Drugs for treatment of very high blood pressure during pregnancy

The diagnostic approach and management of hypertension in the emergency department

Hypertension urgency and emergency represents a challenging condition in which clinicians should determine the assessment and/or treatment of these patients. Whether the elevation of blood pressure (BP) levels is temporary, in need of treatment, or reflects a chronic hypertensive state is not always easy to unravel. Unfortunately, current guidelines provide few recommendations concerning the diagnostic approach and treatment of emergency department patients presenting with severe hypertension. Target organ damage determines: the timeframe in which BP should be lowered, target BP levels as well as the drug of choice to use. It's important to distinguish hypertensive emergency from hypertensive urgency, usually a benign condition that requires more likely an outpatient visit and treatment.

Association between hypertensive medication during pregnancy and risk of several maternal and neonatal outcomes in women with chronic hypertension: a population-based study

BACKGROUND

Several studies have reported an association between perinatal complications and the severity of the hypertensive disease. The increasing number of pregnancies complicated by hypertension and the small assurance about the perinatal effects of hypertensive drug use during pregnancy involves the need of studying the better management of hypertensive mothers.

OBJECTIVE

To evaluate the association between maternal use of antihypertensive drugs and maternal and neonatal outcomes in women with chronic hypertension.

STUDY DESIGN

We conducted a population-based study including all deliveries of hypertensive women that occurred between 2007-2017 in the Lombardy region, Italy. We evaluated the risk of several maternal and neonatal outcomes among women who filled antihypertensive prescriptions within the 20th week of gestation. Propensity score stratification was used to account for key potential confounders.

RESULTS

Out of 5,553 pregnancies, 2,138 were exposed to antihypertensive treatment. With respect to no-users, users of antihypertensive drugs showed an increased risk of preeclampsia (RR:1.68, 95%CI:1.42-1.99), low birth weight (1.30,1.14-1.48), and preterm birth (1.25,1.11-1.42). These results were consistent in a range of sensitivity and subgroup analyses.

CONCLUSION

Early exposure to antihypertensive drugs in the first 20 weeks of gestation was associated with an increased risk of preeclampsia, low birth weight, and preterm birth.

Neurocritical care of the pregnant patient

INTRODUCTION

An estimated 0.1%-0.8% of obstetric patients require admission to an intensive care unit (ICU) during pregnancy or the puerperium. When neurologic emergencies occur in pregnancy, collaboration between the neurointensivist, obstetric anesthesiologist, and obstetrician is key in minimizing morbidity and mortality.

PRINCIPLES

Care of the critically ill pregnant patient mirrors that of the critically ill nonpregnant patient with some minor exceptions. Special care must be taken to consider the normal physiologic changes of pregnancy as well as possible fetal exposure to medical interventions. Timing and method of delivery must be carefully considered when caring for patients with neurologic emergencies. Common neurologic emergencies in pregnancy include hypertensive disorders of pregnancy, intracranial neoplasms, noneclamptic seizures, cerebrovascular disorders, and ventriculoperitoneal shunt malfunctions.

CONCLUSION

While neurologic emergencies in pregnancy are overall rare, when they do occur, they can be devastating. As in the nonpregnant population, prompt recognition and rapid intervention are crucial in optimizing patient outcomes. When neurologic emergencies occur in pregnancy, maternal and fetal care is optimized through a multidisciplinary care team.

Preeclampsia: Disease biology and burden, its management strategies with reference to India

Preeclampsia is the cause of significant maternal and fetal mortality and morbidity. It is characterized by new-onset hypertension and proteinuria after 20 weeks of gestation. Preeclamptic women and children born from preeclamptic pregnancies are at greater risk to develop severe cardiovascular complications and metabolic syndromes later in life. The incidence of preeclampsia is estimated to be seven times higher in developing countries as compared to the developed countries. This review summarizes the pathophysiology of preeclampsia, emerging new hypothesis of its origin, risk factors that make women susceptible to developing preeclampsia and the potential of various biomarkers being studied to predict preeclampsia. The health care of developing countries is continuously challenged by substantial burden of maternal and fetal mortality. India despite being a fast developing country, is still far behind in achieving the required maternal mortality rates as per Millennium Development Goals set by the World Health Organization. Further, this review discusses the prevalence of preeclampsia in India, health facilities to manage preeclampsia, current guidelines and protocols followed and government policies to combat this complication in Indian condition.

Comparison of Hydralazine and Labetalol to lower severe hypertension in pregnancy

OBJECTIVE

To compare the intravenous Labetalol versus intravenous hydralazine in patients having severe Pregnancy induced hypertension (PIH) and pre eclampsia (PE) in pregnancy.

METHODS

Seventy eight women admitted in the Department of Gynecology and Obstetrics, Civil Hospital Karachi, having severe PIH/PE and fulfilling the inclusion criteria were included in the study. Random selection of patients was performed using sealed opaqe envelop for administration of either intravenous noted (IV) Labetalol or Hydrallazine. The mean fall in the MAP in each group was noted. This data was analyzed by applying SPSS version 13. The study was conducted from November 2012 to April 2013.

RESULTS

The mean (±SD) age of the labetalol group was 27.46 (±5.28) years while that in the hydralazine group was 26.28 (±5.17) years. The mean fall in MAP observed in the labetalol group was 29.10 ± 7.21 mmHg and that in the hydralazine group was 25.05 ± 10.15 mmHg which was statistically significant with the p value being 0.046.

CONCLUSION

Intra Venous labetalol lowered MAP more than hydralazine, when administered to pregnant females with severe Pregnancy induced hypertension and pre eclampsia in pregnancy.

Strategies for improving health care seeking for maternal and newborn illnesses in low- and middle-income countries: a systematic review and meta-analysis

BACKGROUND

Lack of appropriate health care seeking for ill mothers and neonates contributes to high mortality rates. A major challenge is the appropriate mix of strategies for creating demand as well as provision of services.

DESIGN

Systematic review and meta-analysis of experimental studies (last search: Jan 2015) to assess the impact of different strategies to improve maternal and neonatal health care seeking in low- and middle-income countries (LMIC).

RESULTS

Fifty-eight experimental [randomized controlled trials (RCTs), non-RCTs, and before-after studies] with 310,652 participants met the inclusion criteria. Meta-analyses from 29 RCTs with a range of different interventions (e.g. mobilization, home visitation) indicated significant improvement in health care seeking for neonatal illnesses when compared with standard/no care [risk ratio (RR) 1.40; 95 confidence interval (CI): 1.17-1.68, 9 studies, n=30,572], whereas, no impact was seen on health care seeking for maternal illnesses (RR 1.06; 95% CI: 0.92-1.22, 5 studies, n=15,828). These interventions had a significant impact on reducing stillbirths (RR 0.82; 95% CI: 0.73-0.93, 11 studies, n=176,683), perinatal deaths (RR 0.84; 95% CI: 0.77-0.90, 15 studies, n=279,618), and neonatal mortality (RR 0.80; 95% CI: 0.72-0.89, 20 studies, n=248,848). On GRADE approach, evidence was high quality except for the outcome of maternal health care seeking, which was moderate.

CONCLUSIONS

Community-based interventions integrating strategies such as home visiting and counseling can help to reduce fetal and neonatal mortality in LMIC.

Diagnosis and management of preeclampsia in community settings in low and middle-income countries

Hypertensive disorders of pregnancy contribute significantly to maternal mortality and morbidity. Preeclampsia belongs to the spectrum of hypertensive disorders of pregnancy and if undiagnosed and/or untreated leads to fatal consequences for both the mother and the baby. Early detection and prevention of preeclampsia is limited by uncertainty in the knowledge about its etiopathogenesis. While much work has been done in establishing clinical guidelines for management of preeclampsia in the hospital or tertiary care settings, there is considerable lack of work in the domain of evidence-based guidelines for screening, identification and management of preeclampsia at the community-level. The article reviews these issues with special considerations and to challenges faced in low and middle-income countries. There is a need to focus on low-cost screening and interventions in the community to achieve a significant impact on preventable maternal and fetal mortality in order to control the burden of preeclampsia significantly as well as investing on more research at primary care level to improve the evidence base for community-level interventions.

Diagnosis and Treatment of Hypertensive Pregnancy Disorders. Guideline of DGGG (S1-Level, AWMF Registry No. 015/018, December 2013)

Purpose: Official guideline published and coordinated by the German Society of Gynecology and Obstetrics (DGGG). Hypertensive pregnancy disorders contribute significantly to perinatal as well as maternal morbidity and mortality worldwide. Also in Germany these diseases are a major course for hospitalization during pregnancy, iatrogenic preterm birth and long-term cardiovascular morbidity. Methods: This S1-guideline is the work of an interdisciplinary group of experts from a range of different professions who were commissioned by DGGG to carry out a systematic literature search of positioning injuries. Members of the participating scientific societies develop a consensus in an informal procedure. Afterwards the directorate of the scientific society approves the consensus. Recommendations: This guideline summarizes the state-of-art for classification, risk stratification, diagnostic, treatment of hypertensive pregnancy disorders.

Community pharmacist surveillance of hypertension in pregnancy: Are we ready for prime time?

BACKGROUND

Hypertensive disorders of pregnancy (HDP) are associated with serious maternal and perinatal complications. For nonsevere hypertension, there is a lack of consensus regarding treatment during pregnancy and while breastfeeding. Further, there is considerable variability in guidelines for antihypertensive drug choices. As part of a Drug Safety and Effectiveness Network (DSEN)-funded project, we piloted a novel surveillance strategy in which community pharmacists recruited pregnant and breastfeeding women to monitor their blood pressure and medication use and to provide education on HDP.

METHODS

Participating pharmacists were required to complete a certified training program, identify and recruit patients who were pregnant or breastfeeding, obtain informed consent, administer a patient questionnaire and complete an initial case report form for enrolled patients. Study outcomes included the feasibility of community pharmacists to enroll patients and carry out study-related documentation and follow-up. The criteria for success in this pilot study included the ability of pharmacists to recruit 10 participants per pharmacy.

RESULTS

178 community pharmacies across British Columbia agreed to participate in this feasibility study, of which 63 pharmacists completed the study training. Of these, only 21 pharmacists recruited at least 1 patient and 1 pharmacist met the success criteria. Overall, 51 patients were enrolled, 2 withdrew from the study and 7 patients were diagnosed with HDP. Antihypertensive medications used by patients included methyldopa and labetalol.

CONCLUSIONS

While postmarketing surveillance is an important tool for the assessment of drug safety in the pregnant and breastfeeding patient population, the feasibility of community pharmacists taking on this role was not successfully demonstrated.

Pre-eclampsia part 2: prediction, prevention and management

An antiangiogenic state might constitute a terminal pathway for the multiple aetiologies of pre-eclampsia, especially those resulting from placental abnormalities. The levels of angiogenic and antiangiogenic proteins in maternal blood change prior to a diagnosis of pre-eclampsia, correlate with disease severity and have prognostic value in identifying women who will develop maternal and/or perinatal complications. Potential interventions exist to ameliorate the imbalance of angiogenesis and, hence, might provide opportunities to improve maternal and/or perinatal outcomes in pre-eclampsia. Current strategies for managing pre-eclampsia consist of controlling hypertension, preventing seizures and timely delivery of the fetus. Prediction of pre-eclampsia in the first trimester is of great interest, as early administration of aspirin might reduce the risk of pre-eclampsia, albeit modestly. Combinations of biomarkers typically predict pre-eclampsia better than single biomarkers; however, the encouraging initial results of biomarker studies require external validation in other populations before they can be used to facilitate intervention in patients identified as at increased risk. Angiogenic and antiangiogenic factors might also be useful in triage of symptomatic patients with suspected pre-eclampsia, differentiating pre-eclampsia from exacerbations of pre-existing medical conditions and performing risk assessment in asymptomatic women. This Review article discusses the performance of predictive and prognostic biomarkers for pre-eclampsia, current strategies for preventing and managing the condition and its long-term consequences.

Oral antihypertensive therapy for severe hypertension in pregnancy and postpartum: a systematic review

BACKGROUND

Pregnant and postpartum women with severe hypertension are at increased risk of stroke and require blood pressure (BP) reduction. Parenteral antihypertensives have been most commonly studied, but oral agents would be ideal for use in busy and resource-constrained settings.

OBJECTIVES

To review systematically, the effectiveness of oral antihypertensive agents for treatment of severe pregnancy/postpartum hypertension.

SEARCH STRATEGY

A systematic search of MEDLINE, EMBASE and the Cochrane Library was performed.

SELECTION CRITERIA

Randomised controlled trials in pregnancy and postpartum with at least one arm consisting of a single oral antihypertensive agent to treat systolic BP ≥ 160 mmHg and/or diastolic BP ≥ 110 mmHg.

DATA COLLECTION AND ANALYSIS

Cochrane RevMan 5.1 was used to calculate relative risk (RR) and weighted mean difference by random effects.

MAIN RESULTS

We identified 15 randomised controlled trials (915 women) in pregnancy and one postpartum trial. Most trials in pregnancy compared oral/sublingual nifedipine capsules (8-10 mg) with another agent, usually parenteral hydralazine or labetalol. Nifedipine achieved treatment success in most women, similar to hydralazine (84% with nifedipine; relative risk [RR] 1.07, 95% confidence interval [95% CI] 0.98-1.17) or labetalol (100% with nifedipine; RR 1.02, 95% CI 0.95-1.09). Less than 2% of women treated with nifedipine experienced hypotension. There were no differences in adverse maternal or fetal outcomes. Target BP was achieved ~ 50% of the time with oral labetalol (100 mg) or methyldopa (250 mg) (47% labetelol versus 56% methyldopa; RR 0.85 95% CI 0.54-1.33).

CONCLUSIONS

Oral nifedipine, and possibly labetalol and methyldopa, are suitable options for treatment of severe hypertension in pregnancy/postpartum.

Pharmacogenetics and individualizing drug treatment during pregnancy

Pharmacogenetics as a tool to aid clinicians implement individualized pharmacotherapy is utilized in some areas of medicine. Pharmacogenetics in pregnancy is still a developing field. However, there are several areas of obstetric therapeutics where data are emerging that give glimpses into future therapeutic possibilities. These include opioid pain management, antihypertensive therapy, antidepressant medications, preterm labor tocolytics, antenatal corticosteroids and drugs for nausea and vomiting of pregnancy, to name a few. More data are needed to populate the therapeutic models and to truly determine if pharmacogenetics will aid in individualizing pharmacotherapy in pregnancy. The objective of this review is to summarize current data and highlight research needs.

Hepatobiliary diseases during pregnancy and their management: An update

Liver diseases in pregnancy although rare but they can seriously affect mother and fetus. Signs and symptoms are often not specific and consist of jaundice, nausea, vomiting, and abdominal pain. Although any type of liver disease can develop during pregnancy or pregnancy may occur in a patient already having chronic liver disease. All liver diseases with pregnancy can lead to increased maternal and fetal morbidity and mortality. It is difficult to identify features of liver disease in pregnant women because of physiological changes. Physiological changes of normal pregnancy can be confounding with that of sign and symptoms of liver diseases. Telangiectasia or spider angiomas, palmar erythema, increased alkaline phosphatase due to placental secretion, hypoalbuminemia due to hemodilution. These normal alterations mimic physiological changes in patients with decompensated chronic liver disease. Besides all these pathological changes however, blood flow to the liver remains constant and the liver usually remains impalpable during pregnancy. The diagnosis of liver disease in pregnancy is challenging and relies on laboratory investigations. The underlying disorder can have a significant effect on morbidity and mortality in both mother and fetus, and a diagnostic workup should be initiated promptly. If we see the spectrum of liver disease in pregnancy, in mild form there occur increase in liver enzymes to severe form, where liver failure affecting the entire system or maternal mortality and morbidity. It can not only complicate mother's life but also poses burden of life of fetus to growth restriction. Most of the times termination is only answer to save life of mother but sometimes early detection of diseases, preventive measures and available active treatment is helpful for both of the life. Extreme vigilance in recognizing physical and laboratory abnormalities in pregnancy is a prerequisite for an accurate diagnosis. This could lead to a timely intervention and successful outcome.

Contemporary clinical management of the cerebral complications of preeclampsia

The neurological complications of preeclampsia and eclampsia are responsible for a major proportion of the morbidity and mortality arising from these conditions, for women and their infants alike. This paper outlines the evidence base for contemporary management principles pertaining to the neurological sequelae of preeclampsia, primarily from the maternal perspective, but with consideration of fetal and neonatal aspects as well. It concludes with a discussion regarding future directions in the management of this potentially lethal condition.

Posterior leukoencephalopathy syndrome: Postpartum focal neurologic deficits: A report of three cases and review of the literature

Posterior reversible encephalopathy syndrome presents with a variety of neurologic features, which, although devastating at some point, are potentially reversible on prompt recognition and institution of appropriated treatment. We report the management of three cases occurring in the last 4 years in our tertiary university hospital.

Drugs for treatment of very high blood pressure during pregnancy

BACKGROUND

Very high blood pressure during pregnancy poses a serious threat to women and their babies. The aim of antihypertensive therapy is to lower blood pressure quickly but safety, to avoid complications. Antihypertensive drugs lower blood pressure but their comparative effectiveness and safety, and impact on other substantive outcomes is uncertain.

OBJECTIVES

To compare different antihypertensive drugs for very high blood pressure during pregnancy.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (9 January 2013).

SELECTION CRITERIA

Studies were randomised trials. Participants were women with severe hypertension during pregnancy. Interventions were comparisons of one antihypertensive drug with another.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and assessed trial quality. Two review authors extracted data and checked them for accuracy.

MAIN RESULTS

Thirty-five trials (3573 women) with 15 comparisons were included. Women allocated calcium channel blockers were less likely to have persistent high blood pressure compared to those allocated hydralazine (six trials, 313 women; 8% versus 22%; risk ratio (RR) 0.37, 95% confidence interval (CI) 0.21 to 0.66). Ketanserin was associated with more persistent high blood pressure than hydralazine (three trials, 180 women; 27% versus 6%; RR 4.79, 95% CI 1.95 to 11.73), but fewer side-effects (three trials, 120 women; RR 0.32, 95% CI 0.19 to 0.53) and a lower risk of HELLP (haemolysis, elevated liver enzymes and lowered platelets) syndrome (one trial, 44 women; RR 0.20, 95% CI 0.05 to 0.81).Labetalol was associated with a lower risk of hypotension compared to diazoxide (one trial 90 women; RR 0.06, 95% CI 0.00 to 0.99) and a lower risk of caesarean section (RR 0.43, 95% CI 0.18 to 1.02), although both were borderline for statistical significance.Both nimodipine and magnesium sulphate were associated with a high incidence of persistent high blood pressure, but this risk was lower for nimodipine compared to magnesium sulphate (one trial, 1650 women; 47% versus 65%; RR 0.84, 95% CI 0.76 to 0.93). Nimodipine was associated with a lower risk of respiratory difficulties (RR 0.28, 95% CI 0.08 to 0.99), fewer side-effects (RR 0.68, 95% CI 0.55 to 0.85) and less postpartum haemorrhage (RR 0.41, 95% CI 0.18 to 0.92) than magnesium sulphate. Stillbirths and neonatal deaths were not reported.There are insufficient data for reliable conclusions about the comparative effects of any other drugs.

AUTHORS' CONCLUSIONS

Until better evidence is available the choice of antihypertensive should depend on the clinician's experience and familiarity with a particular drug; on what is known about adverse effects; and on women's preferences. Exceptions are nimodipine, magnesium sulphate (although this is indicated for women who require an anticonvulsant for prevention or treatment of eclampsia), diazoxide and ketanserin, which are probably best avoided.

Interventionist versus expectant care for severe pre-eclampsia between 24 and 34 weeks' gestation

BACKGROUND

Severe pre-eclampsia can cause significant mortality and morbidity for both mother and child, particularly when it occurs remote from term, between 24 and 34 weeks' gestation. The only known cure for this disease is delivery. Some obstetricians advocate early delivery to ensure that the development of serious maternal complications, such as eclampsia (fits) and kidney failure are prevented. Others prefer a more expectant approach delaying delivery in an attempt to reduce the mortality and morbidity for the child associated with being born too early.

OBJECTIVES

The objective of the review was to compare the effects of a policy of interventionist care and early delivery with a policy of expectant care and delayed delivery for women with early onset severe pre-eclampsia.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 February 2013).

SELECTION CRITERIA

Randomised trials comparing the two intervention strategies for women with early onset severe pre-eclampsia.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, extracted data and assessed risk of bias. Data were checked for accuracy.

MAIN RESULTS

Four trials, with a total of 425 women are included in this review. Trials were at low risk of bias for methods of randomisation and allocation concealment; high risk for blinding; unclear risk for incomplete outcome data and other bias; and low risk for selective reporting. There are insufficient data for reliable conclusions about the comparative effects on most outcomes for the mother. For the baby, there is insufficient evidence for reliable conclusions about the effects on stillbirth or death after delivery (risk ratio (RR) 1.08, 95% confidence interval (CI) 0.69 to 1.71; four studies; 425 women). Babies whose mothers had been allocated to the interventionist group had more intraventricular haemorrhage (RR 1.82, 95% CI 1.06 to 3.14; one study; 262 women), more hyaline membrane disease (RR 2.30, 95% CI 1.39 to 3.81; two studies; 133 women), require more ventilation (RR 1.50, 95% CI 1.11 to 2.02; two studies; 300 women) and were more likely to have a lower gestation at birth in days (average mean difference (MD) -9.91, 95% CI -16.37 to -3.45; four studies; 425 women), more likely to be admitted to neonatal intensive care (RR 1.35, 95% CI 1.16 to 1.58) and have a longer stay in the neonatal intensive care unit (average MD 11.14 days, 95% CI 1.57 to 20.72 days; two studies; 125 women) than those allocated an expectant policy. Nevertheless, babies allocated to the interventionist policy were less likely to be small-for-gestational age (RR 0.30, 95% CI 0.14 to 0.65; two studies; 125 women). Women who had been allocated to the interventionist group were more likely to have a caesarean section (RR 1.09, 95% CI 1.01 to 1.18; four studies; 425 women) than those allocated an expectant policy. There were no statistically significant differences between the two strategies for any other outcomes.

AUTHORS' CONCLUSIONS

This review suggests that an expectant approach to the management of women with severe early onset pre-eclampsia may be associated with decreased morbidity for the baby. However, this evidence is based on data from only four trials. Further large trials are needed to confirm or refute these findings and establish if this approach is safe for the mother.

Prevention and treatment of postpartum hypertension

BACKGROUND

Postpartum blood pressure (BP) is highest three to six days after birth when most women have been discharged home. A significant rise in BP may be dangerous (e.g., can lead to stroke), but there is little information about how to prevent or treat postpartum hypertension.

OBJECTIVES

To assess the relative benefits and risks of interventions to: (1) prevent postpartum hypertension, by assessing whether 'routine' postpartum medical therapy is better than placebo/no treatment; and (2) treat postpartum hypertension, by assessing whether (i) one antihypertensive therapy is better than placebo/no therapy for mild-moderate postpartum hypertension; and (ii) one antihypertensive agent offers advantages over another for mild-moderate or severe postpartum hypertension.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2013), bibliographies of retrieved papers, and personal files.

SELECTION CRITERIA

For women with antenatal hypertension, trials comparing a medical intervention with placebo/no therapy. For women with postpartum hypertension, trials comparing one antihypertensive with either another or placebo/no therapy.

DATA COLLECTION AND ANALYSIS

We extracted the data independently and were not blinded to trial characteristics or outcomes. We contacted authors for missing data when possible.

MAIN RESULTS

Nine trials are included.

PREVENTION

Four trials (358 women) compared furosemide, nifedipine capsules, or L-arginine with placebo/no therapy. For women with antenatal pre-eclampsia, postnatal furosemide is associated with a strong trend towards reduced use of antihypertensive therapy in hospital.

TREATMENT

For treatment of mild-moderate postpartum hypertension, three trials (189 women) compared timolol, oral hydralazine, or oral nifedipine with methyldopa. Use of additional antihypertensive therapy did not differ between groups (risk ratio (RR) 0.92, 95% confidence interval (CI) 0.20 to 4.20; three trials), but the trials were not consistent in their effects. The drugs were well tolerated.For treatment of severe postpartum hypertension, two trials (120 women) compared intravenous hydralazine with either sublingual nifedipine or intravenous labetalol. There were no maternal deaths or hypotension. Use of additional antihypertensive therapy did not differ between groups (RR 0.58, 95% CI 0.04 to 9.07; two trials), but the trials were not consistent in their effects.

AUTHORS' CONCLUSIONS

For women with pre-eclampsia, postnatal furosemide may decrease the need for postnatal antihypertensive therapy in hospital, but more data are needed on substantive outcomes before this practice can be recommended. There are no reliable data to guide management of women who are hypertensive postpartum. Any antihypertensive agent used should be based on a clinician's familiarity with the drug. Future studies should include data on postpartum analgesics, severe maternal hypertension, breastfeeding, hospital length of stay, and maternal satisfaction with care.

Hydralazine in infants with persistent hypoxemic respiratory failure

BACKGROUND

Most deaths of infants with chronic lung disease (CLD) are caused by respiratory failure, unremitting pulmonary artery hypertension (PAH) with cor pulmonale, or infection. Although the exact prevalence of PAH in infants with CLD is unknown, infants with CLD and severe PAH have a high mortality rate. Except for oxygen supplementation, no specific interventions have been established as effective in the treatment for PAH in premature infants with CLD. Little has been proven regarding the clinical efficacy of vasodilators and concerns remain regarding adverse effects.

OBJECTIVES

To review current evidence for the benefits and harms of hydralazine therapy to infants with persistent hypoxemic respiratory failure.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), MEDLINE via PubMed and EMBASE, and other clinical trials registries through November 2011 using the standard search strategy of the Cochrane Neonatal Review Group. We searched these databases using a strategy combining a variation of the Cochrane highly sensitive search strategy for identifying randomised trials in MEDLINE; sensitivity-maximising version with selected MeSH and free-text terms: hydralazine, vasodilator agent, antihypertensive agent, heart diseases, lung diseases, respiratory tract diseases, infant, and randomised controlled trial.

SELECTION CRITERIA

We considered only randomised controlled trials and quasi-randomised trials for inclusion. We included low birth weight (LBW) infants with persistent hypoxemic respiratory failure who were treated with any type of hydralazine therapy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality according to pre-specified criteria.

MAIN RESULTS

We found no studies meeting the criteria for inclusion in this review.

AUTHORS' CONCLUSIONS

There was insufficient evidence to determine the safety and efficacy of hydralazine in LBW infants with persistent hypoxemic respiratory failure. Since hydralazine is inexpensive and potentially beneficial, randomised controlled trials are recommended. Such trials are particularly needed in settings where other medications such as sildenafil, inhaled nitric oxide (iNO), or extracorporeal membrane oxygenation (ECMO) are not available.

Induction of a trophoblast-like phenotype by hydralazine in the p19 embryonic carcinoma cell line

Chemicals that affect cellular differentiation through epigenetic mechanisms have potential utility in treating a wide range of diseases. Hydralazine decreases DNA methylation in some cell types but its effect on differentiation has not been well explored. After five days of exposure to hydralazine, P19 embryocarcinoma cells displayed a giant cell morphology and were binucleate, indicative of a trophoblast-like morphology. Other trophoblast-like properties included the intermediary filament Troma-1/cytokeratin 8 and the transcription factor Tead4. A decrease in CpG methylation at three sites in the TEAD4 promoter and the B1 repeated sequence was observed. Knocking down expression of Tead4 with siRNA blocked the increase in Troma-1/cytokeratin 8 and over expression of Tead4 induced the expression of Troma-1/cytokeratin 8. Cells treated for 5days with hydralazine were no longer capable of undergoing retinoic acid-mediated neuronal differentiation. An irreversible loss of the pluripotent transcription factor Oct-4 was observed following hydralazine exposure. In summary, hydralazine induces P19 cells to assume a trophoblast-like phenotype by upregulating Tead4 expression through a mechanism involving DNA demethylation.

Hypertension and pregnancy

Hypertension in pregnancy is increasing in prevalence and incidence and its treatment becoming more commonplace. Associated complications of pregnancy, including end-organ damage, preeclampsia, eclampsia, and postpartum eclampsia, are leading sources of maternal and fetal morbidity and mortality, requiring an emergency physician to become proficient with their identification and treatment. This article reviews hypertension in pregnancy as it relates to outcomes, with special emphasis on preeclampsia, eclampsia, and postpartum eclampsia.

Hypertension in pregnancy

Hypertension in pregnancy is diagnosed on systolic blood pressure greater than or equal to 140 mm Hg and/or diastolic greater than or equal to 90 mm Hg. The classification systems separate chronic and gestational hypertension from preeclampsia. Significant uncertainty regarding optimal management is reflected in the differing major international society recommendations. Blood pressure treatment is designed to minimize maternal end-organ damage. Methyldopa, labetalol, hydralazine, and nifedipine are oral options; angiotensin-converting enzyme inhibitors and angiotensin receptor antagonists are contraindicated. Women with preeclampsia should be closely monitored and receive intravenous magnesium sulfate.

Hypertension in pregnancy: a review of therapeutic options

Hypertensive disorders in pregnancy are common and can occur as a result of pre-existing hypertension or as new onset hypertension usually in the second half of pregnancy. In either situation there is potential for considerable perinatal and maternal morbidity and mortality. This review article aims to compare therapeutic options outlined in a selection of national guidelines and to look in more detail at the most commonly prescribed drugs - labetalol, methyldopa and nifedipine - with respect to their pharmacology and the evidence for their use in pregnancy. We will also consider the rationale for identifying and treating hypertension in pregnancy and the effect this can have on short- and long-term maternal and neonatal outcomes.

The effect of maternal ketanserin use on the circulation of the neonate: a prospective, observational study

OBJECTIVE

High ketanserin levels are found in the umbilical cord after maternal treatment. However, the effect on the circulation of the neonate has never been investigated.

STUDY DESIGN

A prospective, observational study was performed at the neonate ward at the Medical Centre Leeuwarden, The Netherlands. All neonates exposed in utero to ketanserin administered to the mother, from May 2007 to December 2009 (n=58), were included. We studied the effect of ketanserin exposure on the circulation of the neonate, by monitoring heart rate and blood pressure during the first 24h of life. Non-parametric as well as parametric tests were used to analyze the effect of gestational age, birth weight, gender, various ketanserin factors (cumulative dosage, duration of therapy and last dosage rate), other maternal drug use and maternal diagnosis on the blood pressure of the neonate.

RESULTS

Eight neonates became hypotensive during the first 8h of life (13.8%). The last dosage rate as well as the mean dosage rate (cumulative dosage divided by duration of therapy in hours) were significantly higher in the group with hypotension (P=.005 and P=.002, respectively). All hypotensive neonates were exposed to a last dosage rate of at least 8 mg/h. Maternal HELLP syndrome was diagnosed more often in hypotensive compared to normotensive neonates (P=.048).

CONCLUSION

In utero exposure to ketanserin lowers the blood pressure of the neonate. The risk of hypotension is associated with the last dosage rate of maternal ketanserin treatment and the co-existence of maternal HELLP syndrome.

Treatment of Neurocritical Care Emergencies in Pregnancy

OPINION STATEMENT: Neurologic emergencies are a major cause of morbidity and mortality in pregnant women. In part because the patient population is young, the nihilistic approach that often accompanies neurologically devastating disorders in other contexts is largely absent. A number of studies have demonstrated improved patient outcomes in the setting of aggressive care delivered by neurointensivists in a specialty-specific environment. It stands to reason that young, pregnant women who suffer from neurologically devastating disorders and who have a wide range of prognosis may also benefit from such specialized care. Close collaboration between obstetricians and neurointensivists is critical in this context. A number of unique considerations in diagnosis and management present dilemmas in the context of pregnancy, such as radiation dose from diagnostic neuroimaging, choice of pharmacotherapy for seizures, anticoagulation, and the method of delivery in the context of cerebral mass lesions and elevated intracranial pressure. Patients and their physicians are often faced with the additional challenge of balancing the relative risks and benefits of the impact of a management approach on both mother and fetus. In general, this balance tends to favor the interests of the mother, but the impact on the fetus becomes more relevant over the course of the pregnancy, especially in the third trimester. A low threshold for admission to an intensive care unit (ideally one that specializes in neurointensive care) should be used for pregnant patients. Because of the limited information regarding long-term outcomes in this population, rigid prognosis formation and early care limitations should be deferred in the immediate period. After the patient is stabilized and a plan has been charted for the remainder of the pregnancy, every effort should be made to engage patients in aggressive, urgent neurologic rehabilitation.

The role of genetics in pre-eclampsia and potential pharmacogenomic interventions

The pregnancy-specific condition pre-eclampsia not only affects the health of mother and baby during pregnancy but also has long-term consequences, increasing the chances of cardiovascular disease in later life. It is accepted that pre-eclampsia has a placental origin, but the pathogenic mechanisms leading to the systemic endothelial dysfunction characteristic of the disorder remain to be determined. In this review we discuss some key factors regarded as important in the development of pre-eclampsia, including immune maladaptation, inadequate placentation, oxidative stress, and thrombosis. Genetic factors influence all of these proposed pathophysiological mechanisms. The inherited nature of pre-eclampsia has been known for many years, and extensive genetic studies have been undertaken in this area. Genetic research offers an attractive strategy for studying the pathogenesis of pre-eclampsia as it avoids the ethical and practical difficulties of conducting basic science research during the preclinical phase of pre-eclampsia when the underlying pathological changes occur. Although pharmacogenomic studies have not yet been conducted in pre-eclampsia, a number of studies investigating treatment for essential hypertension are of relevance to therapies used in pre-eclampsia. The pharmacogenomics of antiplatelet agents, alpha and beta blockers, calcium channel blockers, and magnesium sulfate are discussed in relation to the treatment and prevention of pre-eclampsia. Pharmacogenomics offers the prospect of individualized patient treatment, ensuring swift introduction of optimal treatment whilst minimizing the use of inappropriate or ineffective drugs, thereby reducing the risk of harmful effects to both mother and baby.

How to manage hypertension in pregnancy effectively

The hypertensive disorders of pregnancy (HDP) are a leading cause of maternal mortality and morbidity in both well and under-resourced settings. Maternal, fetal, and neonatal complications of the HDP are concentrated among, but not limited to, women with pre-eclampsia. Pre-eclampsia is a systemic disorder of endothelial cell dysfunction and as such, blood pressure (BP) treatment is but one aspect of its management. The most appropriate BP threshold and goal of antihypertensive treatment are controversial. Variation between international guidelines has more to do with differences in opinion rather than differences in published data. For women with severe hypertension [defined as a sustained systolic BP (sBP) of ≥160 mmHg and/or a diastolic BP (dBP) of ≥110 mmHg], there is consensus that antihypertensive therapy should be given to lower the maternal risk of central nervous system complications. The bulk of the evidence relates to parenteral hydralazine and labetalol, or to oral calcium channel blockers such as nifedipine capsules. There is, however, no consensus regarding management of non-severe hypertension (defined as a sBP of 140-159 mmHg or a dBP of 90-109 mmHg), because the relevant randomized trials have been underpowered to define the maternal and perinatal benefits and risks. Although antihypertensive therapy may decrease the occurrence of BP values of 160-170/100-110 mmHg, therapy may also impair fetal growth. The potential benefits and risks do not seem to be associated with any particular drug or drug class. Oral labetalol and methyldopa are used most commonly, but many different β-adrenoceptor blockers and calcium channel blockers have been studied in clinical trials.

Bothrops jararaca peptide with anti-hypertensive action normalizes endothelium dysfunction involved in physiopathology of preeclampsia

Preeclampsia, a pregnancy-specific syndrome characterized by hypertension, proteinuria and edema, is a major cause of fetal and maternal morbidity and mortality especially in developing countries. Bj-PRO-10c, a proline-rich peptide isolated from Bothrops jararaca venom, has been attributed with potent anti-hypertensive effects. Recently, we have shown that Bj-PRO-10c-induced anti-hypertensive actions involved NO production in spontaneous hypertensive rats. Using in vitro studies we now show that Bj-PRO-10c was able to increase NO production in human umbilical vein endothelial cells from hypertensive pregnant women (HUVEC-PE) to levels observed in HUVEC of normotensive women. Moreover, in the presence of the peptide, eNOS expression as well as argininosuccinate synthase activity, the key rate-limiting enzyme of the citrulline-NO cycle, were enhanced. In addition, excessive superoxide production due to NO deficiency, one of the major deleterious effects of the disease, was inhibited by Bj-PRO-10c. Bj-PRO-10c induced intracellular calcium fluxes in both, HUVEC-PE and HUVEC, which, however, led to activation of eNOS expression only in HUVEC-PE. Since Bj-PRO-10c promoted biological effects in HUVEC from patients suffering from the disorder and not in normotensive pregnant women, we hypothesize that Bj-PRO-10c induces its anti-hypertensive effect in mothers with preeclampsia. Such properties may initiate the development of novel therapeutics for treating preeclampsia.

The management of the critically ill obstetric patient

Hypertensive disorders, postpartum hemorrhage, and sepsis are the most common indications for intensive care unit admission among obstetric patients. In general, ICU mortality is low, and better than would be predicted using available mortality prediction tools. Provision of care to this special population requires an intimate understanding of physiologic changes that occur during pregnancy. Clinicians must be aware of the way various diagnostic and treatment choices can affect the mother and fetus. Most clinically necessary radiographic tests can be safely performed and fall under the maternal radiation exposure limit of less than 0.05 Gray (Gy). Careful attention must be paid to acid-base status, oxygenation, and ventilation when faced with respiratory failure necessitating intubation. Cesarean delivery can be justified after 4 minutes of cardiac arrest and may improve fetal and maternal outcomes. The treatment of obstetric patients in the ICU introduces complexities and challenges that may be unfamiliar to many critical care physicians; teamwork and communication with obstetricians is crucial.

Pre-eclampsia: pathophysiology, diagnosis, and management

The incidence of pre-eclampsia ranges from 3% to 7% for nulliparas and 1% to 3% for multiparas. Pre-eclampsia is a major cause of maternal mortality and morbidity, preterm birth, perinatal death, and intrauterine growth restriction. Unfortunately, the pathophysiology of this multisystem disorder, characterized by abnormal vascular response to placentation, is still unclear. Despite great polymorphism of the disease, the criteria for pre-eclampsia have not changed over the past decade (systolic blood pressure > 140 mmHg or diastolic blood pressure ≥ 90 mmHg and 24-hour proteinuria ≥ 0.3 g). Clinical features and laboratory abnormalities define and determine the severity of pre-eclampsia. Delivery is the only curative treatment for pre-eclampsia. Multidisciplinary management, involving an obstetrician, anesthetist, and pediatrician, is carried out with consideration of the maternal risks due to continued pregnancy and the fetal risks associated with induced preterm delivery. Screening women at high risk and preventing recurrences are key issues in the management of pre-eclampsia.

Antihypertensive drugs in pregnancy

Blood pressure targets and medications that are safe differ in pregnant women compared with nonpregnant individuals. The principles of treatment for mild, moderate, and severe hypertension in pregnancy, chronic versus gestational versus preeclampsia, and women hypertensive at term versus remote from term are reviewed. The choice of antihypertensive drugs also is discussed; methyldopa, labetalol, and nifedipine, among others, appear safe for use in pregnancy, whereas angiotensin converting enzyme inhibitors and angiotensin receptor blockers should be avoided. The management of increased blood pressure in the postpartum period, and agents to use in lactation, are also discussed.

Quantifying the fall in mortality associated with interventions related to hypertensive diseases of pregnancy

BACKGROUND

In this paper we review the evidence of the effect of health interventions on mortality reduction from hypertensive diseases in pregnancy (HDP). We chose HDP because they represent a major cause of death in low income countries and evidence of effect on maternal mortality from randomised studies is available for some interventions.

METHODS

We used four approaches to review the evidence of the effect of interventions to prevent or treat HDP on mortality reduction from HDP. We first reviewed the Cochrane Library to identify systematic reviews and individual trials of the efficacy of single interventions for the prevention or treatment of HDP. We then searched the literature for articles quantifying the impact of maternal health interventions on the reduction of maternal mortality at the population level and describe the approaches used by various authors for interventions related to HDP. Third, we examined levels of HDP-specific mortality over time or between regions in an attempt to quantify the actual or potential reduction in mortality from HDP in these regions or over time. Lastly, we compared case fatality rates in women with HDP-related severe acute maternal morbidity with those reported historically in high income countries before any effective treatment was available.

RESULTS

The Cochrane review identified 5 effective interventions: routine calcium supplementation in pregnancy, antiplatelet agents during pregnancy in women at risk of pre-eclampsia, Magnesium sulphate (MgS04) for the treatment of eclampsia, MgS04 for the treatment of pre-eclampsia, and hypertensive drugs for the treatment of mild to moderate hypertension in pregnancy.We found 10 studies quantifying the effect of maternal health interventions on reducing maternal mortality from HDP, but the heterogeneity in the methods make it difficult to draw uniform conclusions for effectiveness of interventions at various levels of the health system. Most authors include a health systems dimension aimed at separating interventions that can be delivered at the primary or health centre level from those that require hospital treatment, but definitions are rarely provided and there is no consistency in the types of interventions that are deemed effective at the various levels.The low levels of HDP related mortality in rural China and Sri Lanka suggest that reductions of 85% or more are within reach, provided that most women give birth with a health professional who can refer them to higher levels of care when necessary. Results from studies of severe acute maternal morbidity in Indonesia and Bolivia also suggest that mortality in women with severe pre-eclampsia or eclampsia in hospital can be reduced by more than 84%, even when the women arrive late.

CONCLUSIONS

The increasing emphasis on the rating of the quality of evidence has led to greater reliance on evidence from randomised controlled trials to estimate the effect of interventions. Yet evidence from randomised studies is often not available, the effects observed on morbidity may not translate in to mortality, and the distinction between efficacy and effectiveness may be difficult to make. We suggest that more use should be made of observational evidence, particularly since such data represent the actual effectiveness of packages of interventions in various settings.

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.

Magnesium sulphate versus diazepam for eclampsia

BACKGROUND

Eclampsia, the occurrence of a seizure in association with pre-eclampsia, remains a rare but serious complication of pregnancy. A number of different anticonvulsants are used to control eclamptic fits and to prevent further fits.

OBJECTIVES

The objective of this review was to assess the effects of magnesium sulphate compared with diazepam when used for the care of women with eclampsia. Magnesium sulphate is compared with phenytoin and with lytic cocktail in other Cochrane reviews.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2010) and CENTRAL (2010, Issue 3).

SELECTION CRITERIA

Randomised trials comparing magnesium sulphate (intravenous or intramuscular administration) with diazepam for women with a clinical diagnosis of eclampsia.

DATA COLLECTION AND ANALYSIS

Two authors assessed and extracted data independently.

MAIN RESULTS

We have included seven trials, involving 1396 women. Three trials (1030 women) were good quality. Magnesium sulphate was associated with a reduction in maternal death (seven trials;1396 women; risk ratio (RR) 0.59, 95% confidence interval (CI) 0.38 to 0.92) and recurrence of seizures (seven trials;1390 women; RR 0.43, 95% CI 0.33 to 0.55) compared to diazepam. There were no clear differences in other measures of maternal morbidity.There was no clear difference in perinatal mortality (four trials; 788 infants; RR 1.04, 95% CI 0.81 to 1.34) or neonatal mortality (four trials; 759 infants; RR 1.18, 95% CI 0.75 to 1.84). In the magnesium sulphate group, fewer liveborn babies had an Apgar score less than seven at one minute (two trials; 597 babies; RR 0.75, 95% CI 0.65 to 0.87) or at five minutes (RR 0.70, 95% CI 0.54 to 0.90), and fewer appeared to need intubation at the place of birth (two trials; 591 infants; RR 0.67, 95% CI 0.45 to 1.00). There was no difference in admission to a special care nursery (four trials; 834 infants; RR 0.91, 95% CI 0.79 to 1.05), but fewer babies in the magnesium sulphate group had a length of stay more than seven days (three trials 631 babies; RR 0.66, 95% CI 0.46 to 0.96).

AUTHORS' CONCLUSIONS

Magnesium sulphate for women with eclampsia reduces the risk ratio of maternal death and of recurrence of seizures, compared with diazepam.

Magnesium sulphate and other anticonvulsants for women with pre-eclampsia

BACKGROUND

Eclampsia, the occurrence of a seizure (fit) in association with pre-eclampsia, is rare but potentially life-threatening. Magnesium sulphate is the drug of choice for treating eclampsia. This review assesses its use for preventing eclampsia.

OBJECTIVES

To assess the effects of magnesium sulphate, and other anticonvulsants, for prevention of eclampsia.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (4 June 2010), and the Cochrane Central Register of Controlled Trials Register (The Cochrane Library 2010, Issue 3).

SELECTION CRITERIA

Randomised trials comparing anticonvulsants with placebo or no anticonvulsant, or comparisons of different drugs, for pre-eclampsia.

DATA COLLECTION AND ANALYSIS

Two authors assessed trial quality and extracted data independently.

MAIN RESULTS

We included 15 trials. Six (11,444 women) compared magnesium sulphate with placebo or no anticonvulsant: magnesium sulphate more than a halved the risk of eclampsia (risk ratio (RR) 0.41, 95% confidence interval (CI) 0.29 to 0.58; number needed to treat for an additional beneficial outcome (NNTB) 100, 95% CI 50 to 100), with a non-significant reduction in maternal death (RR 0.54, 95% CI 0.26 to 1.10) but no clear difference in serious maternal morbidity (RR 1.08, 95% CI 0.89 to 1.32). It reduced the risk of placental abruption (RR 0.64, 95% CI 0.50 to 0.83; NNTB 100, 95% CI 50 to 1000), and increased caesarean section (RR 1.05, 95% CI 1.01 to 1.10). There was no clear difference in stillbirth or neonatal death (RR 1.04, 95% CI 0.93 to 1.15). Side effects, primarily flushing, were more common with magnesium sulphate (24% versus 5%; RR 5.26, 95% CI 4.59 to 6.03; number need to treat for an additional harmful outcome (NNTH) 6, 95% CI 5 to 6).Follow-up was reported by one trial comparing magnesium sulphate with placebo: for 3375 women there was no clear difference in death (RR 1.79, 95% CI 0.71 to 4.53) or morbidity potentially related to pre-eclampsia (RR 0.84, 95% CI 0.55 to 1.26) (median follow-up 26 months); for 3283 children exposed in utero there was no clear difference in death (RR 1.02, 95% CI 0.57 to 1.84) or neurosensory disability (RR 0.77, 95% CI 0.38 to 1.58) at age 18 months.Magnesium sulphate reduced eclampsia compared to phenytoin (three trials, 2291 women; RR 0.08, 95% CI 0.01 to 0.60) and nimodipine (one trial, 1650 women; RR 0.33, 95% CI 0.14 to 0.77).

AUTHORS' CONCLUSIONS

Magnesium sulphate more than halves the risk of eclampsia, and probably reduces maternal death. There is no clear effect on outcome after discharge from hospital. A quarter of women report side effects with magnesium sulphate.

Magnesium sulphate versus lytic cocktail for eclampsia

BACKGROUND

Eclampsia, the occurrence of a seizure in association with pre-eclampsia, is a rare but serious complication of pregnancy. A number of different anticonvulsants have been used to control eclamptic fits and to prevent further seizures.

OBJECTIVES

The objective of this review was to assess the effects of magnesium sulphate compared with lytic cocktail (usually chlorpromazine, promethazine and pethidine) when used for the care of women with eclampsia. Magnesium sulphate is compared with diazepam and with phenytoin in other Cochrane reviews.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (July 2010) and the Cochrane Central Register of Trials (The Cochrane Library 2010, Issue 2).

SELECTION CRITERIA

Randomised trials comparing magnesium sulphate (intravenous or intramuscular administration) with lytic cocktail for women with a clinical diagnosis of eclampsia.

DATA COLLECTION AND ANALYSIS

Two review authors (L Duley and D Chou) assessed trial quality and extracted data.

MAIN RESULTS

We included three small trials (total 397 women) of average quality in the review. Magnesium sulphate was associated with fewer maternal deaths (risk ratio (RR) 0.14, 95% confidence interval (CI) 0.03 to 0.59; 3 trials, 397 women) and was better at preventing further seizures (RR 0.06, 95% CI 0.03 to 0.12; 3 trials, 397 women) than lytic cocktail. Magnesium sulphate was also associated with less respiratory depression (RR 0.12, 95% CI 0.02 to 0.91; 2 trials, 198 women), less coma (RR 0.04, 95% CI 0.00 to 0.74; 1 trial, 108 women), and less pneumonia (RR 0.20, 95% CI 0.06 to 0.67; 2 trials, 307 women). There was no clear difference in the RR for any death of the baby (RR 0.35, 95% CI 0.05 to 2.38, random effects; 2 trials, 177 babies).

AUTHORS' CONCLUSIONS

Magnesium sulphate, rather than lytic cocktail, for women with eclampsia reduces the RR of maternal death, of further seizures and of serious maternal morbidity (respiratory depression, coma, pneumonia). Magnesium sulphate is the anticonvulsant of choice for women with eclampsia; the use of lytic cocktail should be abandoned.

Pre-eclampsia

Pre-eclampsia remains a leading cause of maternal and perinatal mortality and morbidity. It is a pregnancy-specific disease characterised by de-novo development of concurrent hypertension and proteinuria, sometimes progressing into a multiorgan cluster of varying clinical features. Poor early placentation is especially associated with early onset disease. Predisposing cardiovascular or metabolic risks for endothelial dysfunction, as part of an exaggerated systemic inflammatory response, might dominate in the origins of late onset pre-eclampsia. Because the multifactorial pathogenesis of different pre-eclampsia phenotypes has not been fully elucidated, prevention and prediction are still not possible, and symptomatic clinical management should be mainly directed to prevent maternal morbidity (eg, eclampsia) and mortality. Expectant management of women with early onset disease to improve perinatal outcome should not preclude timely delivery-the only definitive cure. Pre-eclampsia foretells raised rates of cardiovascular and metabolic disease in later life, which could be reason for subsequent lifestyle education and intervention.

Effects of pregnancy, hypertension and nitric oxide inhibition on rat uterine artery myogenic reactivity

BACKGROUND/AIMS

The purpose of this study was to examine the effects of hypertension and nitric oxide (NO) inhibition on myogenic tone in uterine arteries during pregnancy.

METHODS

Premyometrial radial uterine arteries from nonpregnant and late pregnant Sprague-Dawley rats were evaluated for myogenic reactivity from the following groups: control, hypertensive/NO-inhibited (L-NAME treatment) and normotensive/NO-inhibited (L-NAME plus hydralazine).

RESULTS

In both nonpregnant and pregnant animals, L-NAME treatment significantly elevated blood pressures, while the addition of hydralazine made the animals normotensive. In nonpregnant animals, little myogenic tone was seen in controls; tone increased significantly in the L-NAME group, and was attenuated in those treated with L-NAME plus hydralazine. In pregnant animals, controls developed significant tone; this was reduced in the L-NAME group, and returned to control levels in the L-NAME plus hydralazine group.

CONCLUSIONS

Dimensional measurements showed that arteries from the pregnant hypertensive group did not undergo expansive remodeling, suggesting that tone development is related to phenotypic alterations in vascular smooth muscle and/or altered physical forces secondary to adaptive changes in arterial diameter. These differences implicate pregnancy-specific pathways in the development and inhibition of myogenic tone, and point to potentially opposing roles of NO and hypertension.