CLASSIC PAGES FROM THE AMERICAN JOURNAL OF

OBSTETRICS AND GYNECOLOGY

Steven G. Gabbe, MD
H,

A PRELIMINARY REPORT ON THE INTRAVENOUS USE OF

MAGNESIUS[ SULPHATE IN PUERPERAL ECLAMPSIA*
BY E. IV[. LAZARD, M.D., F.A.C.S., Los ANGESES, CALIF.
(Senior Atlending Obstetrician Los Angeles Gun.rat Hospital)

I Nof]~IAY, 1924 one of the internes, Dr. E. Bogen, suggested the use
magnesium sulphate intravenously for the control of eelamptic
convulsions. Having in mind the sedative action of magnesium sul-
phate on the nerve ceils as reported by Meltzer and Auer in the
American Journal of Physiology in 1904, as well as the intr,.spinal
use of magnesium sulphate for the control of tetanic convulsions, wc
thought it worth while to giv e it a trial. Our experience in the few
cases here reported has been so uniformly successful, that we f e d it is
worthy of further and more cxtensive trial and we are making this
preliminary report in the hope that more extensive experience may
bear out our impression that in the intravenous administration of
magnesium sulphate, we have at our disposal a means, not only of con-
trolling the convulsions of eclampsia, but an efficient treatment of
the toxemia itself.
The treatment as devcloped at the Los Angeles General Hospital,
consists of the intravenous administration of 20 c.c. of a 10 per cent
solution of magnesium sulphate as soon after the first observed con-
vulsion as possible. Eliminative measures, such as phlebotomy, stom-
ach lavage, administration of castor oil, colonic flushings with glucose
and soda are carried out as in the treatment of any toxemic condition.
We are coming to feel more and more strongly, however, that the best
results can be obtained by the least handling of the patient, consistent
with obtaining the desired results.
The cases herewith reported are in most part from the obstetric
services of Dr. L. ft. l~[eNeile, and of the writer, at the Los Angeles
General Hospital. The cases were under the direct supervision of the
resident obstetricians, Drs. L. 5. Kaffesieder and H. White, to whom
credit is due for the carrying out of the treatment. There are three
cases included from the private practices of members of the attending
staff.
We have now to report seventeen cases of eclampsia, ante-, intra-,
and postpartal, which have received .this treatment, with but one
maternal death. It is to be remembered that these are all cases of the
profoundly toxic type, having convulsions, and in coma when first
seen, and most of whom have had little or no antepartal care.
*Read at the meeting of the Los Angeles Obstetric Society, Oct. 14. 1924.
178

1390 April 1996 American Journal of Obstetrics and Gynecology

Volume 174, Numl)er 4
Am J Obstet Gynecol
A preliminary report on the intravenous use of
magnesium sulphate in puerperal eclampsia
E.M. Lazard, MD, FACS
A.,uJ 01~srl.:'r GFNI,:COL 1 9 2 5 ; 9 : 1 7 8 - 8 8
In his classic 1925 article Lazard was the first to
d e s c r i b e the use o f m a g n e s i u m sulfate for the treat-
m e n t o f a large n u m b e r o f w o m e n with eclampsia.
Overall, t h e t h e r a p y was highly successful, with only
o n e d e a t h in a p a t i e n t who r e m a i n e d in a c o m a t o s e
state.
O u r e x p e r i e n c e in the few cases h e r e r e p o r t e d has b e e n
so u n i f o r m l y successful, t h a t we feel it is worthy of f u r t h e r
a n d m o r e extensive trial a n d we are m a k i n g this prelimi-
n a r y r e p o r t in the h o p e t h a t m o r e extensive e x p e r i e n c e
may b e a r o u t o u r i m p r e s s i o n t h a t in the i n t r a v e n o u s
a d m i n i s t r a t i o n o f m a g n e s i u m sulphate, we have at o u r
disposal a means, n o t only of c o n t r o l l i n g t h e convulsions
of eclampsia, b u t a n efficient t r e a t m e n t o f the t o x e m i a
itself.
T h e t r e a t m e n t as d e v e l o p e d at the Los Angeles G e n e r a l
Hospital, consists of t h e i n t r a v e n o u s a d m i n i s t r a t i o n o f 20
c.c. o f a 10 p e r c e n t solution of m a g n e s i u m s u l p h a t e as
s o o n a l t e r t h e first o b s e r v e d c o n v u l s i o n as possible . . . .
We have now to r e p o r t s e v e n t e e n cases of eclampsia,
ante-, intra-, a n d postpartal, which have received this
t r e a t m e n t with b u t o n e m a t e r n a l d e a t h . It is to be r e m e m -
b e r e d t h a t these are all cases of the p r o f o u n d l y toxic type,
h a v i n g convulsions, a n d in c o m a w h e n first seen, a n d
m o s t of w h o m have h a d little or n o a n t e p a r t a l care . . . .
As stated in t h e b e g i n n i n g , o u r first idea was to c o n t r o l
t h e convulsions by the paralyzant o r sedative effect o n the
v o l u n t a r y muscles. We were at first c o n c e r n e d as to
w h e t h e r we m i g h t n o t get a r e s p i r a t o r y paralysis, b u t have
n o t n o t e d any d e l e t e r i o u s effect in any of the cases . . . .
CONCLUSIONS
(1) By t h e i n t r a v e n o u s use o f m a g n e s i u m s u l p h a t e the
c o n v u l s i o n s of e c l a m p s i a can b e c o n t r o l l e d a n d the c o m a
c l e a r e d by a sufficient dosage.
(2) T h e i n t r a v e n o u s use o f m a g n e s i u m s u l p h a t e re-
d u c e s e d e m a a n d p r o m o t e s diuresis, thus e l i m i n a t i n g t h e
toxins.
(3) O t h e r eliminative measures, such as catharsis, phle-
botomy, lavage, a n d colonic flushings, may be used as
adjuvants; however, as o u r c o n f i d e n c e in the m a g n e s i u m
Historical observations fi'om the AMl~mc:~,\'Joctev~t. ol. OB.vncrluc.s a.',7~ Grxt;cot.ocr, other journals, or texts are ]n'esented
monthly.
Classic pages 1391
s u l p h a t e has increased, we have gradually r e d u c e d this
s u p p l e m e n t a r y t r e a t m e n t until, in t h e last two cases, little
else was d o n e .
(4) Surgical i n t e r f e r e n c e with the p r e g n a n c y s h o u l d
n o t b e u n d e r t a k e n d u r i n g the e c l a m p t i c attack, e x c e p t
for the m o s t u r g e n t obstetric i n d i c a t i o n .
Comment by Dr. Gabbe
In 1933 Lazard,' p u b l i s h i n g again in the AMI~ZRI(:ANJot'R-
NAI.OF OBSTETRICSANDGYXF.COLOC~,d e s c r i b e d his e x p e r i e n c e
with 575 cases of eclampsia a n d p r e e c l a m p s i a t r e a t e d with
i n t r a v e n o u s m a g n e s i u m sulfate. In a series o f 228 cases o f
p r e e c l a m p s i a m a n a g e d f r o m July 1929 to N o v e m b e r 1932
only two m a t e r n a l d e a t h s were n o t e d , o n e associated with
eclampsia a n d the s e c o n d resulting f i o m a b r u p t i o placen-
tae. In b o t h articles Lazard e m p h a s i z e d n o t only the effi-
cacy o f m a g n e s i u m sulfate b u t its safety.
I,azard's work has received i n c r e a s e d a t t e n t i o n within
the past year as t h e result o f r e c e n t p u b l i c a t i o n s t h a t have
c o n f i r m e d the b e n e f i t s of m a g n e s i u m sulfate in t h e treat-
merit o f b o t h eclampsia a n d preeclampsia. In a n i n t e r n a -
tional n m h i c e n t e r r a n d o m i z e d trial of 1680 w o m e n with
eclampsia, the Eclampsia Trial Collaborative G r o u p e
d e m o n s t r a t e d t h a t m a g n e s i u m sulfate was associated with
a lower risk of r e c u r r e n t convulsions a n d m a t e r n a l mor-
tality, w h e n c o m p a r e d with d i a z e p a m or p h e n y t o i n . Lucas
et al. :~ have recently c o n f i r m e d the value o f m a g n e s i u m
sulfate as c o m p a r e d with p h e n y t o i n in p r e v e n t i n g ec-
lampsia. In a prospective r a n d o m i z e d trial i n t r a m u s c u l a r
m a g n e s i u m sulfate, as well as a n a d d i t i o n a l i n t r a v e n o u s
l o a d i n g dose in w o m e n with severe preeclampsia, p r o v e d
s u p e r i o r in p r e v e n t i n g e c l a m p t i c convulsions.
REFERENCES
1. Lazard EM. An analysis of 575 cases of eclamptic and preec-
lamptic toxemias treated by intravenous injections of magne-
siren sulphate. AMJ OBSrETGWECOL 1933;26:647-56.
2. The Eclampsia Trial Collaborative Group. Which anticonvul-
sant tor women with eclampsia? Evidence from the Collabo-
rative Eclampsia Trial. Lancet 1995;345:1455-63.
3. Lucas M], Leveno KJ, Cunningham FG. A comparison of
magnesium sulfate with phenytoin fbr the prevention of ec-
lampsia. N EnglJ Med 1995;333:201-5.