pre eclampsia

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EVIDENCE-
BASED CARE
SHEET
ICD-9
642.4, 642.6
ICD-10
O14.9, O15
Authors
Carita Caple, RN, BSN, MSHS
Cinahl Information Systems, Glendale, CA
Debra A. Schiebel, FNP
Cinahl Information Systems, Glendale, CA
Reviewers
Kathleen Walsh, RN, MSN, CCRN
Cinahl Information Systems, Glendale, CA
Teresa-Lynn Spears, RN, BSN, PHN, AE-
C
Cinahl Information Systems, Glendale, CA
Nursing Practice Council
Glendale Adventist Medical Center,
Glendale, CA
Editor
Diane Pravikoff, RN, PhD, FAAN
Cinahl Information Systems, Glendale, CA
November 25, 2016
Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2017, Cinahl Information Systems. All rights
reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by
any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice
or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare
professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206
Pre-eclampsia/Eclampsia: Seizure Prevention and
Treatment with Magnesium Sulfate
What We Know
› Pre-eclampsia and eclampsia are potentially life-threatening complications of
pregnancy that can lead to adverse consequences for the fetus (e.g., growth restriction),
and substantial maternal morbidity and mortality. In preeclampsia, ischemic changes in
the placenta induce generalized endothelial dysfunction, widespread vasospasm,severe
hypertension,and increased risk for severe multisystem complications (e.g., acute renal
failure, cerebral hemorrhage, pulmonary edema, uteroplacental insufficiency, cardiac
failure, and HELLP syndrome [Hemolysis, Elevated Liver enzymes, and Low Platelets]).
Pre-eclampsia symptoms vary in severity and women with mild cases are monitored
closely as outpatients(2,8,10,13,14,19)(For additional information, see Quick Lesson About
… Pre-Eclampsia and Quick Lesson About … Eclampsia .)
› Eclampsia is a severe complication characterized by new-onset tonic-clonicseizures or
unexplained coma associated with pregnancy; eclampsia can occur during pregnancy,
labor, or after birth, with or without previous symptoms of pre-eclampsia(7,8,9,13,17)
› Prevention of eclampsia and control of eclamptic seizures are essential to prevent
maternal and fetal complications that include
• hypoventilation, hypoxia, hypercarbia, and respiratory acidosis
• tongue hematoma and swelling
• compromised cerebral perfusion, intracerebral hemorrhage, and coma
• aspiration pneumonia
• placental abruption
• fetal compensatory tachycardia, decreased beat-to-beat variability, and transient late
decelerations
› Magnesium sulfate (MgSO4) is the first-line drug for seizure prevention in severe
pre-eclampsia and seizure control in eclampsia; evidence for its use in seizure prevention
in mild pre-eclampsia is conflicting(2,3,6,7,9,13,16)
• MgSO4 is a salt of magnesium, an alkaline mineral element found in the environment
and in the human body; normal adult serum magnesium is 1.5–2.5 mEq/L
(0.75–1.25 mmol/L)(14,16)
–Parenteral administration of MgSO4 produces an anticonvulsant effect by(7,8,9,11,14)
- inducing cerebral vasodilation, which reduces cerebral ischemia
- causing central nervous system (CNS) depression
- inhibiting N-methyl-D-aspartate (NMDA) receptors in the brain, which are activated
in response to hypoxia and cause cell injury
- acting as a calcium antagonist, which lowers intracellular calcium, increases the
seizure threshold, and limits the transport of factors that promote cerebral edema
and seizures.(18)MgSO4 is an effective anticonvulsant at serum concentrations of
2.5–7.5mEq/L (1.25–3.75 mmol/L); a serum concentration of 6 mEq/L (3 mmol/L) is
considered optimal for seizure control(9,11,14,15,16)
› An initial loading dose of 4 g I.V. MgSO4 over 15–20 minutes is recommended for severe
pre-eclampsia seizure prevention, and seizure treatment in eclampsia(2,7,9,15)
• In actual clinical practice, the route of delivery and dosage varies; MgSO4 is used in many clinical settings for prevention
of seizures in women with pre-eclampsia; I.M. delivery or lower I.V. doses are used for the loading dose(5,14)
• Following the loading dose, MgSO4 maintenance therapy is recommended, with either 1 g/hour I.V. for 24 hours after
delivery or 5 g I.M. in each buttock every 4 hours for 24 hours after delivery(7,8,9,15,16)
–About 10–15% of patients experience a second seizure after receiving MgSO4; repeat I.V. administration of 2–4 g over 5
minutes is recommended if seizures recur(15,19)
–Patients with severe renal insufficiency—common in pre-eclampsia and eclampsia—should not receive > 20 grams
MgSO4 for > 48 hours(15)
• Evidence suggests that over half of all women with mild pre-eclampsiawho have a seizure are normotensive or have mild to
moderate hypertension immediately before a seizure suggesting early intervention with MgSO4 (4)
• There is a higher NICU admission rate for neonates whose pre-eclamptic mothers were treated with MgSO4 suggesting that
further studies are needed to standardize the use of MgSO4 (12)
› Women receiving MgSO4 for pre-eclampsia or eclampsia should undergo regular testing of serum magnesium levels and
receive intensive monitoring for signs and symptoms of magnesium toxicity. Magnesium serum concentrations >(8,15,19)
• 6–8 mEq/L (3–4 mmol/L) can cause mild CNS depression(19,20)
• 8–12 mEq/L (4–6 mmol/L) can cause loss of deep tendon reflexes(15,19)
• 12–17 mEq/L (6–8.5 mmol/L) can cause respiratory depression, arrhythmia, and coma(8,15,19)
• 19–20 mEq/L (9.5–10 mmol/L) can cause cardiac arrest(15,19)
–Serum magnesium levels can vary because of altered physiologic response to MgSO4 therapy due to(1,11,13,16,19)
- maternal renal dysfunction causing poor clearance and high magnesium levels
- maternal hemoconcentration, which can↑ magnesium levels
- greatly increased maternal weight, which can cause lower than desired therapeutic levels of MgSO4
- above-average fetal weight, which can cause lower than desired magnesium levels
› Frequent monitoring for signs and symptoms of magnesium toxicity during treatment with MgSO4 should include
assessment of (2,9,13,16,19)
• patellar reflexes (i.e., knee jerk reaction to stimulus); do not administer additional MgSO4 if patellar reflex is absent
• adequate respiratory function; do not administer additional MgSO4 if respirations are < 16/minute
• adequate renal function; discontinue MgSO4 unless urine output is 100 mL during the 4 hours preceding each dose
› Treatment for magnesium toxicity includes immediate cessation of MgSO4 and I.V. administration of 5–10 mEq
(2.5–5 mmol/L) of calcium (10–20 mL of 10% calcium gluconate)(11,19)
• Ventilation support might be necessary until the calcium reverses the magnesium-induced respiratory depression or heart
block; severe cases of magnesium toxicity might require dialysis
› Increasing worldwide acceptance of MgSO4 as the gold standard for seizure prevention and treatment in
pre-eclampsia/eclampsia has reduced maternal and fetal morbidity and maternal mortality(7,9)
• Because MgSO4 is inexpensive and easily produced, clinical access to treatment for pre-eclampsia/eclampsia should be
readily available to women of all sociodemographic and ethnic/racial groups around the world(7,9)
What We Can Do
› Learn about the use of MgSO4 for seizure prevention in pre-eclampsia and seizure treatment in eclampsia so you can
accurately assess your patients’ personal characteristics and health education needs; share this information with your
colleagues
› Verify appropriate blood level testing of magnesium levels in your pre-eclamptic/eclamptic patients receiving MgSO4
therapy, and closely monitor treatment effectiveness and for magnesium toxicity(6,7,9,11,15)
Coding Matrix
Referencesare rated using the following codes, listed in order of strength:
M Published meta-analysis
SR Published systematic or integrative literature review
RCT Published research (randomized controlled trial)
R Published research (not randomized controlled trial)
C Case histories, case studies
G Published guidelines
RV Published review of the literature
RU Published research utilization report
QI Published quality improvement report
L Legislation
PGR Published government report
PFR Published funded report
PP Policies, procedures, protocols
X Practice exemplars, stories, opinions
GI General or background information/texts/reports
U Unpublished research, reviews, poster presentations or
other such materials
CP Conference proceedings, abstracts, presentation
References
1. Aali, B. S., Khazaeli, P., & Ghasemi, F. (2007). Ionized and total magnesium concentration in patients with severe preeclampsia-eclampsia undergoing magnesium sulfate
therapy. Journal of Obstetrics and Gynaecology Research, 33(2), 138-143. doi:10.1111/j.1447-0756.2007.00508.x (R)
2. American College of Obstetricians and Gynecologists: Committee on Obstetric Practice. (2015). Committee opinion no. 623: Emergent therapy for acute-onset, severe
hypertension during pregnancy and the postpartum period, 125(2), 521-525. doi:10.1097/01.AOG.0000460762.59152.d7 (PGR)
3. Bain, E. S., Middleton, P. F., & Crowther, C. A. (2013). Maternal adverse effects of different antenatal magnesium sulphate regimens for improving maternal and infant
outcomes: A systematic review. BMC Pregnancy and Childbirth, 13(1), 195. doi:10.1186/1471-2393-13-195 (SR)
4. Berhan, Y, & Berhan, A. (2015). Should magnesium sulfate be administered to women with mild pre-eclampsia? A systematic review of published reports on eclampsia. The
Journal of Obstetrics and Gynaecology Research, 41(6), 831-842. doi:10.1111/jog.12697 (RV)
5. Cahill, A. G., Macones, G. A., Odibo, A. O., & Stamilio, D. M. (2007). Magnesium for seizure prophylaxis in patients with mild preeclampsia. Obstetrics & Gynecology, 110(3),
601-607. doi:10.1097/01.AOG.0000279152.66491.78 (R)
6. Duley, L. (2009). The global impact of pre-eclampsia and eclampsia. Seminars in Perinatology, 33(3), 130-137. doi:10.1053/j.semperi.2009.02.010 (RV)
7. Duley, L., Gülmezoglu, A. M., & Chou, D. (2010). Magnesium sulphate versus lytic cocktail for eclampsia. Cochrane Database of Systematic Reviews, Issue 9. Art. No.:
CD002960. doi:10.1002/14651858.CD002960.pub2 (M)
8. Duley, L., Henderson-Smart, D., & Chou, D. (2010). Magnesium sulphate versus phenytoin for eclampsia. Cochrane Database of Systematic Reviews, Issue 10. Art. No.:
CD000128. doi:10.1002/14651858.CD000128.pub2 (SR)
9. Duley, L., Henderson-Smart, D., Walker, G. J., & Chou, D. (2010). Magnesium sulphate versus diazepam for eclampsia. Cochrane Database of Systematic Reviews, Issue 12.
Art. No.: CD000127. doi:10.1002/14651858.CD000127.pub2 (SR)
10. English, F. A., Kenny, L. C., & McCarthy, F. P. (2015). Risk factors and effective management of preeclampsia. Integrated Blood Pressure Control, 8, 7-12. doi:10.2147/
IBPC.S50641 (RV)
11. Euser, A. G., & Cipolla, M. J. (2009). Magnesium sulfate for the treatment of eclampsia: A brief review. Stroke, 40(4), 1169-1175. doi:10.1161/STROKEAHA.108.527788 (RV)
12. Girsen, A. I., Greenberg, M. B., El-Sayed, Y. Y., Lee, H., Carvalho, B., & Lyell, D. J. (2015). Magnesium sulfate exposure and neonatal intensive care unit admission at term.
Journal of Perinatology: Official Journal of the California Perinatal Association, 35(3), 181-185. doi:10.1038/jp.2014.184 (RV)
13. Karumanchi, S. A., & Lindheimer, M. D. (2008). Advances in the understanding of eclampsia. Current Hypertension Reports, 10(4), 305-312. doi:10.1007/s11906-008-0057-3
(RV)
14. Lim, K. -H., & Steinberg, G. (2016, September 15). Preeclampsia. Medscape. Retrieved November 7, 2016, from http://emedicine.medscape.com/article/1476919-overview
(RV)
15. Lowe, S. A., Brown, M. A., Dekker, G. A., Gatt, S., McLintock, C. K., McMahon, L. P., ... Walters, B. (2009). Guidelines for the management of hypertensive disorders of
pregnancy 2008. Australian & New Zealand Journal of Obstetrics & Gynaecology, 49(3), 242-246. doi:10.1111/j.1479-828X.2009.01003.x (G)
16. McCoy, S., & Baldwin, K. (2009). Pharmacotherapeutic options for the treatment of preeclampsia. American Journal of Health-System Pharmacy, 66(4), 337-344. doi:10.2146/
ajhp080104 (RV)
17. Niroomanesh, S., & Mirzaie, F. (2008). Atypical postpartum eclampsia: Status epilepticus without preeclamptic prodromi. Women & Birth, 21(4), 171-173. doi:10.1016/
j.wombi.2008.09.003 (C)
18. Rogers, D. T., Colon, M., Gambala, C., Wilkins, I., & Hibbard, J. U. (2010). Effects of magnesium on central arterial compliance in preeclampsia. American Journal of Obstetrics
& Gynecology, 202(5), 448.e1-8. doi:10.1016/j.ajog.2010.03.049 (R)
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