Labour Drug Assailed

Labor Drug Assailed

Article Challenges Mag Sulfate Use

By Sandra G. Boodman
Washington Post Staff Writer

Tuesday, October 10, 2006; HE01



For the past 30 years or so, doctors have routinely given pregnant women intravenous infusions of magnesium sulfate to halt contractions that can lead to premature labor.Now a prominent physician-researcher is calling on his colleagues to stop using the drug for this purpose, saying that the treatment is unproven, ineffective and potentially deadly -- an artifact of an earlier era when the standard of care was based more on pronouncements than on clinical trials.

The drug, sold commercially as Epsom salts and known to doctors as mag sulfate, causes side effects that range from highly unpleasant to lethal: nausea, blurred vision, headache, profound lethargy, a burning sensation and, in rare cases, life-threatening pulmonary edema, in which the lungs fill with fluid."Why has it persisted? Tradition," said David Grimes, vice president of biomedical affairs for the nonprofit public health group Family Health International, who co-authored the provocative commentary "Time to Quit" in the current issue of the journal Obstetrics & Gynecology.Magnesium sulfate for preterm labor, Grimes said, is a "North American anomaly" confined to the United States and Canada whose continued use is predicated on "good hopes and good wishes rather than good data."

The American College of Obstetrics and Gynecology does not endorse use of the drug for this purpose, he noted.Four years ago a team of researchers from Australia reached similar conclusions in a report published by the Cochrane Collaboration, a respected international organization that evaluates scientific studies. The Australian team reviewed 23 clinical trials worldwide involving 2,000 women who had received the drug to quell contractions. They found that it did not reduce preterm labor and that more babies died when their mothers took the drug than in a control group where the mothers had not been given it.

Mag sulfate is typically administered between the 26th and 34th weeks of pregnancy for about 48 hours to stall contractions long enough to permit the injection of steroids, which speed fetal lung development.Grimes said he and Kavita Nanda wrote the commentary to promulgate the Cochrane findings among the nation's OB-GYNs. "The Cochrane review hasn't received wide visibility, so that's why we wanted to put this in a journal all OB-GYNs get."Continued use of the drug, Grimes and other critics of the practice say, exemplifies the slow pace of change in obstetrics, where it is hard to conduct clinical trials because the stakes are regarded as so high.

Doctors seeking to use a drug to stave off premature contractions that can trigger labor are better off using a calcium channel blocker such as nifedipine, which has been proven effective, Grimes said.Grimes and Nanda estimate that about 120,000 American women receive mag sulfate each year for premature contractions, and they say some evidence suggests it may be associated with 1,900 to 4,800 fetal deaths annually in the United States.

The latter figure is derived from a 1998 study in Obstetrics & Gynecology.But jettisoning a long-standing practice in obstetrics involves factors other than evidence, some doctors say.They note that the standard of care -- a benchmark of evidence in malpractice cases -- as well as patients' wishes and the desire to prevent a bad outcome such as premature birth -- all contribute to continued use of the drug.

"There is a current practice [to use the drug] that is the community standard," said Michael Gallagher, a specialist in maternal-fetal medicine, or high-risk pregnancy, who practices at Shady Grove Adventist and Holy Cross hospitals. Gallagher said he regards mag sulfate as a viable and safe option in some cases -- and not as an ineffective and potentially dangerous drug."Suppose we don't use it and a patient delivers," Gallagher said, noting that might violate the prevailing standard among OB-GYNs. "You find yourself in lonely places."

"Medical practice," he added, "doesn't move overnight." Nor, Gallagher said, does he think the evidence is "as cut and dried as Grimes says. This is his opinion."But, Gallagher said, he and many of his colleagues are careful to present the option of using the drug with plenty of caveats."We do a lot of 'we think' and 'maybes' and let women decide whether to take it," he noted.Not surprisingly, few refuse -- fearing the possibility of a bad outcome, he added.

For doctors, "there is pressure to use it from patients, as well as peer pressure" from other physicians, said Dallas OB-GYN Gary Cunningham, a professor at the University of Texas Southwestern Medical Center who noted that doctors are desperate to find something that works to stop preterm labor and prevent a premature birth with possibly devastating results."This drug has a powerful constituency," he said, adding that he is not part of it. The drug, he added, is an effective treatment for preeclampsia or eclampsia, pregnancy-induced hypertension that can be fatal to mothers and babies.

Before mag sulfate became widely used in the 1970s, Cunningham noted, doctors gave women intravenous alcohol to quiet contractions."All we got was a bunch of drunk patients who vomited and aspirated, and some died," he recalled. Before that, doctors used morphine, which was abandoned for similar reasons.Alessandro Ghidini said it took him years to persuade colleagues at Inova Alexandria Hospital to stop using mag sulfate after his arrival about a decade ago."This is a medicine that American doctors are very familiar with," said Ghidini, a maternal-fetal medicine specialist. "It took a long time" to convince doctors the evidence was lacking, he said.In their commentary, Grimes and Nanda wrote that the popularity of the drug has been reinforced by "pronouncements in prestigious medical journals or from famous medical institutions.

" They cite a 1999 review article in the New England Journal of Medicine that stated "magnesium sulfate is safe and has become the first-line treatment for preterm labor in North America."" 'Overgrazing' of ineffective and harmful practices on the 'medical commons' is a stubborn problem in obstetrics," they wrote.

Cunningham said he still vividly recalls the time years ago that he took the drug to see what female patients experienced."It was scary," he said. "You feel like you're burning up."

·Comments:boodmans@washpost.com.http://tinyurl.com/ydr4tm

Reaching out

Take a look at the growth of a fetal hand in utero...

http://standupgirl.com/inside/embryoscopy/video/hand_inutero.wmv

That's a wrap

I just had a wonderful time teaching tonight! We wrapped up another session of our Birth Rhythm Prenatal class and then went out for tea with all the moms- to-be.

It is so exciting to watch women start to realize that they are in control of their births in a way they did not realize before. It is so encouraging to hear the stories of women who begin to ask questions and search out answers. You ladies are like flowers in bloom, and I don't mean just around the middle. I see the strength in you as you wrap your minds and hearts around the prospect of a truly beautiful birth. The possibility is there for each of you and now you can see it. Which means now you can make the choices that bring dreams into reality. You now know where to look for answers and how to ask the questions that you previously may not have known to ask.

When I watched you dancing tonight it was so different from our first class. Strength, confidence, and calm were in the air as the veils were twirling about. The chatter mixed with the music and you allowed yourselves to move freely, and to be witnessed. It really was beautiful to watch.



I look forward to hearing from you all as your little ones are welcomed into the world. Please come back here and post your stories, good or bad. We all have so much to learn from each other!

Be intentional, be proactive, and TRUST BIRTH!

Nursery Rhymes Class for 0-36 month old children

Give your child a head start on language development and social interaction

Please join me in this interactive, family orientated and fun filled class of rhyming and story telling

Classes for children age birth to 18 months
and 18 – 36 months

¨ Learn new ways to interact with your child
¨ Meet other parents with children the same age
¨ Rhyming will give your child a head start on language development as well as a bit of motor skills through rhymes using actions
¨ A beginning stepping stone for your child to experience a semi structured environment
BISHOP POCOCK SCHOOL
Tuesday, October 10 to December 5, 2006
Infant, Birth to 18 mo: 10:30-11:30 am
AND
Classes begin monthly at Buttons’n’Bows Boutique 652-5437
This class uses rhymes, finger plays, songs and a few stories with explanations on how they can be used at home to help with dressing, bathing, feeding, bed time and in general how to calm a child or just play with them.
Given by an experienced instructor

Please call Tracy at 477-1097 for more information or to register. Or email itsybitsytinytalk@hotmail.com

An interesting article...

Hospital-Acquired Infections Turning birth into an illness

http://www.aims.org.uk/Journal/Vol12No3/infection.htm

While not all of the sources are Canadian , I believe these are good questions to ask and that upon investigation we will see our hospitals have very similar problems.

Swayde Waters: The Story of Your Birth


The day you came to breathe your first breath came with stormy waters indeed. After months of caring for you perfectly, your mother’s labour began. Nice and slow, with only a back ache to let her know that she would see you soon. She was so focused and ready to open her body and let you come to greet the world…

Then there came the surprise… Sometime in the days or weeks before you had decided to greet the world feet first. Your little body was turned around in the womb so that your head was tucked quite neatly below your mother’s rib cage and your foot was trying to push through the opening below. I wonder if this is how you will greet all of life’s challenges. Feet first, without looking at what exactly you are getting yourself into.

Where we live there are very few people left who know how to help a determined soul like you get born that way. Sometimes too much science makes us forget the wisdom of ancient ways. You had grown into such a beautiful and healthy child that there was no room left in the womb to try to coax you to turn around. Your mother then asked for the help of good doctors who could help you come into the world safely, in the absence of the knowledge of the ancient ways to bring a strong spirit like you out safely.

Sometimes your mother was afraid; she wanted only the best for you. She is a very courageous woman. You see, courage only comes from walking through fear. She did it so well. Your father stood strongly at her side the entire time. I can see where your strength and determination come from Swayde. They will fight any battle for your safety.

You still managed to be born the way you wanted. Your little feet came first. You stepped into life with confidence.
When you took your first breathe there was a sense of pure joy in the room. The first words spoken over you were of love and greetings,
followed by the story of your Guardian Angel. You are never alone. The Creator of all things watches over his precious ones.

The journey for you has just begun. Continue to stand and walk tall Swadye Waters. You can overcome any obstacle.
You have been born into a legacy of love and courage.
Walk tall.

May love and blessings walk with you always.


With love,
Your birth guardian

L. V. W.