Anticonvulsant therapy for eclampsia

Magnesium sulfate is associated with clinically significant reductions in maternal death. It is inexpensive and its administration and monitoring are relatively straightforward. It can be administered intramuscularly when staff with experience in intravenous administration and monitoring are not available.

RHL Commentary by Atallah AN

1. EVIDENCE SUMMARY

This commentary discusses three Cochrane Reviews comparing magnesium sulfate with diazepam, phenytoin and lytic cocktail. The findings of the first two reviews are largely derived from the Collaborative Eclampsia Trial,(1),which was conducted in a total of 25 centres in India, sub-Saharan Africa and Latin America while the lytic cocktail review is based on two trials in India with 198 women.

The use of magnesium sulfate for the care of women with eclampsia was associated with statistically and clinically significant reductions in the recurrence of convulsions compared with diazepam (RR: 0.44; 95% CI: 0.34 to 0.57), phenytoin (RR: 0.31; 95% CI: 0.20 to 0.47) and lytic cocktail (RR: 0.09; 0.03 to 0.24).

Magnesium sulfate is associated with clinically significant reductions in maternal death when compared to diazepam (RR: 0,59; 95% CI: 0.37 to 0.94), phenytoin (RR: 0.50; 95% CI: 0.24 to 1.05) and lyctic cocktail (RR: 0.25; 95% CI: 0.04 to 1.43). The latter comparison included two trials and a total of 198 women. Therefore the results have a wide confidence interval. Both intramuscular magnesium sulfate regimens(Pritchard) and intravenous (Zuspan) were effective. No adverse effects on the newborn were found.

The methodology of the reviews are sound. All adequately controlled trials that could be identified have been included and appropriately analysed. Two trials in the diazepam review and one trial in the phenytoin review have been included in the recent revision of these two reviews.

2. RELEVANCE TO UNDER-RESOURCED SETTINGS

2.1. Magnitude of the problem

Eclampsia is major health problem in developing countries. It is estimated that every year eclampsia is associated with about 50 000 maternal deaths worldwide, most of which occur in developing countries(2).The incidence of eclampsia is higher in developing countries (1 in 100-1700 deliveries) than in developed countries (1 in 2000 deliveries). This is probably due in particular to pregnant women's lack of easy access to appropriate antenatal care in those settings.

2.2. Applicability of the results

The results of these three reviews would be applicable in under-resourced settings. In fact, except for two small trials conducted in the USA the remaining 14 trials were conducted in developing countries. The Collaborative Eclampsia Trial(1),was a multi-centre trial conducted in 31 centres in 10 developing countries. The findings seem applicable to both antenatal and postnatal women with eclampsia.

2.3. Implementation of the results

Magnesium sulfate is inexpensive and its administration and monitoring are relatively straightforward without a need for expensive equipment. Intramuscular administration can be used when staff with experience in intravenous administration and monitoring is not available.

Magnesium sulfate is also included in WHO Essential Medicines List and in similar lists of many countries. Despite all the evidence supporting its use and inclusion in essential drug lists and international guidelines the availability and utilization of magnesium sulfate seems to be patchy. Active efforts are necessary to find ways of getting magnesium sulfate at health centres.

Once obtained the staff should be trained in the administration and monitoring of magnesium sulfate treatment.

3. RESEARCH

Magnesium sulfate is currently the drug of choice for women witheclampsia and pre-eclampsia.The research in this field should focus on operations research in identifying the barriers to magnesium sulfate availability and utilization and evaluating approaches to overcome those barriers.

Sources of support: Escola Paulista de Medicina Universidade Federal de São Paulo - Brazil Inclen Inc

Acknowledgements: none

References

  • The Eclampsia Trial Collaborative Group. Which anticonvulsant for women with eclampsia? Evidence from the Collaborative Eclampsia Trial. The lancet 1995;345:1455-1463.
  • Duley L. Maternal mortality associated with hypertensive disorders of pregnancy in Africa, Asia, Latin America and the Caribbean. British journal of obstetrics and gynaecology 1992;99:547-553.

This document should be cited as: Atallah AN. Anticonvulsant therapy for eclampsia: RHL commentary (last revised: 14 November 2003). The WHO Reproductive Health Library; Geneva: World Health Organization.