Perinattal Joint Practice

Ca
are of the Patient with
w
Preeclampsia/E
Eclampsia
a Requirin
ng
Ma
agnesium Sulfate Infusion
Wo
omens Hosp
pital-98-023
3B

ginal Appro
oval: July 1998
1
Orig

Typ
pe: Multidi sciplinary C
Clinical Guide
eline

Rev
vision/Review Approv
val: 12/03;
12/0
07; 3/22/10
0

Key
y words: p
preeclampsia, eclampsia, magnesium,
mag

Sup
persedes: WHBC-98-0
023A

Ap
pplicability
All obstetric pa
atients; ante
epartum, intrapartum and
a
postparrtum, who m
meet the clin
nical criteria
a for the
dia
agnosis of prreeclampsia
a and are pla
aced on a magnesium
m
ssulfate infussion.
Purpose
e purpose of
o this guideline is to de
elineate the safe use of Magnesium
m Sulfate in the preeclam
mptic
The
pattient for pre
evention of eclamptic
e
se
eizures.
De
efinitions
Magnesium sulfate (MgSO
O4) is a smooth muscle relaxant. E
Excess magn
nesium depresses the p
peripheral
neu
uromuscular system in three ways: the inhibittion of acety
ylcholine rellease, the re
eduction of the
sen
nsitivity of the motor en
ndplate, and
d the reducttion of the a
amplitude off the motor endplate po
otential.
Magnesium is cleared by the
t
kidneys, the rate depending on
n the GFR. In preecla
ampsia, GFR
R is often
mpromised and less tha
an 100 ml/m
min. Seizure
e prophylax
xis is accomplished at a serum leve
el of 4
com
mg
g/dl.
eeclampsia1
Pre
Pre
eeclampsia is
i a pregnan
ncy-specific syndrome that
t
usually
y occurs afte
er 20 weeks gestation. The
critteria for diagnosis are:
p
of 140 mmHg or higher or 90 mmHg diastolic orr higher thatt occurs afte
er 20
Blood pressure
weeks of gestation
n in a woman with previously norm
mal blood pre
essure
y excretion of
o 0.3g prottein or highe
er in a 24-h
hour urine specimen
Proteinuria, defined as urinary
sia1
Severe Preeclamps
Preecla
ampsia is considered severe if one or more of tthe followin
ng criteria is present:
Blood press
sure of 160 mmHg systtolic or highe
er or 110 m
mmHg diasto
olic or highe
er on two
occasions at
a least 6 ho
ours apart while
w
the pattient is on b
bed rest
Proteinuria of 5g or hig
gher in a 24
4-hour urine specimen o
or 3+ or gre
eater on two
o random
urine samples collected
d at least 4 hours apartt
Oliguria of less than 50
00mL I 24 hours
h
Cerebral or visual distu
urbances
Pulmonary edema or cyanosis
Epigastric or
o right uppe
er-quadrantt pain
Impaired liv
ver function
Thrombocytopenia
n
Fetal growth restriction

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Care of the Patient with Preeclampsia, March 2010

Practice Guidelines
1. Measurement of Blood Pressure2, 3
a. BP should be measured with the woman in the sitting position1 with the arm at the level of the
heart. (Supine positioning has the potential to cause hypotension, and left lateral positioning has
the potential to give the lowest BP value, because the right arm is frequently elevated above the
level of the heart during BP measurement.)
b. An appropriately sized cuff (i.e. length of 1.5 times the circumference of the arm) should be
used.
c. A cuff should not be placed over clothing.
d. Korotkoff phase V should be used to designate diastolic BP (when mercury sphygmomanometry
or an aneroid device is used).
e. If BP is consistently higher in one arm, the arm with the higher values should be used for all BP
measurements.
f. Arm to arm differences and arm and position used for each BP measurement should be
documented.
g. Automated BP machines may underestimate BP in women with preeclampsia, and comparison of
readings using mercury sphygmomanometry or an aneroid device is recommended
h. It is preferable for the woman to rest for five minutes prior to measuring BP.
2. Baseline labs
Preeclampsia Labs
CBCP
Liver enzymes (AST, ALT)
Creatinine
Uric Acid
Spot protein & creatinine
3. Patient will be on continuous fetal monitoring upon admission and until discontinued by health care
provider according to Fetal SurveillanceA guideline.
4. Indication for Magnesium Sulfate Infusion
a. When a patient with preeclampsia meets the clinical criteria for the diagnosis of severe
preeclampsia, the use of magnesium sulfate seizure prophylaxis is recommended.
b. In patients with clinically mild preeclampsia the use of magnesium sulfate seizure prophylaxis is
determined by the care provider.
5. Contraindications to Magnesium Sulfate Use
a. Myasthenia gravis
b. Heart block/recent myocardial infarction
c. Severe renal disease
6. Magnesium Levels
a. If a magnesium level is drawn, send the test as a STAT order.
b. The patients nurse will page the physician with the result of all magnesium levels.
1

Sitting = feet flat on the floor, legs not crossed

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Care of the Patient with Preeclampsia, March 2010

c. Therapeutic levels of magnesium sulfate when administered for preeclampsia range from 4 to 6
mg/dl.
d. Critical magnesium sulfate level in obstetrics is 8 mg/dl.
When the laboratory reports a magnesium level of 8 mg/dl, according to the standard
procedure in the Pathology Department B, the following steps will occur:
i. The nurse will stop the magnesium infusion and notify the senior resident on-call.
ii. The senior resident will assess the patient and write appropriate orders for
the magnesium infusion
next magnesium level check
any new physician notification parameters
7. Administration of Magnesium Sulfate Infusion
a. Main IV line is usually Lactated Ringers with a rate determined by the physician.
b. Magnesium sulfate is supplied in pre-mixed bags of 2gm, 4gm, and 20gm. When administering
a 6gm loading dose, one 2gm and one 4gm pre-mixed bags are used. Loading doses should not
be administered from the 20gm bag.
c. In any patient with marked renal insufficiency, the loading dose will be the same as for someone
with normal renal function; however, the continuous drip rate will be dependent on renal
function and urine output.
See Special Circumstance Patients for loading dose and infusion for
treatment of eclamptic seizure and for patients without an IV access.
Magnesium Sulfate Loading Dose for Seizure Prophylaxis
Concentration

2 grams in 50mL water

4 grams in 50mL water
4 -6 grams IV over 20 minutes

Loading dose

Magnesium Sulfate infusion for Seizure Prophylaxis

Concentration
Maintenance dose
d.

20 grams in 500mL water [dose: 1 gram = 25 mL/hr]

0 2 grams/hr IV

Equipment needed:
Double IV pump (or triple pump if also on Oxytocin or other continuous infusion)
Seizure precautions (check suction equipment and oxygen set-up in room)
Reflex hammer
Blood pressure device
Foley or bedpan
Consider SCDs for patients on long term bed rest and according to VTE guidelineC
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Care of the Patient with Preeclampsia, March 2010

8. High risk medication safety

Piggyback the magnesium sulfate infusion into the main live in the port closest to the IV
site.
Double check verification
o Two (2) RNs will verify the magnesium orders, dosage and rates.
o With two (2) RNs at the bedside, one RN will set the rate and hang the solution.
The second RN will verify the pump settings, the solution hanging against the
order and if all is correct, will lock the pump and sign verification in Carelink.
o This process will be used for all rate changes, and when hanging new bags.
Label the pump
Label the line
9. Frequency of patient observation and assessment6
a. The nurse will remain at the bedside continuously when administering loading/bolus doses5
b.

Upon giving loading dose, blood pressure every 15 minutes for the first hour

if stable then every 30 minutes X 2

c. If above post-loading dose VS are stable, then monitor the following at a minimum according to
Table 1.
Table 1. Post-Magnesium Sulfate Loading Dose Monitoring
Every 1 hour
Every 2 hours
Every 4 hours
Strict intake & output
Blood pressure, Pulse, Respirations
Oxygen saturation (may also be ordered
for continuous monitoring)

Temperature if
ruptured
membranes
Auscultation of lung
sounds
Deep tendon
reflexes (DTRs)

Temperature if
intact membranes

Level of consciousness (LOC) evaluation

Monitoring for symptoms2 or symptom
changes:
headache, visual disturbances,
nausea/vomiting, somnolence, epigastric
pain, shortness of breath, chest tightness
or discomfort,
Monitoring for signs2 or sign changes:
loss of patellar reflexes, decreased urine
output, cough, oxygen saturation <95%,
increased RR or HR, adventitious lung
sounds

Symptoms and signs are monitored for detection of magnesium sulfate toxicity, worsening preeclampsia, and pulmonary edema
Page 4 of 9

Care of the Patient with Preeclampsia, March 2010

Minimum urine output should be at least 25 cc/hr;

Magnesium levels can rise if not cleared by the kidneys.

d. The

10.

physician should be notified if the woman experiences any of the following signs/symptoms:
Significant changes in BP from baseline values
Tachycardia or bradycardia
Respiratory rate <14 or >24
Oxygen saturation <95%
Changes in breath sounds suggestive of pulmonary edema
Changes in level of consciousness or neurologic status
Absent DTRs
Urinary output <30 mL/hr
Any concerns about the fetal heart rate pattern (Classes II and III tracings)7

When magnesium toxicity is identified either by signs/symptoms or critical level of 8 mg/dL

a. Stop the magnesium sulfate infusion.
b. The nurse will remain at the bedside
c. The nurse will notify the senior resident; initiate Birth Center pager for any concern of worsening
condition
d. The senior resident will consult with the attending physician regarding plan of care
e. Increase frequency of monitoring to at least every 15 minutes
f.

Provide basic life support/advanced life support for respiratory or cardiac arrest

g. Anticipate/order stat magnesium level lab

h. Calcium gluconate is used as a reversal agent for magnesium when ordered by the physician
Calcium Gluconate3
Concentration
Dose

10% solution
10 mL (1g) IV push, over 3 minutes

11. General Care Considerations

a. If delivery is imminent, plan for neonatal resuscitation with neonatal providers present at the
delivery.
b. Diet may be NPO, sips of clear liquids or ice chips only as indicated by patient condition.

Immediately available in the Omnicell

Page 5 of 9

Care of the Patien

nt with Preeclam
mpsia, March 2010
2

11. Patient Ed
ducation
a. Teach patient
p
abou
ut expected Side Effects and to rep
port any cha
anges to nurse. These s
side
effects may be unc
comfortable to the patie
ent but are not sympto
oms of toxicity and do n
not require
a chang
ge in the drip rate.
feeling warm
flushed
b
vision
double or blurred
headache
nystagmus4
ention
urinary rete
Special Circu
umstance Patients
P
1. Postparrtum preecla
amptic patie
ent
1. Magnesium is usually continued
c
fo
or 24 hours
n and assesssment as indicated abo
ove
2. Continue frequency of observation
y inserted
3. Patient will either use a bedpan orr have Foley
nitoring of uterine
u
bleed
ding is nece
essary due tto increase risk of postp
partum
4. Careful mon
hemorrhage
e
ptic seizure
2. Eclamp
1. Turn patien
nt on her sid
de
hysical harm
m
2. Protect patiient from ph
ossible, do not
n force herr jaw open
3. Insert oral airway if po
sician, activa
ate the Birth
h Center em
mergency pa
ager, and ca
all for help
4. Notify phys
5. Administer Magnesium Sulfate bollus as orderred
Magnesium
m Sulfate Loading
L
Do
ose for Trea
atment of E
Eclamptic Seizure
Conce
entration
Loadin
ng dose

2 gra
ams in 50mL
L water
4 gra
ams in 50mL
L water
4 -6 grams IV ov
ver 10 15 minutes

Magnesiium Sulfate
e Infusion for Treatm
ment of Ecllamptic Seizure
Conce
entration
Maintenance dose
e

20 grrams in 500
0mL water [[dose: 1 gra
am = 25 mL
L/hr]
2 3 grams/hr IV
I

ecurs, administration o
of magnesium sulfate 2 gm over 3--5 minutes
If seizurre activity re
may be ordered. With
W
continue
ed seizure a
activity, prep
pare patientt for paralyz
zation,
intubation, mechan
nical ventilattion and if u
undelivered,, possible de
elivery.

3. Post-Ec
clamptic Seizure
1. Once seizurre activity sttops-administer O2 at 10L/mask (if not intuba
ated).
se prn
2. Suction mouth and nos
3. Assess BP, pulse, respiiration and FHR every 5 minutes until stable.
cteristics of seizure (pre
esence/abse
ence of aura
a, duration of seizure,
4. Note charac
tonic/clonic
c phases, du
uration of po
ostictal phasse, length of unconsciousness, and
d
maternal/fe
etal respons
ses.
e
of placental abruption an d/or immine
ent delivery
y
5. Assess for evidence

Medline Plu
us: Medical Dictionary: http:://www2.merriiam-webster.co
om/cgi-bin/mw
wmednlm Main
n Entry: nysta
agmus
Pronunciatio
on: nis- tag-m s Involuntary
y usually rapid movement off the eyeballs ((as from side to
o side) occurring normally
with dizzines
ss during and after
a
bodily rottation or abnorrmally following
or as a sympto
om of disease
g head injury o
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Care of the Patient with Preeclampsia, March 2010

4.

Magnesium Sulfate Administration in the Patient Without an IV Access

1. In the event that an IV access is not established, or delay of administration of
magnesium sulfate to start an IV line is not advisable, magnesium sulfate may be given
intramuscularly at the discretion of the provider.
2. Doses up to 10g of undiluted 50% magnesium sulfate solution IM (5g in each buttock)
may be administered.

Exhibit
A. Deep Tendon Reflexes
References
12. ACOG (2002) Diagnosis and Management of Preeclampsia and Eclampsia. Practice Bulletin #33
13. Magee, L.A, Helewa, M., Moutquin, J.M., et al. (2008) Diagnosis, Evaluation, and Management of
the Hypertensive Disorders of Pregnancy. JOGC 30(3): S1-S49.
14. Lowe, S., Brown, M., Dekker, G., et al (2009) Guidelines for the management of hypertensive
disorders of pregnancy 2008. Australian and New Zealand Journal of Obstetrics and Gynecology49:
242-246
15. Micromedex. Magnesium Sulfate. Accessed 3/17/2010
16. Institute for Safe Medication Practices (2005). Preventing Magnesium Toxicity in Obstetrics.
Medication Safety Alert October 20, 2005
http://www.ismp.org/Newsletters/acutecare/articles/20051020.asp accessed 11/20/2009
17. Rice-Simpson, K (2004) Obstetrical Accidents Involving Intravenous Magnesium Sulfate:
Recommendations to Promote Patient Safety. MCN 29 (3) 161-171
18. Macones, G., Hankins, G., Spong, C., et al (2008) The 2008 National Institute of Child Health and
Human Development workshop report on electronic fetal monitoring: Update on definitions,
interpretation, and research guidelines. Am J Obstet Gynecol; 112 (3) 661-666.
19. Nick, J (2003) Deep tendon reflexes: The what, why, where, and how of tapping. JOGNN 32(3);
297-306 http://www3.interscience.wiley.com/cgi-bin/fulltext/118885084/PDFSTART accessed
2/20/2010

Related Policies/Procedures/Guidelines
A. Fetal Surveillance guideline
http://www.med.umich.edu/i/obgyn/birthcenter/clin_practice/policy/fetal_surveillance.pdf
B. Critical Value Reporting policy http://www.pathology.med.umich.edu/policies/index.php?id=6017
C. Venous Thromboembolism and Thrombophilias in Pregnancy guideline
http://www.med.umich.edu/i/obgyn/guidelines/vte_guide.pdf

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Care of the Patient with Preeclampsia, March 2010

Reviewed and Approved by:

Perinatal Joint Practice Committee
Endorsed by:
Womens Clinical Practice Council

Original: July 1998;

Renewal: Dec 2003; Dec 2007; March 2010
Dec 2003; April 2010

Next review:
March 2013
05.25.12 Document updated to correct error: three instances of mEq/dl changed to mg/dl.

Disclaimer: These are general guidelines not based on specific medical diagnosis. Any medical case
depends on specific medical diagnosis. The guidelines do not constitute medical advice and should not be
used for specific cases. Our goal is to provide general information that may assist in the care of patients.
General guidelines can never replace the expertise and clinical judgment of the treating physician. Each
patients situation must be evaluated individually.
2011 The Regents of the University of Michigan
Author: UMHS Perinatal Joint Practice Committee
Last Reviewed 10/2011

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Care of the Patient with Preeclampsia, March 2010

Exhibit A7
Deep Tendon Reflexes
Grade

Definition

Very brisk (often associated with clonus)

Brisker than average (can indicate clonus)

Average/normal

Diminished (often abnormal)

Absent (abnormal)

To elicit a DTR, strike the tendon of the partially stretched muscle

briskly using a quick wrist movement. The flat or the pointed area of
the hammer can be used and the strike should be directly on the
tendon.7

Eliciting the Reflexes

Patellar Reflex. Bend knee to stretch tendon while ensuring that the leg is relaxed.
Palpate tendon to verify location and then tap with broad end of hammer. Leg will
extend.8
Biceps Reflex. Support the arm so that it is completely relaxed. Press tendon at the
base of the biceps with your thumb to stretch the tendon. Tap thumb with pointed end
of the hammer. Arm will flex.8

Page 9 of 9