SDMS ID: P2010/0491-001 2.

17/09WACS Title: Replaces: Description: Target Audience: Key Words: Policy Supported: Magnesium Sulphate (MgSO4) Infusion Magnesium Sulphate (MgSO4) Infusion November 2006 Seizure prophylaxis and/or treatment of eclamptic seizure Midwifery and Medical Staff, Queen Victoria Maternity Unit Eclampsia P2010/0509-001 Management of Eclampsia

Purpose: Eclampsia is an obstetric emergency which requires multidisciplinary management. Anticonvulsants may be used for short-term treatment pending delivery. The suppression of eclamptic seizures does not solve the underlying problems of multi-system disease. Indications for magnesium sulphate infusion: Immediate treatment of an eclamptic seizure Seizure prophylaxis in a women with severe pre eclampsia who is at risk of eclampsia Relative Contraindications Magnesium sulphate can be extremely hazardous in the following circumstances: Renal failure, severe renal compromise or if oliguria is present (magnesium concentration can reach toxic levels as elimination is predominantly renal). Half dose magnesium sulphate should be considered if there is renal compromise. In association with hypocalcaemic stress Myasthenia gravis Cardiac conditions, in particular conduction problems or myocardial damage. Other considerations Magnesium sulphate: May lower blood pressure (secondary to vasodilation) May have some tocolytic effect May decrease fetal heart rate variability May cause loss of reflexes Should be used with caution in the presence of calcium antagonists or other respiratory depressants (eg valium) Common maternal side effects Sensation of pain and warmth in arm Flushing of hands, face and neck Nausea Signs of maternal toxicity Loss of patellar reflexes Respiratory rate < 10
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Slurred speech, weakness, feeling extremely sleepy, double vision Muscle paralysis Respiratory/cardiac arrest Antidote for magnesium toxicity Calcium gluconate 1g in 10ml (10ml of 10% solution) by slow intravenous injection over 5 minutes. Protocol for magnesium sulphate (MgSO4) infusion Administration should always be via a syringe or infusion pump. Magnesium sulphate comes prepared from pharmacy in a 50ml syringe containing magnesium sulphate 50% solution (1g = 2ml). Magnesium sulphate 2.47g in 5ml (50% solution) ampoules are kept in Ward 4B. 10 ampoules of magnesium sulphate 2.47g in 5ml (50% solution) are drawn up into a 50ml leur lock syringe. Loading dose: 8ml (4g) MgSO4 (50% solution) given over 15 minutes pump settings: rate: 32ml volume to be infused: 8ml Maintenance infusion: 2ml (1g) MgSO4 (50% solution) per hour If further convulsions then: Repeat a bolus dose of 4ml (2g) to 8ml (4g) or increase infusion rate to 3ml (1.5g) to 4ml (2.0g)/hour. MgSO4 infusion should continue for a minimum of 24 hours post delivery or 24 hours after the last seizure. Maternal Observations 30 minutely initially then hourly when stable. Blood pressure, pulse, patellar reflexes, respiratory rate and hourly urine measures. Continuous fetal heart rate monitoring for antenatal women. Monitoring of Magnesium Levels Routine serum monitoring of magnesium levels is not required for women receiving 4g bolus and 1g/hour maintenance infusion for 24 hours (see Attachment 2: Clinical Notes) Magnesium is excreted by the kidneys and regular monitoring of serum levels should be considered in women with oliguria (urine output < 100ml over 4 hours) or urea > 10 mmol/L Discontinue infusion and notify registrar or consultant if: Unable to elicit patellar reflexes Respiratory rate less than 10 per minute Or urine output less than 30ml/hour.

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Management of Magnesium Toxicity Absent patellar reflexes: Stop infusion Notify registrar or consultant Collect serum levels Cease infusion until reflexes return Respiratory depression: Stop infusion Place women in recovery position Maintain airway Administer facial O2 Give IV calcium gluconate 1g in 10ml over five minutes Notify registrar or consultant Collect blood for serum level Respiratory arrest: Stop infusion Summon emergency assistance Initiate respiratory support via bag and mask until woman is intubated and ventilated Give IV calcium gluconate 1g in 10ml over five minutes Urinary output of less than 30ml/hr: Stop infusion Notify registrar or consultant Collect blood for serum level

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Attachments
Attachment 1 Attachment 2 Attachment 3 IV Magnesium Sulphate Principles and methods of administration Clinical Notes References

Performance Indicators: Evaluation of compliance with guideline to be achieved through medical record audit annually by clinical Quality improvement Midwife WACS Review Date: Annually verified for currency or as changes occur, and reviewed every 3 years via Policy and Procedure working group coordinated by the Clinical and Quality improvement midwife. January 2012. Midwives and medical staff WACS Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Stakeholders: Developed by:

Dr A Dennis Co-Director (Medical) Womens & Childrens Services

Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Date: _________________________

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APPENDIX 1 IV Magnesium Sulphate Principles and Method of Administration Anticonvulsants may be used for short-term treatment pending delivery 50 ml syringe of 50% solution The intravenous line should not be used to inject any other drugs Administration should always be via a syringe or infusion pump. 8ml (4g) MgSO4 (50% solution) given over 15 minutes pump settings: rate: 32ml volume to be infused: 8ml 2ml (1g) MgSO4 (50% solution) per hour

AIM: Presentation: Administration:

Loading Dose:

Maintenance Infusion Observations

30 minutely initially then 1 hour when stable Maternal blood pressure, patellar reflexes, respiratory rate and hourly urine measures. Continuous CTG if antenatal. Discontinue infusion Unable to elicit patellar reflexes and notify registrar or Respiratory rate less than 10 per minute consultant if: Urine output less than 30ml /hour Antidote for Calcium gluconate (10ml of 10% solution) by slow intravenous magnesium toxicity injection over 5 minutes. Management of Stop infusion respiratory arrest Summon emergency assistance code blue Initiate respiratory support via bag and mask until woman is intubated and ventilated Give IV calcium gluconate 1g in 10ml over five minutes

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APPENDIX 2 The Magpie Trial demonstrated that safe monitoring of serum magnesium sulphate levels could be achieved through the assessment of patellar reflexes, respiratory rate and urinary output thereby eliminating the need for regular serum magnesium levels in women receiving a 4g bolus and 1g/hour maintenance infusion for 24 hours (The Magpie Trial Collaborative Group, 2002) Magnesium is excreted by the kidneys and regular monitoring of serum levels should be considered in women with oliguria (urine output < 100ml over 4 hours) or urea > 10 mmol/L Fluid restriction is advisable to reduce the risk of fluid overload in the intrapartum and postpartum periods. In usual circumstances total fluids should be limited to 80ml/hr or 1ml/kg/hour. Pulmonary oedema has been a significant cause of maternal death. There is no evidence of the benefit of fluid expansion and a fluid restriction regimen is associated with good maternal outcome. The regime of fluid restriction should be maintained until there is a postpartum diuresis, as oliguria is common with severe pre eclampsia. If there is associated maternal haemorrhage, fluid balance is more difficult and fluid restriction is inappropriate (RCOG, 2006).

Magnesium Serum Levels Mg concentration (mmol/L) 0.8 -1.0 1.75-3.5 2.5-5.0 4.0-5.0 >5.0 >7.5 >12

Effects Normal plasma level Therapeutic range ECG changes (p-Q interval prolongation, widen QRS complex) Reduction in deep tendon reflexes Loss of deep tendon reflexes Sinoatrial and atrioventricular blockade. Respiratory paralysis and CNS depression Cardiac arrest

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APPENDIX 3 REFERENCES American Academy of Family Physicians 2000 Advanced life support in obstetrics (ALSO) course syllabus (4th edn). American Academy of Family Physicians, Kansas Australasian Society for the Study of Hypertension in Pregnancy (ASSHP) 2000 The detection, investigation and management of hypertension in pregnancy: full consensus statement. Online: http://www.racp.edu.au/asshp/news.htm Duley L, Henderson-Smart DJ, Meher S. Drugs for treatment of very high blood pressure during pregnancy. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD001449. DOI 10.1002/14651858.CD001449.pub2. Enkin M, Keirse J, Neilsen J et al 2000 A guide to effective care in pregnancy and childbirth. Oxford University Press, London NSW Department of Health Circular 2002/27 Magnesium sulphate (MgSO4) infusion protocol for eclamptic seizure prophylaxis. Online: http://www.health.nsw.gov.au/policies/PD/2005/ The Eclampsia Trial Collaborative Group Which anticonvulsant for women with eclampsia? Evidence from the Collaborative Eclampsia Trial. The Lancet 1995; 345:1455-1463. The Magpie Trial Collaborative Group Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate? The Magpie Trial: a randomised placebo-controlled trial. The Lancet 2002; 351:1877 -1890 Pairman S, Pincombe J, Thorogood C, Tracy S, Midwifery preparation for practice 2006 Elsevier Australia Royal College of Obstetricians and Gynaecologist 2006 Clinical Green Top Guidelines: Eclampsia. Online: http://www.rcog.org.uk/index.asp?PageID=1542

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