Is magnesium sulfate therapy warranted in all cases of late postpartum severe hypertension? A suggested approach to a clinical conundrum

Hypertension Management in Pregnancy

Chronic hypertension and preeclampsia spectrum disorders in pregnancy are important contributors to long-term maternal morbidity and mortality. Due to physiologic changes during pregnancy and the postpartum period, blood pressure expectations differ between primary care providers and obstetricians. The goal of this article is to describe the pathophysiology and definitions of hypertension in the obstetric context and review current evidence for management during pregnancy and the postpartum period. Longitudinal follow-up with a primary care provider after delivery is crucial for long-term cardiovascular risk reduction in hypertensive patients.

Postpartum Management of Hypertensive Disorders of Pregnancy in Six Large U.S. Hospital Systems: Descriptive Review and Identification of Clinical and Research Gaps

Hypertensive disorders of pregnancy (HDPs) are a key contributor to maternal morbidity and mortality. Several gaps in knowledge remain regarding best practices in the postpartum management of HDPs. In this review, we describe postpartum HDPs management among six large academic U.S. hospital systems: Medical College of Wisconsin, University of Pittsburgh, University of Wisconsin-Madison, Northwestern University, University of Minnesota, and Boston Medical Center. We identified that all six health systems discharge patients with HDPs diagnosed with a blood pressure (BP) cuff and use the same two antihypertensive medications, nifedipine and labetalol, as first- and second-line treatment of HDPs. Northwestern University routinely adds oral furosemide for 5 days for patients with BP that exceeds 150/100 mm Hg. Most hospital systems administer magnesium sulfate routinely when readmission for HDPs occurs. In contrast, there was variation in BP threshold for antihypertensive treatment initiation, use of remote BP monitoring program, use of a transition clinic, delivery or lack of education on long-term cardiovascular disease risk, and BP management through the first 6 weeks postpartum and beyond. Based on the clinical review, we identified clinical gaps and formulated considerations for research priorities in the field of postpartum HDPs management. KEY POINTS: · Several gaps in knowledge remain regarding best practices in postpartum management of HDPs.. · There is a variation in the BP threshold for antihypertensive treatment initiation.. · Data are lacking on the reduction in severe maternal morbidity (SMM) and racial disparities in SMM with remote monitoring..

Magnesium Matters: A Comprehensive Review of Its Vital Role in Health and Diseases

Magnesium (Mg), an essential mineral abundantly present within the human body, is intricately involved in a multitude of biochemical processes vital for maintaining health and overall well-being. This review aims to delve into the multifaceted impact of Mg on human health, exploring its physiological functions, dietary sources, and potential health implications of deficiency or insufficiency. Mg plays a pivotal role in various physiological processes, including energy metabolism, muscle contraction, protein synthesis, and DNA synthesis. It acts as a cofactor for more than 300 enzymatic reactions, facilitating the conversion of adenosine triphosphate (ATP) to adenosine diphosphate (ADP) for energy production. Moreover, Mg is essential for the proper functioning of ion channels, particularly calcium channels, influencing nerve transmission and muscle relaxation. Mg is naturally found in a wide array of foods, with green leafy vegetables, whole grains, nuts, seeds, and legumes being particularly rich sources. Additionally, certain fortified foods and dietary supplements provide supplemental Mg intake. Deficiency or insufficiency of mg can have profound implications for health. Inadequate mg levels have been associated with increased risks of various chronic diseases, including hypertension, type 2 diabetes, osteoporosis, and cardiovascular diseases. Furthermore, mg deficiency may manifest as symptoms such as muscle weakness, fatigue, tremors, and irregular heartbeat. Numerous studies have elucidated the relationship between mg intake and the risk of developing chronic diseases. For instance, epidemiological evidence suggests that higher mg intake is associated with a reduced risk of hypertension, possibly due to its vasodilatory effects and influence on blood pressure regulation mechanisms. Similarly, mg has been implicated in the pathophysiology of type 2 diabetes, with mg deficiency contributing to insulin resistance and impaired glucose metabolism. Furthermore, adequate mg intake is crucial for maintaining bone density and reducing the risk of osteoporosis, as mg plays a vital role in bone mineralization and bone health. Understanding the importance of mg in human physiology underscores the significance of ensuring adequate mg intake through diet or supplementation. Healthcare professionals play a critical role in educating individuals about the importance of incorporating mg-rich foods into their diets and considering mg supplementation when necessary, particularly for individuals at risk of deficiency or those with chronic diseases. Mg is an indispensable mineral with far-reaching implications for human health. Its involvement in various physiological processes underscores its importance in maintaining overall health and well-being. Ensuring adequate mg intake is essential for preventing deficiency-related health complications and reducing the risk of chronic diseases. Further research is warranted to elucidate the optimal strategies for mg supplementation and its potential therapeutic applications in disease prevention and management.

Remote blood pressure management for postpartum hypertension: a cost-effectiveness analysis

BACKGROUND

Recognizing the importance of close follow-up after hypertensive disorders of pregnancy, many centers have initiated programs to support postpartum remote blood pressure management.

OBJECTIVE

This study aimed to evaluate the cost-effectiveness of remote blood pressure management to determine the scalability of these programmatic interventions.

STUDY DESIGN

This was a cost-effectiveness analysis of using remote blood pressure management vs usual care to manage postpartum hypertension. The modeled remote blood pressure management included provision of a home blood pressure monitor, guidance on warning symptoms, instructions on blood pressure self-monitoring twice daily, and clinical staff to manage population-level blood pressures as appropriate. Usual care was defined as guidance on warning symptoms and recommendations for 1 outpatient visit for blood pressure monitoring within a week after discharge. This study designed a Markov model that ran over fourteen 1-day cycles to reflect the initial 2 weeks after delivery when most emergency department visits and readmissions occur and remote blood pressure management is clinically anticipated to be most impactful. Parameter values for the base-case scenario were derived from both internal data and literature review. Quality-adjusted life-years were calculated over the first year after delivery and reflected the short-term morbidities associated with hypertensive disorders of pregnancy that, for most birthing people, resolve by 2 weeks after delivery. Sensitivity analyses were performed to assess the strength and validity of the model. The primary outcome was the incremental cost-effectiveness ratio, which was defined as the cost needed to gain 1 quality-adjusted life-year. The secondary outcome was incremental cost per readmission averted. Analyses were performed from a societal perspective.

RESULTS

In the base-case scenario, remote blood pressure management was the dominant strategy (ie, cost less, higher quality-adjusted life-years). In univariate sensitivity analyses, the most cost-effective strategy shifted to usual care when the cost of readmission fell below $2987.92 and the rate of reported severe range blood pressure with a response in remote blood pressure management was <1%. Assuming a willingness to pay of $100,000 per quality-adjusted life-year, using remote blood pressure management was cost-effective in 99.28% of simulations in a Monte Carlo analysis. Using readmissions averted as a secondary effectiveness outcome, the incremental cost per readmission averted was $145.00.

CONCLUSION

Remote blood pressure management for postpartum hypertension is cost saving and has better outcomes than usual care. Our data can be used to inform future dissemination of and support funding for remote blood pressure management programs.

Crisis Management by Obstetrics and Gynecologist Hospitalists: Lessons Learned in a Pandemic

We discuss lessons learned from the COVID-19 pandemic through an obstetrics and gynecology (OB/GYN) hospitalist lens, with a focus on clinical care considerations, workforce changes, communication and collaboration, and provider wellness. We end with a discussion on the role of OB/GYN hospitalists as leaders. Our goal is to share what worked well for hospital systems and OB/GYN hospitalist teams during COVID-19, along with recommendations to consider for future national emergencies.

Population pharmacokinetics and dose optimization of magnesium sulfate in Chinese preeclampsia population

OBJECTIVE

To establish the population pharmacokinetics (PPK) of magnesium sulfate (MgSO4)in women with preeclampsia (PE), and to determine the key covariates having an effect in magnesium pharmacokinetics in Chinese PE.

METHODS

Pregnant women with PE prescribed MgSO4 were enrolled in this prospective study from April 2021 to April 2023. On the initial day of administration, the patients were administered a loading dose of 5 g in conjunction with 10 g of magnesium sulfate as a maintenance dose. On the second day, only the maintenance dose was administration, and maternal blood samples were taken at 0, 4, 5, and 12 h after the second day's 10 g maintenance dose. The software Phoenix was used to estimate PPK parameters of MgSO4, such as clearance (CL) and volume of distribution (V), and to model PPK models with patient demographic, clinical, and laboratory covariates.

RESULTS

A total of 199 blood samples were collected from 51 women with PE and PPK profiles were analyzed. The PPK of MgSO4 is consistent with to a one-compartment model. The base model adequately described the maternal serum magnesium concentrations after magnesium administration. The population parameter estimates were as follows: CL was 2.98 L/h, V was 25.07 L. The model predictions changed significantly with covariates (BMI, creatinine clearance, and furosemide). Furosemide statistically influences V. The creatinine clearance, BMI and furosemide jointly affects CL. Monte Carlo simulation results showed that a loading dose combined with a maintenance dose would need to be administered daily to achieve the therapeutic blood magnesium concentrations. For the non-furosemide group, the optimal dosing regimen was a 5 g loading dose combined with a 10 g maintenance dose of MgSO4. For the furosemide group, the optimal dosing regimen was a 2.5 g loading dose combined with a 10 g maintenance dose of MgSO4.

CONCLUSIONS

The magnesium PPK model was successfully developed and evaluated in Chinese preeclampsia population, and the dose optimization of MgSO4 was completed through Monte Carlo simulation.