculated using multivariate logistic regression.

Results: The incidence of pre-eclampsia and eclampsia was 7.0%. Older maternal age at delivery (OR?=?3.18; 95%CI: 1.31, 7.76) and higher maternal weight (OR?=?3.24; 95%CI: 1.76, 5.98) measured during prenatal care were significantly associated with pregnancy-related hypertensive disorders. Prenatal care was not significantly associated with reduced risk of pre-eclampsia/eclampsia.

Conclusions: The prevalence of pregnancy-related hypertensive disorders was high relative to rates in other developing countries. More is required to reduce the rate of pre-eclampsia perhaps by targeting older and women with high weight for preconception and more intensive prenatal care.     

Probiotics in pregnancy and maternal outcomes: a systematic review

Abstract

Objectives: To systematically review the literature on the use of probiotics in pregnancy and their impact on maternal outcomes.

Methods: Online databases were searched in April 2012 using the following terms to identify eligible studies: “probiotics”, “pregnancy”, “maternal outcomes” and “metabolism”. Primary outcomes of selected studies were maternal fasting glucose during pregnancy and rates of gestational diabetes mellitus (GDM). Secondary outcomes were rates of pre-eclampsia, maternal inflammatory markers and lipid profiles and gestational weight gain. Studies whose primary outcomes were bacterial vaginosis, pre-term delivery and infant atopy were excluded. Only English-language articles were included. The limited number of eligible studies and varying outcomes precluded formal meta-analysis of these data.

Results: Initially, 189 articles were identified and screened. Seven articles met inclusion criteria and are included in the present review. Results demonstrated that probiotic use in pregnancy could significantly reduce maternal fasting glucose, incidence of GDM and pre-eclampsia rates and levels of C-reactive protein.

Conclusions: Probiotics hold potential as a safe therapeutic tool for the prevention of pregnancy complications and adverse outcomes related to maternal metabolism. Further randomised controlled trials are urgently required, particularly among those at high risk of metabolic disorders, such as overweight and obese pregnant women.     

The use of magnesium sulfate for women with severe preeclampsia or eclampsia diagnosed during the postpartum period

This was a systematic review of randomized controlled trials comparing anticonvulsants with placebo or no anticonvulsant for prevention (a) of eclampsia in women with severe preeclampsia diagnosed during the postpartum period or diagnosed before delivery but without previous treatment and (b) prevention of seizures recurrence in women with eclampsia postpartum. We did not find study with full inclusion criteria. However, a total of two randomised controlled trials meet inclusion criteria as subgroup analysis; one for severe preeclampsia diagnosed during the postpartum period and one for eclampsia postpartum. For severe preeclampsia diagnosed during postpartum, there was no clear difference between the groups reporting eclampsia (relative risk: 0.54, 95% confidence interval: 0.16–1.80). For seizure recurrence, magnesium sulfate was superior to diazepam, but there was no significant difference compared with phenytoin. No conclusion can be drawn on the role of magnesium sulfate post partum as established in antepartum pre-eclampsia/eclampsia management because of lack of powered randomised controlled trials.     

Are we increasing serious maternal morbidity by postponing termination of pregnancy in severe pre-eclampsia/eclampsia?

The objective of this study was to evaluate the impact of admission--delivery interval on maternal morbidity in patients with severe pre-eclampsia/eclampsia. This was a retrospective study, which involved review of case sheets of 188 women (admitted to St John's Medical College Hospital during the year 2000--2001 with the above diagnosis). The incidence of severe pre-eclampsia and eclampsia was 5.18% (188/3,627) with 119 primigravida and 69 multigravida. The incidence of serious maternal complications in the post partum period was 17% (11/68) in the category of women who delivered within 12 hours of admission compared with 40.6% (28/69) in the 12--48-h category and 60.8% (31/51) in the>48-h category. The incidence of serious maternal complications in the subset with HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome was 33.4% (7/21) in the12-h. We concluded that termination of pregnancy within 12 hours of admission in severe pre-eclampsia/eclampsia especially in patients with HELLP syndrome helps to prevent avoidable serious maternal morbidity.     

Selective magnesium sulfate prophylaxis for the prevention of eclampsia in women with gestational hypertension

OBJECTIVE: To describe the incidence of eclampsia in women with mild gestational hypertension when only women with severe gestational hypertension are given magnesium sulfate prophylaxis. METHODS: This is a prospective 4(1/2)-year observational study. Those women who met our criteria for severe gestational hypertension received intravenous magnesium sulfate prophylaxis, and women with nonsevere hypertension did not. Data were collected at delivery to ascertain the incidence of eclampsia and maternal and neonatal morbidity. RESULTS: A total of 72,004 women were delivered during the study period, 6,431 had gestational hypertension, 3,935 met the criteria for severe disease and were given magnesium sulfate prophylaxis, 2,496 women with nonsevere hypertension were not treated. Eighty-seven women developed eclampsia, for an overall incidence of 1 in 828 deliveries, a 50% increase when compared with 5 preceding years where all women with gestational hypertension were given magnesium sulfate prophylaxis. Of the 2,496 women with nonsevere hypertension who were not treated, 27 had eclampsia (1 in 92). Women with eclampsia were more likely to require general anesthesia for cesarean delivery compared with hypertensive women without eclampsia (23% versus 4%, P < .001), but they had no additional morbidity. Infants of eclamptic mothers had more adverse outcomes than those without convulsions (12% versus 1%, P < .04). CONCLUSION: Selective magnesium sulfate prophylaxis results in an increased overall incidence of eclampsia because of more seizures in women with nonsevere gestational hypertension who are not given magnesium sulfate prophylaxis. LEVEL OF EVIDENCE: II-3.     

Outcomes of severe pre-eclampsia/eclampsia in Yorkshire 1999/2003

OBJECTIVE: To establish the risk of serious complications from severe pre-eclampsia and eclampsia in a region using a common guideline for the management of these conditions. DESIGN: A five-year prospective study. SETTING: Sixteen maternity units in Yorkshire. POPULATION: All women managed with severe pre-eclampsia and eclampsia. METHODS: A common guideline was developed for the management of women with these conditions. A network of midwives prospectively collected outcome data. MAIN OUTCOME MEASURE: Incidence of the conditions and serious complication rates. RESULTS: A total of 210,631 women delivered in the 16 units between 1 January 1999 and 31 December 2003. One thousand eighty-seven women were diagnosed with severe pre-eclampsia or eclampsia (5.2/1000). One hundred and fifty-one women had serious complications including 82 women (39/10,000) having eclamptic seizures and 49 women (23/10,000) requiring ICU admission. There were no maternal deaths but 54 out of 1145 babies died before discharge, giving a mortality rate of 47.2/1000. Of the 82 cases of eclampsia, 45 occurred antenatally (55%), 18 before admission to the maternity unit. Eleven cases occurred in labour (13%), including 1 during a caesarean section, and 26 cases occurred following delivery (32%). Twenty-five women developed pulmonary oedema (2.3% of cases) and six women required renal dialysis (0.55% of cases). One hundred and sixty-five (15%) required no antihypertensive therapy and 489 (53%) of the remainder required only oral therapy. Two hundred and one (18.5%) required more than one drug. CONCLUSION: A regional guideline for severe pre-eclampsia and eclampsia can be developed and implemented. Its use may contribute to a low rate of serious complications.     

A shortened postpartum magnesium sulfate prophylaxis regime in pre-eclamptic women at low risk of eclampsia

ObjectiveTo determine whether magnesium sulfate (MgSO₄) prophylaxis is needed for up to 24 hours postpartum in all patients with pre-eclampsia.MethodsIn a randomized open clinical trial conducted in a tertiary health center in India between September 2008 and April 2010, 150 women with severe pre-eclampsia who received intrapartum MgSO₄ and delivered at more than 20 weeks gestation were enrolled. After 6 hours postpartum, the participants were randomized to continue receiving (control group) or to discontinue (intervention group) MgSO₄, and outcomes were compared.ResultsAdministration of MgSO₄ had to be reinstituted for 1 woman in the intervention group. Under the current protocol in the institution, all 75 women in the intervention group would have received MgSO₄ for 24 hours postpartum. A significant reduction in time spent by the doctors (P < 0.001) and nurses (P < 0.001) was seen in the intervention group. The pain score in the intervention group was significantly less (P < 0.001), and women in the intervention group were able to look after themselves better (P < 0.001).ConclusionFor women at low risk for postpartum eclampsia, a shortened (6-hour) MgSO₄ regime was as effective for seizure prophylaxis as the conventional 24-hour regime, with significant benefits in terms of cost and morbidity.     

The effects of hands on and hands off/poised techniques on maternal outcomes: A systematic review and meta-analysis

BackgroundNegative maternal outcomes such as perineal trauma and related perineal pain may cause both long-and short- term morbidities. Hands on and hands off/poised technique are two kinds of techniques to protect perineum during the second-stage of labor. Hands on technique has been the routine midwifery practice for a long time; nevertheless, the effects of hands on technique on protecting perineum has been doubted. Hands off/poised as a promising technique seems prevalent in clinical practice. However, there is no consensus on use of hands off/poised technique and hands on technique. The effects of these techniques on maternal outcomes have not been fully investigated.ObjectiveTo evaluate the effects of hands on hands off/poised technique on maternal outcomes during the second-stage of labor.DesignSystematic review and meta-analysis of relevant quantitative studies.Data sourcesSeven databases: PubMed, EMBASE, The Cochrane Library, CINAHL, WanFang Data, China National Knowledge Infrastructure (CKNI), SinoMed were systematically searched from inception to July 23,2018 for relevant quantitative studies comparing the effects of hands on and hands off/poised technique on maternal outcomes.Review methodsQuantitative studies were retrieved for relevant studies. Two reviewers independently screened the studies, evaluated the methodological quality using JBI appraisal checklist tools and extracted the data. The included studies were divided into two groups for analysis according to study types.ResultsNine RCTs with a total of 7112 participants and eight non-RCTs with 37,786 participants were included for meta-analysis. Based on the results from RCTs, this study did not find difference between hands on and hands off/poised technique regarding the risk of 2nd perineal tears, 3rd /4th degree perineal tears, duration of second-stage labor and incidence of postpartum hemorrhage (PPH>500 ml). The results from 9 non-RCTs were similar with that of RCTs, except for showing less 2nd degree perineal tears in hands off/poised technique than in hands on technique.ConclusionEvidence in the present study indicated that hands off/poised technique may be a promising delivery technique to maintain intact perineum, and reduce perineal pain and episiotomy use among women with low-risk pregnancy undergoing vaginal delivery. In addition, hands off/poised technique might be safe to use as it did not increase the risk of severe perineal trauma, postpartum hemorrhage, and longer duration of second-stage labor when compared with hands on technique. More studies with stringent study design, especially large randomized controlled trial, should be conducted before strong recommendation of the hands off/poised technique.