Magnesium sulfate to reduce risk of eclampsia-related mortality
Eclampsia complicates approximately 1 in 1,000 deliveries, affecting 0.5% to 3.0% of patients with preeclampsia.30 Women in developed nations who have regular prenatal care and delivery at tertiary care centers have mortality rates ranging between 0% to 1.8%, with the leading cause being intracranial hemorrhage. Magnesium sulfate can reduce the incidence of eclampsia by 42.6% and reduce severe maternal morbidity from 16.7% to approximately 2%.29,31 Because nearly half of eclamptic convulsions in the US occur before a mother can be hospitalized and treated with magnesium sulfate, providing enhanced prenatal and postpartum care to patients at risk for eclampsia is important.
Acute pulmonary edema in preeclampsia
Acute pulmonary edema is a leading cause of maternal death that complicates approximately 3% of preeclampsia cases, with up to 70% occurring in the postpartum period.32 Pulmonary edema is more common among hypertensive women who are postoperative, receiving excess intravenous fluids and magnesium sulfate infusion. Restrictive fluid management is generally recommended for patients with preeclampsia/eclampsia so that euvolemia is not exceeded.33 Women reporting dyspnea or demonstrating decreased oxygen saturation should be suspected of developing acute pulmonary edema and urgently evaluated, initially with bedside exam and chest radiography. Physical exam alone and the absence of audible rales is insufficient to rule out pulmonary edema.34 EKG, transthoracic echocardiography and CT scan may be needed to clarify diagnosis and guide therapy. Intravenous diuretic therapy such as furosemide 20 – 40 mg should be administered along with oxygen support and ongoing hemodynamic monitoring.
When pregnancy is complicated by HELLP syndrome, there is increased risk of maternal death particularly from hemorrhagic stroke.35 The mortality rate associated with HELLP syndrome ranges from less than 1% to up to 30%, depending upon site of treatment and associated patient comorbidities.36 Isler found among 54 deaths from HELLP syndrome that the majority of women (71%) presented with symptoms of nausea, vomiting and epigastric pain and 42% had or developed eclampsia. The primary causes of maternal death included intracranial hemorrhage (26.4%), cardiopulmonary arrest (15.1%), respiratory failure (13.2%), hepatic hemorrhage (7.5%), hypoxic ischemic encephalopathy (7.5%), and DIC (5.7%).35 Several analyses have demonstrated that clinical symptoms are more predictive of poor outcomes than lab values alone.37
To further reduce hypertension-related mortality, efforts must be undertaken to reduce the incidence of preeclampsia. Daily low-dose aspirin (81-150 mg) initiated between 12 and 24 weeks’ gestation has been shown in several score studies to reduce development of preeclampsia by 10% to 29%. In women with both moderate- and high-risk factors for preeclampsia, initiation of an aspirin regimen should be routine.38
Patient education and empowerment
It is critical for pregnant women to know the warning signs of preeclampsia, when to seek medical attention and to encounter a medical system that listens and responds to their needs. In the ProPublica and National Public Radio series on 134 maternal deaths in the United States in 2016, Lost Mothers, many families reported instances of dismissed or discounted patient complaints prior to the death of a loved one. Physicians are encouraged to provide specific education to women with and/or at risk of a severe gestational hypertensive disorder and include patient and family interviews as part of debriefs and state morbidity and mortality reviews. 39
The authors report no potential conflicts of interest with regard to this article.
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