Obstetrical Accidents Involving Intravenous Magnesium Sulfate

Treatment of Severe Preeclampsia With Eclamptic Seizures in Cesarean Delivery With Postoperative Ionized Magnesium Monitoring

Prevention of recurrent eclamptic seizures requires the administration of magnesium sulfate. However, to our knowledge, there are no reports of cases in which the ionized magnesium concentration has been monitored during magnesium sulfate administration to prevent eclampsia. We describe a case in which monitoring of ionized magnesium permitted the use of magnesium sulfate to prevent a third eclamptic seizure. A 31-year-old primigravida with severe preeclampsia and eclampsia underwent emergency cesarean delivery. The patient had a recurrence of seizures intraoperatively. Postoperatively, she was managed with continuous magnesium sulfate infusion under ionized magnesium monitoring at the bedside using a blood gas analyzer in the intensive care unit. This approach might have helped prevent further seizures and complications associated with the administration of magnesium sulfate, such as hypermagnesemia. This case indicates that in the use of magnesium sulfate for patients with preeclampsia, ionized magnesium measurement was used for the rapid determination of magnesium levels.

Two Cases of Liver Transplantation With a High Ionized Magnesium to Total Magnesium Ratio

Magnesium (Mg), an important cation, is involved in the activation of enzymes important for life support. The incidence of hypomagnesemia in critically ill patients admitted to the intensive care unit (ICU) is high and has been reported to be a factor in worsening prognosis. Ionized magnesium (iMg) is physiologically active, although total magnesium (tMg) is often used to evaluate the concentration of magnesium because of the limited availability of instruments that can measure iMg. However, the changes in tMg and iMg are not correlated in critically ill patients. We obtained considerable data on the simultaneous measurements of iMg and tMg in two patients with severe liver disease who underwent liver transplantation. In both patients, the iMg/tMg values were high, suggesting the influence of hypoalbuminemia associated with liver dysfunction. Mg correction using tMg as a guide may lead to overdose. Furthermore, when considering the data for each case, the correlation between iMg and tMg was very high, which suggested that the iMg/tMg ratio may be a value unique to each individual or disease. Investigating in a large-scale study the correlation between iMg levels and clinical symptoms and prognosis is necessary in the future.

Successful Management of Refractory Torsades De Pointes Due to Drug-Induced Long QT Syndrome Guided by Point-of-Care Monitoring of Ionized Magnesium

Ionized magnesium (iMg) is the physiologically active fraction, although total magnesium (tMg) is often used clinically because a dedicated electrode is required to measure the iMg concentration. The tMg concentration is not correlated with the iMg concentration, especially in severely ill patients. In this report, a case of refractory torsades de pointes (TdP) due to drug-induced long QT syndrome was successfully treated with high-dose magnesium sulfate guided by point-of-care monitoring of the iMg concentration. A woman in her 60s had taken osimertinib for two months to treat lung cancer. TdP occurred after the operation of a thoracic compression fracture under general anesthesia. She was diagnosed with drug-induced long QT syndrome. TdP continued, despite treatment with 6 g magnesium sulfate. The iMg value on the admission to the intensive care unit was 0.92 mmol/L, but TdP occurred intermittently and circulatory dynamics were unstable. After an additional intravenous administration of 1 g magnesium sulfate, continuous intravenous administration was initiated at 1 g/h. TdP terminated when the iMg concentration reached 1.31 mmol/L. Then, the target iMg was set to 1.3 mmol/L. The iMg concentration was measured every two hours to adjust the continuous dose of magnesium sulfate. Magnesium administration was tapered, and she was transferred to a general ward on the third day. She was discharged without complications on the 11th day. Point-of-care monitoring of the iMg concentration and observation of the patient's clinical symptoms were important for the effective and safe treatment of TdP due to drug-induced long QT syndrome.

CE: Preeclampsia: Current Approaches to Nursing Management

: Preeclampsia, one of four hypertensive disorders of pregnancy, has traditionally been characterized as new-onset hypertension and proteinuria developing after 20 weeks' gestation. It is, however, now understood to be a complex, progressive, multisystem disorder with a highly variable presentation and a number of potentially life-threatening complications. The American College of Obstetricians and Gynecologists Task Force on Hypertension in Pregnancy has refined preeclampsia diagnostic criteria accordingly, and as the disorder's pathogenesis has been more clearly defined, new targets for screening, diagnosis, prevention, and treatment have emerged. This clinical update provides a review of current practice related to preeclampsia risk assessment, prediction, and management. It discusses preeclampsia pathophysiology and points readers to valuable health care resources on the topic.

Assessing the neuroprotective benefits for babies of antenatal magnesium sulphate: An individual participant data meta-analysis

BACKGROUND

Babies born preterm are at an increased risk of dying in the first weeks of life, and those who survive have a higher rate of cerebral palsy (CP) compared with babies born at term. The aim of this individual participant data (IPD) meta-analysis (MA) was to assess the effects of antenatal magnesium sulphate, compared with no magnesium treatment, given to women at risk of preterm birth on important maternal and fetal outcomes, including survival free of CP, and whether effects differed by participant or treatment characteristics such as the reason the woman was at risk of preterm birth, why treatment was given, the gestational age at which magnesium sulphate treatment was received, or the dose and timing of the administration of magnesium sulphate.

METHODS AND FINDINGS

Trials in which women considered at risk of preterm birth (<37 weeks' gestation) were randomised to magnesium sulphate or control treatment and where neurologic outcomes for the baby were reported were eligible for inclusion. The primary outcomes were infant death or CP and severe maternal outcome potentially related to treatment. Studies were identified based on the Cochrane Pregnancy and Childbirth search strategy using the terms [antenatal or prenatal] and [magnesium] and [preterm or premature or neuroprotection or 'cerebral palsy']. The date of the last search was 28 February 2017. IPD were sought from investigators with eligible trials. Risk of bias was assessed using criteria from the Cochrane Collaboration. For each prespecified outcome, IPD were analysed using a 1-stage approach. All 5 trials identified were included, with 5,493 women and 6,131 babies. Overall, there was no clear effect of magnesium sulphate treatment compared with no treatment on the primary infant composite outcome of death or CP (relative risk [RR] 0.94, 95% confidence interval (CI) 0.85 to 1.05, 6,131 babies, 5 trials, p = 0.07 for heterogeneity of treatment effect across trials). In the prespecified sensitivity analysis restricted to data from the 4 trials in which the intent of treatment was fetal neuroprotection, there was a significant reduction in the risk of death or CP with magnesium sulphate treatment compared with no treatment (RR 0.86, 95% CI 0.75 to 0.99, 4,448 babies, 4 trials), with no significant heterogeneity (p = 0.28). The number needed to treat (NNT) to benefit was 41 women/babies to prevent 1 baby from either dying or having CP. For the primary outcome of severe maternal outcome potentially related to magnesium sulphate treatment, no events were recorded from the 2 trials providing data. When the individual components of the composite infant outcome were assessed, no effect was seen for death overall (RR 1.03, 95% CI 0.91 to 1.17, 6,131 babies, 5 trials) or in the analysis of death using only data from trials with the intent of fetal neuroprotection (RR 0.95, 95% CI 0.80 to 1.13, 4,448 babies, 4 trials). For cerebral palsy in survivors, magnesium sulphate treatment had a strong protective effect in both the overall analysis (RR 0.68, 95% CI 0.54 to 0.87, 4,601 babies, 5 trials, NNT to benefit 46) and the neuroprotective intent analysis (RR 0.68, 95% CI 0.53 to 0.87, 3,988 babies, 4 trials, NNT to benefit 42). No statistically significant differences were seen for any of the other secondary outcomes. The treatment effect varied little by the reason the woman was at risk of preterm birth, the gestational age at which magnesium sulphate treatment was given, the total dose received, or whether maintenance therapy was used. A limitation of the study was that not all trials could provide the data required for the planned analyses so that combined with low event rates for some important clinical events, the power to find a difference was limited.

CONCLUSIONS

Antenatal magnesium sulphate given prior to preterm birth for fetal neuroprotection prevents CP and reduces the combined risk of fetal/infant death or CP. Benefit is seen regardless of the reason for preterm birth, with similar effects across a range of preterm gestational ages and different treatment regimens. Widespread adoption worldwide of this relatively inexpensive, easy-to-administer treatment would lead to important global health benefits for infants born preterm.

The role of magnesium sulfate in the intensive care unit

Magnesium (Mg) has been developed as a drug with various clinical uses. Mg is a key cation in physiological processes, and the homeostasis of this cation is crucial for the normal function of body organs. Magnesium sulfate (MgSO4) is a mineral pharmaceutical preparation of magnesium that is used as a neuroprotective agent. One rationale for the frequent use of MgSO4 in critical care is the high incidence of hypomagnesaemia in intensive care unit (ICU) patients. Correction of hypomagnesaemia along with the neuroprotective properties of MgSO4 has generated a wide application for MgSO4 in ICU.

Effects of Maternal Magnesium Sulfate Treatment on Neonatal Feeding Tolerance

OBJECTIVE

To determine whether antenatal exposure to magnesium sulfate has an effect on neonatal enteral feeding tolerance.

METHODS

In this single-center, retrospective, observational study, charts of pregnant women who received intravenous magnesium sulfate infusions prior to delivery between July 1, 2012, and July 31, 2013, were reviewed. Neonates born at 24 weeks' gestational age or greater admitted to the neonatal intensive care unit (NICU) whose mothers received magnesium sulfate infusions prior to delivery were included. Neonates with independent factors that could lead to feeding intolerance were excluded. The primary outcome was incidence of neonatal enteral feeding intolerance measured by deviations from the NICU feeding protocol. Secondary outcomes included days on parenteral nutrition, incidence of necrotizing enterocolitis, time to first stool, and urine output in the first 72 hours of life.

RESULTS

Cumulative maternal magnesium sulfate dose was significantly higher in the enteral feeding intolerance group than those infants who tolerated enteral feeds (70.4 ± 52.3 vs 47.4 ± 40.1 g; p = 0.04). Infants exposed to more than 80 g of maternal magnesium sulfate therapy were more likely to develop enteral feeding intolerance (44% vs 22%; p = 0.04). Multivariate logistic regression indicated that prematurity and cumulative maternal magnesium sulfate dose were the strongest predictors of neonatal enteral feeding intolerance.

CONCLUSIONS

Infants of mothers who received more than 80 g of intravenous magnesium sulfate prior to delivery were more likely to develop feeding intolerance. Prematurity also was a significant predictor of intolerance.

Magnesium Sulphate for Eclampsia and Fetal Neuroprotection: A Comparative Analysis of Protocols Across Canadian Tertiary Perinatal Centres

BACKGROUND

Magnesium sulphate (MgSO4) has been recommended for fetal neuroprotection to prevent cerebral palsy, with national societies adopting new guidelines for its use. A knowledge translation project to implement Canadian guidelines is ongoing. Discussion about MgSO4 for fetal neuroprotection could not occur distinct from MgSO4 for eclampsia prophylaxis and treatment. Thus, in order to explore standardization of MgSO4 use in Canada, we sought to compare local protocols for eclampsia and fetal neuroprotection across tertiary perinatal centres.

METHODS

Twenty-five Canadian tertiary perinatal centres were asked to submit their protocols for use of MgSO4 for eclampsia prophylaxis/treatment and fetal neuroprotection. Information abstracted included date of protocol, definitions of indications for treatment, details of MgSO4 administration, maternal and fetal monitoring, antidote for toxicity, and abnormal signs requiring physician attention. Descriptive analyses were used to compare site protocols with known definitions of preeclampsia. Data from the Canadian Perinatal Network (CPN) were used to verify what was done in clinical practice.

RESULTS

Twenty-two of the 25 centres submitted protocols for eclampsia prevention/treatment. Eleven of these provided a definition of preeclampsia that warranted treatment; five of the 22 advised treatment of severe preeclampsia only. Criteria for treatment and monitoring procedures varied across centres. Sixteen of the 22 sites with protocols had data from the CPN. Of 635 women with pre-eclampsia, 422 (66.5%) received MgSO4. Twenty of 25 centres provided protocols for fetal neuroprotection. Definitions of indications were consistent across sites, except for gestational age cut-off.

CONCLUSION

This study suggests that local protocols are often inconsistent with published evidence. While this may be related to local institutional practices, relevant processes must be put in place to maximize uniformity of practice and improve patient care.

Barriers and enablers to implementing antenatal magnesium sulphate for fetal neuroprotection guidelines: a study using the theoretical domains framework

BACKGROUND

Strong evidence supports administration of magnesium sulphate prior to birth at less than 30 weeks' gestation to prevent very preterm babies dying or developing cerebral palsy. This study was undertaken as part of The WISH (Working to Improve Survival and Health for babies born very preterm) Project, to assess health professionals' self-reported use of antenatal magnesium sulphate, and barriers and enablers to implementation of 2010 Australian and New Zealand clinical practice guidelines.

METHODS

Semi-structured, one-to-one interviews were conducted with obstetric and neonatal consultants and trainees, and midwives in 2011 (n = 24) and 2012-2013 (n = 21) at the Women's and Children's Hospital, South Australia. Transcribed interview data were coded using the Theoretical Domains Framework (describing 14 domains related to behaviour change) for analysis of barriers and enablers.

RESULTS

In 2012-13, health professionals more often reported 'routinely' or 'sometimes' administering or advising their colleagues to administer magnesium sulphate for fetal neuroprotection (86% in 2012-13 vs. 46% in 2011). 'Knowledge and skills', 'memory, attention and decision processes', 'environmental context and resources', 'beliefs about consequences' and 'social influences' were key domains identified in the barrier and enabler analysis. Perceived barriers were the complex administration processes, time pressures, and the unpredictability of preterm birth. Enablers included education for staff and women at risk of very preterm birth, reminders and 'prompts', simplified processes for administration, and influential colleagues.

CONCLUSIONS

This study has provided valuable data on barriers and enablers to implementing magnesium sulphate for fetal neuroprotection, with implications for designing and modifying future behaviour change strategies, to ensure optimal uptake of this neuroprotective therapy for very preterm infants.

Iatrogenic magnesium toxicity following intravenous infusion of magnesium sulfate: risks and strategies for prevention

A 65-year-old man being treated with radiotherapy and chemotherapy for recurrent colonic adenocarcinoma was admitted for management of hypokalaemia and hypomagnesaemia secondary to diarrhoea. He was treated with intravenous infusions of potassium chloride and magnesium sulfate. Following an infusion of magnesium sulfate, he experienced a sudden neurological deterioration. A CT of the head revealed no haemorrhage or evidence of acute ischaemic injury. Results of serum biochemistry later that day revealed an elevated magnesium level. Iatrogenic magnesium toxicity was suspected. Further discussions between the pharmacist and ward staff confirmed that a medication error had been made in the preparation of the infusion resulting in an overdose of intravenous magnesium.

Maternal adverse effects of different antenatal magnesium sulphate regimens for improving maternal and infant outcomes: a systematic review

BACKGROUND

Antenatal magnesium sulphate, widely used in obstetrics to improve maternal and infant outcomes, may be associated with adverse effects for the mother sufficient for treatment cessation. This systematic review aimed to quantify maternal adverse effects attributed to treatment, assess how adverse effects vary according to different regimens, and explore women's experiences with this treatment.

METHODS

Bibliographic databases were searched from their inceptions to July 2012 for studies of any design that reported on maternal adverse effects associated with antenatal magnesium sulphate given to improve maternal or infant outcomes. Primary outcomes were life-threatening adverse effects of treatment (death, cardiac arrest, respiratory arrest). For randomised controlled trials, data were meta-analysed, and risk ratios (RR) pooled using fixed-effects or random-effects models. For non-randomised studies, data were tabulated by design, and presented as RR, odds ratios or percentages, and summarised narratively.

RESULTS

A total of 143 publications were included (21 randomised trials, 15 non-randomised comparative studies, 32 case series and 75 reports of individual cases), of mixed methodological quality. Compared with placebo or no treatment, magnesium sulphate was not associated with an increased risk of maternal death, cardiac arrest or respiratory arrest. Magnesium sulphate significantly increased the risk of 'any adverse effects' overall (RR 4.62, 95% CI 2.42-8.83; 4 trials, 13,322 women), and treatment cessation due to adverse effects (RR 2.77; 95% CI 2.32-3.30; 5 trials, 13,666 women). Few subgroup differences were observed (between indications for use and treatment regimens). In one trial, a lower dose regimen (2 g/3 hours) compared with a higher dose regimen (5 g/4 hours) significantly reduced treatment cessation (RR 0.05; 95% CI 0.01-0.39, 126 women). Adverse effect estimates from studies of other designs largely supported data from randomised trials. Case reports supported an association between iatrogenic overdose of magnesium sulphate and life-threatening consequences.

CONCLUSIONS

Appropriate administration of antenatal magnesium sulphate was not shown to be associated with serious maternal adverse effects, though an increase in 'minor' adverse effects and treatment cessation was shown. Larger trials are needed to determine optimal regimens, achieving maximal effectiveness with minimal adverse effects, for each antenatal indication for use. Vigilance in the use of magnesium sulphate is essential for women's safety.

Accidental intravenous infusion of a large dose of magnesium sulphate during labor: A case report

During labor and child delivery, a wide range of drugs are administered. Most of these medications are high-alert medications, which can cause significant harm to the patient due to its inadvertent use. Errors could be caused due to unfamiliarity with safe dosage ranges, confusion between similar looking drugs, mislabeling of drugs, equipment misuse, or malfunction and communication errors. We report a case of inadvertent infusion of a large dose of magnesium sulphate in a pregnant woman.

Development of a simplified protocol for administration of 20% magnesium sulphate for prophylaxis and treatment of eclampsia

BACKGROUND

Magnesium sulphate is a high-risk medication that is used extensively for prophylaxis and treatment of eclampsia. To accommodate recommendations related to fluid restrictions and patient safety, a protocol was developed for the administration of 20% magnesium sulphate.

OBJECTIVES

To determine whether administration of 20% magnesium sulphate increased the risk of phlebitis relative to 2% to 8% magnesium sulphate solutions, to determine if the institution's protocol for administration of 20% magnesium sulphate reduced errors during administration, and to identify strategies to further reduce potential errors.

METHODS

A retrospective chart audit was undertaken for patients who had received magnesium sulphate for prophylaxis of eclampsia from December 2004 to December 2007. A failure mode and effect analysis was used to identify additional safety strategies.

RESULTS

A total of 47 patients received magnesium sulphate according to the old administration protocol (2% to 8% solution) and 29 according to the new protocol (20% solution). No evidence of phlebitis was documented for any of these 76 patients. A few errors occurred with changes in rates or concentrations and because of failure to reset the pump after the loading dose, but there was no documented harm to any of the patients. Strategies to further reduce errors in the administration of magnesium sulphate included development of preprinted orders, use of 20% magnesium sulphate for all infusion rates, changes to pump settings to enable use of fractional infusion rates, preparation of magnesium sulphate in mini-bags in the pharmacy, double-check of pump settings by nurses, anesthesiology consult, and distribution of protocols to all areas in the hospital (to limit errors associated with patient transfers).

CONCLUSIONS

There was no documented phlebitis, and fewer errors occurred when 20% magnesium sulphate was used. Several additional strategies were identified to reduce errors in the administration of this high-risk medication.

Benchmarking and patient safety in hypertensive disorders of pregnancy

Hypertensive disorders of pregnancy are a major cause of morbidity and mortality worldwide. Reliable, published individual patient data from units and countries are lacking. Without these data, clinicians are unable to benchmark their incidence, treatments and outcomes, and patient safety is unable to be routinely assessed. Available data suggest that a notable proportion of the adverse events that occur with hypertensive disease of pregnancy may be preventable. Theory and practice indicate several methods that can offer the possibility of averting these preventable adverse events. These methods include benchmarking outcomes, standardisation of care processes, simulation, and enhancement of patient knowledge. However, data on optimal methods to enhance patient safety and quality of care of pregnant women with hypertensive disease remain limited, and further research is required.

Perinatal patient safety and quality

The leadership team and clinicians in hospitals and healthcare system must focus on perinatal safety and quality to minimize risk of preventable harm to mothers and infants. A review of current issues in perinatal patient safety and quality is presented.

Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events

Our objective was to describe a comprehensive obstetric patient safety program and its effect on reducing compensation payments and sentinel adverse events. From 2003 to 2009, we implemented a comprehensive obstetric patient safety program at our institution with multiple integrated components. To evaluate its effect on compensation payments and sentinel events, we gathered data on compensation payments and sentinel events retrospectively from 2003, when the program was initiated, through 2009. Average yearly compensation payments decreased from $27,591,610 between 2003-2006 to $2,550,136 between 2007-2009, sentinel events decreased from 5 in 2000 to none in 2008 and 2009. Instituting a comprehensive obstetric patient safety program decreased compensation payments and sentinel events resulting in immediate and significant savings.

Strategies for safe care of critical care perinatal patients

In most inpatient settings, the complexity of care required by individual patients coupled with the wide range of services provided within a single institution mean patients are routinely cared for in highly specialized units. Service lines, such as surgical services; intensive care; emergency services; and maternity, typically operate cooperatively, but independently, within larger facilities. Units are distinguished from one another, not only by their mission, geographic location, and work processes, but by the expertise and specialty knowledge of clinicians who practice there. From a patient safety perspective, specialty care is advantageous because it promotes clinical benchmarking, standardization of practice norms, acquisition and maintenance of specialty knowledge and skills, and interdisciplinary teamwork.

Impact of a comprehensive patient safety strategy on obstetric adverse events

OBJECTIVE

We implemented a comprehensive strategy to track and reduce adverse events.

STUDY DESIGN

We incrementally introduced multiple patient safety interventions from September 2004 through November 2006 at a university-based obstetrics service. This initiative included outside expert review, protocol standardization, the creation of a patient safety nurse position and patient safety committee, and training in team skills and fetal heart monitoring interpretation. We prospectively tracked 10 obstetrics-specific outcome. The Adverse Outcome Index, an expression of the number of deliveries with at least 1 of the 10 adverse outcomes per total deliveries, was analyzed for trend.

RESULTS

Our interventions significantly reduced the Adverse Outcome Index (linear regression, r(2) = 0.50; P = .01) (overall mean, 2.50%). Concurrent with these improvements, we saw clinically significant improvements in safety climate as measured by validated safety attitude surveys.

CONCLUSION

A systematic strategy to decrease obstetric adverse events can have a significant impact on patient safety.

Magnesium sulphate therapy in women with pre-eclampsia and eclampsia in Kuwait

OBJECTIVE

To evaluate the outcome of the use of MgSO4 therapy in women with severe pre-eclampsia in Kuwait from January 2002 to December 2004.

SUBJECTS AND METHODS

The study involved 450 women managed at the Maternity Hospital in Kuwait with a blood pressure of 160/110 mm Hg and proteinuria of >0.3-5 g/24 h. A loading dose of 4 g MgSO4 was administered intravenously over 20 min and then the maintenance dose continued at 1 g/h for 24 h postpartum. Magnesium sulphate toxicity was monitored by urine output, deep tendon reflexes and serum magnesium levels and managed with an infusion of 10 ml of 10% calcium gluconate and cessation of magnesium infusion. Adjunct therapy included intravenous hydralazine 10 mg and labetalol 100 mg. The mode of delivery was determined after stabilizing the patient.

RESULTS

The women included Kuwaitis (n = 200, 44.4%), Asians (n = 129, 28.7%) and other Arabs (n = 116, 25.8%) with a mean age of 29.7 +/- 6.7 years (primigravida: n = 233, 51.8%; other parities: n = 217, 48.2%). Antenatal complications included intra-uterine growth restriction (n = 136, 30.2%), oliguria (n = 39, 8.7%), haemolysis, elevated liver enzymes and low platelet count syndrome (n = 30, 6.6%), abruptio placentae (n = 20, 4.4%), eclampsia (n = 15, 3.3%), and preterm birth (n = 253, 55.2%). Caesarean section (n = 241, 53.6%) was the main mode of delivery. The perinatal mortality rate was 27 per 1,000. Magnesium sulphate toxicity observed as reduced tendon reflexes occurred in 14 (3.1%) patients and flushing, nausea and vomiting and blocked nostrils in 86 (19.1%). There was no association between adverse outcomes and maternal serum magnesium concentrations and no maternal mortality occurred.

CONCLUSION

Magnesium sulphate was effective in preventing recurrence of eclamptic fits and safe for both mother and fetus.

Error reduction and quality assurance in obstetrics

This article outlines an approach to improve patient safety in obstetrics and gynecology, with the goal to reduce errors in labor and delivery. Every institution should create guidelines and provide education and training to address potential safety issues such as fetal heart rate pattern interpretation, induction and stimulation of labor, vaginal birth after cesarean, magnesium sulfate, shoulder dystocia, hemorrhage, forceps/vacuum, and thromboembolic disease. This article discusses the patient safety objectives published by the American College of Obstetricians and Gynecologists Committee on Quality Improvement and Patient Safety; the National Patient Safety Goals, which are regularly established by the Joint Committee on Accreditation of Healthcare Organizations; and patient safety indicators developed by the Agency for Healthcare Research and Quality.

Magnesium Sulfate Compared With Nifedipine for Acute Tocolysis of Preterm Labor

OBJECTIVE

To compare the efficacy and side effects of intravenous magnesium to oral nifedipine for acute tocolysis of preterm labor.

METHODS

A multicenter randomized trial was performed. Patients in active preterm labor who were at 24 to 33 weeks and 6 days of gestation were randomly assigned to receive magnesium sulfate or nifedipine. The primary outcome was arrest of preterm labor, defined as prevention of delivery for 48 hours with uterine quiescence.

RESULTS

One hundred ninety-two patients were enrolled. More patients assigned to magnesium sulfate achieved the primary outcome (87% compared with 72%, P=.01). There were no differences in delivery within 48 hours (7.6% magnesium sulfate compared with 8.0% nifedipine, P=.92), gestational age at delivery (35.8 compared with 36.0 weeks, P=.61), birth before 37 and 32 weeks (57% compared with 57%, P=.97, and 11% compared with 8%, P=.39), and episodes of recurrent preterm labor. Mild and severe maternal adverse effects were significantly more frequent with magnesium sulfate. Birth weight, birth weight less than 2,500 g, and neonatal morbidities were similar between groups, but newborns in the magnesium sulfate group spent longer in the neonatal intensive care unit (8.8+/-17.7 compared with 4.2+/-8.2 days, P=.007).

CONCLUSION

Patients who received magnesium sulfate achieved the primary outcome more frequently. However, delay of delivery, gestational age at delivery, and neonatal outcomes were similar between groups. Nifedipine was associated with fewer maternal adverse effects.

Failure to rescue: implications for evaluating quality of care during labor and birth

Failure to rescue is an indicator that has been used to measure quality of care for surgical patients by evaluating the number of patients who die after developing postoperative complications. There are 2 key components of failure to rescue: (a) careful surveillance and timely identification of complications and (b) taking action by quickly initiating appropriate interventions and activating a team response. This concept has not been explored as a potential method to evaluate quality of intrapartum care. In obstetrics, complications leading to death are relatively rare because mothers and infants are generally healthy. Thus, there are not large numbers of maternal or infant deaths in individual hospitals or healthcare systems that allow the types of statistical analyses that have been previously used to measure failure to rescue rates. With modifications in the measurement process for failure to rescue in this population, there are direct implications for perinatal patient safety and lessons to be learned. A new use of the failure to rescue concept in a population not previously considered is proposed.