Cardiogenic pulmonary oedema: presentation of pre-eclampsia exacerbated by prostaglandin abortifacients

Sulprostone for pregnancy termination in women with severe (pre-) eclampsia

CONDENSATION

Sulprostone, used in a continuous low-dose intravenously, is effective for pregnancy termination. Caution is necessary when using this drug in severely preeclamptic patients.

OBJECTIVE

To evaluate the safety and efficacy of induction of labor with a prostaglandin analogue in women with severe (pre-) eclampsia.

STUDY DESIGN

A retrospective analysis of a 12-year cohort in which labor was induced in women with severe (pre-) eclampsia with sulprostone (a prostaglandin E2 analogue) in a continuous intravenous low-dose intravenous dose of 1 microg/min.

RESULTS

In 30 severely preeclamptic and one eclamptic women, labor was induced on maternal indication with sulprostone. The median gestational age at induction was 28 weeks (range 16-37 weeks). The fetuses were either dead (n=19) or considered not viable (n=12). All women delivered vaginally after a median induction-expulsion interval of 14 hr (range 6-57 hr). In all but one woman, a delivery was achieved within 37 hr. Two of the nine women who suffered dyspnea at the time induction was started, experienced deterioration during infusion of sulprostone. In one of these women, infusion had to be discontinued after 2 hr and the pregnancy was terminated by dilatation and evacuation. One woman gave birth after 57 hr of sulprostone infusion. We did not observe any cardiovascular complications. All but one woman recovered after pregnancy termination: a severely eclamptic woman died 10 days after delivery, after developing adult respiratory distress syndrome, sepsis and multiple organ failure.

CONCLUSION

Sulprostone, in a continuous low-dose intravenously, is effective for termination of pregnancy in the critically ill preeclamptic woman. Our study, including two patients with serious deterioration of pulmonary function during and one maternal death after induction, does not permit definitive conclusions regarding the safety in these patients.

Prostanoid EP(1)- and TP-receptors involved in the contraction of human pulmonary veins

1. To characterize the prostanoid receptors (TP, FP, EP(1) and/or EP(3)) involved in the vasoconstriction of human pulmonary veins, isolated venous preparations were challenged with different prostanoid-receptor agonists in the absence or presence of selective antagonists. 2. The stable thromboxane A(2) mimetic, U46619, was a potent constrictor agonist on human pulmonary veins (pEC(50)=8.60+/-0.11 and E(max)=4.61+/-0.46 g; n=15). The affinity values for two selective TP-antagonists (BAY u3405 and GR32191B) versus U46619 were BAY u3405: pA(2)=8.94+/-0.23 (n=3) and GR32191B: apparent pK(B)=8.25+/-0.34 (n=3), respectively. These results are consistent with the involvement of TP-receptor in the U46619 induced contractions. 3. The two EP(1)-/EP(3)- agonists (17-phenyl-PGE(2) and sulprostone) induced contraction of human pumonary veins (pEC(50)=8.56+/-0.18; E(max)=0.56+/-0.24 g; n=5 and pEC(50)=7.65+/-0.13; E(max)=1.10+/-0.12 g; n=14, respectively). The potency ranking for these agonists: 17-phenyl-PGE(2) > sulprostone suggests the involvement of an EP(1)-receptor rather than EP(3). In addition, the contractions induced by sulprostone, 17-phenyl-PGE(2) and the IP-/EP(1)- agonist (iloprost) were blocked by the DP-/EP(1)-/EP(2)-receptor antagonist (AH6809) as well as by the EP(1) antagonist (SC19220). 4. PGF(2alpha) induced small contractions which were blocked by AH6809 while fluprostenol was ineffective. These results indicate that FP-receptors are not implicated in the contraction of human pulmonary veins. 5. These data suggest that the contractions induced by prostanoids involved TP- and EP(1)-receptors in human pulmonary venous smooth muscle.

Fluid management in pre-eclampsia

We review the evidence base for fluid management in pre-eclampsia. Current understanding of the relevant pathophysiology and the possible impact of styles of fluid management on maternal and fetal outcome are presented. There is little evidence upon which to base the management of fluid balance in pre-eclampsia. Reports are conflicting and no large prospective outcome studies of fluid management have been performed. Volume expansion does not appear to reduce the incidence of fetal distress. Pulmonary oedema and oliguria receive particular attention. There is no evidence of long-term renal damage in pre-eclampsia, but there are strong suggestions that pulmonary oedema is linked to fluid administration. Monitoring is discussed and some principles of management are suggested

Maternal and perinatal outcome of temporizing management in 254 consecutive patients with severe pre-eclampsia remote from term

OBJECTIVE

To assess maternal and perinatal outcomes of expectant management with plasma volume expansion and pharmacologic vasodilatation in patients with severe pre-eclampsia remote from term.

STUDY DESIGN

All women with severe pre-eclampsia between 20 and 32 weeks' gestation, not in labor and with a live, single fetus admitted to the University Hospital Rotterdam from 1985 to 1993 were managed with the intention to prolong gestation. Treatment consisted of correction of the maternal circulation with vasodilatation by means of dihydralazine and plasma volume expansion under central hemodynamic monitoring. Primary end-points of the study were prolongation of gestation, maternal antepartum and postpartum complications, and fetal and neonatal outcome.

RESULTS

Two-hundred fifty-four patients were included. The median prolongation of pregnancy was 14 (range 0-62) days. Hemodynamic treatment was associated with marked objective and subjective improvement in maternal condition. Complications of central hemodynamic monitoring were not observed. Perinatal mortality was 20.5%.

CONCLUSION

Expectant management with plasma volume expansion and pharmacologic vasodilatation under central hemodynamic monitoring of the maternal circulation may delay delivery and enhance fetal maturity and does not appear to be associated with an increased risk of maternal morbidity and mortality.