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

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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 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 Mellitus, and others (Sibai et al, 2005)

4 Preeclampsia and eclampsia (1) Preeclampsia Multisystem disorder of unknown cause High blood pressure Excess protein in the urine >20 weeks of gestation

5 Preeclampsia and eclampsia (2) Preeclampsia Classification in mild and severe preeclampsia Preeclampsia can lead to eclampsia Eclampsia Preeclampsia with convulsions

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 live births) 57.4 Maternal deaths due to hypertensive disorders 279 (24.1%) Source: Cube of Maternal Deaths , DGIS Mexico 2009

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 KEY RESULTS

14 Socio-demographic and obstetric characteristics Characteristic (N=87) % Age Previous pregnancies Number of prenatal care visits > >2 Not recorded None 1-2 visits 3-5 visits >6 visits Not recorded

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 135 cases

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 MS combined Other anticonv. None Not recorded

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 mortality medical files

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 healthy mothers. healthy families.

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