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01.12.2018 | Research | Ausgabe 1/2018 Open Access

Implementation Science 1/2018

MAGnesium sulphate for fetal neuroprotection to prevent Cerebral Palsy (MAG-CP)—implementation of a national guideline in Canada

Zeitschrift:
Implementation Science > Ausgabe 1/2018
Autoren:
Dane A. De Silva, Anne R. Synnes, Peter von Dadelszen, Tang Lee, Jeffrey N. Bone, Laura A. Magee, MAG-CP, CPN and CNN collaborative groups
Wichtige Hinweise

Electronic supplementary material

The online version of this article (https://​doi.​org/​10.​1186/​s13012-017-0702-9) contains supplementary material, which is available to authorized users.
An abstract related to the content of this paper was accepted for presentation at the Canadian National Perinatal Research Meeting, Montebello, CA (Feb 14–17, 2017), and the Royal College of Obstetricians and Gynecologists Congress, Cape Town, ZA (Mar 20–22, 2017).

Abstract

Background

Evidence supports magnesium sulphate (MgSO4) for women at risk of imminent birth at < 32–34 weeks to reduce the likelihood of cerebral palsy in the child. MAGnesium sulphate for fetal neuroprotection to prevent Cerebral Palsy (MAG-CP) was a multifaceted knowledge translation (KT) strategy for this practice.

Methods

The KT strategy included national clinical practice guidelines, a national online e-learning module and, at MAG-CP sites, educational rounds, focus group discussions and surveys of barriers and facilitators. Participating sites contributed data on pregnancies with threatened very preterm birth. In an interrupted time-series study design, MgSO4 use for fetal neuroprotection (NP) was tracked prior to (Aug 2005–May 2011) and during (Jun 2011–Sept 2015) the KT intervention. Effectiveness of the strategy was measured by optimal MgSO4 use (i.e. administration when and only when indicated) over time, evaluated by a segmented generalised estimating equations logistic regression (p < 0.05 significant). Secondary outcomes included maternal effects and, using the Canadian Neonatal Network (CNN) database, national trends in MgSO4 use for fetal NP and associated neonatal resuscitation. With an anticipated recruitment of 3752 mothers over 4 years at Canadian Perinatal Network sites, we anticipated > 95% power to detect an increase in optimal MgSO4 use for fetal NP from < 5 to 80% (2-sided, alpha 0.05) and at least 80% power to detect any increases observed in maternal side effects from RCTs.

Results

Seven thousand eight hundred eighty-eight women with imminent preterm birth were eligible for MgSO4 for fetal NP: 4745 pre-KT (18 centres) and 3143 during KT (11 centres). The KT intervention was associated with an 84% increase in the odds of optimal use (OR 1.00 to 1.84, p < 0.001), a reduction in the odds of underuse (OR 1.00 to 0.47, p < 0.001) and an increase in suboptimal use (too early or at ≥ 32 weeks; OR 1.18 to 2.18, p < 0.001) of MgSO4 for fetal NP. Maternal hypotension was uncommon (7/1512, 0.5%). Nationally, intensive neonatal resuscitation decreased (p = 0.024) despite rising MgSO4 use for fetal NP (p < 0.001).

Conclusion

Multifaceted KT was associated with significant increases in use of MgSO4 for fetal NP, with neither important maternal nor neonatal risks.
Zusatzmaterial
Additional file 1: Figure S1. Between-centre variability of optimal, under and suboptimal uses of MgSO4 among the 11 participating centres. Figure S2. Trend of antenatal corticosteroid administration over time among women with underuse of MgSO4 as a proxy for non-precipitous deliveries. Figure S3. Variability of MgSO4 use for fetal neuroprotection among MAG-CP centres (represented by the blue triangles) and non-MAG-CP centres (represented by the green circles). Table S1. MAG-CP (MAGnesium sulphate for fetal neuroprotection to prevent Cerebral Palsy), CPN (Canadian Perinatal Network) and CNN (Canadian Neonatal Network) collaborative groups. Table S2. Definitions of conditions and variables as used in the Canadian Perinatal Network (CPN). Table S3. Geographic regions of participating centres in the Canadian Perinatal Network (CPN). Table S4. Absolute utilisation rates of MgSO4 for fetal NP by study time period (from August 01/05 to September 30/15). Table S5. Segmented regression analysis of the nine centres that contributed data to both pre-MAG-CP and MAG-CP eras. Table S6. Sensitivity analyses of overall utilisation rates of MgSO4 using data from the nine centres that contributed data to both pre-MAG-CP and MAG-CP eras. Table S7. Determinants of engagement of participating sites in MAG-CP. Table S8. Components of engagement and relation to optimal use. Table S9. Antenatal MgSO4 use at GA 24–31+6 weeks by indication, from Jan 1/11 to Sep 30/15. (DOCX 281 kb)
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