Prenatal High Blood Pressure

Mamas on Bedrest: Magnesium Sulfate and Your Baby’s Bones

May 31st, 2013

Magnesium Sulfate has long been used in obstetrics to prevent seizures associated with pre-eclampsia, eclampsia, pregnancy induced hypertension and preterm labor. On May 30, 2013, the United States Food and Drug Administration issued a drug safety alert stating that clinicians should not prescribe Magnesium Sulfate for seizure prevention during pregnancy for more than 5-7 days because of the risk of low calcium and bone abnormalities in the fetus.

Magnesium Sulfate has been used for decades “off label ” (not for its originally FDA approved indication) for the prevention of preterm labor and the prevention of seizures caused by markedly increased blood pressure as seen in pre-eclampsia and eclampsia. It was first prescribed in Germany in 1906 to prevent seizures associated with eclampsia and was injected into the intrathecal cavity (at the base of the spine). In 1926 it was prescribed intra-muscularly and in  1933, the IV form of “Mag Sulfate” became available.

As recently as February 2013, researchers published a study touting the benefits of Magnesium Sulfate and saying that there were no appreciable side effects. Upon close scrutiny of  the article, one clearly sees that this particular study only addressed potential side effects to the mother. This study, like many others, completely ignored the potential harm to the developing fetus, assuming that if  magnesium sulfate is in fact safe for mamas it is safe for babies. This simply isn’t the case.

In response to 18 adverse drug reports submitted to the Safety Information and Adverse Event Reporting system, the FDA conducted its own research to see why some mothers had problems and some did not.  Babies born to these 18 women all had osteopenia (low bone mass density) and were at greater risk of sustaining fractures. The average amount of time the mamas received Magnesium sulfate was over a 10 weeks.  The FDA found that the maximum time that a mamas should take Magnesium Sulfate is a mere 5-7 days and then the FDA recommends stopping the medication. The prolonged administration of Magnesium Sulfate led to the side effects, which seem to resolve once Magnesium Sulfate is stopped.

This MedScape News Report has a couple of really good take home messages. First and foremost, clinicians must closely monitor Magnesium Sulfate administration and ensure that mamas understand that the drug is being used off label, has the potential to affect their unborn babies’ bones and that they have the right to say “no”. Second, we health care researchers have to be careful when reading studies lest we draw false conclusions and inform the public that there is no harm when there is or there is harm when there is not.

References

MedScape Newshttp://www.medscape.com/viewarticle/805009

Jeffrey Michael Smith, Richard F Lowe, Judith Fullerton, Sheena M Currie, Laura Harris and Erica Felker-Kantor

An integrative review of the side effects related to the use of magnesium sulfate for pre-eclampsia and eclampsia management.  BMC Pregnancy Childbirth, May 2013

The US Food and Drug Administration-Safety Alerts for Human Medical Products.

Mamas on Bedrest: Pre-Eclampsia…More than Pregnancy Induced Hypertension

May 8th, 2013

Pre-Eclampsia is a leading cause for which women receive the bed rest prescription. Bedrest Coach Darline Turner shares the definition of pre-eclampsia, how it is diagnosed, how it is treated and what Mamas on Bedrest can do to care for themselves and partner in their health care if they are diagnosed with Pre-eclampsia. For more information, see our previous blog posts on Pre-Eclampsia or send e-mail us at info@mamasonbedrest.com.

May is National Pre-Eclampsia Awareness Month. Viacord, a cord blood bank company, is planning and supporting activities to benefit the Pre-Eclampsia Foundation.  The Campaign is called the “Aware Because I Care” Campaign and it is a month long initiative to raise funds for the Pre-Eclampsia Foundation. They are accepting donations of $10, collecting and donating up to $10,000. The funds will be used for Pre-Eclampsia patient education, medical research and direct support for women with the disorder. Learn more about the #awarebecauseicare campaign here.

Mamas on Bedrest: Is Being on Bedrest a (More) Common Occurence?

February 6th, 2013

I was speaking with my mom the other day and we were chit chatting away about my work. My mom is really interested in “this bed rest stuff” as it was not really common when she was having us in the late 50’s and early 60’s. My mom asked me, “Is bed rest really that common?”

Bed rest is certainly more common now than when my mom was having kids and there are a myriad of reasons. Just to bring folks up to speed, according to the CDC the numbers are still holding at some 750,000 women going on bed rest annually in the United States. But my mom’s question is one that hounds me. Why are so many women going on bed rest? I tried to find a specific answer and while the literature is not specific, here is what I have been able to gleen.

1. Bed rest is more common right now because we have more diagnostic tools to diagnose conditions for which bed rest is recommended. When my mom was having my sisters and I, many of the ultrasound machines and fetal monitors that are used today to evaluate a mama and her unborn child simply didn’t exist. If a woman had a short cervix, she simply had a short cervix. Now I can hear the collective cyber gasp at that statement. But at the same time it makes you wonder, “How many women over the centuries had a shortened cervix during pregnancy and had a completely healthy baby?” One could give the opposing view, “Well how many women lost babies due to shortened cervix?” We don’t know the answers to these questions, but it does make for interesting mental gymnastics.

I am currently researching the life and career of my great grandmother, a “granny midwife” in the south from the late 1910’s to the early 1950’s. I hear tell that she had an uncanny way of knowing which women were going to have problems and which women were going to be “good breeders”. I also am learning that she had phenomenal clinical skills. I wonder if she was able to examine a woman and note if her cervix was shortened? Or if she would have preterm labor? I do know that she saw a lot of women through their pregnancies and advised them when to stop working (most were farm women) and to rest. It’s an interesting historical perspective and as I learn more, I will certainly share with you all.

2. Bed rest is more common because we have more women having children later in life. I don’t know if I completely agree with this. My grandmother gave birth to my dad at age 43 and he was her 15th child, 13th pregnancy (2 sets of twins, yikes!!) Now one could argue that her body was accustomed to having kids (one about every 18 months!).  But one could also argue that her body was “worn out”. As far as I know, she had no problems during pregnancy, no bed rest and no still births. She did lose the twin boys to infant illnesses.

One thing that my reproductive endocrinologist told me when I was in the “height of my childbearing years” is that ovarian age can be uncertain. By that he meant that some women may be 20 yet have the ovarian age of a 40 year old, and some 40 year old women will have more youthful ovarian tissue and function than their much younger counterparts. There is no way to predict which women will have “youthful” ovarian function and which women will not. Likewise, there is no way to predict when a woman will cease to have ovarian function. When we speak of advanced maternal age, we know that in general, as a woman ages, her ovarian function decreases as well as the quality of her eggs. However, we all know of older women who have had completely healthy, unassisted pregnancies, labors and deliveries, and young 30 somethings who have struggled.  The best that we can say for now is, relatively speaking, as a woman ages, her chances of having difficulty conceiving and having complications during her pregnancy are increased and continue to increase as she ages.

3. Assisted Reproductive Technologies (ART). Today there are thousands of women who become pregnant as a result of assisted reproductive technologies (IVF, GIFT, ZIFT, IUI, ICI, Surrogacy/gestational carrier).  The use of ARTs is a relative risk factor for a woman being prescribed bed rest because women who use ART are often older and often have pre-existing reproductive issues that would predispose them to complications any way. Additionally, women who conceive via ART are at greater risk for having a multiple pregnancy which increases the risk of going on bed rest.

3. Stress. I have written extensively in previous blogs about the role that stress plays on a woman’s ability not only to become pregnant but to maintain that pregnancy. Today more than ever women are balancing the demands of a career, a family that they have created, caring for family members from family of origin (parents or even grand parents) or have other pressing responsibilities not common to women 30 or more years ago. The work of Kathleen Kendall-Tackett PhD and others shows that the stress response has a direct effect on the cervix and preterm labor. Women who are under stress are releasing neurochemicals that soften the cervix and “ripen” it in preparation for labor and delivery-even if it isn’t time.  Stress also increases a mama’s blood pressure and may cause her not to eat or take optimum care of herself so her baby may experience Intrauterine growth retardation (IUGR).  It is critical that pregnant women avoid stress as much as possible not only for their own health but also for the health of their unborn babies.

4. Litigation. I hate bringing this topic into the argument, but in our current culture, litigation is probably closer to the top as opposed to the bottom of the list of reasons some OB’s put patients on bed rest. Currently, there is not scientific or medical evidence that bed rest is beneficial in preventing preterm labor or preterm birth. In a review article published just over a year ago, I reviewed the current medical literature regarding the efficacy of bed rest and again found no solid medical or scientific evidence for the use of bed rest as a treatment to prevent preterm birth. But as a former clinician, I also understand why OB’s prescribe bedrest. If on the off chance an OB discovered an anomaly with the pregnancy, yet did not prescribe bed rest and the pregnancy had an unhappy ending, that OB can count on being sued and would likely lose his or her ability to practice as an obstetrician. At the current time, medicine in the United States (or globally) has not discovered any other, more effective ways to deal with the complications of pregnancy that often result in the bed rest prescription. Until that occurs, bed rest, effective or not, will remain a “standard of care” in the management of pregnancy complications.
Now whether or not a woman should be put on bed rest is still a heated debate. Given that there is no scientific or medical evidence that bed rest is effective in the treatment of preterm labor, one could argue that we are potentially creating more problems for mamas and babies than solving. But to mamas who have been on bed rest and now have healthy babies, there is no other route to go and no talking her out of the fact that bedrest saved her baby’s life.

I pass no judgement because I know that when I was having my kids, if my OB had told me to spin on my head and shoot marbles out of my nose, I would have done it. I think that high risk pregnancy is an emerging field and one in which there is still much to learn. I am very excited to watch what is emerging in the medicine and science, and I am very excited to be a part of the public health solution of supporting mamas on bed rest.