MgSO4 regimens in

ECLAMPSIA……

MAGNESIUM SULPHATE
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ECLAMPSIA

“Like A Flash Of Lightening”
Acute Convulsive Disorder

Hypertension ….Induced
12/1/10

Aggravated ….by

Or…. Pregnancy
22

Best Anticonvulsive
MAGNESIUM SULPHATE

is the drug of choice for routine anti- convulsant management of women with eclampsia, rather than diazepam or phenytoin.
Evidence from the Collaborative Eclampsia Trial. Lancet. 1995 Jun 10. 345(8963). pp 1455-1463.

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33

DIFFERENT MgSO4 REGIMENS …
Ø Ø Ø Ø Ø Ø Ø Ø Ø Ø

Eastman. Pritchard. Chesley & Teppers. Hall, Anderson, Harbert. Flowers. Zuspan. Cruik Shant. Sibai. Sardesai Leens. etc

TOXICITY

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44

‘Hypertensive Disorders . dose > 10 gm Lucas etc. LOW dose regimens: loading dose < 10 gm SINGLE DOSE Regimen: VIMS Regimen ● loading Zuspan. Suman Sardesai etc.MgSO4 Regimens… VIMS classification HIGH dose regimens: Pritchard’s. 12/1/10 55 Joshi Suyajna D.

Pritchard’s regimen LOADING DOSE Loading dose: 4g (20ml of 20%). MAINTENANCE Maintenance dose: 5g (10ml of 50%)is given every 4 hours & alternate sites after assuring 1)Presence of knee reflex 2)Respiratory rate >14/min 3)Urine output 10 12/1/10 66 . ( 10 g ) If convulsion persists over 15 min 2g (10ml of 20%) is given over 2 min.IV -over not less than 3 min followed by 5 g (10 ml of 50%) IM in each buttock.

loading maintenance 4g IV over 5-10 1-2g/hr as IV minutes infusion Zuspan Charles Flowers 4g IV in 250 ml 5g every4-6 hrs of 5% D as IM Chesley -Tepper Eastman 12/1/10 5g every 4th hour given as IM 5g every 4th hour given as IM 5g every 4th hour given as IM 5g every 4th hour given as IM 77 .LOW Dose regimens….

M. Medical College Sholapur 12/1/10 . Loading dose 4g MgSO4 given as IV or IM Maintenance dose 2g given as IV /IM every 3hrs. If convulsions recurred after 15 min additional dose of MgSo4 given 88 In 1997 Suman Sardesai from V.Suman Sardesai….

Issue 9108. Volume 351.” 12/1/10 Which regimen to use 99 ….. Sibai's work.2 and the research at the Parkland Memorial Hospital5 shows that Zuspan's regimen is eight times less effective than Pritchard's regimen in the prevention of convulsions in preeclampsia and eclampsia. Page 1061. Maternal mortality was 2·5 times greater in the women who received Zuspan's regimen than among those on Pritchard's regimen.????? .Pritchard Vs Zuspan Kathleem M Graham The Lancet. 4 April 1998 Magnesium sulphate in eclampsia Review of CET “Examination of the Collaborative Eclampsia Trial.1 Zuspan's regimen should not be used for routine clinical use.

CONVENTIONAL WESTERN REGIMENS: can not be given outside ‘obstetric care units’ 12/1/10 1010 .

Hospital Bellary 12/1/10 1111 . ANTICONVU LSANTS 1979 To 2010 30 years VIMS.GLIMPSES OF ….

M. Shanthi LOW DOSE –Dr.1978-1990 KRISHNA MENON’S REGIMEN PRITCHARD’S OR K.M. 1990-1995 1995-I998 1998-2001 2001-2003 12/1/10 SINGLE DOSE Dr. Veerendrakumar C.REGIMEN PRITCHARD’S …Dr. Noorulameen 1212 .

1979-1990 Ø 1990-1995 l 1995-I998 KRISHNA MENON’S REGIMEN PRITCHARD’S OR K.2 l SDM 12/1/10 1313 .M.1 l l 2004 onwards- ‘SINGLE DOSE Magnesium Sulphate…’ Study.REGIMEN PRITCHARD’S 1998-2001 LOW DOSE or `PRITCHARD’S l2001-2004 SINGLE DOSE OR LOW DOSE Study.

” Surg Gynecol Obstet.Pritchard’s Regimen…. 54 years old ! Pritchard J. 1955. 100: 131–140 12/1/10 1414 .A. “ The use of the magnesium ion in the management of eclamptogenic toxemias.

PRITCHARD’S REGIMEN 1995-1998 ABANDONED AFTER LOADING DOSE ah ! NO CONVULSIONS !!! 12/1/10 1515 .

Low-Dose Regimen… DOSE REDUCED 12/1/10 1616 .

“Low dose magnesium sulphate for eclampsia and imminent eclampsia: regimen tailored for tropical women”.A Low-Dose Magnesium Sulphate Treatment for Eclampsia. J Obstet Gynaecol Ind. IM and 2 gm IM Sardesai Suman. Gynecol Obstet Invest 2009. Comparison of intramuscular magnesium sulfate with low dose intravenous magnesium sulfate regimen for treatment of eclampsia. 35 (1): 119 -125 12/1/10 1717 . Maira Shivanjali. 67:20-24 Joydeb Roy Chowdhury.2 gram IM DOSE SUB-OPTIMAL MgSO4……2 gram IV MgSO4……. Mahajan NN. J Obstet Gynecol Res 2009 Feb.Low…Dose….. Gaikwad NL. Patil uday. Snehamay Chaudhuri. 53: 546-50. Thomas A. Patil Ajit. Pranab Kumar Biswas and Madhabi Panpalia.2 gm.Indian Scenario… MgSO4…. 2003. Soni RN. Nabendu Bhattacharyya.Steady Reduction in dose…. Jain SM:'Padhar Regime' .

INNOVATIONS… “Disciplined use of MgSO4 is difficult to achieve..in ‘resource poor settings’ of developing countries” 12/1/10 1818 .Thinking….

admitted in moribund state… Lopez and Llera 12/1/10 1919 ..Thinking…. Delay in MgSO4 treatment- wrong-treatment referred to tertiary hospitals with no or 13..9% maternal deaths.

Adetoro reported 14.referral without treatment….4% of maternal mortality.. 2020 .Early and –’PROPER” referral is the cornerstone in the success of saving the mother in eclampsia.

FRU At the DOORSTEP 12/1/10 2121 .Safe to follow in any setup.SEARCH for a NEW MgSO4 regimen 1. Easy to monitor 2.

SINGLE DOSE MgSO4 4+4 SUYAJNA JOSHI 1998 12/1/10 2222 .

ONE Convulsion within 30 minutes NO TREATMENT 12/1/10 2323 .

MORE THAN ONE CONVULSION WITHIN 30 MINUTES…… 2 grams of IV MgSO4 12/1/10 2424 .

Convulsions after 30 minutes… 2 grams of IV MgSO4 Can be repeated twice… 12/1/10 2525 .

CONVULSIONS CONTROLLED NOT Switch on to … Phenytoin Sodium regimen 12/1/10 2626 .

359-june 1.IMPLICATIONS OF RESEARCH- Magpie Trial Remaining question about Magnesium Sulphate WHAT IS THE MINIMUM EFFECTIVE DOSE ? THE LANCET-vol.psge-1888 12/1/10 2727 . 2002.

Andrew d weeks. Samuel Ononge The Lancet. 26 October 2002 12/1/10 2828 .Support…came after Magpie… To make magnesium sulphate available to women at risk from eclampsia. a short regimen is suitable for use in underdeveloped countries – ideally this would include a single magnesium sulphate injection. Page 1331.Volume 360.

Bellary SINGLE DOSE LOW DOSE PRITCHARD’S 94 12/1/10 102 28 2929 .1st study……2001 & 2002….2004 admitted in Eclampsia Labour Room - District Hospital . KSOGA -patients Mysore 224 Ø Ø .

2nd Study from 2003-2007 Prospective Observational study Total of 513 cases of eclampsia studied All patients received ‘single dose MgSo4’ 12/1/10 3030 .

36% 1.77% more than 6 hours 4.6% interval0.16% Recurrence with single dose 1 2 1 3 Convulsion treatment 0.1% 1.5% 2 3131 .Maternal Complications & recurrence with SDM… Complication No of women HELLP 11 syndrome Abruption 10 Cortical venous 7 thrombosis Pulmonary edema Aspiration pneumonia Post partum hemorrhage Cortical blindness Acute renal failure 12/1/10anemia Severe 8 7 6 3 4 23 Percentage (n=513) 2.56% 1.94% 1.3% 1.

Maternal deaths….41% 5.82% 29.in eclampsia Cause No of women ( Percentage n=17) % 10 5 58.88% 5.88% Intracranial hemorrhage Pulmonary edema Ante partum 1 hemorrhage Acute renal failure 1 12/1/10 Convulsiontreatment 3232 .

MgSO4 before referral and after reaching the referral centre.?????? 87. treatment at the doorstep! 12/1/10 3333 .The ‘convulsion-treatment ’ interval..….5% of the patients did not receive any treatment before reaching the referral centre.

SEIZURE -FREE TRANSPORTATION text styles Click to edit Master Second level ● Third level ● Fourth level ● Fifth level ‘MgSO4’ before referral 12/1/10 3434 .

FOGSI PROJECTS Bellary District REACHING & SENSITISING ALL THE 24 X 7 MEDICAL OFFICER’S IN INDIA UNDER SAFE.MOTHERHOOD INITIATIVE EMOC 12/1/10 3535 .

Shimogga… 3636 .Hospet… Koppal… 12/1/10 Gangavathi..

Vijayanagar Institute of Medical Sciences.88 patients) Pritchard regimen July 2009 (group A-80 patients) to June 2010 12/1/10 42 patients came with SDM given at FRU 3737 . Single dose MgSo4 (group B.Study 3….RCT Single dose MgSO4 (VIMS Regimen) Pritchard regimen 168 Eclamptic women admitted to Dept of OBG.

To gain time for the ANTIHYPERTENSIVE to act… ‘ONE ADEQUATE DOSE’ sufficient 12/1/10 is 3838 . To prevent immediate recurrence of convulsions 3.Why Magnesium Sulphate …? 1. To abort an attack of convulsion 2.

Maternal mortality vs MAP MATERNAL MORTALITY CASE `1 CASE 2 Study 3….RCT MAP (mmHg) 120 to 130 > 130 Single dose MgSo4 (VIMS Regimen) Vs Pritchard regimen 12/1/10 3939 .

Recurrence Vs MAP P atients < 120mmHg 120-130mmHg > 130mmHg Single dose MgSo4 (VIMS Regimen) Vs Pritchard regimen 12/1/10 Study 3….RCT 4040 .

RCT 12/1/10 Single dose MgSo4 (VIMS Regimen) Vs Pritchard regimen 4141 .Maternal complications vs MAP Study 3….

5 2.22 12/1/10 4242 .5 100 166 02 168 Total Comparison of maternal deaths between two groups Fischer exact test P – value – 0.Maternal mortality Maternal death VIMS regime N No Yes Total 88 88 % 100 100 Pritchard regime N 78 02 80 % 97.

8 66.80% Toxicity Yes No Total VIMS regime N % 88 88 100 100 - Pritchard regime N % 27 53 80 33.VIMS Vs PRITCHARD’S 2010 Comparison of toxicity between two treatment groups 40% 35% 30% Toxicity 25% 20% 15% 10% 5% 0% 0% Mgso4 regime Groups Pritchard regime Series1 33.2 100 Total 27 141 168 Comparison of toxicity between two groups Fischer exact test P – value – 0.00 12/1/10 4343 .

Loading dose is MORE than necessary 2.What is the problem with PRITCHARD’S REGIMEN 1. Maintenance dose is NOT necessary 12/1/10 4444 .

Maintenance dose is NOT necessary 12/1/10 4545 . ZUSPAN’s 1.What is the problem with LOW DOSE REGIMEN…eg. Loading dose is NOT sufficient 2.

suyajna.TO CONTACT ME suyajna@yahoo. 46 .com www.com JOSHI SUYAJNA D.

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