Authors: M. van Dijk, MD, MA (1), P. Zúñiga Uribe MD (2), R. Luna Gordillo, MD (2),

(1)

Magnesium Sulfate use for the

treatment of severe preeclampsia

and eclampsia among cases of

related maternal deaths:

A review of maternal deaths in

Mexico

Claudia Díaz Olavarrieta, Population Council-Mexico Global Maternal Health Conference, Delhi

30 August to 1 September, 2010

Authors: M. van Dijk, MD, MA (1), P. Zúñiga Uribe MD (2), R. Luna Gordillo, MD (2),

ME Reyes Gutiérrez MSc (2), J. Valencia MSc (3), C Díaz Olavarrieta Ph.D (1) S.G. García, DSc (1) (1) Population Council Mexico, (2) Ministry of Health, (3) Mexico Independent consultant

(2)

Context

• Worldwide: 529,000 maternal deaths per year; 99% in developing countries (WHO et al., 2004)

• Gestational hypertension disorders

(preeclampsia and eclampsia) account

for about 50.000 maternal deaths per year (Magpie, 2002)

(3)

Context

• Prevalence range 2%-7% (Sibai et al, 2005)

• Risk factors: multifetal gestation, chronic hypertension, previous

preeclampsia, pregestational Diabetes

(4)

Preeclampsia and eclampsia (1)

Preeclampsia

• Multisystem disorder of unknown cause

• High blood pressure

• Excess protein in the urine

(5)

Preeclampsia and eclampsia (2)

Preeclampsia

• Classification in mild and severe preeclampsia

• Preeclampsia can lead to eclampsia Eclampsia

(6)

Anticonvulsant treatment of

preeclampsia and eclampsia

• Several large randomized controlled trials were conducted (e.g. Magpie trial)

• Magnesium Sulfate (MS) is more effective in reducing convulsions and maternal death, compared to

Diazepam and Phenytoin.

• International consensus:

– Mild preeclampsia: no anticonvulsant treatment – Severe preeclampsia: MS is standard of care to

prevent convulsions

– Eclampsia: MS is standard of care to treat convulsions

(7)

Statistics maternal mortality and

hypertensive disorders in Mexico

(2007)

Maternal mortality statistics Mexico

Total # of maternal deaths 1,157

Maternal mortality ratio

(per 100.000 live births) 57.4

Maternal deaths due to hypertensive

disorders _{279 (24.1%)}

(8)

Actions of Mexican Ministry of

Health(1)

• Update of clinical guidelines on

prevention, diagnosis and treatment of preeclampsia and eclampsia: MS

stipulated as drug of choice (2006)

• MS included on the National Essential Drug List

(9)

Actions of Mexican Ministry of

Health(2)

• Distribution of guidelines, trainings on their application, widespread availability of MS in health facilities

• However, previous studies indicate MS

use in Mexico remains low

(Lumbiganon et al., 2007; Population Council studies, in process of analysis)

(10)

Objectives

We conducted a detailed review of

maternal mortality medical files of women who died from hypertensive disorders in Mexico, to:

• describe the type and quality of the information available in these files

• document whether MS was used when

indicated

• assess, quantify and attempt to qualify how often/how well MS was used

(11)

Methods (1)

• Review of Mexico maternal mortality

medical files where hypertensive disorder was the cause of death

• Simple random sample of files year 2005

• Exclusion criteria:

– File does not include a patient chart and/or a clinical summary

– Contradiction in cause of death between medical information and death certificate – Late maternal deaths and sequelae

(12)

Methods (2)

• Final sample: 87 patient files

• Confidential data abstraction in MS Excel (version 2007)

• Data analysis with SPSS (version 14.0, 2005)

• Variables included:

– Socio-demographical and reproductive history data

– Type of institution, level of care, type of provider at every

visit to a medical health care facility

– Objective symptoms, diagnosis and anticonvulsant treatment at every visit to a medical health care facility

(13)

(14)

Socio-demographic and obstetric

characteristics

Characteristic (N=87) % Age 15-19 20-24 25-29 30-34 35-39 >39 13.8 24.1 21.8 18.4 16.1 5.7 Previous pregnancies 0 1-2 >2 Not recorded 36.8 33.3 28.7 1.1

Number of prenatal care visits

None 1-2 visits 3-5 visits >6 visits Not recorded 11.5 20.7 25.3 28.7 13.8

(15)

Analysis of “cases”

• We also analyzed MS use at first visit prior to final and final clinical visit

(even if it concerns the same women)

• Each visit gives clinicians a new

“opportunity” to diagnose and treat correctly

• Sample changes from 87 women to

(16)

Anticonvulsant use in 135 cases, per

diagnosis

Anticonvulsant use Total N=135 Severe preeclampsia N=8 Eclampsia N=48 Other N=79 % N % N % N % N MS alone 9 6.7 0.0 0 6.2 3 7.6 6 MS combined 24.4 33 0.0 0 45.9 22 13.9 11 Other anticonv. 11.1 15 25.0 2 14.6 7 7.6 6 None 27.3 37 12.5 1 31.3 15 26.7 21 Not recorded 30.2 41 62.5 5 2.1 1 39.2 31

(17)

Strengths and limitations (1)

Strengths:

• First detailed documentation of women’s

diagnoses, treatments and pathways to care in Mexico

• Reliable information on the use of MS and other anticonvulsants in cases of maternal death due to hypertensive disorder in Mexico

(18)

Strengths and limitations (2)

Limitations:

• We only analyzed medical files of women who died

• Incompleteness of medical files and non-recorded data

• MS may not have been indicated anymore for women brought to a hospital who already

presented very severe complications

• We did not take into account other treatment

measures that should be taken with women with hypertensive disorders

(19)

Conclusions

• Generally low use of MS alone for severe preeclampsia (0%) and eclampsia (6.3%) • Relatively high use of other, less effective

anticonvulsants (Phenytoin and Diazepam), with or without MS

• Alarming percentages of women who did not

receive any anticonvulsant treatment (12.5% with severe preeclampsia and 31.3% with eclampsia) • Poor quality and incompleteness of the maternal

(20)

Implications

• Operations research interventions should be conducted to study effective strategies for increasing physician uptake and proper use of evidence-based treatments, such as MS use

• Federal and state-level MOH should reinforce monitoring and supervision over their correct implementation

• Federal and state-level MOH should design and implement mechanisms to ensure that medical files contain correct, legible and complete information

(21)

Thank you!

• ACKNOWLEDGEMENTS:

– John D. And Catherine T. MacArthur Foundation

– Mexico City MOH

– Population Council colleagues and

consultants: Katherine Wilson, Xipatl Contreras, Karla Berdichevsky

– Expert colleagues: Drs. Leila Duley, Stephen Kennedy, Ana Langer

(22)