Preventing and treating eclamptic seizures

Editor—I agree with Roberts et al that the evidence from the eclampsia trial published in 1995 justifies the use of magnesium sulphate for eclampsia.¹,² However, I am not yet convinced by the results of the Magpie study³ that treating all patients with severe pre-eclampsia will have a clinically significant benefit in the setting in which I work.

We have a very busy unit and are critically understaffed, a situation that is probably the norm in many developing countries. We often admit several patients with severe pre-eclampsia a day. Giving magnesium sulphate to all of them would create an increased workload for our unit (administration of magnesium sulphate, monitoring of intravenous infusion if that route is chosen, monitoring of respiratory rates, reflexes, urine output), which might detract from the care we offer other patients.

According to the Magpie study, for every 60 women we treat, we would prevent one case of eclampsia.³ Would the prevention of this one case be important? We keep all patients with severe pre-eclampsia in hospital. If one has an eclamptic seizure, we manage it appropriately with magnesium sulphate and delivery, and we expect a good outcome for the mother. The women who die or develop severe morbidity from eclampsia in our setting are usually those who have had multiple seizures before they reach hospital. Thus the number we would need to treat to prevent one death or one case of severe morbidity would be many more than 60.

The critical issues in the management of patients with severe pre-eclampsia are appropriate monitoring for complications and appropriate timing of delivery. If these aspects are managed well, I doubt that magnesium sulphate will have a clinically significant impact on the outcome in these patients.