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Maternal Outcome with Discontinuation of Magnesium Sulfate immediately Postpartum in Severe Preeclampsia

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Objective: To assess the effectiveness of discontinuation of magnesium sulfate (MgSO4) infusion in patients with severe preeclampsia immediately postdelivery. Materials and methods: In a prospective-randomized study, women with severe preeclampsia attending the Jawaharlal Nehru Medical College, Aligarh, India, between January 2013 and September 2014 were enrolled. The inclusion criteria were blood pressure of at least 160/110 mm Hg after 24 weeks and either of the following: Proteinuria (dipstick value ≥1), platelet <100,000, and serum transaminase levels twice as normal. Participants were assigned to control and study groups accord- ing to the time of enrollment (6-month blocks). All patients received MgSO4 loading dose (4 gm intravenously), followed by maintenance doses (1 gm/hour) until delivery (study group) and 24 hours (control group). The primary outcome was occurrence of convulsions after completion of MgSO4 therapy. Patients with treatment failure were excluded from analyses. Results: Analyses included 48 patients in the study group and 43 patients in the control group. No convulsions occurred in either group after the completion of treatment. Conclusion: For women with severe preeclampsia, discontinu- ing MgSO4 immediately after delivery could effectively prevent convulsions. Keywords: Convulsions, Magnesium sulfate, Severe preeclampsia.
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Shaheen Anjum et al
84
ABSTRACT
Objective: To assess the effectiveness of discontinuation of
magnesium sulfate (MgSO4) infusion in patients with severe
preeclampsia immediately postdelivery.
Materials and methods: In a prospective-randomized study,
women with severe preeclampsia attending the Jawaharlal
Nehru Medical College, Aligarh, India, between January 2013
and September 2014 were enrolled. The inclusion criteria were
blood pressure of at least 160/110 mm Hg after 24 weeks and
either of the following: Proteinuria (dipstick value ≥1), platelet
<100,000, and serum transaminase levels twice as normal.
Participants were assigned to control and study groups accord-
ing to the time of enrollment (6-month blocks). All patients
received MgSO4 loading dose (4 gm intravenously), followed by
maintenance doses (1 gm/hour) until delivery (study group) and
24 hours (control group). The primary outcome was occurrence
of convulsions after completion of MgSO4 therapy. Patients with
treatment failure were excluded from analyses.
Results: Analyses included 48 patients in the study group and
43 patients in the control group. No convulsions occurred in
either group after the completion of treatment.
Conclusion: For women with severe preeclampsia, discontinu-
ing MgSO4 immediately after delivery could effectively prevent
convulsions.
Keywords: Convulsions, Magnesium sulfate, Severe
preeclampsia.
How to cite this article: Anjum S, Gade PR, Garg N, Bano I,
Alvi Y. Maternal Outcome with Discontinuation of Magnesium
Sulfate immediately Postpartum in Severe Preeclampsia.
J South Asian Feder Obst Gynae 2017;9(2):84-87.
Source of support: Nil
Conict of interest: None
Date of received: 7 January 2017
Date of acceptance: 14 February 2016
Date of publication: March 2017
INTRODUCTION
Preeclampsia is a preventable cause of maternal morbidity
and mortality, and with evolving terminologies, definition,
and classification of hypertension in pregnancy, its diag-
nostic prevalence is expected to increase by 20%.1 Hyper-
tensive disorders complicate 5 to 10% of all pregnancies,2
as concluded by the Magpie trial.3 Magnesium sulfate
(MgSO4) is the drug of choice in the management of severe
preeclampsia. Recommendations for the least possible
dosing schedule that can effectively prevent convulsions
in patients with preeclampsia still have prospects of sci-
entific scrutiny as there have been multiple randomized
controlled trials which speculate that seizures can be effec-
tively controlled by only loading dose of MgSO4 in patients
with preeclampsia and eclampsia.4-7 With an intention to
decrease the duration of treatment and monitoring and the
risk of side effects of MgSO4, we have planned this study
to determine the effectiveness of short-duration MgSO4
by discontinuing the maintenance dose immediately after
delivery to improve maternal and neonatal outcomes in
severe preeclampsia.
MATERIALS AND METHODS
In the present prospective-randomized study, women
with severe preeclampsia attending the Department of
Obstetrics and Gynecology at Jawaharlal Nehru Medical
College, Aligarh Muslim University, Aligarh, India, were
enrolled between January 1, 2013, and September 30, 2014.
The inclusion criteria were antenatal patients beyond
24 weeks gestational age with a systolic blood pressure
160 mm Hg or diastolic blood pressure 110 mm Hg
after 24 weeks of pregnancy with either of the follow-
ing symptoms: Proteinuria (dipstick value 1), platelet
<100,000, and serum transaminase levels twice as normal.
Patients with severe preeclampsia with cerebral symp-
toms, such as headache, visual symptoms, and convul-
sions, serum creatinine > 1.2 mg/dL, previous history of
eclampsia, and associated maternal medical diseases were
excluded from the study. Patients with contraindication
to MgSO4 (e.g., drug hypersensitivity, myasthenia gravis,
anuria, or oliguria), prior intake of any other anticonvul-
sant, and a history of epilepsy were also excluded from
the study. The exclusion of serum creatinine >1.2 mg/dL
and cerebral symptoms was owing to nonanalysis of
serum magnesium levels and since the study was being
conducted for the first time respectively. A total of
258 patients with severe preeclampsia reported to the
labor room during the entire duration of study. A total
JSAFOG
ORIGINAL ARTICLE
10.5005/jp-journals-10006-1464
Maternal Outcome with Discontinuation of Magnesium
Sulfate immediately Postpartum in Severe Preeclampsia
1Shaheen Anjum, 2Pramod R Gade, 3Nidhi Garg, 4Imam Bano, 5Yasir Alvi
1Associate Professor, 2,3,5Postgraduate Student, 4Professor
1-4Department of Obstetrics and Gynecology, Jawaharlal Nehru
Medical College, Aligarh, Uttar Pradesh, India
5Department of Community Medicine, Jawaharlal Nehru Medical
College, Aligarh, Uttar Pradesh, India
Corresponding Author: Shaheen Anjum, Associate Professor
Department of Obstetrics and Gynecology, Jawaharlal Nehru
Medical College, Aligarh, Uttar Pradesh, India, Phone:
+91-9319861442, e-mail: shahanjum73@gmail.com
Maternal Outcome with Discontinuation of Magnesium Sulfate immediately Postpartum in Severe Preeclampsia
Journal of South Asian Federation of Obstetrics and Gynaecology, April-June 2017;9(2):84-87 85
JSAFOG
of 167 patients were excluded due to the presence of
exclusion criteria, such as serum creatinine >1.2 mg/dL
and cerebral symptoms. The Ethical Committee of the
Institution approved the study, and the patients provided
informed consent before the administration of MgSO4.
Patients with severe preeclampsia, who were admit-
ted during the study period, were randomly assigned
to either the study group (0 hour group) or the control
group (24-hour MgSO4) as follows: Patients admitted in
the first 6 months were enrolled into the control group,
and those admitted in the next 6 months were enrolled
into the study group alternately for the entire duration of
study. Participants were not told which group they had
been assigned to, but because the groups received treat-
ments for different lengths of time, full masking was not
possible. Investigators and data analysts were not masked
to group assignment.
A detailed history and examination was done for all
women at the time of admission. Complete blood counts,
coagulograms, liver and renal function tests, and urine
protein measurements were performed. Women in the
study group were given a loading dose of 4 gm of intra-
venous MgSO4, followed by a maintenance dose of 1 gm
per hour until the patient delivered. Those in the control
group were given a loading dose of 4 gm of intravenous
MgSO4, followed by a maintenance dose of 1 gm per hour
for 24 hours after delivery.
Monitoring of the patients for the entire duration of
MgSO4 infusion was done by trained obstetricians with
documentation of blood pressure, patellar reflexes, respi-
ratory rate, urine output, and occurrence of convulsions.
In the case of MgSO4 toxicity, the plan of management
was to stop further MgSO4 infusion and to inject 1 gm of
calcium gluconate (10 mL of 10% solution) intravenously,
followed by switch to another anticonvulsant therapy.
These patients were considered to have treatment failure.
After completion of the MgSO4 infusion, patients were
monitored every 4 hours until normalization of blood
pressure, and then every 12 hours until discharge.
Labetalol was used as an antihypertensive drug as per
the management protocol of the study institute. The par-
ticipants were induced, allowed to undergo spontaneous
labor, or underwent cesarean delivery depending on the
obstetric indication and the patient’s general condition.
The primary outcome was occurrence of convulsions
once the MgSO4 therapy was completed. If a convulsion
occurred before completion of therapy, the patient was
infused with a 2 gm loading dose of MgSO4, and women
in the study group were switched to a maintenance dose
of MgSO4 for 24 hours postdelivery. If a second convul-
sion was observed during the therapy, the treatment was
switched from MgSO4 to phenytoin and considered as an
MgSO4 failure.
Patient recovery was analyzed in terms of total dose of
MgSO4 given, duration of hospital stay, and duration of
Foley catheterization as secondary outcome. The patients
were followed up until discharge from hospital.
The study data were analyzed by Statistical Package
for the Social Sciences version 21 (IBM, Armonk, New
York, USA). The study and control groups were compared
by t test and χ2 test as appropriate. Patients who did not
fulfill the inclusion criteria were excluded from analysis.
The p 0.05 was considered significant.
RESULTS
All patients with severe preeclampsia after fulfillment of
the inclusion criteria were included in the study. In our
study, 55.1% cases belonged to rural background and
49.1% cases were literate and 80.2% were not booked.
Among the study participants, 48 were assigned to the
study group and received no MgSO4 infusion following
delivery, and 43 were assigned to the control group and
received the conventional 24-hour regime of MgSO4. The
baseline characteristics of cases are depicted in Table 1.
With respect to baseline characteristics in terms of age,
number of previous pregnancies, and length of pregnancy
of cases, no significant differences were found between
the groups. In addition, systolic blood pressure, diastolic
blood pressure, and albuminuria on admission and at
discharge were similar in the two groups.
Regarding the primary outcome, no convulsions
occurred in either group after the completion of MgSO4.
Regarding the secondary outcomes, significantly higher
total amounts of MgSO4, duration of Foley catheteriza-
tion, and duration of monitoring were noted in the control
group when compared with the study group (p 0.001
for all) (Table 2).
In our study, 51 (56.04%) patients had vaginal delivery
and 40 (43.95%) had cesarean section. Overall, 77 (84.6%)
patients had live births, and 14 (15.4%) patients had intra-
uterine fetal death on admission.
The mean duration of hospital stay for cases of vaginal
delivery and cesarean section in study group was 2.82 ±
0.77 days and 5.05 ± 1.96 days respectively, whereas the
mean duration of hospital stay in control group was 4.04 ±
1.47 days and 11.11 ± 3.14 days respectively, which is
statistically significant (t-value = 3.8 for vaginal deliveries,
t-value = 7.1 for cesarean section cases, p < 0.001).
No toxic effects or treatment failures were noted with
MgSO4 infusion in either group.
DISCUSSION
Erstwhile, substantiated 24 hours infusion of MgSO4
postpartum is highly effective in preventing convulsions
in women with severe preeclampsia during labor, when
Shaheen Anjum et al
86
propensity to develop convulsions is high. In our study,
MgSO4 loading 4 gm was injected intravenously fol-
lowed by infusion of MgSO4 at the rate of 1 gm/hour to
all patients of severe preeclampsia during the antenatal
period, which was subsequently stopped immediately
after delivery in patients randomized to study group and
continued for 24 hours in patients randomized to control
group. No occurrence of convulsions was observed in any
case of severe preeclampsia in either of our study groups,
after stopping postpartum MgSO4 infusion irrespective
of duration of therapy, i.e., 0 hr/24 hours, which may
be because our study size was small. Larger trials may
be needed to assess the effectiveness of short-course
postpartum MgSO4 therapy. A similar result with 0%
seizure incidence had been reported by Jiraphol et al.4
In another study by Ranganna et al,8 rate of occurrence
of convulsions was 2% in both study and control group.
The mean amount of MgSO4 used in the study group,
i.e., 12.6 ± 8.3 gm, was very less as against 42.3 ± 7.3 gm
used in the 24-hour therapy group. In our study, by reduc-
ing the duration of MgSO4 infusion, we have achieved
reduction in the total amount of MgSO4 gone, thereby
safeguarding the patients against the untoward effects
of MgSO4 toxicity, which could be beneficial to patients
with higher serum creatinine values as well; however, this
needs further study. In the study group, patients had an
early removal of Foley’s catheter with a mean duration
Table 1: Baseline characteristics
Group A (n = 48) Group B (n = 43) t-value Signicance
Age (years) 24.90 ± 4.2 25.8 ± 4.7 0.95 NS
Gravidity
1 28 20 52.7
2–4 14 14 30.7
5 6 9 16.6
Gestational age at delivery (weeks) 37.04 ± 3.1 37.2 ± 3.5 0.27 NS
Systolic blood pressure (SBP) on admission (mm Hg) 176.8 ± 15.2 172.9 ± 10.2 1.4 NS
Diastolic blood pressure (DBP) on admission (mm Hg) 112.3 ± 9.9 111.1 ± 5.2 0.70 NS
Platelet on admission
Aspartate aminotransferase (AST)/alanine
aminotransferase (ALT) on admission
SBP on discharge (mm Hg) 117.17 ± 5.56 115.26 ± 5.11 1.7 NS
DBP on discharge (mm Hg) 80.1 ± 5.3 79.3 ± 5.0 0.72 NS
Platelet on discharge
AST/ALT on discharge
NS: Not signicant
Table 2: Secondary outcome
Group A Group B t-value Signicance
Amount of MgSO4 (gm) 12.6 ± 8.3 42.3 ± 7.3 18.5 p < 0.001
Duration of Foley catheterization (hours) 10.9 ± 8.7 38.3 ± 7.3 16.1 p < 0.001
Duration of monitoring (hours) 8.5 ± 8.2 38.4 ± 7.2 18.6 p < 0.001
Hospital stay (days)
Vaginal delivery 2.82 ± 0.77 4.04 ± 1.47 3.8 p < 0.001
Cesarean 5.05 ± 1.96 11.11 ± 3.14 7.1 p < 0.001
of 10.9 ± 8.7 hours, which further helped mothers in early
mobilization, whereas, the risk of infection prevails with
prolonged Foley’s catheterization as in patients of control
group where the mean duration was 38.3 ± 7.3 hours.
With an intention to decrease the duration of monitoring
and hospital stay of the patient, our study speculates that
shortened duration of MgSO4 decreases the overall cost of
treatment, unnecessary exposure to iatrogenic infections,
and allows better utilization of available health resources,
where the mean duration of monitoring in study group
was 8.5 ± 8.2 hours, whereas in control group, the mean
value is 38.4 ± 7.2 hours.
CONCLUSION
Evidence-based medicine accepts MgSO4 to be the prime
drug in the management of women with severe pre-
eclampsia. With a conation to reduce overall burden of
health care system and provide patient congenial manage-
ment, we conclude that reducing the duration of MgSO4
infusion in patients with severe preeclampsia to 0 hour
postpartum is as effective as conventional 24 hours of
infusion as in Zuspan regimen. Although larger random-
ized trials in multiple centers are needed before making a
definitive guideline, the findings of our study support the
use of reduced duration of MgSO4 therapy for preventing
convulsions in severe preeclampsia.
Maternal Outcome with Discontinuation of Magnesium Sulfate immediately Postpartum in Severe Preeclampsia
Journal of South Asian Federation of Obstetrics and Gynaecology, April-June 2017;9(2):84-87 87
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ACKNOWLEDGMENT
The authors take this opportunity to thank all the patients
without whose cooperation the study could not have been
conducted, and they also appreciate the Almighty God
for the divine intervention in this academic endeavor.
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Article
Background: Randomised trials and their syntheses in meta-analyses offer a unique opportunity to assess the frequency and severity of adverse reactions. Objective: To assess safety reporting in pre-eclampsia trials. Search strategy: Systematic search using bibliographic databases, including Cochrane Central Register of Controlled Trials, Embase, and MEDLINE, from inception to August 2017. Selection criteria: Randomised trials evaluating anticonvulsant or antihypertensive medication for pre-eclampsia. Data collection and analysis: Descriptive statistics appraising the adequacy of adverse reaction and toxicity reporting. Main results: We included 60 randomised trials. Six trials (10%) were registered with the International Clinical Trials Registry Platform, two registry records referred to adverse reactions, stating "safety and toleration" and "possible side effects" would be collected. Twenty-six trials (43%) stated the frequency of withdrawals within each study arm and five (8%) trials adequately reported these withdrawals. Adverse reactions were inconsistently reported across eligible trials: 24 (40%) reported no serious adverse reactions and 36 (60%) reported no mild adverse reactions. The methods of definition or measurement of adverse reactions were infrequently reported within published trial reports. Conclusions: Pre-eclampsia trials regularly omit critical information related to safety. Despite the paucity of reporting, randomised trials collect an enormous amount of safety data. Developing and implementing a minimum data set could help to improve safety reporting, permitting a more balanced assessment of interventions considering the trade-off between the benefits and harms. This article is protected by copyright. All rights reserved.
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Objectives:To compare the benefits and risks of shortened postpartum magnesium sulfate with traditional 24 hours postpartum magnesium sulfate for treatment of severe preeclampsia and evaluate reinitiation rate of magnesium sulfate and eclamptic seizure after shortened treatment.Materials and Methods: We recruited labouring pregnant patients in their 2nd to 3rd trimester who were diagnosed as preeclampsia (blood pressure ≥ 140/90 mmHg plus urine protein dipstick ≥ 1+) between March 1st, 2009 and February 28th, 2010. Inclusion criteria for severe preeclampsia were (1) blood pressure ≥ 160/110 mmHg, (2) urine protein dipstick ≥ 2+, (3) severe headache and blurred vision, (4) epigastric pain and willing to be enrolled in the study. Exclusion criteria were (1) platelet count
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Objective To compare the use of magnesium sulfate for 12 hours versus 24 hours in postpartum women with stable severe pre-eclampsia. Methods In 2011, an open randomized clinical trial was conducted with 120 postpartum women with severe pre-eclampsia who gave birth at a tertiary hospital in Brazil; 60 women received magnesium sulfate for 24 hours and 60 for 12 hours. The analysis was by intention-to-treat and the intervention was not masked. Results Abbreviated (12-hour) magnesium sulfate therapy was associated with less exposure to the drug, and clinical outcomes were similar in both groups. No woman developed eclampsia and there was no need to re-initiate treatment after completing the scheduled magnesium sulfate therapy in either group. Magnesium sulfate therapy was extended in only three women in the 12-hour group. In addition, in this group, significant reductions were found in the duration of postpartum use of an indwelling bladder catheter, the time to ambulation, and the time to maternal contact with the newborn. Conclusion Abbreviated postpartum magnesium sulfate therapy in patients with stable severe pre-eclampsia was associated with less drug exposure, similar outcomes, and benefits such as a reduction in the time to contact with the newborn. Clinical trials registration: clinicaltrials.gov NCT1408979
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Continuing the administration of magnesium sulphate for 24 hours after the last fit in patients with eclampsia is at best empirical. The challenge of such a regimen is enormous in low-resource countries. The objective of this study was to assess the effectiveness of an ultra-short regimen of magnesium sulphate in eclamptics. This was a prospective, cohort study of eclamptic patients admitted between July 2007 and June 2008 that were given 4 grams magnesium sulphate intravenously and 10 grams intramuscularly (5 grams in each buttock) as the sole anticonvulsant agent. Main outcome measure was the absence of a repeat fit. Other aspects of eclampsia management were as in standard practice. One hundred and twenty one (121) patients were managed with this regimen. There were 29 ante partum, 76 intrapartum and 16 post partum cases of eclampsia. Most of the patients were primigravidae (100; 83%) with an average age of 18.7 years. There were nine cases (7.4%) of recurrent fits that occurred within four hours of the loading dose. One recurrent fit occurred in the ante partum group, seven in the intra partum and one in the post partum group. There were 12 maternal deaths giving a case fatality rate of 9.9%. Limiting the dosage of magnesium sulphate to 14 grams loading dose (4 grams intravenous and 10 grams intramuscular) was effective in controlling fits in 92.6% of cases in the study group. A properly conducted, randomized controlled trial is needed to test our proposed regimen.
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Objective: To assess the effectiveness of a reduced duration (12hours) of magnesium sulfate (MgSO4) administration for eclampsia. Methods: In a prospective randomized study, women with eclampsia (prepartum, intrapartum, or postpartum) attending Jawaharlal Nehru Medical College, Aligarh, India, between January 2012 and September 2013 were enrolled. The inclusion criteria were blood pressure of at least 140/90mm Hg after 20weeks, proteinuria (dipstick value≥+1), and seizures not attributed to other causes. Participants were assigned to control and study groups according to the time of enrollment (6-month blocks). All patients received a MgSO4 loading dose (4g, intravenously), followed by maintenance doses (1g/hour) for 12hours (study group) and 24hours (control group). The primary outcome was recurrent convulsions after completion of MgSO4 therapy. Patients with treatment failure were excluded from analyses. Results: Analyses included 132 patients in the study group and 72 patients in the control group. No convulsions recurred in either group after the completion of treatment. Conclusion: For women with eclampsia, 12hours of magnesium sulfate could effectively prevent recurrent convulsions.
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To estimate the change in the diagnostic prevalence of preeclampsia after introduction of revised definitions of preeclampsia in the 2013 ACOG Report of the Task Force on Hypertension in Pregnancy. A multicenter, prospective, observational study was conducted in 24 maternity units in North America of women with suspected preeclampsia. Subjects were enrolled in gestational age blocks between 20 and 41weeks, and were managed according to local protocols. Final diagnoses were adjudicated by an independent expert panel. Preeclampsia (PE) was defined as Traditional (TrPE, both hypertension and proteinuria, ACOG, 2002), or Revised (RePE, hypertension with either proteinuria or ⩾1 severe feature, ACOG, 2013). Standard definitions of Chronic (CH) and Gestational (GH) hypertension were unchanged. Subjects who did not meet any definition were classified as No Disease (NoD). 1223 subjects with signs or symptoms of preeclampsia were followed through delivery. At, enrollment, 980 subjects (80.1%) had hypertension (67% new onset; 33% worsening hypertension) and 602 (49.2%) had new onset proteinuria. 395 (32.3%) reported headaches or visual changes and 80 (6.5%) had RUQ pain. After adjudication of final diagnosis, 120 subjects (9.8%) had GH, 74 (6.1%) had CH, and 199 (16.3%) had NoD. 661 (54.0%) pregnancies met criteria for TrPE, while 794 (64.9%) met criteria for RePE, an increase of 20.1% (p<0.05). At term (>37weeks), the number of subjects meeting criteria for preeclampsia increased from 81 (33.5%) with TrPE to 119 (49.2%) with RePE, a 46.9% increase, due primarily to an increase in the prevalence of preeclampsia without proteinuria. Redefining preeclampsia by the revised 2013 ACOG criteria will increase the diagnostic prevalence of preeclampsia by 20%. The effect of this diagnostic change on rates of intervention (hospital admission, laboratory testing, and iatrogenic delivery) and prevention of adverse outcome, remains to be determined. D. Woelkers: None. J. Barton: None. P. von Dadelszen: None. B. Sibai: None. Copyright © 2014.
Article
Anticonvulsants are used for pre-eclampsia in the belief they prevent eclamptic convulsions, and so improve outcome. Evidence supported magnesium sulphate as the drug to evaluate. Eligible women (n=10141) had not given birth or were 24 h or less postpartum; blood pressure of 140/90 mm Hg or more, and proteinuria of 1+ (30 mg/dL) or more; and there was clinical uncertainty about magnesium sulphate. Women were randomised in 33 countries to either magnesium sulphate (n=5071) or placebo (n=5070). Primary outcomes were eclampsia and, for women randomised before delivery, death of the baby. Follow up was until discharge from hospital after delivery. Analyses were by intention to treat. Follow-up data were available for 10,110 (99.7%) women, 9992 (99%) of whom received the allocated treatment. 1201 of 4999 (24%) women given magnesium sulphate reported side-effects versus 228 of 4993 (5%) given placebo. Women allocated magnesium sulphate had a 58% lower risk of eclampsia (95% CI 40-71) than those allocated placebo (40, 0.8%, vs 96, 1.9%; 11 fewer women with eclampsia per 1000 women). Maternal mortality was also lower among women allocated magnesium sulphate (relative risk 0.55, 0.26-1.14). For women randomised before delivery, there was no clear difference in the risk of the baby dying (576, 12.7%, vs 558, 12.4%; relative risk 1.02, 99% CI 0.92-1.14). The only notable difference in maternal or neonatal morbidity was for placental abruption (relative risk 0.67, 99% CI 0.45-0.89). Magnesium sulphate halves the risk of eclampsia, and probably reduces the risk of maternal death. There do not appear to be substantive harmful effects to mother or baby in the short term.
Magpie Trial Collaboration Group. Do women with pre-eclampsia, and their babies, benefit from magnesium sulfate? The Magpie Trial: a randomized placebo controlled trial
  • D Altman
  • G Carroli
  • L Duley
  • B Farrell
  • J Moodley
  • J Neilson
  • D Smith
Altman D, Carroli G, Duley L, Farrell B, Moodley J, Neilson J, Smith D. Magpie Trial Collaboration Group. Do women with pre-eclampsia, and their babies, benefit from magnesium sulfate? The Magpie Trial: a randomized placebo controlled trial. Lancet 2002 Jun;359(9321):1877-1890.
Hypertensive disorders.” Williams’ obstetrics
  • F G Cunningham