Title: All Seizures Stop…Eventually (Magnesium and Eclampsia)
A healthy 23 year old woman presents 37 weeks pregnant seizing. She has no history of seizures, drugs, trauma, illness, etc. You are addressing the A, B, Cs and the nurses asks “what med do you want to stop the seizure”?
- Ativan 2mg IV
- Diazepam 10mg IV
- Phenytoin 20mg/kg IV
- MgSO4 4g IV
- Hide in Bathroom
- visual scintillations and scotomata (occipital cortical ischemia)
- presistent headaches (cerebral ischemia or edema)
- right upper quadrand pain (capsular irritation secondary to hepatic necrosis and/or hematoma)
- shortness of breath or chest pain (secondary to non-cardigenic pulmanary edema)
While pre-eclampsia is fairly common, eclampsia is a fairly rare complications. Interestingly, only 20% of women with eclampsia have documented HTN in the week before their seizure, 10% will only have proteinuria and 10% will have neither. Eclampsia typically occurs in the second half of pregnancy or during labor. However, it can still occur after the birth.
The prevention and treatment of pregnancy induced HTN and pre-eclampsia are beyond the scope of this podcast. For more information please visit the Society of Obstetricians and Gynecologists of Canada (SOGC) Guidelines on the topic: Diagnosis, Evaluation and Management of the Hypertension Disorders of Pregnancy.
What is the better treatment for eclampsia, magnesium sulphate or diazepam?
Duley L, Henderson-Smart DJ, Walker GJA, Chou D. Magnesium sulphate versus diazepam for eclampsia. Cochrane Database of Systematic Reviews 2010, Issue 12. Art. No.: CD000127. DOI: 10.1002/14651858.CD000127.pub2.
- Population: Seven trials in low-to middle income countries with 1386 women with eclampsia.
- Intervention: MgSO4 4g IV loading dose followed by 1g/hr infusion vs. diazepam 40mg IV loading dose followed by an infusion of 20mg/500ml titrating to effect.
- Analyses: Death, recurrence of seizures, stroke or any serious morbidity
- 41% relative risk reduction in death with MgSO4
- 57% relative risk reduction in recurrence of seizures MgSO4
Evidence Based Medicine:
Forest Plots: “A graphical display designed to illustrate the relative strength of treatment effects in multiple quantitative scientific studies addressing the same question. It was developed for use in medical research as a means of graphically representing a meta-analysis of the results of randomized controlled trials.”
The mechanism of action for magnesium suphate to treat eclampsia is not clearly understood. Infusion of magnesium can cause serious reactions such as cardiovascular collapse and respiratory paralysis.
Magnesium is also recommended as prophylasis against eclampsia in women with severe pre-eclampsia (TheNNT).
“Magnesium sulphate for women with eclampsia reduces the risk ratio of maternal death and of recurrence of seizures, compared with diazepam.”
BEEM Bottom Line:
Delivery of the baby is the only definitive treatment for pre-eclampsia or eclampsia. However, giving magnesium sulphate 4g IV loading dose followed by 1gm/hr infusion for 24hrs saves lives and prevents further seizures in women with eclampsia.
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This weeks Keener Kontest question is what book did the quote “Don’t Panic” come from?
Email your answer to TheSGEM@gmail.com or go to the “Contact Us” link at the top of the home page. Use “Keener Kontest” in the subject line. First one to email me the correct answer will win a cool skeptical prize:)
Silver Star, BC