Magnesium sulfate is considered first-line treatment for the prevention of primary and recurrent

eclamptic seizures. It is also utilized for prophylactic treatment in all patients with severe preeclampsia.

The mechanism of action of magnesium sulfate is thought to trigger cerebral vasodilation, thus reducing
ischemia generated by cerebral vasospasm during an eclamptic event. The substance also acts
competitively in blocking the entry of calcium into synaptic endings, thereby altering neuromuscular
transmission.

Identification

Pharmacology

Indication

Associated Conditions

Associated Therapies
Contraindications & Blackbox Warnings

Pharmacodynamics

Mechanism of action

Absorption

Volume of distribution

Protein binding

Metabolism

Route of elimination

Half-life

Clearance

Adverse Effects

Toxicity

Affected organisms

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Targets (1)
Magnesium sulfate

IDENTIFICATION

Name

Magnesium sulfate

Accession Number

DB00653

Description

A small colorless crystal used as an anticonvulsant, a cathartic, and an electrolyte replenisher in the
treatment of pre-eclampsia and eclampsia. It causes direct inhibition of action potentials in myometrial
muscle cells. Excitation and contraction are uncoupled, which decreases the frequency and force of
contractions. (From AMA Drug Evaluations Annual, 1992, p1083)

Type

Small Molecule

Groups

Approved, Investigational, Vet approved

Structure

Thumb

Weight

Average: 120.368

Monoisotopic: 119.936771076

Chemical Formula

MgO4S

Synonyms

Magnesium sulfate (1:1)

Magnesium sulphate

magnesium(II) sulfate
Magnesiumsulfat

MgSO4

PHARMACOLOGY

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Indication

Used for immediate control of life-threatening convulsions in the treatment of severe toxemias (pre-
eclampsia and eclampsia) of pregnancy and in the treatment of acute nephritis in children. Also
indicated for replacement therapy in magnesium deficiency, especially in acute hypomagnesemia
accompanied by signs of tetany similar to those of hypocalcemia. Also used in uterine tetany as a
myometriat relaxant.

Associated Conditions

Constipation

Convulsions

Hypomagnesemia

Torsades de Pointes
Barium poisoning

Severe Exacerbation of asthma

Associated Therapies

Bowel preparation therapy

Soaking aid for minor sprains and bruises

Contraindications & Blackbox Warnings

Learn about our commercial Contraindications & Blackbox Warnings data.

Pharmacodynamics

Magnesium sulfate is a small colorless crystal used as an anticonvulsant, a cathartic, and an electrolyte
replenisher in the treatment of pre-eclampsia and eclampsia. It causes direct inhibition of action
potentials in myometrial muscle cells. Excitation and contraction are uncoupled, which decreases the
frequency and force of contractions. Magnesium sulfate is gaining popularity as an initial treatment in
the management of various dysrhythmias, particularly torsades de pointes, and dyrhythmias secondary
to TCA overdose or digitalis toxicity.

Mechanism of action

Magnesium is the second most plentiful cation of the intracellular fluids. It is essential for the activity of
many enzyme systems and plays an important role with regard to neurochemical transmission and
muscular excitability. Magnesium sulfate reduces striated muscle contractions and blocks peripheral
neuromuscular transmission by reducing acetylcholine release at the myoneural junction. Additionally,
Magnesium inhibits Ca2+ influx through dihydropyridine-sensitive, voltage-dependent channels. This
accounts for much of its relaxant action on vascular smooth muscle.
Toxicity

LD50 = 1200 mg/kg (rat, subcutaneous). May be harmful if swallowed. May act as an irritant. Adverse
reactions include hypotension, ECG changes, diarrhea, urinary retention, CNS depression and respiratory
depression.
magnesium sulfate

Pharmacologic classification: mineral/ electrolyte

Therapeutic classification: anticonvulsant

Pregnancy risk category A

Available forms

Available by prescription only

Injection for I.V. use: 4% (4, 20, and 40 g); 8% (4 g)

Parenteral injection: 10%, 12.5%, 50%

Parenteral injection for I.V. use: 1% (1 and 10 g) in D5W; 2% (10 and 20 g) in D5W

Indications and dosages

Hypomagnesemic seizures. Adults: 1 g I.V. or I.M. Or, 1 to 2 g (as 10% solution) I.V. over 15 minutes;
then 1 g I.M. q 4 to 6 hours, based on patient’s response and magnesium blood levels.

Seizures secondary to hypomagnesemia in acute nephritis. Children: 0.2 ml/kg of 50% solution I.M. q 4
to 6 hours, p.r.n., or 100 to 200 mg/kg as a 1% to 3% solution I.V. given slowly over 1 hour with the first
half of dose in the first 15 to 20 minutes. Also, 0.1 to 0.2 ml/kg of 20% solution (20 to 40 mg/kg) I.M.
Adjust dosage according to magnesium blood levels and seizure response.

Life-threatening arrhythmias. Adults: For patient with sustained ventricular tachycardia or torsades de
pointes, give 1 to 6 g I.V. over several minutes followed by 3- to 20-mg/minute I.V. infusion for 5 to 48
hours depending on patient response and serum magnesium levels. For patient with paroxysmal atrial
tachycardia, give 3 to 4 g I.V. over 30 seconds.

Prevention or control of seizures in preeclampsia or eclampsia. Adults: Initially, 4 g I.V. in 250 ml D5W
and 4 to 5 g deep I.M. into each buttock (using undiluted 50% magnesium sulfate injection); then 4 to 5
g deep I.M. into alternate buttock q 4 hours, p.r.n. Or, 4 g I.V. as a loading dose followed by 1 to 3 g
hourly as an I.V. infusion. Maximum daily dose is 30 to 40 g. Or, 8 to 15 g depending on weight of patient
(8 g for 45-kg [100-lb] patient and 15 g for 90-kg [198-lb] patient); 4 g of magnesium sulfate (as
magnesium sulfate injection or magnesium sulfate in D5W) is given I.V. and the remaining dose is given
I.M. using undiluted 50% magnesium sulfate injection. Dosage over next 24 hours based on serum level
and urinary excretion of magnesium following initial dose. Later doses should be sufficient to replace
magnesium excreted in urine, about 65% of the initial dose given I.M. q 6 hours.

≡ Dosage adjustment. For patients with severe renal insufficiency, maximum dose is 20 g in 48 hours.

Barium poisoning, asthma. Adults: 1 to 2 g I.V.

Management of preterm labor ◇. Adults: 4 to 6 g I.V. over 20 minutes as a loading dose, followed by
maintenance infusions of 2 to 4 g/hour for 12 to 24 hours as tolerated after contractions subside.

Mild hypomagnesemia. Adults: 1 to 3 g I.M. q 6 hours for four doses. Or, 5 g in 1 L of D5W or dextrose
5% in normal saline solution I.V. over 3 hours.

Reduction of CV morbidity and mortality caused by acute MI. Adults: 2 g I.V. over 5 to 15 minutes,
followed by infusion of 18 g over 24 hours (12.5 mg/minute). Start therapy as soon as possible, and no
longer than 6 hours after MI.

Pharmacodynamics

Anticonvulsant action: Magnesium sulfate has CNS and respiratory depressant effects. It acts
peripherally, causing vasodilation; moderate doses cause flushing and sweating, whereas high doses
cause hypotension. It prevents or controls seizures by blocking neuromuscular transmission.

Drug is sometimes used in pregnant women to prevent or control preeclamptic or eclamptic seizures; it
also is used to treat hypomagnesemic seizures in adults, and in children with acute nephritis.

Pharmacokinetics

Absorption: Given I.V. and I.M.

Distribution: Distributed widely throughout the body.

Metabolism: None.
Excretion: Excreted unchanged in urine; some appears in breast milk.

Route Onset Peak Duration

I.V. 1-2 min Rapid 1/2 hr

I.M. 1 hr Unknown 3-4 hr

Contraindications and precautions

Parenteral administration of drug contraindicated in patients with heart block or myocardial damage.
Use cautiously in patients with impaired renal function and in women in labor. Don’t give to patients
with toxemia of pregnancy during the 2 hours preceding delivery.

Interactions

Drug-drug. Antidepressants, antipsychotics, anxiolytics, barbiturates, general anesthetics, hypnotics,

Cardiac glycosides: Changes in cardiac conduction in digitalized patients may lead to heart block if I.V.
calcium is administered. Avoid use together, if possible.

Succinylcholine, tubocurarine: Potentiates and prolongs neuromuscular blocking action of these drugs.
Use cautiously.

Drug-lifestyle. Alcohol use: Increases CNS depressant effects. Discourage alcohol use.

Adverse reactions

CNS: drowsiness, depressed reflexes, flaccid paralysis.

CV: hypotension, flushing, circulatory collapse, depressed cardiac function.

Metabolic: hypocalcemia.

Respiratory: respiratory paralysis.

Skin: diaphoresis.
Other: hypothermia.

Effects on lab test results

• May increase magnesium levels. May decrease calcium levels.

Overdose and treatment

Signs and symptoms of overdose with magnesium sulfate include a sharp decrease in blood pressure,
respiratory paralysis, ECG changes (increased PR, QRS, and QT intervals), heart block, and asystole.

Treatment requires artificial ventilation and I.V. calcium salt to reverse respiratory depression and heart
block. Usual dose is 5 to 10 mEq of calcium (10 to 20 ml of a 10% calcium gluconate solution).

Special considerations

ALERT Read label closely to ensure proper dosage and concentration.

• Effective anticonvulsant serum levels are 2.5 to 7.5 mEq/L.

• Inject I.V. bolus slowly to avoid respiratory or cardiac arrest.

• Administer by constant infusion pump if possible; maximum infusion rate is 150 mg/minute. Rapid drip
causes feeling of heat.

• Discontinue drug as soon as needed effect is achieved.

• Level of magnesium sulfate for I.V. administration shouldn’t exceed 20% and rate shouldn’t exceed
150 mg/minute (1.5 ml of a 10% concentration or equivalent). For I.M. administration in adults, levels of
25% or 50% are generally used; in infants and children, levels shouldn’t exceed 20% (200 mg/ml).

• Respiratory rate must be 16 breaths per minute or more before each dose. Keep I.V. calcium gluconate
20% on hand.

• To calculate grams of magnesium in a percentage of solution: X% = X g/100 ml (for example, 25% = 25

• Monitor serum magnesium level and clinical status to avoid overdose.

• When giving repeated doses, test knee jerk reflex before each dose; if absent, discontinue magnesium.
Use of drug beyond this point risks respiratory center failure.
• When using drug as a tocolytic agent, monitor patient for magnesium toxicity and monitor I.V. infusion
to avoid circulatory overload.

• After use in toxemic women within 24 hours before delivery, newborn requires observation for signs
of magnesium toxicity, including neuromuscular and respiratory depression.

Breast-feeding patients

• Drug appears in breast milk. In patients with normal renal function, all magnesium sulfate is excreted
within 24 hours of discontinuing drug. Recommend an alternative to breast-feeding during therapy.

Pediatric patients

• Drug isn’t indicated for use in children.

Patient education

• Inform patient about short-term need for drug, and address any questions or concerns.

- Reactions may be common, uncommon, life-threatening, or COMMON AND LIFE THREATENING.

3. Allow for expression of anxiety concerning infant’s

prematurity. Arranging for the staff of the neonatal intensive

care unit to visit the patient to answer questions may be helpful.

4. Continually update patient and family on maternal and fetal status.

5. Begin patient education to increase knowledge and skills concerning preterm labor. Patient education
is individualized but may include the following:

a) Medication administration, scheduling, and side effects.

b) Abdominal palpation and timing of contractions.

c) Importance of bed rest in lateral recumbent position.

d) Subtle signs or symptoms of preterm labor and

e) Adequate hydration

b) Vital signs

1) Antepartum and Intrapartum: Blood pressure, pulse and respirations at start of bolus and every 15
minutes for the first hour, then hourly x 2 then every 4 hours or as ordered by physician. Pulse oximetry
with same frequency as vital signs. If patient progresses to active labor, VS per labor protocol.

c) Fetal Monitoring

1) Antepartum: External fetal monitor on continuously for two

(2) hours after bolus started, then EFM as per physician order.

2) Intrapartum: Continuous fetal monitoring when patient moves into active labor.

CAUTION NOTE: Magnesium Sulfate may depress the central nervous system of the fetus and, therefore,
may diminish variability. Be prepared at delivery to resuscitate any baby with a mother on Magnesium
Sulfate regardless of FHR tracing. Babies may have normal pH values at delivery yet be unable to
breathe independently.

d) Auscultate chest for any adventitious sounds, such as congestion, rales and rhonchi with vital signs.

e) Observe for signs of Magnesium Sulfate toxicity.

f) Observe for signs of impending labor and/or delivery.

1) Increased abdominal pain, cramping, back pain.

2) Present and/or increase in vaginal discharge or bleeding.

3) Increased pelvic pressure.

5) Signs of fetal stress/fetal distress.

6. Limit visitors to support person only when acceptable to patient.

7. Emergency care of a pre-term infant:

a) When patient is identified as having pre-term labor, have room prepared for delivery. Oxygen and
suction checked and available.

b) Emergency delivery pack should be available at bedside or case cart set up for delivery in the LDR.

c) Initial NICU notification of patient and fetal status with updates periodically. NICU staff and a
neonatologist should be present at delivery of a preterm infant less than 34 weeks gestation, or as
appropriate.

d) When delivery occurs use NRP protocol for neonatal resuscitation.

8. Monitor fetal well-being by observing for:

a) Uterine activity.

b) Decreased baseline variability which may indicate depressed fetal CNS. Presence of fetal HR changes
(i.e., late decelerations and/or accelerations and/or a rise in baseline FHR).

c) Intrapartum complications, e.g., hemorrhage, abruption, shock, maternal respiratory distress.

9. Have blood bank clot drawn and current.

10. Provide psychological support. Keep patient and family

informed

PREPARATION AND ADMINISTRATION OF MAGNESIUM

BEFORE AND DURING MAGNESIUM SULFATE ADMINISTRATION:

1. Ensure proper patient identification

2. Assess physical and mental status of patient. Any change in alertness may be a very important finding
indicating central nervous system irritability or depression.
3. Provide quiet environment when feasible.

4. Position patient on side as much as possible, discourage semi-fowler’s position for extended periods
of time.

5. Obtain hourly intake/output (or as ordered by physician).

a) If significant concern regarding intake/output, obtain order for an indwelling Foley catheter. Notify
the

physician for output less than 30ml/hour. If the

physician does not want a Foley catheter inserted,

have the patient void on the bedpan every one to

two hours.

b) Monitor intravenous fluids carefully via electronic infusion

device to prevent overload.

CAUTION NOTE: Magnesium Sulfate is excreted

through the kidneys. If the patient’s output is high, an

increase in Magnesium Sulfate may be indicated. If

the output is low ( 30 ml /hour) a lower dose may be

risk for Magnesium Sulfate toxicity.

5. Assess important physical parameters and document findings.

a) Assess deep tendon reflexes utilizing patellar and/or

biceps jerk bilaterally at least every hour and PRN

(or per physician order). Responses are as follows:

1) 0 = no response. Notify physician and DO

NOT administer Magnesium Sulfate.

2) +1 = low response.

3) +2 = normal response.

4) +3 = greater than normal response.

5) +4 = hyperactive response. Notify

physician.
SULFATE SOLUTION:

1. Start mainline intravenous access with #18 IV catheter.

2. Infuse magnesium sulfate as ordered by provider. Ensure

compatibility of all other IV medications with magnesium

sulfate

3. Magnesium Sulfate solution will be premixed by Pharmacy as

ordered and administered IVPB. Monitor closely with Infusion

Pump.

4. Label IV with date and time of start, patient’s name.

5. Perform independent verification due to magnesium sulfate as

a high alert medication at the initiation of the dose, change in

dose and at any maintenance bag changes.

a) IV-Bolus dose of 4-6 gm in 50 ml SW infused over 20 to 30

minutes, followed by a maintenance dose. Nurse must remain

at bedside during bolus infusion.

b) Maintenance dose of Magnesium Sulfate is 1 to 4

gm/hour by infusion pump.

CAUTION NOTES: 1. Prior to re-bolusing Magnesium Sulfate or increasing

dosages, check to make sure:

a) Deep tendon reflexes are present.

b) Respiratory rate is more than 12/minute.

c) Urine output is at least 30 ml /hour.

2. Patient response to rise in serum levels:

b) Loss of deep tendon reflexes: 10 mEq/L

c) Respiratory failure: 12-15 mEq/L

d) Cardiac arrest: 25 mEq/L

3. Calcium gluconate is the antidote for Magnesium Sulfate

toxicity. If ordered, administer Calcium Gluconate 10%, IV

Push, 10 ml over 3 minutes. The signs of Magnesium

Sulfate toxicity include:

a) Absent DTRs.

b) Respirations less than 12/minute, shortness of breath, or

respiratory arrest.

c) Chest pain

d) Urinary output less than 30 ml /hour.

f) Signs of fetal distress.

g) Coma.

DOCUMENTATION: 1. Pertinent maternal and fetal assessments.

2. Initiation of protocols used in patient care.

3. All nursing and medical interventions and patient’s response.

4. Magnesium sulfate in grams per hour.

5. Initial and subsequent tocolytic dosages as well as times of

dosage changes.

6. Physician notification, including indication and response.

Washington, D.C. AAP, ACOG. (2007).

2. Mattson, Susan; Smith, Judy E. (Editors) (2007). Core

Curriculum for Maternal-Newborn Nursing. (3

rd edition).

Philadelphia: W.B. Saunders.

3. Iams, J.D. (2007). Obstetrics: Normal and Problem

Pregnancies. (5

th edition). Gabbe, S.G., Niebyl, J.R.,

Simpson, J.G. Preterm Birth. Philadelphia, PA: Churchill

Livingston