Pembimbing : dr.

Ajeng Normala, SpOG

Dibuat oleh :
Keisha Maeko 406171033
Kevin Rayadi 406171034

FAKULTAS KEDOKTERAN UNIVERSITAS TARUMANAGARA

KEPANITERAAN KLINIK ILMU KEBIDANAN DAN KANDUNGAN
RSUD CIAWI
PERIODE 8 JANUARI – 17 MARET 2018
 Abstract
Background

 Magnesium Sulphate (MgSO4) has been recommended for fetal
neuroprotection to prevent cerebral palsy.

 Discussion about MgSO4 for eclampsia for fetal

neuroprotection couldn’t occur distinct from MgSO4 for
eclampsia prophylaxis and treatment.

 In order to explore standarization of MgSO4 use in Canada,

they sought to compare local protocols for eclampsia and fetal
neuroprotection across tertiary perinatal centres.
 Abstract
Methods

 Twenty-five Canadian tertiary perinatal centres were asked to
submit their protocols for use of MgSO4 for eclampsia
prophylaxis/ treatment and fetal neuroprotection.

 Descriptive analyses were used to compare site protocols with

known definitions of preeclampsia. Data from CPN ( Canadian
Perinatal Network) were used to verify what was done in
clinical practice
 Abstract
Results

 22 of 25 centres submitted protocols for eclampsia
prevention/treatment. Eleven of these provide definition
of preeclampsia that warranted treatment; 5 of the 22
advised treatment of severe preeclampsia only

 From 635 women with pre-eclampsia, 422 (66.5%)

received MgSO4. 20 of 25 centres provide protocols for
fetal neuroprotection
 Abstract
Conclusions

 This study suggests that local protocols are often inconsistent with

published evidence. While this may be related to local institutional

practices, relevant processes must be put in place to maximize

uniformity of practice and improve patient care.

 Introduction

Magnesium sulphate (MgSO4) has long been used in
obstetrics for prophylaxis and treatment of
preeclampsia and eclampsia, and historically as a
tocolytic for preterm labour.
Recently..

MgSO4 has been advocated for fetal neuroprotection in

the preterm infant to decrease the risk of cerebral palsy.
 Introduction

 Canadian Institutes of Health Research and designed promoted
the implementation of “Magnesium sulphate for fetal
neuroprotection” in Canadian tertiary perinatal centres

 In order to explore existing standardization of MgSO4

administration in Canadian Tertiary perinatal centres, we
undertook a comparative analysis of MgSO4 protocols for
preeclampsia/eclampsia and fetal neuroprotection
 Methods
 25 tertiary perinatal centres was asked to submit MgSO4 protocols for


eclampsia prophylaxis and treatment and for fetal neuroprotection ( From

May 2012 to May 2013 ).Between January and June 2014, the centres were

contacted to obtain any subsequent update protocols.

The Information included:

• Date of protocol, definition of indications for treatment, routes of MgSO4

administration, Availability of pre mixed bags of MgSO4 and concentration used,

loading and maintanance dosage and duration of treatment, maternal and fetal

monitoring and its frequency, abnormal signs requiring physician attention and any

antidote for toxicity

 Methods

 Descriptive analysis were used to describe site protocol
recommendations; they were then compared with the
1997 and 2008 definition of preeclampsia
 Current recommendations to use MgSO4 for eclampsia
prevention and treatment:
- IA for women with severe Preeclampsia and IC for women
with non severe preeclampsia (Canadian Task Force on
preventing Health Care)
- MgSO4 4gr IV, followed by 1g/hour IV untul 24 hours of
delivery (MgSO4 dosing regimens of the 2002 Magpie Trial)
 Methods

 They examined the data from preeclampsia women
who received MgSO4 for eclampsia prevention or
treatment including gestational age, characteristics of
preeclampsia, primary indication for admission,
route of administration of MgSO4, maternal
outcomes, administration of anticonvulsants and
whether calcium gluconate was administered
 Methods

 Desciriptive analyses were undertaken to describe who
received MgSO4 in these centres, and how their
characteristics compared with both their local institutional
protocol and the 2008 recommendations by the SOGC.

 Ethics approval for this qualitiy assurance project was

obtained centrally from the University of British
Columbia Research Ethics Board and at each study site
 Results

 Preeclampsia/ Eclampsia Prophylaxis protocols
- Out of 25 Canadian tertiary perinatal centres, 22 of them
submitted one or more protocols describing MgSO4 for either
eclampsia prevention, treatment and fetal neuroprotection.
 Eclampsia Prevention/Treatment
- From 25 Canadian tertiary perinatal centres 22 sites (80%)
responded and provided protocols for eclampsia prevention/
treatment. The protocols were approved locally between 2002 and
2012. Fifteen protocols (68,2%) were approved after publication of the
2008 SOGC HDP guidline.
 Results

 A definition of preeclampsia warranting treatment
with MgSO4 was provided by 11/22 eclampsia
prevention treatment protocols (50%), 6 protocols
advised treatment of any preeclampsia, 5 protocols
advised treatment only in severe preeclampsia
 Results

 The “adversed conditions” specified were usually
maternal symptoms or signs like headache and
epigastric abdominal pain were the most frequent
symptomps, and pulmonary edema and
hypereflexia/clonus the most common signs. Fewer
protocols specified abnormal laboratory test or fetal
signs as indicaitons for MgSO4.
 Results

 All sites outlined an intravenous option for loading and
maintenance doses for eclampsia prophylaxis, only 3 sites
included an intramuscular option

 All protocols specified a loading dose of 4g, given over 15

to 30 minutes. Maintenance dosing was usually 1g/ hour

 The duration of maintance therapy was for 24 hours

postpartum when it was specified.
 Results

 5 protocols are specified to routine testing of serum
magnesium and 6 other protocols recommended
measuring serum magnesium levels under certain
circumstances.
 An antidote for magnesium toxicity usually 1g of IV
Calcium gluconate was listed by almost of all, but 1
protocol doesn’t include it.
 Results

 For eclampsia treatment only 11 protocols specified
MgSO4 dosing (2g IV) to administer if eclampsia
developed.

 3 sites with protocols also listed the use of diazepam

control seizures if necessary
 Results

 Fetal neuroprotection protocols

- They received a total of 20/25 protocols were finalized

- One site representative disclosed that they didn’t use

MgSO4 for fetal neuroprotection.

- Protocols indicated treatment for preterm birth with a

gestational age specified from 23 to 24 weeks through 39
weeks.
 Results

- All protocols outlined IV administration of MgSO4
without specifying an IM option, and a loading dose of 4g
over 10-30 minutes.

- Maintenance dosing was usually 1g/hour until delivery

- Three sites omitted the need to monitor fluid balance.

- All but one protocol listed calcium gluconate as an

antidote for magnesium toxicity
 Results

 Canadian Perinatal Network Data
- 635 women were admitted with preeclampsia , 546 women
(85,9%) have BP >160/110 mmHg

- 602 (94,8%) women have urine test and 367 (57,8%) have 3+
proteinuria dipstick, or >3g/day

- 174 (27,4%) women were considered severe preeclampsia

- There were no maternal death as well as sepsis

72 women who delivered at <32 weeks received MgSO4 for fetal

neuroprotection
 Discussion

 Many guidelines lacked sufficient detail to guide
maternity care providers in the use of MgSO4, and several
contained misinformation included routine monitoring of
serum magnesium levels and use diazepam to treat
seizure.
 There was more consistency among fetal neuroprotection
protocols, which generally followed the
recomemendations of the 2011 SOGC guidelines.
 Discussion

 There were some inconsistencies apparent between local protocols and
local CPN data for preclampsia.

1. The number of women with pre-eclampsia or severe preeclampsia who

were treated with MgSO4 was similar regardless of the relevant
recommendation in the local protocols, clinicians appear to be
uncomfortable if they do not treat most women with non-severe disease,
and are barely able to reach the goal of treating at least 80% of women
with severe disease. These controversies remained unsolved

2. In the single centre used phenytoin to treat eclamptic seizure, there was
no recommendation to do in the relevant local protocol.
 Discussion

 The major strength of our study is that it provided a
comprehensive review of MgSO4 protocols for eclampsia
prevention and treatment and fetal neuroprotection derived
from academic perinatal centres, which have processes in place
for standardization and quality improvement.

 A limitation of the study is that all protocols were included and

included protocols in draft from, after that Before 1st April 2011
the CPN database didn’t record MgSO4 dose and duration of
therapy.
 Conclusion

 Administration of MgSO4 for eclampsia prevention and treatment and for
fetal neurprotection is one of the few interventions in obstetrics for which,
there are highest-level recommendations based on high quality
randomized controlled trials.

 The use of MgSO4 for eclampsia prevention and treatment are often at
variance with the published evidence and specific guidance from the
SOGC, although this variance may relate in part to local instiutional
culture and practice patterns, patient care must not be compromised,and
maximizing uniformity of practice will facilitate audit and feedback to
improve care overall

 Institution need to put relevant processes for use of MgSO4 in place

