Seizures in Critical Care by Panayiotis Varelas

Author:Panayiotis Varelas
Language: eng
Format: epub
Publisher: Humana Press, Totowa, NJ

9.2.1.5 Management

Early detection remains the mainstay of treatment in EC patients. The best treatment for PREC and EC is delivery. If delivery is not possible, then management of the patient should include hospitalization, close observation, and seizure prophylaxis until delivery can be performed. In a review of obstetric patients admitted to a medical-surgical ICU in a large tertiary referral center over a 5-year period, PREC was the single most common diagnosis, representing 22% of all patients (27).

Over the last two decades magnesium has emerged as the drug of choice for preventing eclampsia. Large randomized trials and systematic reviews have shown the usefulness of magnesium sulfate in treating recurrent eclamptic seizures and in the prophylaxis of EC (28–30).

In 1995 the Eclampsia Trial Collaborative Group showed unequivocally that magnesium given intramuscularly or intravenously is superior to phenytoin or diazepam in reducing recurrent eclamptic seizures (26). This international multi-center randomized study included 1,687 women with EC. The women allocated to magnesium sulfate therapy had a 52% (95% C.l. 37–64%) reduction in incidence of recurrent seizures than those given diazepam (13.2% vs. 27.9%). Maternal and perinatal morbidity were comparable between the two groups. In a second comparison between magnesium sulfate and phenytoin, the women randomized to receive magnesium sulfate had a 67% (95% C.I. 47–79%) reduced incidence of recurrent seizures (5.7% vs. 17.1%). Maternal mortality was non-significantly lower in the magnesium group compared with the phenytoin group (26). Women who received magnesium were also less likely to be ventilated when compared to phenytoin (14.9% vs. 22.5%). Women in the magnesium group were also less likely to develop pneumonia (3.9% vs. 8.8%) and less likely to be admitted to the ICU (16.7% vs. 25.1%) when compared to phenytoin.

The Magpie study, another randomized placebo-controlled trial, was designed to assess the value of magnesium for prophylaxis in EC (30). The study included approximately 10,000 women with PREC who were randomized to receive magnesium sulfate before or during labor, or after giving birth (30). Magnesium was effective in reducing seizures in 58% (95% C.I. 40–71%). Treatment was also safe for the neonate in this selling, and without any excess of serious maternal morbidity or mortality. Of the 5055 women who were randomized in each group, 46 (0.9%) had respiratory depression and 5 (0.1%) had respiratory arrest with magnesium compared to 27 (0.5%) and 2 (0.04%) in the placebo group. Respiratory arrest was responsible for one death in each group. (30).

Another multi-center randomized un-blinded study, compared magnesium to the calcium channel blocker nimodipine, a cerebral vasodilator, to prevent EC (31). PREC women who received nimodipine were more likely to have a seizure than those who received magnesium sulfate (2.6% vs. 0.8%, p = 0.01). The antepartum risk for EC did not differ between the two treatment arms, but the nimodipine arm had a higher risk of post-partum seizures (1.1% vs.0%, p = 0.01). Neonatal outcomes did not differ between the two groups (31).

Similar results were reported in a Cochrane review analysis that included published randomized studies between magnesium and placebo or anti-epileptics (29).

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