Management and monitoring of severe preeclampsia

Effect of Lippia alba (Mill.) N.E. Brown Essential Oil on the Human Umbilical Artery

Lippia alba is popularly known as lemon balm, with its essential oil (EO) cited for displaying antimicrobial, sedative, and vasorelaxant effects. Yet, its action on isolated human vessels has not been described in the literature. Thus, we evaluated the vasorelaxant effect of essential oil of L. alba (EOLa) on human umbilical arteries (HUA) isolated in organ baths. HUA rings were isolated, subjected to contractions induced by potassium chloride (KCl), serotonin (5-HT), or histamine (HIST) to record the isometric tension, and then treated with EOLa (30-1000 µg/mL). The EOLa showed a more prominent inhibitory effect on the pharmacomechanical coupling contraction via HIST with an EC₅₀ value of 277.1 ± 8.5 µg/mL and maximum relaxant effect at 600 µg/mL. The addition of tetraethylammonium (TEA) or 4-aminopyridine (4-AP) in HUA preparations did not inhibit EOLa total relaxant effect at 1000 µg/mL. In the presence of gliblenclamide (GLI), the oil relaxed the HUA rings by 90.8% at maximum concentration. The EOLa was also investigated for its effects on voltage-operated calcium channels (VOCCs), where the HUA preincubation with this oil at 1000 μg/mL inhibited BaCl₂ (0.1-30 mM)-induced contractions. This study demonstrates for the first time that EOla has a vasorelaxant effect on HUA and its particular blockade of VOCCs.

Clinical Experiences of Intravenous Hydralazine and Labetalol for Acute Treatment of Severe Hypertension in Pregnant Thai Women

Response to acute treatment of severe hypertension during pregnancy in Asian women was not known. Labor and delivery checklists of Thai women treated with intravenous hydralazine or labetalol for systolic blood pressure (SBP) ≥ 160 or diastolic blood pressure (DBP) ≥ 110 mm Hg from January 2011 to December 2013 were reviewed as parts of an audit. Primary outcome was prompt achievement of SBP 140-150 and DBP 90-100 mm Hg after the first bolus. Secondary outcomes were medication-related undesired effects. The mean ± standard deviation age and prevalence of chronic hypertension in hydralazine (n = 62) versus labetalol (n = 64) groups were 32.5 ± 6 versus 29.9 ± 6.8 years and 50% versus 21.9%, respectively (P < .05). Magnesium sulfate was promptly administered on admission to every woman to prevent seizure. Targeted blood pressure was timely achieved in 41.9% and 67.2% of the hydralazine and labetalol groups, respectively (P < .05). Nonreassuring fetal heart rate occurred in 51.6% and 32.8% of the hydralazine and labetalol groups, respectively (P = .05). The prevalence of cesarean section and Apgar score < 7 were not significantly different (P > .05). Real-life clinical experiences suggested significant advantages of intravenous labetalol over hydralazine in pregnant women with severe hypertension.

The Association Between Serum Magnesium and Premenstrual Syndrome: a Systematic Review and Meta-Analysis of Observational Studies

A number of studies have assessed the association between serum magnesium (Mg) and premenstrual syndrome (PMS) in different population, but the findings have been inconclusive. Herein, we systematically reviewed available observational studies to elucidate the overall relationship between Mg and PMS. PubMed, Cochrane's library, ScienceDirect, Scopus, Google Scholar, and ISI web of science databases were searched for all available literature until January 2019 for studies evaluating the association between Mg and PMS. The Newcastle-Ottawa Quality Assessment Scale was used to assess the quality of observational studies. A total of 13 studies out of 196 met our inclusion criteria and were included in our systematic review and meta-analysis. There were no associations between serum magnesium and PMS (WMD - 0.04; 95% CI, - 0.14 to 0.06; P = 0.46) during follicular or serum/erythrocyte magnesium (WMD - 0.37; 95% CI, - 1.01 to 0.27; P = 0.25)/(WMD - 0.04; 95% CI, - 0.10 to 0.03; P = 0.26) and during luteal phase except for the sub-group of studies done outside of the US in which recent association became significant and means that serum Mg is lower in PMS subjects. According to what have been discussed, although our study did not show any significant association between serum/erythrocyte Mg and PMS except for serum Mg in luteal phase in the sub-group of studies done outside of the USA, heterogeneity between studies should be taken into accounts when interpreting these results. Additional well-designed clinical trials should be considered in future research to develop firm conclusions on the efficacy of magnesium on PMS.Registration number: CRD42018114473 .

Evaluation of Some Cytokines and Gene Expressions in Pre-eclampsia

BACKGROUND AND OBJECTIVE

Preeclampsia(PE) is adisordercharacterized byhypertensionandproteinuria. There is accumulating evidence that this is a disease of the endothelium. Angiogenic factors may be responsible for the regulation of placental vascular development. Clinicians cannot predict pre-eclampsia prior to the onset symptoms. An ideal bio-marker for pre-eclampsia prediction is during the first trimester. This study investigated the serum levels of tumor necrosis factor-α (TNF-α), C-reactive protein (CRP) and the gene expressions of vascular endothelial growth factor (VEGF), endothelial nitric oxide synthase (eNOS) and p53 in PE trying to find out potential bio-markers for prediction and diagnosis of PE.

MATERIAL AND METHODS

A total of 100 female volunteers were involved in this study and their ages were ranged from 25-35 years. They were divided into three groups: Group (1) was 20 healthy non-pregnant women, group (2) was 20 pregnant women normal pregnancies and group (3) was 60 preeclamptic patients. The study participants were enrolled at the Department of Obstetrics and Gynaecology at Mansoura University Hospital, Mansoura, Egypt. The study was approved by the Research Ethics Committee (Faculty of Science, Al Azhar University, Egypt) approved on the March 15, 2014) all women gave written informed consent. Serum levels of CRP, IL-10 and TNF-α were evaluated, in addition to the gene expression of VEGF, eNOS and p53.

RESULTS

Significant elevations in the serum levels of blood pressure, TNF-α and CRP were observed in PE patients. Additionally, the gene expression of VEGF, eNOS and P53 were down-regulated in preeclampsia.

CONCLUSION

Elevated serum levels of TNFα and CRP, in addition to the down-regulation of eNOS may be used as good predictors for preeclampsia. The TNF-α and VEGF gene were recommended used as markers for PE to be added to routine testes of pregnant women.

To study the changes in fetal hemodynamics with intravenous labetalol or nifedipine in acute severe hypertension

OBJECTIVE

To compare the efficacy of intravenous labetalol or oral nifedipine in treatment of acute maternal hypertension and study the fetal hemodynamic changes using color Doppler ultrasound that follows treatment.

STUDY DESIGN

Thirty women with severe preeclampsia having acute hypertension (more than or equal to 160/105 mmHg) were randomized in 2 groups to receive intravenous labetalol or oral nifedipine until blood pressure was lowered to less than or equal to 140/90 mmHg. Doppler vascular indices namely pulsatility index, resistance index, S/D ratio of umbilical (UA) and middle cerebral artery (MCA) were measured baseline at the time of acute severe hypertension and repeated after control of blood pressure, to assess the changes in fetal hemodynamics if any with labetalol or nifedipine.

RESULTS

Both nifedipine and labetalol were found to be effective when used for rapid control of blood pressure. Mean age of women in both groups and mean gestational age was statistically comparable. No change in fetal heart rate before and after treatment was observed in both groups. Doppler vascular indices of UA and MCA showed no significant changes as compared to baseline values in both groups.

CONCLUSION

The use of labetalol and nifedipine were not related to any significant changes in fetal Doppler, which is reassuring about the safety of these drugs when treating acute severe hypertension in pregnancy. Choice between these two drugs should be based on cost, availability respective contraindications, and clinician's experience.

Placental Growth Factor Administration Abolishes Placental Ischemia-Induced Hypertension

Preeclampsia is a pregnancy-specific disorder of new-onset hypertension. Unfortunately, the most effective treatment is early delivery of the fetus and placenta. Placental ischemia appears central to the pathogenesis of preeclampsia because placental ischemia/hypoxia induced in animals by reduced uterine perfusion pressure (RUPP) or in humans stimulates release of hypertensive placental factors into the maternal circulation. The anti-angiogenic factor soluble fms-like tyrosine kinase-1 (sFlt-1), which antagonizes and reduces bioavailable vascular endothelial growth factor and placental growth factor (PlGF), is elevated in RUPP rats and preeclampsia. Although PlGF and vascular endothelial growth factor are both natural ligands for sFlt-1, vascular endothelial growth factor also has high affinity to VEGFR2 (Flk-1) causing side effects like edema. PlGF is specific for sFlt-1. We tested the hypothesis that PlGF treatment reduces placental ischemia-induced hypertension by antagonizing sFlt-1 without adverse consequences to the mother or fetus. On gestational day 14, rats were randomized to 4 groups: normal pregnant or RUPP±infusion of recombinant human PlGF (180 μg/kg per day; AG31, a purified, recombinant human form of PlGF) for 5 days via intraperitoneal osmotic minipumps. On day 19, mean arterial blood pressure and plasma sFlt-1 were higher and glomerular filtration rate lower in RUPP than normal pregnant rats. Infusion of recombinant human PlGF abolished these changes seen with RUPP along with reducing oxidative stress. These data indicate that the increased sFlt-1 and reduced PlGF resulting from placental ischemia contribute to maternal hypertension. Our novel finding that recombinant human PlGF abolishes placental ischemia-induced hypertension, without major adverse consequences, suggests a strong therapeutic potential for this growth factor in preeclampsia.

Preeclampsia transforms membrane N-glycome in human placenta

Posttranslational modifications (PTM) which accompany pathological conditions affect protein structure, characteristics and modulate its activity. Glycosylation is one of the most frequent PTM influencing protein folding, localisation and function. Hypertension is a common gestational complication, which can lead to foetal growth restriction (IUGR) and even to foetal or maternal death. In this work we focused on the impact of preeclampsia complicated with IUGR on placental membrane N-glycome. Results have shown that preeclampsia reduced fucosylation of placental glycans, increased the appearance of paucimannosidic and mannosidic structures with lower number of mannose residues and decreased the amount of glycans with more mannose residues. Since preeclampsia is tightly connected to IUGR, glycosylation changes were investigated also on the functional membrane receptors responsible for growth: insulin receptor and the type 1 insulin-like growth factor receptor (IR and IGF1R). It was found that IR present in the IUGR placenta contained significantly less α2,6-Sia. Therefore, glycans on placental membranes alter due to preeclampsia, but changes seen at the level of the entire N-glycome may be different from the changes detected at the level of a specific glycoprotein. The difference recorded due to pathology in one membrane molecule (IR) was not found in another homologous molecule (IGF1R). Thus, besides studying the glycosylation pattern of the entire placental membrane due to preeclampsia, it is inevitable to study directly glycoprotein of interest, as no general assumptions or extrapolations can be made.

Oxidation of placental insulin and insulin-like growth factor receptors in mothers with diabetes mellitus or preeclampsia complicated with intrauterine growth restriction

Placental insulin receptor (IR) and insulin-like growth factor receptors (IGFRs) are essential for fetal growth. We investigated structural changes of these receptors exposed to increased oxidative stress in mothers diagnosed with diabetes mellitus (DM) or preeclampsia (PE) complicated with intrauterine growth restriction. Increased amount of IR and decreased amounts of IGF1R and IGF2R were found in both pathologies, accompanied by significant elevation in protein carbonyls. When isolated receptors were examined, increased carbonylation of IR and IGF1R in PE placentas was detected, whereas the amounts of carbonylated IR and IGF1R were similar in DM and healthy placentas. Carbonylation status of IGF2R did not change due to pathology, confirming the detrimental role of primary structure and conformation in oxidative susceptibility. Ligand binding was similar in all three groups of samples and did not seem to be affected by receptor oxidation. Since babies delivered by mothers with PE were smaller than the referent population, increased carbonylation of receptors might have affected downstream receptor signaling post-ligand binding.

Metabolic syndrome in preeclampsia women in gorgan

The aim of study was to assess the metabolic syndrome in preeclampsia women. The study was performed on 50 women. The metabolic syndrome prevalence was 66%. Serum glucose, triglyceride and LDL-cholesterol levels significantly were increased and HDL- cholesterol level significantly was decreased in metabolic syndrome patients. These patients showed high prevalence of components of the syndrome. Our results show the importance of dyslipidemia in preeclampsia in overweight and obese women. Preeclampsia and cardiovascular disease are important problems for the health of women. It may be useful to give a treat to people with a high-normal blood pressure in early pregnancy.

Serum copper, zinc and lipid peroxidation in pregnant women with preeclampsia in gorgan

The aim of study was to assay serum copper, zinc and lipid peroxidation levels in pregnant women with and without preeclampsia. There were significant differences between systolic, diastolic blood pressures and copper, Cu/Zn ratio and malondialdehyde among two groups. There were significant differences in weight, pre-pregnancy body mass index, systolic, diastolic blood pressures and copper, Cu/Zn ratio and malondialdehyde levels when compared to healthy pregnant women with mild and severe preeclampsia patients. A positive correlation was observed between systolic and diastolic blood pressure and copper, malondialdehyde and Cu/Zn ratio. Copper and malondialdehyde may play a role in the pathophysiology of preeclampsia.

Role of biomarkers in early detection of preeclampsia

Preeclampsia (PE) is a pregnancy-related, potentially life threatening condition. The incidence of PE has increased in the past decade, which has been attributed to various predisposing factors. Abnormal placentation is central to the evolution of this disease process. However, the triggering factor for this is still unknown. Interestingly, intense research done in this arena has unveiled the names of some important biomolecules which play important role in the vasculognesis of the early placenta, namely, vascular endothelial growth factor (VEGF) and placental growth factor (PlGF) and their antagonists, namely, soluble fms-like tyrosine kinase 1 (sFlt-1, also known as sVEGFR1), and soluble endoglin (sEng). Besides these, Renin Angiotensin System (RAS) was also implicated in this disease process. The roles of immune factors, genetic factors have been stressed from time to time. More novel approaches made, have shed light on the upcoming biomolecules. All these endeavours are directed to diagnose PE as early as possible, which is a real challenge. Question remains whether a single set parameters could diagnose a disease entity which is as complex as PE. Therefore, it is imperative to design feasible, predictive test-set utilizing multiple biomarkers.

Evaluation of the macula, retinal nerve fiber layer and choroid in preeclampsia, healthy pregnant and healthy non-pregnant women using spectral-domain optical coherence tomography

OBJECTIVE

To evaluate the macular, retinal nerve fiber layer (RNFL) and choroidal thickness alterations by using spectral-domain optical coherence tomography (SD-OCT) in preeclampsia and compare with healthy pregnant and healthy non-pregnant controls.

METHOD

The study population included healthy pregnant control group (n: 25), healthy non-pregnant control group (n: 26) and study group with preeclampsia (n: 27). Retinal thickness parameters were measured by SD-OCT.

RESULTS

There was a statistically significant difference among all of the groups for choroidal thickness (p < 0.001). Choroidal thickness in preeclamptic women was significantly thinner than healthy pregnant women. The most thick choroid layer was detected in healthy pregnant group, and also the most thin choroidal thickness was detected in healthy non-pregnant group (p < 0.001). Macular central subfield and foveal center thickness were significantly thinner in preeclamptic study and healthy pregnant groups than healthy non-pregnant group (p < 0.001). However, there was no statistically significant difference between preeclamptic study group and healthy pregnant group for both macular central subfield and foveal center thickness. Average of RNFL thickness was significantly thicker in healthy pregnant group than healthy non-pregnant group (p = 0.004).

CONCLUSIONS

This study revealed that choroidal thickness measured using SD-OCT increased in women with preeclampsia and healthy pregnant women but the increase in choroidal thickness in preeclampsia was lower than the healthy pregnant controls. This lower rise in choroidal thickness can be generally attributed to the markedly increased systemic vascular vasospasm secondary to preeclampsia.

Preeclampsia - Aetiology, Current Diagnostics and Clinical Management, New Therapy Options and Future Perspectives

Preeclampsia is a multisystem disease for which the exact causes have not yet been sufficiently clarified. However, in the past few years it has become clear that a placental imbalance between angiogenic and anti-angiogenic proteins is the decisive pathogenetic factor for the occurrence of preeclampsia. With the possibility to measure these angiogenic factors (sFlt-1/PlGF ratio) in maternal blood full new diagnostic possibilities have been opened that enable the certain diagnosis or exclusion of the diseases as well as a short-term prognosis to be made. In secondary prevention the current data situation for ASA confirms a moderate but measurable utility. The management concept depends on gestational age. In the case of early clinical manifestations (< 34th week of pregnancy) the clinical management in a perinatal centre remains unchanged with foeto-maternal monitoring and induction of pulmonary maturation, symptomatic therapy under careful blood pressure lowering and determination of the optimal delivery time. A balance must be made here between foetal immaturity and maternal risks upon prolongations. The pathomechanism of anti-angiogenic overload with sFlt-1 provides a starting point for first therapeutic interventions. The present article gives an overview of current diagnostic options and presents possible future therapeutic perspectives for discussion.

The promise of angiogenic markers for the early diagnosis and prediction of preeclampsia

BACKGROUND

An imbalance in circulating factors that regulate blood vessel formation and health, referred to as angiogenic factors, plays a central role in the pathogenesis of preeclampsia.

CONTENT

Several studies have demonstrated a strong association between altered circulating angiogenic factors and preeclampsia. These factors include circulating antiangiogenic proteins such as soluble fms-like tyrosine kinase 1 and soluble endoglin and proangiogenic protein such as placental growth factor. Abnormalities in these circulating angiogenic factors are not only present during clinical disease, but also antedate clinical signs and symptoms by several weeks. These alterations are particularly prominent in patients who present with preeclamptic signs and symptoms prematurely and/or in patients with severe preeclampsia. The availability of automated platforms for the rapid measurement of circulating angiogenic proteins in blood samples has now allowed researchers and clinicians to evaluate the utility of these assays in the diagnosis of the disease, in the stratification of patients in clinical trials, or in the monitoring of therapies. In this review we highlight the various studies that have been performed, with a focus on large validation studies.

SUMMARY

Measurement of circulating angiogenic proteins for the diagnosis and prediction of preeclampsia is still at an early stage but is rapidly evolving. Standardization across the various automated platforms and prospective studies that demonstrate clinical utility are needed.

Changes in fetal and maternal Doppler parameters observed during acute severe hypertension treatment with hydralazine or labetalol: a randomized controlled trial

We evaluated 16 pregnant women with gestational age between 20 and 32 weeks in acute severe hypertension which were randomly allocated to receive either hydralazine or labetalol. Blood pressure and Doppler ultrasound parameters from maternal uterine and fetal middle cerebral and umbilical arteries were assessed during acute severe hypertension and after treatment. A significant reduction in systolic and diastolic blood pressure was observed in both groups. A significant change in Doppler parameters was observed only in pregnant women who received hydralazine: an increase in uterine arteries resistance index. We concluded that both drugs were highly effective in reducing blood pressure in these women. Despite the observed increase in resistance index of uterine arteries associated with hydralazine, the use of hydralazine and labetalol were not related to any significant changes in fetal Doppler, which is reassuring about the safety of these drugs when treating acute severe hypertension in pregnancy.

Management of severe hypertension in the postpartum period with intravenous hydralazine or labetalol: a randomized clinical trial

OBJECTIVE

To compare the safety and efficacy of intravenous labetalol and intravenous hydralazine for acutely lowering blood pressure in the puerperium.

DESIGN

Randomized clinical trial.

SETTING

Critical care unit of gynecology and obstetrics department in the Complejo hospitalario "Dr. AAM" de la Caja de Seguro Social in Panama.

POPULATION

Eighty-two women with severe hypertension during the postpartum period.

METHODS

Patients were randomized to receive hydralazine (5 mg as a slow bolus dose given intravenously, and repeated every 20 minutes to a maximum of five doses) or labetalol (20 mg in an intravenous bolus dose followed by 40 mg if not effective within 20 minutes, followed by 80 mg every 20 minutes to a maximum dose of 300 mg). The primary endpoint was the successful lowering of blood pressure. Secondary endpoints were maternal complications and side-effects.

RESULTS

Forty-two women were enrolled in the hydralazine group and 40 in the labetalol group. Women were similar with respect to characteristics at randomization. No significant differences were observed for persistent severe hypertension or maternal side-effects. There was only one case of persistent severe hypertension in the labetalol group. There were no maternal deaths in any of the women studied.

CONCLUSIONS

This randomized clinical trial shows that intravenous hydralazine and intravenous labetalol are effective and safe in the management of severe hypertension in the postpartum period.

Heparin-mediated extracorporeal low density lipoprotein precipitation as a possible therapeutic approach in preeclampsia

Preeclampsia is a pregnancy-related hypertensive disease resulting in substantial maternal and neonatal morbidity and mortality. Until today there is no satisfactory treatment to stop disease progression except immediate delivery of the fetus. Heparin-mediated extracorporeal low density lipoprotein (LDL) precipitation (H.E.L.P.) apheresis removes simultaneously circulating LDL, lipoprotein(a) [Lp(a)], fibrinogen, C-reactive protein (CRP) and various proinflammatory and procoagulatory factors. This study was to test the feasibility of H.E.L.P. apheresis in preeclamptic patients and its potential effects on blood and placental markers of preeclampsia. We applied H.E.L.P. apheresis to nine preeclamptic patients and it was well tolerated. Their gestational ages could be continued by 17.7 (3-49) more days. Eight of the nine neonates did well during their neonatal stage. One infant died of late-onset sepsis. H.E.L.P. apheresis reduced significantly circulating levels of triglycerides, total and LDL-cholesterol, Lp(a), fibrinogen, hs-CRP, TNFalpha, sVCAM-1, E-selectin, lipopolysaccharide binding protein (LBP), homocysteine and plasma viscosity. We conclude that H.E.L.P. apheresis reduced maternal circulating levels of proinflammatory and coagulatory markers and plasma viscosity without overt maternal or neonatal clinical side effects.

Severe hypertension in pregnancy: Hydralazine or labetalol

OBJECTIVE

The objective was to compare the safety and efficacy of intravenous labetalol and intravenous hydralazine for acutely lowering blood pressure in pregnancy.

STUDY DESIGN

Two hundred women with severe hypertension in pregnancy were randomized to receive hydralazine (5 mg as a slow bolus dose given intravenously, and repeated every 20 min up to a maximum of five doses) or labetalol (20-mg intravenous bolus dose followed by 40 mg if not effective within 20 min, followed by 80 mg every 20 min up to a maximum dose of 300 mg). The primary end point was successful lowering of blood pressure and maternal hypotension.

RESULTS

Women were similar with respect to characteristics at randomization. No significant differences were observed for maternal hypotension or persistent severe hypertension; only two patients in the hydralazine group presented with hypotension. Palpitations (p=0.01) and maternal tachycardia (p=0.05) occurred significantly more often in patients treated with hydralazine. The main neonatal outcomes were very similar per group; however, hypotension and bradycardia were significantly more frequent in the labetalol group. There were two neonatal deaths per antihypertensive drug group.

CONCLUSIONS

This randomized clinical trial shows that labetalol and hydralazine fulfill the criteria required for an antihypertensive drug to treat severe hypertension in pregnancy.

Oncotic therapy in management of preeclampsia

BACKGROUND

We undertook this study to examine the effects of oncotic therapy for preeclampsia (PE).

METHODS

The study included 29 pregnant women with PE and 14 pregnant women with PE and intrauterine growth retardation (IUGR) and hematocrit (Htc) concentration >0.38. All study women received regular antihypertensive therapy and oncotic therapy (dextran 40 or hydroxyethyl starch). The parameters of Htc, uric acid, fibrinogen and platelet count, sonography RI (resistance index) of uterine artery, umbilical artery, middle cerebral artery and fetal biophysical profile were monitored before and after oncotic therapy. Perinatal outcome assessment was based on 5-min Apgar score, umbilical pH, need of neonatal intensive care unit (NICU) treatment, and birth weight.

RESULTS

Statistically significant improvement of hemorheological parameters upon the introduction of oncotic therapy was recorded in the values of Htc, fibrinogen and diastolic blood pressure, whereas other parameters (uric acid, platelet count, uterine arterial RI on the side of placentation, and systolic blood pressure) showed a decrease that did not reach statistical significance. Upon the introduction of oncotic therapy, favorable changes in perinatal Doppler ultrasonography parameters were recorded in uterine arterial RI but not in middle cerebral artery RI. There was no statistically significant change in the fetal biophysical profile (FBP) values either. Perinatal outcome was favorable with a mean 5-min Apgar score 8 and pH 7.26. Lower birth weight values (mean 2631 +/- 407 g) were consequential to preterm delivery and IUGR, resulting in a number of neonates requiring NICU treatment.

CONCLUSIONS

Careful oncotic treatment with antihypertensive therapy improves the maternal hemorheological parameters and uteroplacental sonographic parameters.

Magnesium (mg) retention and mood effects after intravenous mg infusion in premenstrual dysphoric disorder

BACKGROUND

Conflicting data exist regarding the presence of magnesium (Mg) deficiency and the therapeutic efficacy of Mg in premenstrual syndrome or premenstrual dysphoric disorder (PMDD).

METHODS

The % Mg retention was determined using 24-hour urinary Mg excretion and the total dose of Mg given intravenously. In women with (n = 17) and without (n = 14) prospectively diagnosed PMDD, several blood measures of Mg and mood were obtained before, immediately after, and the day following an intravenous Mg (.1 mmol/kg) loading dose. A positive mood response was seen under open conditions; as open Mg infusion improved mood, subsequent PMDD patients (n = 10) were randomized in a double-blind, placebo-controlled, crossover fashion.

RESULTS

Patients (31.5%) and control subjects (27.5%) retained comparable mean percentages of Mg. Neither group differed in measures of mean Mg before, immediately after, or the day following Mg infusion. Although there was a time effect for all mood measures in the patient group (p < .01 for all), there was neither a treatment nor time-by-treatment effect.

CONCLUSIONS

Contrary to prior reports, we found no evidence of Mg deficiency in women with PMDD compared with control subjects. Furthermore, Mg was not superior to placebo in the mitigation of mood symptoms in women with PMDD.

Serum iron and copper status and oxidative stress in severe and mild preeclampsia

Our aim was to investigate parameters of iron and copper status and oxidative stress and antioxidant function in women with healthy pregnancy, mild and severe preeclampsia with a view to exploring the possible contribution of these parameters to the aetiology. Thirty healthy, 30 mild preeclamptic and 30 severe preeclamptic pregnant women were included. Serum and placental lipid peroxides, and serum vitamin E and total carotene levels were measured by colorimetric assay. Cholesterol, copper, iron, total iron binding capacity (TIBC), ceruloplasmin and transferrin concentrations were measured by commercially available procedures. Data were analysed statistically using one-way analysis of variance and Pearson correlation test. Logistic regression procedures were used to calculate odds ratios. Lipid peroxides in serum and placental tissue, and iron, copper and ceruloplasmin levels in serum were significantly increased, and transferrin, TIBC, vitamin E/total cholesterol and total carotene/total cholesterol ratios in serum were significantly decreased especially in women with severe preeclampsia. Significant correlations were detected between serum iron and lipid peroxides in serum and placental tissue and between serum iron and vitamin E/total cholesterol in severe preeclamptic pregnancy. Furthermore, there were significant correlations between serum malondialdehyde and ceruloplasmin and vitamin E/total cholesterol in women with severe preeclampsia, and changes in serum and placental lipid peroxides and serum iron concentrations were significantly associated with preeclampsia. In conclusion, ischaemic placental tissue may be a primary source of potentially toxic iron in preeclampsia and the released iron species may contribute to the aetiology and would exacerbate lipid peroxidation and endothelial cell injury, which may be abated by antioxidant supplementation.

Lysosomal enzymes in preeclamptic women in northern Nigeria

BACKGROUND

The incidence of preeclampsia is high in northern Nigeria, as it is in many other developing countries, and preeclampsia is associated with significant maternal and fetal morbidity and mortality. We inquired if proteinuria or hypertension alone could account for the altered concentrations of urinary lysosomal hydrolases that have been reported in preeclamptic women and pregnant women without preeclampsia.

METHODS

The activities of urinary beta-hexosaminidase and beta-galactosidase were determined fluorometrically in pregnant women assigned to one of four groups: Group I: 41 preeclamptic women; Group II: 31 hypertensive aproteinuric women; Group III: 44 normotensive proteinuric women; and Group IV: 52 healthy pregnant women (controls).

RESULTS

The urinary beta-hexosaminidase concentrations were decreased in the preeclamptic women (P<0.005) and proteinuric women (P<0.001) when compared to the healthy pregnant controls. There was no significant difference in beta-hexosaminidase concentrations between the hypertensive women and the healthy pregnant controls. The urinary beta-galactosidase concentrations for preeclamptic, hypertensive, and proteinuric women did not differ significantly versus healthy pregnant controls.

CONCLUSIONS

The reduced urinary excretion of beta-hexosaminidase in preeclamptic women is associated with proteinuria, but not hypertension. Measuring urinary concentrations of lysosomal hydrolases alone or in conjunction with urinary protein concentrations is not likely to be useful in predicting or monitoring the clinical course of preeclampsia; however, it might prove important in gaining a more complete understanding of the pathogenesis of renal tubular epithelial cell injury and proteinuria that occurs in preeclampsia.

Anesthetic management of Cesarean delivery in a patient with hypoplastic anemia and severe pre-eclampsia

PURPOSE

To describe the anesthetic management of Cesarean delivery in a patient with hypoplastic anemia and severe pre-eclampsia.

CLINICAL FEATURES

A 28-yr-old parturient with a history of thrombocytopenia was admitted with signs of pre-eclampsia (blood pressure of 140/90 mmHg, heavy proteinuria and moderate bilateral ankle edema) at 25 weeks of gestation. Laboratory studies revealed pancy-topenia (hemoglobin 6.4 g.dL(-1), white cell count 3.43 x 10(9).L(-1), platelet count 20 x 10(9).L(-1)) and bone marrow biopsy showed hypoplastic anemia. As pre-eclampsia worsened, a Cesarean delivery was performed at 27 weeks with prophylactic platelet transfusion and meticulous blood pressure control. The procedure was uneventful, conducted under general anesthesia with an estimated blood loss of around 600 mL and a live female baby was delivered. Postoperatively her blood pressure and neurological symptoms improved but thrombocytopenia remained at discharge.

CONCLUSIONS

Hypoplastic anemia is rare in pregnancy but it poses an increased risk for both mother and fetus. The mother is at risk of life-threatening episodes of bleeding and infection and a multidisciplinary team approach (obstetrician, anesthesiologist, hematologist and pediatrician) is essential. An accurate assessment of the hematological condition should be made and abnormalities corrected before surgery. Regional anesthesia may not be possible in this circumstance.

Intermittent iron supplementation regimens are able to maintain safe maternal hemoglobin concentrations during pregnancy in Venezuela

Daily iron supplementation programs for pregnant women recommend amounts of iron that are considered by some to be excessive, and either lower-dose or less frequent iron supplementation regimens have been proposed. A randomized, placebo-controlled study was performed to assess and compare the relative effectiveness of a weekly (WS) or twice weekly (TW) iron supplementation schedule in maintaining or achieving hemoglobin (Hb) levels at term considered to carry minimal maternal and fetal risk (90-130 g/L). Pregnant women (n = 116) at wk 10-30 of gestation (63 WS and 53 TW) were enrolled in the study (52 in WS and 44 TW completed the study). Women were randomly allocated to receive a 120-mg oral dose of iron as ferrous sulfate and 0.5 mg of folic acid weekly (n = 52) or 60 mg iron and 0.25 mg folic acid and a placebo twice weekly (n = 44). Hb, hematocrit, serum ferritin, and transferrin saturation were estimated at baseline and at 36-39 wk of gestation. Baseline dietary data and the presence and intensity of intestinal helminthic infections were assessed. The duration of supplementation was 14 +/- 4 wk and the median level of adherence was 60.5%. Hb concentrations improved in women following the TW regimen and in women following WS who had low baseline Hb levels. About 89% of WS women and 95% of TW women maintained Hb levels at term (between 90 g/L and 130 g/L), a range associated with optimal pregnancy outcomes. One woman in the TW group exhibited higher Hb levels that potentially carried perinatal risk (>130 g/L). Intermittent iron and folic acid supplementation may be a valid strategy when used as a preventive intervention in prenatal care settings.

The impact of maternal plasma volume expansion and antihypertensive treatment with intravenous dihydralazine on fetal and maternal hemodynamics during pre-eclampsia: a clinical, echo-Doppler and viscometric study

OBJECTIVES

To establish the effects of plasma volume expansion (PVE) followed by intravenous dihydralazine (DH) administration on maternal whole blood viscosity (WBV) and hematocrit, uteroplacental and fetoplacental downstream impedance and umbilical venous (UV) volume flow in pre-eclampsia.

METHODS

In 13 pre-eclamptic women maternal and fetal hemodynamics were established by means of combined measurement of maternal arterial blood pressure (BP), WBV, hematocrit and uterine artery (UtA) resistance index (RI) in addition to umbilical artery (UA) pulsatility index (PI) and UV volume flow obtained from UV vessel area and UV time-averaged flow velocity. In each woman all parameters were measured four times at baseline, after PVE, after DH and 24 h after the start of treatment.

RESULTS

Maternal diastolic BP, hematocrit and WBV display a significant reduction after PVE. In the fetus UA PI decreases significantly whereas a significant increase in UV cross-sectional area was detected. After maternal DH administration, arterial systolic and diastolic BP and UA PI show a significant decrease compared with the measurements following PVE. At 24 h, only maternal systolic and diastolic BP display a significant further decrease. No significant changes were established for the UtA RI, UV time-averaged velocity and UV volume flow during the entire study period.

CONCLUSIONS

During pre-eclampsia, maternal PVE followed by DH administration results in a significant reduction in maternal diastolic BP, maternal hematocrit and WBV. Maternal PVE is associated with a significant increase in UV cross-sectional area and a non-significant rise of 11% in UV volume flow. Maternal DH administration does not result in any change in UV cross-sectional area. However, UA PI decreases significantly after both PVE and DH treatment.

Pre-term birth and severe pre-eclampsia are not associated with altered expression of HLA on human trophoblasts

PROBLEM

The unusual pattern of human leukocyte antigen (HLA) expression on human trophoblasts could play an important role in successful pregnancy outcome. To determine whether alterations in HLA expression are associated with pregnancy abnormalities we have investigated expression of these antigens on chorionic and extravillous cytotrophoblasts.

METHODS

Frozen tissue sections of placenta and fetal membranes were collected after pre-term spontaneous delivery, severe pre-eclampsia pre-term Caesarean section, normal term delivery and term Caesarean section. HLA expression was analyzed by immunohistochemistry.

RESULTS

We did not observe differences in the expression of HLA on chorionic and extravillous cytotrophoblasts in pregnancy abnormalities. However, we noted higher expression levels of HLA class Ia molecules in amnion epithelial cells in pre-term deliveries. Furthermore, in severe pre-eclampsia the number of extravillous cytotrophoblast islands were elevated when compared with pre-term deliveries.

CONCLUSIONS

No alterations in expression of HLA class Ia, HLA-G and HLA class II on human trophoblasts in pregnancy abnormalities were seen.

Pre-eclampsia: fluids, drugs, and anesthetic management

Severe pre-eclampsia is a complex disease, which taxes the expertise of even the most experienced obstetric anesthesiologist. The treatment should focus on stabilization of blood pressure, optimization of fluid status, and prevention of convulsions. Neuraxial blocks for labor and delivery offer many benefits to the mother and her infant. For cesarean section, there is unequivocal evidence of superiority of neuraxial anesthesia over general anesthesia. If general anesthesia is needed, careful preanesthetic preparation and meticulous airway management is essential. The successful and safe peripartum management of the pre-eclamptic patient and her infant is a team effort among the anesthesiologist, obstetrician, and neonatologist.

Non-Linear Analysis Approach of Maternal Heart Rate Patterns in Normal and Pre-Eclamptic Pregnancies

Identification of the pregnant woman prone to develop pre-eclampsia later during her course of the pregnancy is a clinical challenge in clinical obstetrics. A new and non-invasive approach to detect abnormalities in pre-eclamptic women that differentiate from women with uneventful pregnancies is presented here. We applied non-linear and fractal features for classifying the dynamical complexity of the heart rate (HR) patterns corresponding to seven normal subjects and eight pre-eclamptic patients. Significant differences in the estimated largest Lyapunov exponent and in the correlation dimension between normotensive women and those with pre-eclampsia were found, suggesting they may have potential as new markers for pre-eclampsia. HR patterns in healthy and pre-eclamptic pregnancies correspond to complex non-linear dynamics, which could arise from the contribution of stochastic and chaotic components. HR of pre-eclamptic patients also revealed a more regular dynamic behavior than those belonging to normal pregnancies, corroborating the general observation that diseased states may be associated with regular HR patterns.