Egyptian Journal of Chest Diseases and Tuberculosis (2014) 63, 285289

The Egyptian Society of Chest Diseases and Tuberculosis

Egyptian Journal of Chest Diseases and Tuberculosis

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ORIGINAL ARTICLE

The value of magnesium sulfate nebulization in treatment

of acute bronchial asthma during pregnancy
M.S.H. Badawy
a
b

a,*

, Ibrahim M.A. Hassanin

Chest Department, Qena Faculty of Medicine, South Valley University, Egypt

Obstetric Department, Faculty of Medicine, Sohag University, Egypt

Received 23 November 2013; accepted 19 December 2013

Available online 20 January 2014

KEYWORDS
Acute asthma with
pregnancy;
Magnesium sulfate
nebulization

Abstract Little is known about the effect of inhaled Mg sulfate when added to B2 agonist in acute
asthma with pregnancy.
Our objective: To evaluate the broncho-dilator effect of nebulized magnesium sulfate with B2
agonist in the treatment of acute asthma during pregnancy, and its safety on pregnancy outcome.
Material and methods: The studied patients were randomized into two groups. Group A
patients received the routine treatment of acute asthma exacerbation plus nebulized salbutamol
in dose of 1 ml of salbutamol solution dissolved in 9 ml of normal saline. Group B patients
received the same above treatment plus 500 mg (1 ml) of magnesium sulfate. Two hours after therapy, pulmonary function test and blood gas analysis were done.
Result: Total 60 pregnant women with acute asthma, 30 patients in each group with mean age
were 25.9 4.01 and 25.7 3.8. Comparison between both groups in pulse rate, arterial oxygen
tension and oxygen saturation was signicant (P < 0.001). FEV1 was 32.68 7.15 and
56.31 8.25 in groups A and B respectively and % of change was 69% with signicant
P value < 0.001. The frequency of asthma exacerbation till delivery was 3.2 0.98 & 0.4 0.57
in groups A and B respectively (95% CI 2.43.1) with signicant P value (P < 0.001). All patients
had either normal delivery (60% and 66.6%) or Cesarian (40% and 33.6%) with smooth neonatal
period.
In Conclusion: Adding Nebulized Mgs for acute asthma during pregnancy is effective and safe.
The availability, cheapness of this drug especially for the developing countries added to its advantage.
2014 Production and hosting by Elsevier B.V. on behalf of The Egyptian Society of Chest Diseases and
Tuberculosis.

* Corresponding author. Tel.: +20 01115454856.

E-mail address: mohamad_badawy@yahoo.com (M.S.H. Badawy).
Peer review under responsibility of The Egyptian Society of Chest
Diseases and Tuberculosis.

Production and hosting by Elsevier

Introduction
Bronchial asthma is a common respiratory disease complicating 4% of pregnancies. It is characterized by airway obstruction, inammation and increase the responsiveness to a
variety of allergen. The severity of symptoms may improve,

0422-7638 2014 Production and hosting by Elsevier B.V. on behalf of The Egyptian Society of Chest Diseases and Tuberculosis.
http://dx.doi.org/10.1016/j.ejcdt.2013.12.011

286
worsen or remain unchanged as compared with pre-pregnant
state [1,2].
In pregnant women with asthma, there is an increased risk
for preterm delivery and intrauterine growth retardation [3].
The maternal and fetal risks of uncontrolled asthma are greater than risks from using asthma medications for management
of acute asthma [4], and the benets of any medications used
during pregnancy must be balanced against their risks to the
fetus.
The commonest cause of deterioration of asthma during
pregnancy in Egypt is incomplete hesitant treatment because
of the patients or her treating doctors mistaken belief that
such treatment will harm the fetus [5].
Pregnant women with acute asthma exacerbation are at
increased risk of having low birth weight but not associated
with increased risk of pre-eclampsia or preterm delivery.
Inhaled corticosteroids may reduce the risk of exacerbation
during pregnancy [6]. Some studies show that, 1118% of asthmatic pregnant women have at least one visit to emergency
unit for acute asthma [3], where [7] found that 62% of
pregnant women with acute asthma require hospitalization, so
rapid therapeutic intervention at the time of exacerbation is
important to prevent impaired maternal and fetal oxygenation.
In acute asthmatic episodes, the use of inhaled B2 agonist is
not enough to reduce bronchospasms and inammations
resulting in the use of variety of other treatment options in
the management of acute asthma [8]. Magnesium sulfate is
the drug of choice used by obstetrician in prevention of preterm labor in high risk women and in the management of severe pre-eclampsia and eclampsia. Also they know its side
effect and its toxicity and how to manage it.
Magnesium sulfate has anti-convulsant and peripheral
vasodilator effect. It improves the pulmonary function when
used as an additive treatment in patient with acute asthma
[9]. Also it has smooth muscle relaxation and anti-inammatory effect [10].
Several studies had investigated the effect of intravenous
magnesium sulfate in acute asthma but little is known about
the effect of inhaled Mg sulfate when added to B2 agonist in
acute asthma with pregnancy [9].
Aim of the study
To evaluate the broncho-dilator effect of nebulized magnesium
sulfate with B2 agonist in the treatment of acute asthma during
pregnancy, and its safety on pregnancy outcome.
Patients and methods
The study was conducted from October 2010 through June
2011 at Sohag University Hospital, Sohag, Egypt. Approval
was taken from the review board of the Chest and Obstetric
and Gynecological departments of Sohag University.
Pregnant women with acute exacerbation of bronchial asthma attending to emergency unit with the following inclusion
criteria:
1. Pregnant women were not either completely or partially
controlled on routine acute asthma therapy.
2. Those with history of bronchial asthma and under routine
therapy.

M.S.H. Badawy, I.M.A. Hassanin

3. Clinical evaluation of bronchial asthma according to
GINA guidelines [11].
The following were the exclusion criteria from the study:
(1) Any risk factor rather than asthma with pregnancy as
congestive heart failure, history of angina, renal problems, history suggestive of pulmonary embolism.
(2) Very severe asthma patients who presented with manifestations requiring endotracheal intubation (disturbed
level of consciousness, respiratory acidosis, and cardiopulmonary arrest).
(3) Any associated medical illness from history and medical
examination (diabetes, hypertension).
(4) Patients with fever more than 38 C.
(5) Inability to perform pulmonary function test.
All participants in the study gave their written informed
consent. Assessments of all patients on arrival to the emergency unit of the department with: Oxygen administration
and intravenous line insertion. History (Medical and obstetric), general examination (pulse, temperature, respiratory rate
and blood pressure), abdominal and chest examination with
routine ultra-sonography were done.
The studied patients were randomized into two groups
through separate envelopes. The medications were given by
doctor who was not a part of the study and were:
Group A patient received the routine treatment of acute
asthma exacerbation in the form of Oxygen, I.V. corticosteroids (solucortif 100 mg vial, Pzer/Eipico), I.V. aminophylline (500 mg/5 ml, Alex, Egypt), and nebulized salbutamol
(farcoline solution, Pharco, Egypt) in dose of 1 ml of salbutamol solution dissolved in 9 ml of normal saline.
Group B patients received the same above treatment except change of nebulized salbutamol by nebulized mixture of
(1 ml salbutamol solution + 500 mg (1 ml) of magnesium sulfate + 8 ml normal saline) (Magnisol amp, Memphis, Egypt).
N.B; the solution should be isotonic because hyperosmolar
solution produces broncho-constriction and increases airway
reactivity to histamine.
A maximum three sets of nebulization with 20 min apart
over a period of 8 min for every nebulization session in both
groups.
Two hours after the therapy pulmonary function test was
done by using a bellows spirometer (Jaeger, Master screen
PFT) according to the standards of the American Thoracic
Society [12]. The following parameters were determined:
forced expiratory volume in the rst second (FEV1), forced vital capacity (FVC), FEV1/FVC ratio, maximal mid-expiratory
ow rate (FEF 2575%) and peak expiratory ow (PEF%) in
both groups. And arterial blood gas analyses, blood was
drawn from the radial artery to blood gas analyzer (Roche
OMNI_C, Roche Diagnostics, Germany). Once the sample
was obtained, it was submitted immediately to the blood gas
analyzer to avoid alteration in blood gas content. Arterial
oxygen tension, PH, carbon dioxide tensions and oxygen saturation and serum potassium level were detected in both groups.
The patients were allowed to be discharged from emergency
unit when signs of improvement were:
(1) *Improving of distress and dyspnea,
(2) *Oxygen saturation more than 94%,

The value of magnesium sulfate nebulization in treatment of acute bronchial asthma during pregnancy
(3) *Forced expiratory volume1 more than 60%.
If the patients in either group did not reach the signs of
improvement, they were admitted to intensive care unit for
close monitoring and management. The patients were followed
up in outpatient clinic with routine antenatal care. Phone contacts with patients for follow up and recording any acute exacerbation for asthma required hospitalization till delivery
(recurrence rate). Mode of delivery and pregnancy outcome
were noted and any neonatal mortality or morbidity.

287

Table 2 Arterial blood gas results and pulse rate after the end
of therapy in both groups.
Variables

Group (A)

Group (B)

P value

Pulse rate/min
PH
PaO2
PaCO2
SO2
K level

117.56 7.05
7.38 3.1
63 8.17
36.46 3.74
89.80 2.04
3.6 0.3

92.10 4.1
7.40 2.9
87.84 6.86
35.70 2.32
97.96 1.95
3.4 0.2

>0.001
>0.001
>0.001
NS
>0.001
NS

Statistical analysis
All statistical analyses were performed using the software SPSS
for Windows version 15 (SPSS; Chicago, IL, USA). Continuous data were reported as mean SD and categorical data
as number (percentage). The t test for independent sample,
the X2 test and sher exact probability test were used as appropriate P value < 0.05 was considered signicant.
Results
A total 60 pregnant women with acute asthma from outpatient
clinic or emergency department of Sohag university hospital
were recruited to participate in the study. They were randomly
classied into two groups A and B, both groups were comparable in socio demographic criteria (P > 0.05) as shown in
Table 1. The mean age was 25.9 4.01 and 25.7 3.8 in both
groups respectively. Most of the patients had education below
university degree (70% and 66.6%), multigravida (73.34% and
67%) and in the second trimester (63.34% and 60%).
The results of arterial blood gas in both groups are shown
in Table 2 where PH, arterial oxygen tension (PO2) and oxygen saturation (SO2) were highly signicant (P < 0.001) as
these factors were the most important factors to allow patients
for discharge. Also the arterial pulse rates were 107 7.05 and
92.1 4.1 in groups A and B respectively with highly signicant P value (P < 0.001).
All variables of the spirometry studies were highly signicant between groups A and B (P < 0.001) and the most important variable was FEV1 (Forced Expiratory volume in 1st
second which was 32.68 7.15 and 56.31 8.25) in groups

Table 1

A and B respectively and the percentage of change was 69%

with highly signicant P value < 0.001 (Table 3).
Table 4 shows the frequency of acute asthma exacerbation
till delivery of the patients in both groups which was
3.2 0.98 and 0.4 0.57 in groups A and B respectively
(95% CI 2.43.1) with highly signicant P value (P < 0.001).
All patients had either normal delivery which was 60% and
66.6% or C.S which was 40% and 33.6% in both groups
respectively with smooth neonatal period.
Discussion
The basic principles for managing acute asthma are similar in
pregnant and non pregnant state. The principles include maintenance of oxygen saturation above 94%, repeated doses of inhaled B2 agonists, and the early administration of systemic
corticosteroids, and repetitive lung function measurements
with fetal monitoring [7,1315].
Good neonatal outcomes will be obtained via controlling
maternal symptoms during acute asthma exacerbation,
through optimizing oxygenation and routine asthma therapy
during pregnancy. As sever uncontrolled asthma is potentially
harmful to fetus rather than its medication.
Murphy et al. [6], reported that exacerbation of asthma
during pregnancy occurs in late 2nd trimester and the
major triggers were viral infections and non adherence to
inhaled corticosteroids, and this is in agreement with our study
where 63.34% and 60% of study groups either (A and B)
respectively were presented with acute asthma in the second
trimester.

The socio demographic and pregnancy duration in both groups.

Characteristics

Group (A)
No

Group (B)
%

No

P value
%

Age Mean SD

25.93 4.01

25.66 3.82

NS

Education
Illiterate
Lower than University

5
21

16.67
70

4
20

13.34
66.67

NS
NS

Parity
Primigravida
Multigravida

8
22

26.66
73.34

10
20

33
67

NS
NS

Duration of pregnancy
1st trimester
2nd trimester
3rd trimester

2
19
9

6.67
63.34
30

3
18
9

10
60
30

NS
NS
NS

288
Table 3

M.S.H. Badawy, I.M.A. Hassanin

Spirometry data after the end of therapy in both groups with the percent of change.

Variables

Group (A)

Group (B)

% of change

P value

FEV1
FVC
FEV1/FVC
FEF25%
FEF75%
PEF

32.68 7.15
67.57 11.67
48.32 8.60
29.57 7.19
33.49 8.91
36.17 10.80

56.31 8.25
84.20 12.75
67.74 10.67
41.22 6.99
46.41 6.78
54.20 11.09

69
23
42
37
39
50

<0.001
<0.001
<0.001
<0.001
<0.001
<0.001

Table 4 The Frequency of exacerbation of acute asthma till

delivery and the pregnancy outcome.
Variable

Group
(A)

Group
(B)

P
value

Frequency of
Exacerbations till delivery

3.2 0.98

0.4 0.57

0.001

18
12

20
10

Mode of delivery
Normal delivery
Caesarian section

60%
40%

6.6%
33.3%

In our study the pulse rates were 107.6 7.05 and

92.1 4.1 in groups A and B with highly signicant P value,
also in arterial blood gas parameter (PH, PaO2 and SO2) were
7.38 3.1 and 63 8.17 and 89.8 2.04 in group A and
(7.4 2.9 87.84 6.8 and 97.89 1.9) in group B with
highly signicant P value. This was in agreement with
Aggrawal et al. [16], who reported that the pulse rate declined
signicantly at 120 min and also raise in arterial oxygen
tension signicantly in group used MgSO4 through relieving
bronchoconstriction by decreasing the uptake and release of
calcium in bronchial smooth muscle.
Decreasing excitability of muscle membrane by inhibition
of acetylcholine release with inhibition of histamine release
from mast cells may stimulate nitrous oxide generation and
prostacycline synthesis [17,18], and thus improve oxygen
saturation.
All parameters of pulmonary function tests were highly signicant in group B especially FEV1 (56.31 8.25) in group B
and was (32.68 7.15) in group A with 69% change, and this
was in agreement with Classen et al. [26], who also explain this
through additional of MgSO4 nebulization increase the bronchodilator response of salbutamol in acute asthma through increase afnity of B2 receptors to salbutamol or up-regulating
this receptors.
Currie et al. [19] suggested that IV Magnesium may be of
some benet in patients with acute asthma with severely impaired FEV1. Nannini [20], Hughes [21], and Mahajan [22]
found a great increase in the peak ow rate when single dose
of MgSO4 was added to nebulized salbutamol and more bronchodilator effect compared with three doses of salbutamol
alone. However this was counter reversed to Aggarwal et al.
[16], who showed that no benet for adding nebulized MgSO4
to conventional treatment of acute asthma.
As regards frequency of exacerbation till delivery, it was
0.40 0.57 in group B compared with 3.2 0.98 in group
A with 95% CI 2.43.1 highly signicant P value, and this
indicates that adding MgSO4 to salbutamol inhalation reduces

the exacerbation rate and this is consistent with wendel et al.

[7], who found the same results. They reported that 33% of
acute asthma during pregnancy necessitates hospitalization
and readmission due to the differences in the assessment and
treatment of acute asthma between obstetricians and emergency physicians, also the severity of asthmatic exacerbation
between patients and lack of corticosteroids.
Blitz et al. [23] found that combination of aerolized rather
than IV MgSO4 with standard care (oxygen and systemic corticosteroids and IV Aminophyllin) with B2 agonist decreases
airway obstruction and reduces admission to hospital. Villeneure et al. [24] suggested that nebulized magnesium preparation was used as a vehicle for salbutamol in improving the
pulmonary function and blood gas in patients with mild to
moderate asthma.
Despite the relatively small sample size in the present study
it appears that the benet of adding Mg sulfate to salbutamol
(B2 agonist) nebulization in management of acute asthma during pregnancy leads to marked improvement of pulmonary
function and blood gas parameters with decrease in the exacerbation rate with high safety, cheap, availability and proven
usefulness in severe cases. Noppen et al. [25] argues that there
is no reason not to use Mg sulfate nebulization with B2 agonist
in these circumstances.
The limitations of the present study include short term follow up period (just till delivery) and the small sample size. We
believe that the present study provides initial evidence supporting the efcacy and safety of adding magnesium sulfate to
salbutamol nebulization as a therapy for acute asthma during
pregnancy. The availability, cheapness of this drug especially
for the developing countries added to its advantage.
Further studies are needed to compare B2 agonist (salbutamol) with Mg sulfate nebulization versus salbutamol alone in
acute exacerbation of asthma during pregnancy.
Conict of interest
None.
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