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Benefits of using magnesium sulphate (MgSO4) for eclampsia management and maternal mortality reduction: lessons from Kano State in Northern Nigeria
Ekechi Okereke, Babatunde Ahonsi, Jamilu Tukur, Salisu Ishaku, Ayodeji Oginni
BMC Research Notes , 2012, DOI: 10.1186/1756-0500-5-421
Abstract: This retrospective study, including 1045 patients with eclampsia and pre-eclampsia during the years 2008 and 2009, reports a drop in case fatality rates from 20.9% (95% CI: 18.7, 23.2) to 2.3% (95% CI: 1.4, 3.2) among eclampsia patients following the MgSO4 intervention. The study observed no significant difference in the cost of using MgSO4 therapy compared to diazepam therapy.The study found a remarkable reduction in case fatality rate due to eclampsia in those who received MgSO4 therapy with minimal increase in costs when compared to diazepam therapy. Concerted efforts should be focused on properly introducing MgSO4 into emergency obstetric protocols especially within developing countries to reduce maternal mortality and also impact on health system performance.Maternal mortality in the developing world is receiving increasing attention in recent years [1-4] and significantly it is a key emphasis of the Millennium Development Goals (MDGs). The World Health Organization (WHO) reports that hemorrhage/bleeding, infections, unsafe abortions and eclampsia are common causes of maternal mortality especially in developing countries [5]. Severe pre-eclampsia and eclampsia-related deaths are common causes of preventable maternal deaths with 99% of these deaths occurring in low and middle income countries [6,7].Eclampsia is a major cause of maternal morbidity and mortality in Nigeria. It was reported to have contributed to 46.3% of maternal deaths in Kano State [8] and 43% of maternal deaths in Jigawa State [9]. These figures indicate remarkably high rates of maternal mortality with high contributions from eclampsia-related maternal deaths in northern Nigeria.WHO has recommended the use of magnesium sulphate (MgSO4) as a safe and low-cost drug to manage severe pre-eclampsia and eclampsia cases [10]. Studies have shown that the drug significantly lowers the possibility of seizures in women with severe pre-eclampsia or eclampsia, prevents progression from severe pre-eclampsia
Magnesium sulphate therapy in eclampsia: the Sokoto (ultra short) regimen
Bissallah A Ekele, Danjuma Muhammed, Lawal N Bello, Ibrahim M Namadina
BMC Research Notes , 2009, DOI: 10.1186/1756-0500-2-165
Abstract: 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.Pre-eclampsia and eclampsia account for about 9% of maternal deaths in Africa and Asia and about one-quarter of maternal deaths in Latin America and the Caribbean [1]. In some parts of northern Nigeria, eclampsia alone contributes to almost one third of maternal mortality [2-4]. It is has been established that magnesium sulphate is the anticonvulsant of choice for both prevention and treatment of eclampsia [5,6]. But the routine 24-hour administration of maintenance doses of magnesium sulphate after a loading dose to all patients with eclampsia [7,8] has not been properly subjected to scientific scrutiny.The exact mechanism of action of magnesium sulphate is also not clearly understood. Some workers have suggested the blockade of N-methyl D-aspartate (NMDA) receptors involved in seizure genesis [9] or calcium channel blocki
Simple and safe heparin regimen for acute ischaemia
Bittencourt, P. R. M.;Padilha, S.;Mazer, S.;
Arquivos de Neuro-Psiquiatria , 1986, DOI: 10.1590/S0004-282X1986000100003
Abstract: the risk/benefit ratio of acute anticoagulation in ischaemic cerebro-vascular disease is not clearly established. a simple and safe intermittent intravenous heparin regimen (20000 iu daily) was used prospectively in 50 patients of 57 ± 14 (m ± sd) years of age whose blood pressures ranged from normal to severe hypertension. twenty-two patients had cardiogenic embolism and the remaining had recurrent severe transient ischaemic attacks of recent onset or progressive cerebral infarcts. time of exposure to heparin was 6.4 ± 4 (m±sd) days. two patients had recurrences of cerebral thromboembolism and none had bleeding complications. this is a safe and efficient method of anticoagulation for patients with cerebral ischaemia when continuous infusion of heparin or close monitoring of clotting times are not used routinely.
ECLAMPSIA
SHAHIDA SHERAZ
The Professional Medical Journal , 2006,
Abstract: Objective: To evaluate incidence, morbidity and mortalityassociated with eclampsia. Design: A prospective study. Place and Duration: The study which was carried out at PAFHospital Rafiqui, Shorkot spanned over a period of 2 years from Jun 2002-Dec 2004. Patients and Methods: Thestudy comprises of 55 eclamptic cases diagnosed out of 3391 consecutive deliveries, carried out in our hospital.Results: The incidence of eclampsia, in this study, was found to be 1.62%. Out of 55 cases 38(69.1%) patients wereprimigravida. Forty three (78.2%) of the patients were between the ages of 21 to 30 years. In 50(90.9%) patientsgestational age was less than 35 weeks. Thirty seven (67.3%) cases had antepartum eclampsia. Forty four (80%)patients received diazepam while the remaining 11(20%) received magnesium sulphate (MgSO4) as anticonvulsant.Commonest mode of delivery was spontaneous vaginal delivery (31 cases, 56.4%) followed by lower caesareansection (21 cases, 38.2%). Fetal loss was seen in 12(20.7%) cases. Two patients died of eclampsia, maternal mortalityrate being 3.6%. Conclusion: Eclampsia is a life threatening complication of pregnancy. However an improvement inantenatal care, upgrading the neonatal facilities and early delivery by cesarean section can improve the perinataloutcome.
ECLAMPSIA
TASNEEM ASHRAF
The Professional Medical Journal , 2004,
Abstract: Objective: To evaluate incidence, morbidity andmortality associated with Eclampsia. Design: Prospective study of 98 cases of eclampsia. Setting: departmentof obstetrics and gynaecology unit II Bolan Medical Collage Complex Quetta. Patients: 98 cases were admittedwith eclampsia during two years and six months period from 1st June 2001 to December 2003. Results: Totalno of admissions were 6952. 98 patients presented with eclampsia making a frequency of 1.40%. Of these 98cases of eclampsia 58 % were primigravidas, mean age of eclamptic patients was 34 years. Gestational age atadmission was less than 35 weeks in 80(78.4%) cases. 54(55%) patients had intrapartum eclampsia.64 (66.7%)patients received diazepam and rest received Magnesium sulphate as anticonvulsant. Caesarean section was donein 10 (11.49%) cases rest delivered vaginally. Fetal loss was seen in 72(82.75%) patients, while 7(7.14%) mothersdied of eclampsia. Conclusion: Maternal and perinatal mortality and morbidity is very high in eclempticpatients. Magnesium sulphate is good anticonvulsant, helpful in reducing maternal morbidity and mortalityconsiderably. Good antenatal practices, maternal education and awareness, provision of better health facilitiesand their utilization will definitely improve maternal and fetal outcome.
Raltegravir-based post-exposure prophylaxis (PEP): a safe, well-tolerated alternative regimen
D Annandale,C Richardson,M Fisher,D Richardson
Journal of the International AIDS Society , 2012, DOI: 10.7448/ias.15.6.18165
Abstract: Three-drug regimens are routinely recommended in the UK for PEP after possible high-risk exposure to HIV. The current Department of Health and British Association for Sexual Health and HIV first-line regimen is lopinavir/ritonavir, tenofovir and emtricitabine (Truvada). Raltegravir-based regimens may be used as an alternative. This is a review of the use of raltegravir-containing PEP to identify why and when this is initiated and its tolerability and safety compared to first-line PEP. From February 2010 to April 2012, 509 courses of PEP were prescribed; 33 (6.5%) raltegravir-containing PEP. Pharmacy records identified eligible patients; these were compared to 33 courses of first-line PEP in the same time period. 18/33 (54%) of raltegravir-containing PEP were initiated due to potential drug-drug interactions with ritonavir, 3/33 (10%) due to the resistance profile of the contact and 12/33 (36%) due to intolerance of first-line regimen. All switches to raltegravir-based PEP occurred by day 3 of the course with 83% identified on day 1. All switches to raltegravir-containing PEP due to the resistance profile of the contact took place by day 3 of the course. Patients switching due to drug intolerance was largely due to gastrointestinal side effects between days 1 to 16; 2 cases were due to ALT changes. 19 courses of raltegravir-containing PEP were commenced on day one. Reported side effects in the raltegravir-containing PEP were lower than courses of first-line PEP: 10/19 (53%) patients reported no side effects by day 28 treatment compared to 5/33 (15%) patients on first-line PEP. 12/14 (79%) patients on first-line PEP who were switched to raltegravir-containing PEP reported improvement in their side effects. There were no significant liver or renal toxicities in the raltegravir group; 3 patients on first-line PEP had a significant ALT rise. One patient who started first-line PEP was found to be HIV-positive at baseline. An MSM who received raltegravir-containing PEP seroconverted 4.5 months after the course of PEP. He reported 3 episodes of unsafe sexual behaviour since PEP. Raltegravir-based regimens are safe and as well tolerated when compared to first-line regimen. Switching to raltegravir-based regimen is associated with a decrease in reported side effects. Self-reported adherence is better if patients are started on raltegravir. This study suggests that raltegravir-based PEP may be a preferred first-choice regimen.
Treatment of refractory seizures in eclampsia with propofol: A case report  [cached]
Dam A,Mishra J,Shome P
Indian Journal of Critical Care Medicine , 2003,
Abstract: We describe the management of a case of refractory status epilepticus evolving in post-partum eclampsia. The seizures were refractory to therapy with benzodiazepines, MgSO4, barbiturates and phenytoin, but responded rapidly to propofol infusion.
The use of magnesium sulphate for the treatment of severe pre-eclampsia and eclampsia
J Tukur
Annals of African Medicine , 2009,
Abstract: Background : Pre-eclampsia and eclampsia are important causes of maternal and perinatal morbidity and mortality in the developing countries. There is need to provide the most effective management to pre-eclamptic and eclamptic patients. There is now evidence that magnesium sulphate is the most effective anticonvulsant. Method : In this article , a literature review was made on the contribution of pre-eclampsia and eclampsia to maternal mortality and how it can be curtailed by the use of magnesium sulphate. Results : The drug is administered by the Pritchard or Zuspan regimen, although modifications in the two protocols have been reported. Conclusion : A Nigerian national protocol has been developed on its use. There is need for further training of health workers on how to use this important drug.
The use of magnesium sulphate for the treatment of severe pre-eclampsia and eclampsia  [cached]
Tukur Jamilu
Annals of African Medicine , 2009,
Abstract: Background : Pre-eclampsia and eclampsia are important causes of maternal and perinatal morbidity and mortality in the developing countries. There is need to provide the most effective management to pre-eclamptic and eclamptic patients. There is now evidence that magnesium sulphate is the most effective anticonvulsant. Method : In this article , a literature review was made on the contribution of pre-eclampsia and eclampsia to maternal mortality and how it can be curtailed by the use of magnesium sulphate. Results : The drug is administered by the Pritchard or Zuspan regimen, although modifications in the two protocols have been reported. Conclusion : A Nigerian national protocol has been developed on its use. There is need for further training of health workers on how to use this important drug.
Health System Barriers to Access and Use of Magnesium Sulfate for Women with Severe Pre-Eclampsia and Eclampsia in Pakistan: Evidence for Policy and Practice  [PDF]
Maryam Bigdeli, Shamsa Zafar, Hafeez Assad, Adbul Ghaffar
PLOS ONE , 2013, DOI: 10.1371/journal.pone.0059158
Abstract: Severe pre-eclampsia and eclampsia are rare but serious complications of pregnancy that threaten the lives of mothers during childbirth. Evidence supports the use of magnesium sulfate (MgSO4) as the first line treatment option for severe pre-eclampsia and eclampsia. Eclampsia is the third major cause of maternal mortality in Pakistan. As in many other Low- and Middle-Income Countries (LMIC), it is suspected that MgSO4 is critically under-utilized in the country. There is however a lack of information on context-specific health system barriers that prevent optimal use of this life-saving medicine in Pakistan. Combining quantitative and qualitative methods, namely policy document review, key informant interviews, focus group discussions and direct observation at health facility, we explored context-specific health system barriers and enablers that affect access and use of MgSO4 for severe pre-eclampsia and eclampsia in Pakistan. Our study finds that while international recommendations on MgSO4 have been adequately translated in national policies in Pakistan, the gap remains in implementation of national policies into practice. Barriers to access to and effective use of MgSO4 occur at health facility level where the medicine was not available and health staff was reluctant to use it. Low price of the medicine and the small market related to its narrow indications acted as disincentives for effective marketing. Results of our survey were further discussed in a multi-stakeholder round-table meeting and an action plan for increasing access to this life-saving medicine was identified.
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