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Quist-Nelson J, de Ruigh A, Lemoine ER, Pajkrt E, Mol B, Vigil-De Gracia P, Ludmir J, Askie L, Berghella V. Early magnesium discontinuation postpartum and eclampsia risk: A systematic review and meta-analysis. Pregnancy Hypertens 2024; 37:101141. [PMID: 39018830 DOI: 10.1016/j.preghy.2024.101141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 05/15/2024] [Accepted: 06/26/2024] [Indexed: 07/19/2024]
Abstract
INTRODUCTION The optimal duration of magnesium administration postpartum for prevention of eclampsia has not yet been established. Our objective was to investigate the effect of early discontinuation of postpartum magnesium on the rates of postpartum eclampsia compared to continuation for 24-hours postpartum. MATERIAL AND METHODS Searches were performed using keywords related to "preeclampsia" and "magnesium sulfate" from inception of database until August 2023. Randomized controlled trials of women with preeclampsia were included if they received magnesium prior to delivery and were randomized to early discontinuation versus 24-hours of magnesium postpartum. The primary outcome was the rate of postpartum eclampsia. RESULTS Nine RCTs with 2183 women were included with five different magnesium administration time frames. In total, seven patients with postpartum eclampsia were reported in three studies. Eclampsia rates were not different between the two groups (5/1088 (0.5 %) after early discontinuation, versus 2/1095 (0.2 %) in the 24-hour group; RR 2.25, 95 % CI 0.5-9.9, I2 = 0 %, 8 studies, 2183 participants). A number needed to treat was calculated; 374 women would need to receive 24-hours of magnesium postpartum to prevent one episode of postpartum eclampsia. The early discontinuation group had a significant decrease in time to ambulation (-9.1 h, 95 % CI -14.7 - (-3.6), I2 = 98 %, 3 studies, 1509 participants) and breastfeeding (-8.4 h, 95 % CI -12.0 - (-4.8), I2 = 98 %, 2 studies, 1397 participants). CONCLUSIONS Early magnesium discontinuation postpartum, usually ≤6 h or none at all, did not significantly increase the rate of postpartum eclampsia, however this study is likely underpowered to demonstrate a difference. The number needed to treat is similar to the number needed to treat for antepartum preeclampsia without severe features, for which magnesium is not recommended. The largest proportion of women did not receive magnesium postpartum after receiving at least 8 h of magnesium intrapartum (e.g., loading and maintenance dose). Thus, it is reasonable to consider not using magnesium postpartum, particularly if a woman has received similar adequate dose prior to delivery.
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Affiliation(s)
- Johanna Quist-Nelson
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Annemijn de Ruigh
- Department of Obstetrics and Gynecology, Academic Medical Centre, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Elizabeth R Lemoine
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Eva Pajkrt
- Department of Obstetrics and Gynecology, Academic Medical Centre, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ben Mol
- Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Paulino Vigil-De Gracia
- Hospital de la Caja de Seguro Social, Investigador distinguido del Sistema Nacional de Investigación, SENACYT, Panama City, Panama
| | - Jack Ludmir
- Department of Obstetrics, Gynecology and Reproductive Sciences, Lewis Katz School of Medicine at Temple University, USA
| | - Lisa Askie
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Vincenzo Berghella
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Mayrink J, Reis ZSN. Pre-eclampsia in low and middle-income settings: What are the barriers to improving perinatal outcomes and evidence-based recommendations? Int J Gynaecol Obstet 2024; 164:33-39. [PMID: 37329226 DOI: 10.1002/ijgo.14913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 05/08/2023] [Accepted: 05/17/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVE To discuss the points that still challenge low- and middle-income countries (LMICs) and strategies that have been studied to help them overcome these issues. METHODS Narrative review addressing 20 years of articles concerning pre-eclampsia morbidity and mortality in LMICs. We summarized evidence-based strategies to overcome the challenges in order to reduce the pre-eclampsia impact on perinatal outcomes. RESULTS Pre-eclampsia is the first or second leading cause in the ranking of avoidable causes of maternal death, and approximately 16% of all maternal deaths are attributable to eclampsia and pre-eclampsia. Considering the social and economic contexts, it represents a major public health concern, and prevention and early detection of pre-eclampsia seem to be a major challenge. Reducing maternal mortality related to hypertensive disturbances depends on public policies to manage these preventable conditions. Early and continuous recognition of signs of severity related to hypertensive disorders during pregnancy and childbirth, self-monitoring of symptoms and blood pressure, as well as preventive approaches such as aspirin and calcium, and magnesium sulfate, are lifesaving procedures that have not yet reached a universal scale. CONCLUSION This review provides a vision of relevant points to support pregnant women in overcoming the constraints to healthcare access in LMICs, and strategies that can be applied in primary prenatal care units.
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Affiliation(s)
- Jussara Mayrink
- Federal University of Minas Gerais, Department of Obstetrics and Gynecology, Belo Horizonte, Brazil
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Jiang W, Zeng X, Zhou X, Liao O, Ju F, Zhao Z, Zhang X. Effect of magnesium sulfate perioperative infusion on postoperative catheter-related bladder discomfort in male patients undergoing laparoscopic radical resection of gastrointestinal cancer: a prospective, randomized and controlled study. BMC Anesthesiol 2023; 23:396. [PMID: 38042781 PMCID: PMC10693125 DOI: 10.1186/s12871-023-02346-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 11/17/2023] [Indexed: 12/04/2023] Open
Abstract
BACKGROUND Laparoscopic radical resection of gastrointestinal cancer is associated with a high incidence of postoperative catheter-related bladder discomfort (CRBD). Studies on the benefits of magnesium sulfate intravenous infusion during the perioperative period post-laparoscopic surgery are yet lacking. METHODS A total of 88 gastrointestinal cancer male patients scheduled for laparoscopic radical resection were randomly divided into two groups: normal saline (control) and magnesium. In the magnesium group, a 40 mg/kg loading dose of intravenous magnesium sulfate was administered for 10 min just after the induction of anesthesia, followed by continuous intravenous infusion of 15 mg/kg/h magnesium sulfate until the end of the surgery; the control group was administered the same dose of normal saline. Subsequently, 2 μg/kg sufentanil was continuously infused intravenously by a postoperative patient-controlled intravenous analgesia (PCIA) device. The primary outcome was the incidence of CRBD at 0 h after the surgery. The secondary outcomes included incidence of CRBD at 1, 2, and 6 h postsurgery, the severity of CRBD at 0, 1, 2, and 6 h postsurgery. Remifentanil requirement during surgery, sufentanil requirement within 24 h postsurgery, the postoperative numerical rating scale (NRS) score at 48 h after the surgery, magnesium-related side effects and rescue medication (morphine) requirement were also assessed. RESULTS The incidence of CRBD at 0, 1, 2, and 6 h postoperatively was lower in the magnesium group than the control group (0 h: P = 0.01; 1 h: P = 0.003; 2 h: P = 0.001; 6 h: P = 0.006). The incidence of moderate to severe CRBD was higher in the control group at postoperative 0 and 1 h (0 h: P = 0.002; 1 h: P = 0.028), remifentanil requirement during surgery were significantly lower in the magnesium group than the control group. Sufentanil requirements during the 24 h postoperative period were significantly lower in the magnesium group than the control group. The NRS score was reduced in the magnesium group compared to the control group in the early postoperative period. Magnesium-related side effects and rescue medication (morphine) did not differ significantly between the two groups. CONCLUSIONS Intravenous magnesium sulfate administration reduces the incidence and severity of CRBD and remifentanil requirement in male patients undergoing radical resection of gastrointestinal cancer. Also, no significant side effects were observed. TRIAL REGISTRATION Chictr.org.cn ChiCTR2100053073. The study was registered on 10/11/2021.
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Affiliation(s)
- Wencai Jiang
- Department of Anesthesiology, Deyang People's Hospital, Deyang, 618000, China
| | - Xu Zeng
- Clinical Medicine Department, Chengdu Medical College, Chengdu, 610500, China
| | - Xinyu Zhou
- Clinical Medicine Department, Chengdu Medical College, Chengdu, 610500, China
| | - Ou Liao
- Department of Anesthesiology, Deyang People's Hospital, Deyang, 618000, China
| | - Feng Ju
- Department of Anesthesiology, Deyang People's Hospital, Deyang, 618000, China
| | - Zhifu Zhao
- Department of Anesthesiology, Deyang People's Hospital, Deyang, 618000, China
| | - Xianjie Zhang
- Department of Anesthesiology, Deyang People's Hospital, Deyang, 618000, China.
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Cagino K, Prabhu M, Sibai B. Is magnesium sulfate therapy warranted in all cases of late postpartum severe hypertension? A suggested approach to a clinical conundrum. Am J Obstet Gynecol 2023; 229:641-646. [PMID: 37467840 DOI: 10.1016/j.ajog.2023.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/10/2023] [Accepted: 07/11/2023] [Indexed: 07/21/2023]
Abstract
Magnesium sulfate reduces the risk for eclamptic seizures antepartum, intrapartum, and in the immediate postpartum period, however, there are no studies that have evaluated the benefits and risks of magnesium sulfate among women with late postpartum severe hypertension only. Juxtaposed on this clinical uncertainty is the increased incidence of severe hypertension owing to a rise in pregnancies complicated by advanced maternal age, obesity, chronic hypertension, diabetes, and recent protocols for intensive monitoring of blood pressure in the postpartum period. These factors have led to a significant increase in postpartum presentations for the evaluation and management of severe hypertension, in some cases leading to postpartum readmissions for administration of antihypertensive therapy and magnesium sulfate without data demonstrating clear clinical benefit. Postpartum readmissions can have several negative consequences, including interfering with early bonding with a newborn, breastfeeding, and use of scarce healthcare resources. In addition, magnesium sulfate is associated with risks for serious cardiorespiratory depression and bothersome side effects and can delay determining the optimal antihypertensive regimen, which is typically the most pressing clinical need during postpartum presentations of late-postpartum severe hypertension. Eclampsia that occurs more than 48 hours after delivery is rare (constitutes 16% of all cases of eclampsia) and is most commonly preceded by headaches or other cerebral symptoms. In this commentary, we propose an approach to evaluating and managing patients with late postpartum severe hypertension aimed at identifying those women at highest risk for end-organ injury. We recommend that the short- and long-term focus for all patients with severe hypertension should be the optimal management of blood pressures with a goal of close outpatient monitoring when logistically feasible and clinically appropriate. We suggest reserving magnesium sulfate therapy for the subset of patients with neurologic symptoms who may be at highest risk for an eclamptic seizure.
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Affiliation(s)
- Kristen Cagino
- Department of Obstetrics and Gynecology, University of Texas Health Science Center at Houston, Houston, TX.
| | - Malavika Prabhu
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA
| | - Baha Sibai
- Department of Obstetrics and Gynecology, University of Texas Health Science Center at Houston, Houston, TX
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Ristovska EC, Genadieva-Dimitrova M, Todorovska B, Milivojevic V, Rankovic I, Samardziski I, Bojadzioska M. The Role of Endothelial Dysfunction in the Pathogenesis of Pregnancy-Related Pathological Conditions: A Review. Pril (Makedon Akad Nauk Umet Odd Med Nauki) 2023; 44:113-137. [PMID: 37453122 DOI: 10.2478/prilozi-2023-0032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
In the recent decades, endothelial dysfunction (ED) has been recognized as a significant contributing factor in the pathogenesis of many pathological conditions. In interaction with atherosclerosis, hypercholesterolemia, and hypertension, ED plays a crucial role in the pathogenesis of coronary artery disease, chronic renal disease, and microvascular complications in diabetes mellitus. Although ED plays a significant role in the pathogenesis of several pregnancy-related disorders such as preeclampsia, HELLP syndrome, fetal growth restriction, and gestational diabetes mellitus, the exact pathogenetic mechanisms are still a matter of debate. The increased prevalence of these entities in patients with preexisting vascular diseases highlights the essential pathological role of the preexisting ED in these patients. The abnormal uteroplacental circulation and the release of soluble factors from the ischemic placenta into the maternal bloodstream are the main causes of the maternal ED underlying the characteristic preeclamptic phenotype. Besides the increased risk for maternal and fetal poor outcomes, the preexisting ED also increases the risk of development of future cardiovascular diseases in these patients. This study aimed to look deeper into the role of ED in the pathogenesis of several pregnancy-related hypertensive and liver diseases. Hopefully, it could contribute to improvement of the awareness, knowledge, and management of these conditions and also to the reduction of the adverse outcomes and additional long-term cardiovascular complications.
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Affiliation(s)
- Elena Curakova Ristovska
- 1University Clinic for Gastroenterohepatology, Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, Skopje, RN Macedonia
| | - Magdalena Genadieva-Dimitrova
- 1University Clinic for Gastroenterohepatology, Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, Skopje, RN Macedonia
| | - Beti Todorovska
- 1University Clinic for Gastroenterohepatology, Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, Skopje, RN Macedonia
| | - Vladimir Milivojevic
- 2Section for Internal Medicine, Medcompass Alliance, School of Medicine, Belgrade University, Belgrade, Serbia
| | - Ivan Rankovic
- 3Section for Internal Medicine, Medcompass Alliance, Belgrade, Serbia
| | - Igor Samardziski
- 4University Clinic for Gynecology and Obstetrics, Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, Skopje, RN Macedonia
| | - Maja Bojadzioska
- 5University Clinic for Rheumatology, Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, Skopje, RN Macedonia
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Medico legal and ethical aspects of surrogacy; A case report of a tragic maternal death from Sri Lanka. J Forensic Leg Med 2022; 91:102425. [PMID: 36058108 DOI: 10.1016/j.jflm.2022.102425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 08/10/2022] [Accepted: 08/13/2022] [Indexed: 11/20/2022]
Abstract
A case report from Sri Lanka on surrogacy leading to a tragic maternal death; medico-legal and ethical aspects. Surrogacy, with multiple ethical and legal issues associated with it, is practised worldwide. Although regulations are not available in Sri Lanka, we report a woman who had a tragic death as a complication of surrogate pregnancy. The body of a young mother with four living children was brought for autopsy examination. According to the documents provided, there was a controversy about the deceased's identity. A woman volunteered to show a pillow trapped in her abdomen, simulating a pregnancy. By surrogacy, her husband's sperm were inseminated in this woman's uterus artificially according to a contract. She was diagnosed and managed for pregnancy-induced hypertension in the second trimester. At 36 weeks of gestation, she was admitted to the hospital in labour. On admission, she was icteric with elevated blood pressure. A cesarean section delivered a baby, and it was noted that she had an abruption of the placenta. She developed a postpartum haemorrhage following delivery, and resuscitation failed, resulting in her death. She had elevated liver enzymes and low serum proteins before death. Autopsy findings included intense icterus, congested lungs, global ischemic changes in the myocardium, pale kidneys and fatty soft yellow liver. This case discusses many unanticipated legal and ethical issues related to surrogate pregnancy, especially in a lack of regulations regarding the practice and relatively cheap medical expenses.
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Qi J, Wu B, Chen X, Wei W, Yao X. Diagnostic biomolecules and combination therapy for pre-eclampsia. Reprod Biol Endocrinol 2022; 20:136. [PMID: 36068569 PMCID: PMC9446775 DOI: 10.1186/s12958-022-01003-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/24/2022] [Indexed: 11/10/2022] Open
Abstract
Pre-eclampsia (PE), associated with placental malperfusion, is the primary reason for maternal and perinatal mortality and morbidity that can cause vascular endothelial injury and multi-organ injury. Despite considerable research efforts, no pharmaceutical has been shown to stop disease progression. If women precisely diagnosed with PE can achieve treatment at early gestation, the maternal and fetal outcomes can be maximally optimized by expectant management. Current diagnostic approaches applying maternal characteristics or biophysical markers, including blood test, urine analysis and biophysical profile, possess limitations in the precise diagnosis of PE. Biochemical factor research associated with PE development has generated ambitious diagnostic targets based on PE pathogenesis and dissecting molecular phenotypes. This review focuses on current developments in biochemical prediction of PE and the corresponding interventions to ameliorate disease progression, aiming to provide references for clinical diagnoses and treatments.
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Affiliation(s)
- Jingqi Qi
- International Institutes of Medicine, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, No. N1, Shangcheng Avenue, Yiwu, 322000, China
- Zhejiang University-University of Edinburgh Institute (ZJU-UoE Institute), Zhejiang University School of Medicine, International Campus, Zhejiang University, 718 East Haizhou Road, Haining, 314400, China
| | - Bingbing Wu
- International Institutes of Medicine, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, No. N1, Shangcheng Avenue, Yiwu, 322000, China
| | - Xiuying Chen
- International Institutes of Medicine, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, No. N1, Shangcheng Avenue, Yiwu, 322000, China
| | - Wei Wei
- International Institutes of Medicine, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, No. N1, Shangcheng Avenue, Yiwu, 322000, China.
| | - Xudong Yao
- International Institutes of Medicine, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, No. N1, Shangcheng Avenue, Yiwu, 322000, China.
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Abstract
Simulation is a critical part of training for obstetric emergencies. Incorporation of this training modality has been shown to improve outcomes for patients and is now required by national accrediting organizations.
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Peraçoli JC, Silva PB, Neves HM, Borges VTM, Abbade JF, Costa RAA, Batista FRG, Peraçoli MTS, Romão-Veiga M. Modulatory effect of two regimens of magnesium sulfate on the systemic inflammatory response in pregnant women with imminent eclampsia. Pregnancy Hypertens 2022; 29:46-53. [PMID: 35728369 DOI: 10.1016/j.preghy.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/30/2022] [Accepted: 06/12/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE This study compared the modulatory effect of two intravenous magnesium sulfate (MgSO4) regimens on the systemic inflammatory response in pregnant women diagnosed with imminent eclampsia. STUDY DESIGN In a single-blind cross-sectional study, 33 women were allocated according to the Zuspan (n = 16) and Sibai (n = 17) MgSO4 regimens, and treated for 24 h. Blood samples were collected pre-administration of the loading dose, at 24 h of the maintenance dose of MgSO4, and at 48 h, when patients were without treatment. Plasma was used to determine interleukin (IL)-1 beta (IL-1β), IL-6, IL-10, tumor necrosis factor-alpha (TNF-α), heat shock protein (Hsp70), and heme oxygenase-1 (HO-1) by ELISA. RESULTS The treatment with the Zuspan's regimen didn't change plasma concentrations of TNF-α, IL-10, and Hsp70 in the three-time points studied. However, it decreased IL-1β at 24 h and 48 h and IL-6 at 48 h, and increased HO-1 concentration at 48 h. On the other hand, compared to the pre-treatment period, Sibai's regimen induced a significant decrease in TNF-α, IL-1β, IL-6, and Hsp70, while increased HO-1 levels both at 24 h and 48 h and, IL-10 concentration at 48 h. CONCLUSIONS Sibai's regimen determined an early and efficient immunoregulatory effect on systemic inflammatory response in preeclampsia, suggesting that the maintenance dose of two grams of MgSO4 was better than one gram in the treatment of imminent eclampsia.
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Affiliation(s)
- José C Peraçoli
- Department of Gynecology and Obstetrics, Botucatu Medical School and Department of Chemistry and Biological Sciences, Institute of Biosciences, Sao Paulo State University, UNESP, Botucatu, SP, Brazil
| | - Patricia B Silva
- Department of Gynecology and Obstetrics, Botucatu Medical School and Department of Chemistry and Biological Sciences, Institute of Biosciences, Sao Paulo State University, UNESP, Botucatu, SP, Brazil
| | - Haroldo M Neves
- Department of Gynecology and Obstetrics, Botucatu Medical School and Department of Chemistry and Biological Sciences, Institute of Biosciences, Sao Paulo State University, UNESP, Botucatu, SP, Brazil
| | - Vera T M Borges
- Department of Gynecology and Obstetrics, Botucatu Medical School and Department of Chemistry and Biological Sciences, Institute of Biosciences, Sao Paulo State University, UNESP, Botucatu, SP, Brazil
| | - Joelcio F Abbade
- Department of Gynecology and Obstetrics, Botucatu Medical School and Department of Chemistry and Biological Sciences, Institute of Biosciences, Sao Paulo State University, UNESP, Botucatu, SP, Brazil
| | - Roberto A A Costa
- Department of Gynecology and Obstetrics, Botucatu Medical School and Department of Chemistry and Biological Sciences, Institute of Biosciences, Sao Paulo State University, UNESP, Botucatu, SP, Brazil
| | - Fernanda R G Batista
- Department of Gynecology and Obstetrics, Botucatu Medical School and Department of Chemistry and Biological Sciences, Institute of Biosciences, Sao Paulo State University, UNESP, Botucatu, SP, Brazil
| | - Maria T S Peraçoli
- Department of Gynecology and Obstetrics, Botucatu Medical School and Department of Chemistry and Biological Sciences, Institute of Biosciences, Sao Paulo State University, UNESP, Botucatu, SP, Brazil; Department of Chemistry and Biological Sciences, Institute of Biosciences, Sao Paulo State University, UNESP, Botucatu, SP, Brazil
| | - Mariana Romão-Veiga
- Department of Gynecology and Obstetrics, Botucatu Medical School and Department of Chemistry and Biological Sciences, Institute of Biosciences, Sao Paulo State University, UNESP, Botucatu, SP, Brazil.
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Kahramanoglu Ö, Schiattarella A, Demirci O, Sisti G, Ammaturo FP, Trotta C, Ferrari F, Rapisarda AMC. Preeclampsia: state of art and future perspectives. A special focus on possible preventions. J OBSTET GYNAECOL 2022; 42:766-777. [PMID: 35469530 DOI: 10.1080/01443615.2022.2048810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Preeclampsia (PE) is characterised by the new onset of hypertension after the 20th week of pregnancy, with or without proteinuria or hypertension that leads to end-organ dysfunction. Since the only definitive treatment is delivery, PE still represents one of the leading causes of preterm birth and perinatal mobility and mortality. Therefore, any strategies that aim to reduce adverse outcomes are based on early primary prevention, prenatal surveillance and prophylactic interventions. In the last decade, intense research has been focussed on the study of predictive models in order to identify women at higher risk accurately. To date, the most effective screening model is based on the combination of anamnestic, demographic, biophysical and maternal biochemical factors. In this review, we provide a detailed discussion about the current and future perspectives in the field of PE. We will examine pathogenesis, risk factors and clinical features. Moreover, recent developments in screening and prevention strategies, novel therapies and healthcare management strategies will be discussed.
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Affiliation(s)
- Özge Kahramanoglu
- Department of Perinatology, Zeynep Kamil Education and Research Hospital, İstanbul, Turkey
| | - Antonio Schiattarella
- Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Oya Demirci
- Department of Perinatology, Zeynep Kamil Education and Research Hospital, İstanbul, Turkey
| | - Giovanni Sisti
- Department of Obstetrics and Gynecology, New York Health and Hospitals/Lincoln, Bronx, NY, USA
| | - Franco Pietro Ammaturo
- Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Carlo Trotta
- Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Federico Ferrari
- Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Agnese Maria Chiara Rapisarda
- Department of General Surgery and Medical Surgical Specialties, Obstetrics and Gynecology Unit, University of Catania, Catania, Italy
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Duration of Postpartum Magnesium Sulphate for the Prevention of Eclampsia: A Systematic Review and Meta-analysis. Obstet Gynecol 2022; 139:521-528. [PMID: 35271534 DOI: 10.1097/aog.0000000000004720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 01/13/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To estimate the optimal duration of postpartum magnesium sulphate to prevent eclampsia. DATA SOURCES MEDLINE, EMBASE, CINAHL, the Cochrane Database of Systematic Reviews, and ClinicalTrials.gov databases were searched from inception until January 2020 and limited to English-language human randomized controlled trials. Search strategy included the key works "eclampsia," "magnesium sulphate," and "postpartum." METHODS OF STUDY SELECTION Title, abstract, and full-text review was performed using Covidence data-management software. Of the 3,629 articles screened, 10 studies were included in the final review. Studies were included if they compared two different time points of magnesium sulphate postpartum in women with either preeclampsia or eclampsia. TABULATION, INTEGRATION AND RESULTS Two authors reviewed studies independently. RevMan software was used to calculate risk difference (RD) for categorical outcomes and mean difference for continuous outcomes. Shorter duration of magnesium sulphate (12 hours or less) was not associated with increased risk of eclampsia compared with 24-hour postpartum regimens (RD -0.01, 95% CI -0.02 to 0.01, I2 70%). Studies randomizing women with preeclampsia did not show increased risk of eclampsia with shorter regimens (RD 0, 95% CI -0.01 to 0.01, I2 0%), nor did trials randomizing those with eclampsia (RD -0.04, 95% CI -0.14 to 0.07, I2 87%). Secondary outcomes, including flushing, duration of Foley catheter insertion, time to ambulation, and duration of hospital stay, were all reduced with shorter-duration magnesium sulphate. CONCLUSION This systematic review and meta-analysis suggests that a shorter duration of postpartum magnesium sulphate does not increase the risk for eclamptic seizure; however, data remain underpowered to render firm conclusions. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42020182432.
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12
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Fishel Bartal M, Lindheimer MD, Sibai BM. Proteinuria during pregnancy: definition, pathophysiology, methodology, and clinical significance. Am J Obstet Gynecol 2022; 226:S819-S834. [PMID: 32882208 DOI: 10.1016/j.ajog.2020.08.108] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 08/24/2020] [Accepted: 08/27/2020] [Indexed: 12/31/2022]
Abstract
Qualitative and quantitative measurement of urine protein excretion is one of the most common tests performed during pregnancy. For more than 100 years, proteinuria was necessary for the diagnosis of preeclampsia, but recent guidelines recommend that proteinuria is sufficient but not necessary for the diagnosis. Still, in clinical practice, most patients with gestational hypertension will be diagnosed as having preeclampsia based on the presence of proteinuria. Although the reference standard for measuring urinary protein excretion is a 24-hour urine collection, spot urine protein-to-creatinine ratio is a reasonable "rule-out" test for proteinuria. Urine dipstick screening for proteinuria does not provide any clinical benefit and should not be used to diagnose proteinuria. The classic cutoff cited to define proteinuria during pregnancy is a value of >300 mg/24 hours or a urine protein-to-creatinine ratio of at least 0.3. Using this cutoff, the rate of isolated proteinuria in pregnancy may reach 8%, whereas preeclampsia occurs among 3% to 8% of pregnancies. Although this threshold is widely accepted, its origin is not based on evidence on adverse pregnancy outcomes but rather on expert opinion and results of small studies. After reviewing the available data, the most important factor that influences maternal and neonatal outcome is the severity of blood pressures and presence of end organ damage, rather than the excess protein excretion. Because the management of gestational hypertension and preeclampsia without severe features is almost identical in frequency of surveillance and timing of delivery, the separation into 2 disorders is unnecessary. If the management of women with gestational hypertension with a positive assessment of proteinuria will not change, we believe that urine assessment for proteinuria is unnecessary in women who develop new-onset blood pressure at or after 20 weeks' gestation. Furthermore, we do not recommend repeated measurement of proteinuria for women with preeclampsia, the amount of proteinuria does not seem to be related to poor maternal and neonatal outcomes, and monitoring proteinuria may lead to unindicated preterm deliveries and related neonatal complications. Our current diagnosis of preeclampsia in women with chronic kidney disease may be based on a change in protein excretion, a baseline protein excretion evaluation is critical in certain conditions such as chronic hypertension, diabetes, and autoimmune or other renal disorders. The current definition of superimposed preeclampsia possesses a diagnostic dilemma, and it is unclear whether a change in the baseline proteinuria reflects another systemic disease such as preeclampsia or whether women with chronic disease such as chronic hypertension or diabetes will experience a different "normal" pattern of protein excretion during pregnancy. Finally, limited data are available regarding angiogenic and other biomarkers in women with chronic kidney disease as a potential aid in distinguishing the worsening of baseline chronic kidney disease and chronic hypertension from superimposed preeclampsia.
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Fishel Bartal M, Sibai BM. Eclampsia in the 21st century. Am J Obstet Gynecol 2022; 226:S1237-S1253. [PMID: 32980358 DOI: 10.1016/j.ajog.2020.09.037] [Citation(s) in RCA: 66] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 09/14/2020] [Accepted: 09/22/2020] [Indexed: 12/12/2022]
Abstract
The reported incidence of eclampsia is 1.6 to 10 per 10,000 deliveries in developed countries, whereas it is 50 to 151 per 10,000 deliveries in developing countries. In addition, low-resource countries have substantially higher rates of maternal and perinatal mortalities and morbidities. This disparity in incidence and pregnancy outcomes may be related to universal access to prenatal care, early detection of preeclampsia, timely delivery, and availability of healthcare resources in developed countries compared to developing countries. Because of its infrequency in developed countries, many obstetrical providers and maternity units have minimal to no experience in the acute management of eclampsia and its complications. Therefore, clear protocols for prevention of eclampsia in those with severe preeclampsia and acute treatment of eclamptic seizures at all levels of healthcare are required for better maternal and neonatal outcomes. Eclamptic seizure will occur in 2% of women with preeclampsia with severe features who are not receiving magnesium sulfate and in <0.6% in those receiving magnesium sulfate. The pathogenesis of an eclamptic seizure is not well understood; however, the blood-brain barrier disruption with the passage of fluid, ions, and plasma protein into the brain parenchyma remains the leading theory. New data suggest that blood-brain barrier permeability may increase by circulating factors found in preeclamptic women plasma, such as vascular endothelial growth factor and placental growth factor. The management of an eclamptic seizure will include supportive care to prevent serious maternal injury, magnesium sulfate for prevention of recurrent seizures, and promoting delivery. Although routine imagining following an eclamptic seizure is not recommended, the classic finding is referred to as the posterior reversible encephalopathy syndrome. Most patients with posterior reversible encephalopathy syndrome will show complete resolution of the imaging finding within 1 to 2 weeks, but routine imaging follow-up is unnecessary unless there are findings of intracranial hemorrhage, infraction, or ongoing neurologic deficit. Eclampsia is associated with increased risk of maternal mortality and morbidity, such as placental abruption, disseminated intravascular coagulation, pulmonary edema, aspiration pneumonia, cardiopulmonary arrest, and acute renal failure. Furthermore, a history of eclamptic seizures may be related to long-term cardiovascular risk and cognitive difficulties related to memory and concentration years after the index pregnancy. Finally, limited data suggest that placental growth factor levels in women with preeclampsia are superior to clinical markers in prediction of adverse pregnancy outcomes. This data may be extrapolated to the prediction of eclampsia in future studies. This summary of available evidence provides data and expert opinion on possible pathogenesis of eclampsia, imaging findings, differential diagnosis, and stepwise approach regarding the management of eclampsia before delivery and after delivery as well as current recommendations for the prevention of eclamptic seizures in women with preeclampsia.
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Affiliation(s)
- Michal Fishel Bartal
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX.
| | - Baha M Sibai
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX
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Barbagallo M, Schiappa E. MOF in Pregnancy and Its Relevance to Eclampsia. POSTINJURY MULTIPLE ORGAN FAILURE 2022:205-239. [DOI: 10.1007/978-3-030-92241-2_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Getaneh Y, Fekadu E, Jemere AT, Mengistu Z, Tarekegn GE, Oumer M. Incidence and determinants of adverse outcomes among women who were managed for eclampsia in the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia. BMC Pregnancy Childbirth 2021; 21:734. [PMID: 34715798 PMCID: PMC8555341 DOI: 10.1186/s12884-021-04199-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 10/11/2021] [Indexed: 11/21/2022] Open
Abstract
Background The incidence of eclampsia and its adverse maternal outcomes are very high in developing countries, particularly in Subsaharan African Countries. Identifying predictors for adverse maternal outcomes of eclampsia has paramount importance for helping health care providers to optimize their management outcomes. Therefore, this study aimed to assess the incidence of adverse maternal outcomes of eclampsia and its determinant factors. Methods A retrospective follow-up study design was applied. The data were extracted from patient charts using a structured, pre-tested, questionnaire. Descriptive analyses (frequencies, means, and standard deviation) were calculated, and bi-variable and multivariable logistic regression models were used to testing the association between independent variables and an outcome variable. After the data were coded and entered into Epi-Info Version 7.2 Software, the data were analyzed using STATA Version 14 Statistical Software. Results The magnitude of eclampsia was 5.36 per 1000 pregnancies (95% CI: 4.72, 6.10). The incidence of adverse maternal outcomes in eclamptic mothers was 53.7% (95% CI: 47.02, 60.24%). After adjusting for covariates maternal age 30–34, AOR 5.4 [95% CI = 1.02, 28.6]; age above 34, AOR 10.5 [95% CI = 1.3, 88.6]; gravidity 2–4, AOR 0.3 [95% CI = 0.1, 0.9]; 10 or more convulsions, AOR 4.6 [95% CI = 1.4, 14.9]; mild pyrexia, AOR 20.4 [95% CI = 3.7, 112.7]; moderate pyrexia, AOR 14.6 [95% CI = 1.7125.1]; platelet count below 50,000 cells/mm3, AOR 34.9 [95% CI = 3.6, 336.2]; platelet count between 50,000 and 99,000 cells/mm3, AOR 24.5 [95%CI = 5.4111.6]; and stillbirth of the current pregnancy, AOR 23.2 [95%CI = 2.1257.5] were strong predictors of adverse maternal outcomes in eclamptic mothers. Conclusions The incidence of adverse maternal outcomes of eclampsia was found to be high compared to similar studies discussed in this study. This study recommends early identification of patients with the risk factors (having many convulsions, high body temperature, low platelet count, patient age above 30 years, and 2–4 pregnancies), strengthening the referral system, and advocation of research on the area of adverse maternal outcomes and thereby encourage evidence-based medicine. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-04199-1.
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Affiliation(s)
- Yisfa Getaneh
- Department of Gynecology and Obstetrics, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Elfalet Fekadu
- Department of Gynecology and Obstetrics, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Adamu Takele Jemere
- Department of Health Informatics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Zelalem Mengistu
- Department of Gynecology and Obstetrics, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Gebrekidan Ewnetu Tarekegn
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Mohammed Oumer
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia. .,Department of Human Anatomy, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
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Deck GM, Yarrington CD, Pennell PB. Factors associated with anti-seizure medication utilization for eclamptic seizures: 1995-2015. Epilepsy Behav 2021; 124:108299. [PMID: 34600278 DOI: 10.1016/j.yebeh.2021.108299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 08/16/2021] [Accepted: 08/17/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE We sought to ascertain the drivers of the use of anti-seizure medications (ASMs) other than magnesium sulfate (MgSO4) in seizure management in a cohort of pregnant and postpartum women with eclamptic seizure. METHODS Cases of seizure activity attributed to eclampsia from 1995-2015 at 2 large urban academic medical centers were identified and reviewed by a neurologist and an obstetrician. Analyses focused on patterns of ASM utilization among women according to timing, recurrence, posterior reversible encephalopathy syndrome, and specialty consultation with additional sub-analysis focusing on recurrent seizures only. RESULTS 93 cases of eclampsia were identified. 100% of subjects received MgSO4. 52% of women received an ASM in addition to MgSO4. Subjects with seizures occurring post-partum, with >1 seizure, or who had a formal neurology consult were more likely to receive an ASM in addition (risk ratio [RR] 3.05 [95% confidence interval [CI] [1.30-7.11], RR 3.01 [95% CI 1.29-7.02], and RR 6.29 [2.37, 16.71] respectively). Postpartum recurrent seizures or those receiving a neurology consult were also more likely to be treated with ASMs compared to recurrent or comanaged seizures occurring before delivery (RR 1.55 [1.02, 2.37] and 1.65 [1.02, 2.69]). CONCLUSIONS In this retrospective cohort, patients with atypical seizure presentation (e.g., postpartum and/or recurrent) and women who were comanaged with a neurologist were more likely to receive an ASM other than MgSO4.
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Affiliation(s)
- Gina M Deck
- Massachusetts General Hospital, Department of Neurology, 55 Fruit Street, Boston, MA 02114, United States.
| | - Christina D Yarrington
- Brigham and Women's Hospital, Department of Obstetrics and Gynecology, 45 Francis Ave., Boston, MA 02115, United States.
| | - Page B Pennell
- Brigham and Women's Hospital, Department of Neurology, 45 Francis Ave., Boston, MA 02115, United States.
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Spencer NM, Gabra M, Bedell SM, Scott DM, Rauk P. Improving compliance with guidelines for hypertensive disorders of pregnancy through an electronic health record alert: A retrospective chart review. Pregnancy Hypertens 2021; 25:1-6. [PMID: 34004478 DOI: 10.1016/j.preghy.2021.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 03/28/2021] [Accepted: 04/08/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Improve appropriate and timely administration of rapid acting antihypertensive medication for the management of hypertensive emergency in pregnancy with utilization of an automated electronic health record (EHR) alert in an academic birthplace. STUDY DESIGN An automated alert was incorporated into an existing EHR that notified providers of a documented severe range blood pressure, defined as systolic blood pressure (SBP) ≥ 160 mmHg or diastolic blood pressure (DBP) ≥ 110 mmHg. Retrospective chart review was utilized to evaluate appropriate intervention before and after implementation of the alert (referred to as pre-implementation and post-implementation cohorts). MAIN OUTCOME MEASURES The primary outcome was appropriate administration of rapid-acting antihypertensive medication for the management of hypertensive emergency. Secondary outcomes included: appropriate administration of intravenous (IV) magnesium sulfate for seizure prophylaxis, initiation of oral antihypertensive medication postpartum, and appropriate timing of follow up for blood pressure evaluation following discharge. RESULTS Of 98 patients identified as having hypertensive emergency in the pre-implementation cohort, 34 (35%) received treatment with a rapid acting antihypertensive medication within one hour compared with 54 of 104 (55%) of patients in the post-implementation cohort (35% vs 55%, RR 1.40 95% CI 1.07-1.82). Significantly more patients followed up for a blood pressure check within one week of discharge (41% vs 31%; p = 0.02). There was not a significant effect on the administration of IV magnesium sulfate or initiation of oral medications postpartum. CONCLUSION An automated EHR alert improved timely administration of rapid-acting antihypertensive medications for hypertensive emergency and has the potential to improve compliance with national preeclampsia guidelines.
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Affiliation(s)
- Nicole M Spencer
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota School of Medicine, 420 Delaware Street SE, Minneapolis, MN 55455, USA.
| | - Martina Gabra
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota School of Medicine, 420 Delaware Street SE, Minneapolis, MN 55455, USA
| | - Sabrina M Bedell
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota School of Medicine, 420 Delaware Street SE, Minneapolis, MN 55455, USA
| | - Dana M Scott
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota School of Medicine, 420 Delaware Street SE, Minneapolis, MN 55455, USA
| | - Phillip Rauk
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota School of Medicine, 420 Delaware Street SE, Minneapolis, MN 55455, USA
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Malek AM, Wilson DA, Turan TN, Mateus J, Lackland DT, Hunt KJ. Maternal Coronary Heart Disease, Stroke, and Mortality Within 1, 3, and 5 Years of Delivery Among Women With Hypertensive Disorders of Pregnancy and Pre-Pregnancy Hypertension. J Am Heart Assoc 2021; 10:e018155. [PMID: 33619981 PMCID: PMC8174275 DOI: 10.1161/jaha.120.018155] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 01/04/2021] [Indexed: 12/26/2022]
Abstract
Background Pre-pregnancy hypertension and hypertensive disorders of pregnancy (HDP; preeclampsia, eclampsia, gestational hypertension) are major health risks for maternal morbidity and mortality. However, it is unknown if racial/ethnic differences exist. We aimed to determine the impact of HDP and pre-pregnancy hypertension on maternal coronary heart disease, stroke, and mortality risk ≤1, 3, and 5 years post-delivery and by race/ethnicity ≤5 years. Methods and Results This retrospective cohort study included women aged 12 to 49 years with a live, singleton birth between 2004 to 2016 (n=254 491 non-Hispanic White; n=137 784 non-Hispanic Black; n=41 155 Hispanic). Birth and death certificates and International Classification of Diseases, Ninth and Tenth Revision, Clinical Modification (ICD-9-CM and ICD-10-CM) diagnosis codes in hospitalization/emergency department visit data defined HDP, pre-pregnancy hypertension, incident coronary heart disease and stroke, and all-cause mortality. During at least 1 pregnancy of the 433 430 women, 2.3% had pre-pregnancy hypertension with superimposed HDP, 15.7% had no pre-pregnancy hypertension with HDP, and 0.4% had pre-pregnancy hypertension without superimposed HDP, whereas 81.6% had neither condition. Maternal deaths from coronary heart disease, stroke, and all causes totaled 2136. Within 5 years of delivery, pre-pregnancy hypertension, and HDP were associated with all-cause mortality (hazard ratio [HR], 2.21; 95% CI, 1.61-3.03), incident coronary heart disease (HR, 3.79; 95% CI, 3.09-4.65), and incident stroke (HR, 3.10; 95% CI, 2.09-4.60). HDP alone was related to all outcomes. Race/ethnic differences were observed for non-Hispanic Black and non-Hispanic White women, respectively, in the associations of pre-pregnancy hypertension and HDP with all-cause mortality within 5 years of delivery (HR, 2.34 [95% CI, 1.58-3.47]; HR, 2.11 [95% CI, 1.23-3.65]; P interaction=0.001). Conclusions Maternal cardiovascular outcomes including mortality were increased ≤5 years post-delivery in HDP, pre-pregnancy hypertension, or pre-pregnancy hypertension with superimposed HDP. The race/ethnic interaction for all-cause mortality ≤5 years of delivery warrants further research.
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Affiliation(s)
- Angela M. Malek
- Department of Public Health SciencesMedical University of South CarolinaCharlestonSC
| | - Dulaney A. Wilson
- Department of Public Health SciencesMedical University of South CarolinaCharlestonSC
| | - Tanya N. Turan
- Department of NeurologyMedical University of South CarolinaCharlestonSC
| | - Julio Mateus
- Atrium HealthDepartment of Obstetrics & GynecologyMaternal‐Fetal Medicine DivisionCharlotteNC
| | | | - Kelly J. Hunt
- Department of Public Health SciencesMedical University of South CarolinaCharlestonSC
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Mathew AA, Panonnummal R. 'Magnesium'-the master cation-as a drug-possibilities and evidences. Biometals 2021; 34:955-986. [PMID: 34213669 PMCID: PMC8249833 DOI: 10.1007/s10534-021-00328-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 06/19/2021] [Indexed: 02/06/2023]
Abstract
Magnesium (Mg2+) is the 2nd most abundant intracellular cation, which participates in various enzymatic reactions; there by regulating vital biological functions. Magnesium (Mg2+) can regulate several cations, including sodium, potassium, and calcium; it consequently maintains physiological functions like impulse conduction, blood pressure, heart rhythm, and muscle contraction. But, it doesn't get much attention in account with its functions, making it a "Forgotten cation". Like other cations, maintenance of the normal physiological level of Mg2+ is important. Its deficiency is associated with various diseases, which point out to the importance of Mg2+ as a drug. The roles of Mg2+ such as natural calcium antagonist, glutamate NMDA receptor blocker, vasodilator, antioxidant and anti-inflammatory agent are responsible for its therapeutic benefits. Various salts of Mg2+ are currently in clinical use, but their application is limited. This review collates all the possible mechanisms behind the behavior of magnesium as a drug at different disease conditions with clinical shreds of evidence.
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Affiliation(s)
- Aparna Ann Mathew
- Amrita School of Pharmacy, Amrita Institute of Medical Science & Research Centre, Amrita VishwaVidyapeetham, Kochi, 682041, India
| | - Rajitha Panonnummal
- Amrita School of Pharmacy, Amrita Institute of Medical Science & Research Centre, Amrita VishwaVidyapeetham, Kochi, 682041, India.
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Li J, Tang L, Tang R, Peng L, Chai L, Zhu L, Yu Y. Risk factors for sub-therapeutic serum concentrations of magnesium sulfate in severe preeclampsia of Chinese patients. BMC Pregnancy Childbirth 2020; 20:578. [PMID: 33004015 PMCID: PMC7528234 DOI: 10.1186/s12884-020-03277-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 09/23/2020] [Indexed: 11/29/2022] Open
Abstract
Background Magnesium sulfate (MgSO4) is the standard drug for eclampsia prophylaxis and treatment. In China, the effective therapeutic serum magnesium level is 1.8–3.0 mmol/L. There is little information on how to achieve and maintain effective therapeutic concentrations. This study aimed to investigate risk factors for sub-therapeutic serum concentrations of MgSO4 in patients with severe preeclampsia. Methods Patients with severe preeclampsia who received MgSO4 intravenous infusion were retrospectively reviewed. The maternal demographic characteristics, regimens for the administration of MgSO4, and lab test results of patients were collected. Multivariate logistic regression analysis and receiver operating characteristic (ROC) curve analysis were conducted for the risk factors influencing the serum magnesium concentration. Results A total of 93 patients with severe preeclampsia were included in the study. 52 (55.91%) patients did not attain therapeutic serum magnesium levels. A multivariate logistic regression analysis identified creatinine clearance (Ccr), whether the loading dose was given, and measurement time of serum magnesium concentration (referring to the time from start of MgSO4 infusion to blood draw for serum sampling) as independent risk factors for sub-therapeutic serum magnesium concentration (P < 0.05). ROC curve analysis indicated that the continuous variable Ccr had a significant predictive value for the serum magnesium concentration, which resulted in a cutoff point of 133 mL/min; while measurement time had limited predictive value, with cutoff point of 2.375 h. Conclusions Ccr, whether the loading dose was given, and measurement time were independent risk factors for sub-therapeutic serum magnesium concentration. A loading dose of MgSO4 everytime before the maintenance dose, as well as the duration of MgSO4 maintenance dose of more than 2.375 h are recommended for all the patients with severe PE. Routine evaluation of serum magnesium levels is a recommended practice for women with severe PE and whose Ccr is ≥133 mL/min.
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Affiliation(s)
- Jingjing Li
- Department of Pharmacy, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, 215002, Jiangsu, China
| | - Lian Tang
- Department of Pharmacy, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, 215002, Jiangsu, China
| | - Ruiheng Tang
- School of Medicine, Xuzhou Medical University, Xuzhou, 221000, Jiangsu, China
| | - Lan Peng
- Department of Obstetrics, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, 215002, Jiangsu, China
| | - Liqiang Chai
- Department of Obstetrics, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, 215002, Jiangsu, China
| | - Liping Zhu
- Department of Obstetrics, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, 215002, Jiangsu, China
| | - Yanxia Yu
- Department of Pharmacy, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, 215002, Jiangsu, China.
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22
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Ibrahim ZM, Kishk EA, Elzamlout MS, Elshahat AM, Taha OT. Fetal gender, serum human chorionic gonadotropin, and testosterone in women with preeclampsia. Hypertens Pregnancy 2020; 39:302-307. [PMID: 32406308 DOI: 10.1080/10641955.2020.1765174] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Evaluation of the association between fetal gender, serum beta-human chorionic gonadotropin, and serum testosterone, and preeclampsia. METHODS Case-control study conducted at the Obstetrics and Gynecology Department. 120 patients divided into study group (patients with preeclampsia subdivided into mild and severe) and control group (normotensive women). INTERVENTIONS Fetal gender was determined. Serum testosterone and HCG levels were estimated at 32 weeks or at the time of diagnosis of preeclampsia (study group) or recruitment (control group). RESULTS Positive association between the male gender of the fetus and preeclampsia. Increased HCG and Testosterone were associated with developing preeclampsia. CONCLUSION The mechanism of preeclampsia could be androgen-mediated. There is a significant correlation between serum HCG and testosterone and preeclampsia.
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Affiliation(s)
- Zakia M Ibrahim
- Department of Obstetrics and Gynecology, Faculty of Medicine, Suez Canal University , Ismailia, Egypt
| | - Eman A Kishk
- Department of Obstetrics and Gynecology, Faculty of Medicine, Suez Canal University , Ismailia, Egypt
| | - Mahmoud S Elzamlout
- Department of Obstetrics and Gynecology, Faculty of Medicine, Suez Canal University , Ismailia, Egypt
| | - Amal M Elshahat
- Department of Obstetrics and Gynecology, Faculty of Medicine, Suez Canal University , Ismailia, Egypt
| | - Omima T Taha
- Department of Obstetrics and Gynecology, Faculty of Medicine, Suez Canal University , Ismailia, Egypt
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Katarey D, Westbrook RH. Pregnancy-specific liver diseases. Best Pract Res Clin Obstet Gynaecol 2020; 68:12-22. [PMID: 32381461 DOI: 10.1016/j.bpobgyn.2020.03.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 03/21/2020] [Accepted: 03/26/2020] [Indexed: 12/17/2022]
Abstract
Liver disease presenting in pregnancy may be due to a pregnancy-specific liver disorder, due to previously unrecognised pre-existing liver disease, or de novo liver disorders coincidentally presenting in a pregnant woman. The pregnancy-specific liver diseases can span from mild disease with limited impact on maternal and foetal health to severe disorders that can result in significant morbidity and mortality for mother and foetus. Swift identification of these disorders is essential to allow timely and appropriate management via a multi-disciplinary approach. The pregnancy-specific conditions, including their presentation, investigations, and management are reviewed in this chapter in detail.
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Affiliation(s)
- Dev Katarey
- Royal Free Hospital, Pond Street, London, NW3 2QG, United Kingdom
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Yifu P, Lei Y, Yujin G, Xingwang Z, Shaoming L. Shortened postpartum magnesium sulfate treatment vs traditional 24h for severe preeclampsia: a systematic review and meta-analysis of randomized trials. Hypertens Pregnancy 2020; 39:186-195. [PMID: 32338165 DOI: 10.1080/10641955.2020.1753067] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objectives: This meta-analysis aimed to compare the benefits and risks of shortened magnesium sulfate with traditional 24 h for severe postpartum preeclampsia.Methods: We systematically searched the Cochrane, Embase, Web of science and Pubmed database from inception till May 15 2019. Studies included type is limited to randomized controlled trial (RCT). Pooled risks difference (RDs), odds risks (ORs), mean difference (MD), standard mean difference (SMD) and 95% confifidence intervals (CIs) were used to summarize the effect sizes.Results: Totally studies included are 7 randomized controlled trials (RCTs). Shortened magnesium sulfate treatment has the same risk as eclampsia (RD 0.00, 95%CI-0.01-0.01) and total complications (OR 0.78, 95% CI 0.53-1.15), however, significant difference was observed in both groups pertaining to flushing (OR 0.40, 95% CI 0.20-0.82), and the need for prolonged treatment (RD 0.05, 95% CI 0.01 - 0.1), Others factors,namely the benefits of shortened magnesium sulfate treatment,showed differences in both groups.Conclusions: Shortened postpartum magnesium sulfate treatment was as effective as traditional 24 h magnesium sulfate in seizure prevention and total complications. But flushing and needed for prolonged treatment in the shortened groups warrants further research.
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Affiliation(s)
- Pu Yifu
- Centre for Reproductive Medicine, Shandong Provincial Hospital Affifiliated to Shandong University, Jinan, China
| | - Yan Lei
- Centre for Reproductive Medicine, Shandong Provincial Hospital Affifiliated to Shandong University, Jinan, China.,School of Medicine, Shandong University, Jinan, China
| | - Guo Yujin
- Centre for Reproductive Medicine, Shandong Provincial Hospital Affifiliated to Shandong University, Jinan, China
| | - Zhu Xingwang
- Centre for Reproductive Medicine, Shandong Provincial Hospital Affifiliated to Shandong University, Jinan, China
| | - Lu Shaoming
- Centre for Reproductive Medicine, Shandong Provincial Hospital Affifiliated to Shandong University, Jinan, China
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Tlaye KG, Endalfer ML, Kassaw MW, Gebremedhin MM, Aynalem YA. Preeclampsia management modalities and perinatal death: a retrospective study in Woldia general hospital. BMC Pregnancy Childbirth 2020; 20:205. [PMID: 32272909 PMCID: PMC7146893 DOI: 10.1186/s12884-020-02909-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 03/29/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Hypertensive disorders of pregnancy are among the most common causes of perinatal death. The disorders are highly linked to multiple factors that make prediction and prevention challenging. Early diagnosis and proper management play a crucial role in the wellbeing and life of the women and her baby. In this study, we aimed to assess the association between different management options of preeclampsia and perinatal death at a public hospital in Ethiopia. METHODS A document review was conducted on 241 preeclamptic patients' medical files who have been admitted and delivered in Woldia General Hospital from 2011 to 2016. The study was conducted from August 8 - September 10, 2017 in the aforementioned public hospital in Woldia town, Ethiopia. Associations were tested using Pearson chi squared test and binary logistic regression with a p-value < 0.05 considered significant. RESULT In this study, nearly 20 every 100 neonates from preeclamptic women has been died and the figure was higher (76.59% Vs 23.4%) among neonates from severe preeclamptic women than mild preeclamptic women (p = 0.01). More than two thirds of the patients (69.3%) received magnesium sulfate to prevent convulsion. Perinatal death among women with diastolic blood pressures greater than 110 mmHg at admission was nearly 3 times (Adjusted Odds Ratio (AOR) = 2.824; 95% Confidence Interval (CI) (1.154-6.038)) higher compared to women with diastolic blood pressures below 110 mmHg. CONCLUSION In the 5-year period, the magnitude of perinatal death among inpatient preeclamptic women was remarkably high and of which stillbirths exceeded pre-discharge early neonatal death. Utilization of magnesium sulfate tended to increase across years. Maternal diastolic blood pressure at admission was significantly associated with perinatal death.
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da Costa TX, de Almeida Pimenta Cunha MD, do Vale Bezerra PK, Azeredo FJ, Martins RR, Oliveira AG. Incidence of Adverse Drug Reactions in High-Risk Pregnancy: A Prospective Cohort Study in Obstetric Intensive Care. Eur J Clin Pharmacol 2019; 76:291-298. [PMID: 31768575 DOI: 10.1007/s00228-019-02789-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 10/25/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE To estimate the cumulative incidence of adverse drug reactions (ADRs) in women with high-risk pregnancy hospitalized in an obstetric intensive care unit, then to describe the medicines involved and to identify major risk factors. METHODS From June 2016 to December 2017, patients admitted to the ICU with high-risk pregnancy were considered eligible in this observational, longitudinal, prospective study. Patients were investigated daily for the occurrence of ADRs through pharmaceutical anamnesis, active search in medical records and questioning of the health team. Suspected ADRs were classified according to Naranjo's algorithm. Written informed consent was obtained from all patients. Univariate and multivariate logistic regression were used to identify risk factors of ADR. RESULTS The study population consisted of 607 high-risk pregnancies from 851 women admitted to the ICU, of whom 244 admitted for non-obstetric conditions, with an ICU stay less than 24 h or readmitted to the ICU were excluded. The mean age was 27.0 ± 7.5 years-old, mean gestational age was 33.8 ± 6.3 weeks. ADR were observed in 165 women (27.2%). No severe ADR was observed and 29.7% were of moderate severity. The most often implicated medicine was magnesium sulphate (25.2%) with 44.5% of patients administered that substance experiencing ADRs consisting of somnolence (68.6%), absent patellar reflex (21.6%) and hypotension (9.8%). Risk factors of ADR were blood pressure (adjusted odds-ratio (aOR) 1.02), haemoglobin level (aOR 1.21) and body temperature (aOR 0.71). CONCLUSIONS ADRs affect about one third of high-risk pregnancies, mainly due to magnesium sulphate administrations. High blood pressure, lower body temperature, and high haemoglobin concentration on admission were associated with an increased risk of ADR.
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Affiliation(s)
- Tatiana Xavier da Costa
- Postgraduate Program in Pharmaceutical Sciences, Centro de Ciências da Saúde, Universidade Federal do Rio Grande do Norte, Natal, Brazil. .,Maternity School Januário Cicco, Centro de Ciências da Saúde, Universidade Federal do Rio Grande do Norte, Natal, Brazil. .,Faculdade de Farmácia, Centro de Ciências da Saúde, Universidade Federal do Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil.
| | - Marta Danielle de Almeida Pimenta Cunha
- Postgraduate Program in Pharmaceutical Sciences, Centro de Ciências da Saúde, Universidade Federal do Rio Grande do Norte, Natal, Brazil.,Maternity School Januário Cicco, Centro de Ciências da Saúde, Universidade Federal do Rio Grande do Norte, Natal, Brazil
| | | | | | - Rand Randall Martins
- Department of Pharmacy, Centro de Ciências da Saúde, Universidade Federal do Rio Grande do Norte, Natal, Brazil
| | - Antonio Gouveia Oliveira
- Department of Pharmacy, Centro de Ciências da Saúde, Universidade Federal do Rio Grande do Norte, Natal, Brazil
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Abstract
Hypertensive disorders of pregnancy constitute one of the leading causes of maternal and perinatal mortality worldwide. It has been estimated that preeclampsia complicates 2-8% of pregnancies globally (). In Latin America and the Caribbean, hypertensive disorders are responsible for almost 26% of maternal deaths, whereas in Africa and Asia they contribute to 9% of deaths. Although maternal mortality is much lower in high-income countries than in developing countries, 16% of maternal deaths can be attributed to hypertensive disorders (). In the United States, the rate of preeclampsia increased by 25% between 1987 and 2004 (). Moreover, in comparison with women giving birth in 1980, those giving birth in 2003 were at 6.7-fold increased risk of severe preeclampsia (). This complication is costly: one study reported that in 2012 in the United States, the estimated cost of preeclampsia within the first 12 months of delivery was $2.18 billion ($1.03 billion for women and $1.15 billion for infants), which was disproportionately borne by premature births (). This Practice Bulletin will provide guidelines for the diagnosis and management of gestational hypertension and preeclampsia.
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Sharara HA, Shaikh N, Ummunnisa F, Aboobacker N, Tamimi HA. Changes in trends and outcomes of eclampsia: a success story from Qatar. Qatar Med J 2019; 2019:10. [PMID: 34113550 PMCID: PMC8170619 DOI: 10.5339/qmj.2019.10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 06/26/2019] [Indexed: 12/30/2022] Open
Abstract
Background: Preeclampsia and eclampsia are two hypertensive disorders of pregnancy that significantly contribute to higher morbidity and mortality rates. Eclampsia is the occurrence of seizures in patients with preeclampsia without any previous history of seizure disorders. The incidence and prevalence of eclampsia varies, and there is scarce literature about the prevalence and trends of eclampsia in the Arabian Gulf countries. This study aimed to identify the incidence and changing trends of eclampsia in Qatar. Patients and Methods: This retrospective study was conducted at Hamad Medical Corporation, the only tertiary heathcare center in Qatar, and included all patients admitted with eclampsia from 1979 to 2017. The demographic data, maternal age, parity, gestational age, antenatal visits, timing of seizures, mode of delivery, treatment, maternal morbidity, and mortality were recorded. The study period was divided into the initial period of 1979–1988, 1991–2009, and the recent period of 2010–2017. Data analysis was performed using chi-square tests to identify trends among the three different periods. A p value of ≤ 0.05 (two-tailed) was considered statistically significant. Results: A total of 151 patients with eclampsia were admitted with an increasing incidence of eclampsia over time. There was a statistically significant improvement in antenatal follow-up and an increase in the maternal age of patients with eclampsia (p = 0.001). The incidence of eclampsia without proteinuria increased significantly over time (p = 0.03). Postpartum eclampsia was more common (p = 0.002). Labetalol was the most frequently used antihypertensive agent (p = 0.001), and magnesium sulfate has been increasingly used as an anticonvulsant agent (p = 0.001). The rate of maternal morbidity was decreasing, and in the recent period, posterior reversible encephalopathy syndrome was becoming a common comorbidity in patients with eclampsia. Maternal mortality displayed significant improvement, reaching 0% in the recent study period (p = 0.02). Perinatal mortality likewise displayed a decreasing trend and reached 3.17% in the recent period. Conclusion: The incidence of eclampsia is increasing in Qatar. The antenatal care of patients with eclampsia has improved significantly. The medical management of patients with eclampsia has also drastically improved, leading to a significant decrease in maternal mortality and improvement in perinatal outcomes.
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Affiliation(s)
- Hussain A Sharara
- Department of Obstetrics & Gynecology, Al-Khor Hospital, Hamad Medical Corporation, Qatar
| | - Nissar Shaikh
- Surgical Intensive Care Unit, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Firdous Ummunnisa
- Department of Obstetrics & Gynecology, Al-Khor Hospital, Hamad Medical Corporation, Qatar
| | - Naseera Aboobacker
- Department of Obstetrics & Gynecology, Al-Khor Hospital, Hamad Medical Corporation, Qatar
| | - Halima Al Tamimi
- Women's Wellness and Research Center, Hamad Medical Corporation, Doha, Qatar
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Bergman L, Torres-Vergara P, Penny J, Wikström J, Nelander M, Leon J, Tolcher M, Roberts JM, Wikström AK, Escudero C. Investigating Maternal Brain Alterations in Preeclampsia: the Need for a Multidisciplinary Effort. Curr Hypertens Rep 2019; 21:72. [PMID: 31375930 DOI: 10.1007/s11906-019-0977-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE OF REVIEW To provide insight into the mechanisms underlying cerebral pathophysiology and to highlight possible methods for evaluation, screening, and surveillance of cerebral complications in preeclampsia. RECENT FINDINGS The pathophysiology of eclampsia remains enigmatic. Animal studies show that the cerebral circulation in pregnancy and preeclampsia might be affected with increased permeability over the blood-brain barrier and altered cerebral blood flow due to impaired cerebral autoregulation. The increased blood pressure cannot be the only underlying cause of eclampsia and cerebral edema, since some cases of eclampsia arise without simultaneous hypertension. Findings from animal studies need to be confirmed in human tissues. Evaluation of brain alterations in preeclampsia and eclampsia is challenging and demands a multidisciplinary collaboration, since no single method can accurately and fully describe how preeclampsia affects the brain. Cerebral complications of preeclampsia are significant factors in maternal morbidity and mortality worldwide. No single method can accurately describe the full picture of how preeclampsia affects the brain vasculature and parenchyma. We recommend an international and multidisciplinary effort not only to overcome the issue of limited sample availability but also to optimize the quality of research.
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Affiliation(s)
- Lina Bergman
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.
- Center for Clinical Research Dalarna, Falun, Uppsala, Sweden.
| | - Pablo Torres-Vergara
- Pharmacy Department, Faculty of Pharmacy, Universidad de Concepción, Concepción, Chile
- Group of Research and Innovation in Vascular Health (GRIVAS Health), Chillán, Chile
| | - Jeffrey Penny
- Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Johan Wikström
- Department of Radiology, Uppsala University, Uppsala, Sweden
| | - Maria Nelander
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Jose Leon
- Group of Research and Innovation in Vascular Health (GRIVAS Health), Chillán, Chile
- Vascular Physiology Laboratory, Group of Investigation in Tumor Angiogenesis, (LFV-GIANT), Department of Basic Sciences, Faculty of Sciences, Universidad del Bío-Bío, Chillán, Chile
| | - Mary Tolcher
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - James M Roberts
- Magee Womens Research Institute, Dept of Obstetrics Gynecology and Reproductive Sciences, Epidemiology and Clinical and Translational Research, University of Pittsburgh, Pittsburgh, PA, USA
| | - Anna-Karin Wikström
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Carlos Escudero
- Group of Research and Innovation in Vascular Health (GRIVAS Health), Chillán, Chile.
- Vascular Physiology Laboratory, Group of Investigation in Tumor Angiogenesis, (LFV-GIANT), Department of Basic Sciences, Faculty of Sciences, Universidad del Bío-Bío, Chillán, Chile.
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Pascoal ACF, Katz L, Pinto MH, Santos CA, Braga LCO, Maia SB, Amorim MMR. Serum magnesium levels during magnesium sulfate infusion at 1 gram/hour versus 2 grams/hour as a maintenance dose to prevent eclampsia in women with severe preeclampsia: A randomized clinical trial. Medicine (Baltimore) 2019; 98:e16779. [PMID: 31393402 PMCID: PMC6709127 DOI: 10.1097/md.0000000000016779] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 02/15/2019] [Accepted: 07/18/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Magnesium sulfate is the ideal drug for the prevention and treatment of eclampsia. Nevertheless, the best regimen for protection against eclampsia with minimal side effects remains to be established. This study aimed to compare serum magnesium levels during intravenous infusion of magnesium sulfate at 1 gram/hour versus 2 grams/hour as a maintenance dose to prevent eclampsia in pregnant and postpartum women with severe preeclampsia. METHODS A randomized, triple-blind clinical trial was conducted, comparing serum magnesium levels during the intravenous infusion of magnesium sulfate at 1 gram/hour versus 2 grams/hour as a maintenance dose for the prevention of eclampsia in 62 pregnant and postpartum women with severe preeclampsia, 31 in each group. An intravenous loading dose of 6 grams of magnesium sulfate was administered over 30 minutes in both groups. The patients were then randomized to receive a maintenance dose of either 1 or 2 grams/hour for 24 hours. Primary outcomes consisted of serum magnesium levels at the following time points: baseline, 30 minutes, every 2 hours until the end of the first 6 hours, and every 6 hours thereafter until the termination of magnesium sulfate infusion. Side effects, maternal complications, and neonatal outcomes were the secondary outcomes. RESULTS Serum magnesium levels were higher in the 2-gram/hour group, with a statistically significant difference from 2 hours after the beginning of the magnesium sulfate infusion (P <.05). Oliguria was the most common complication recorded in both groups, with no significant difference between the 2 regimens (RR 0.88; 95% CI: 0.49-1.56; P = .65). No cases of eclampsia occurred. Side effects were more common in the 2-gram/hour group (RR 1.89; 95% CI: 1.04-3.41; P = .02); however, all were mild. There were no differences between the 2 groups regarding neonatal outcomes, except for admission to neonatal intensive care, which was more frequent in the 1-gram/hour group (25% vs 6.3%; P = .04). CONCLUSION Magnesium sulfate therapy at the maintenance dose of 1 gram/hour was just as effective as the 2-gram maintenance dose, with fewer side effects.
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Gasparini S, Ferlazzo E, Sueri C, Cianci V, Ascoli M, Cavalli SM, Beghi E, Belcastro V, Bianchi A, Benna P, Cantello R, Consoli D, De Falco FA, Di Gennaro G, Gambardella A, Gigli GL, Iudice A, Labate A, Michelucci R, Paciaroni M, Palumbo P, Primavera A, Sartucci F, Striano P, Villani F, Russo E, De Sarro G, Aguglia U. Hypertension, seizures, and epilepsy: a review on pathophysiology and management. Neurol Sci 2019; 40:1775-1783. [PMID: 31055731 DOI: 10.1007/s10072-019-03913-4] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 04/23/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Epilepsy and hypertension are common chronic conditions, both showing high prevalence in older age groups. This review outlines current experimental and clinical evidence on both direct and indirect role of hypertension in epileptogenesis and discusses the principles of drug treatment in patients with hypertension and epilepsy. METHODS We selected English-written articles on epilepsy, hypertension, stroke, and cerebrovascular disease until December, 2018. RESULTS Renin-angiotensin system might play a central role in the direct interaction between hypertension and epilepsy, but other mechanisms may be contemplated. Large-artery stroke, small vessel disease and posterior reversible leukoencephalopathy syndrome are hypertension-related brain lesions able to determine epilepsy by indirect mechanisms. The role of hypertension as an independent risk factor for post-stroke epilepsy has not been demonstrated. The role of hypertension-related small vessel disease in adult-onset epilepsy has been demonstrated. Posterior reversible encephalopathy syndrome is an acute condition, often caused by a hypertensive crisis, associated with the occurrence of acute symptomatic seizures. Chronic antiepileptic treatment should consider the risk of drug-drug interactions with antihypertensives. CONCLUSIONS Current evidence from preclinical and clinical studies supports the vision that hypertension may be a cause of seizures and epilepsy through direct or indirect mechanisms. In both post-stroke epilepsy and small vessel disease-associated epilepsy, chronic antiepileptic treatment is recommended. In posterior reversible encephalopathy syndrome blood pressure must be rapidly lowered and prompt antiepileptic treatment should be initiated.
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Affiliation(s)
- Sara Gasparini
- Medical and Surgical Sciences Department, School of Medicine, Magna Græcia University of Catanzaro, Viale Europa, Catanzaro, Italy.,Regional Epilepsy Centre, Great Metropolitan Hospital, Via Melacrino, Reggio Calabria, Italy
| | - Edoardo Ferlazzo
- Medical and Surgical Sciences Department, School of Medicine, Magna Græcia University of Catanzaro, Viale Europa, Catanzaro, Italy.,Regional Epilepsy Centre, Great Metropolitan Hospital, Via Melacrino, Reggio Calabria, Italy.,Institute of Molecular Bioimaging and Physiology, National Research Council, Viale Europa, Catanzaro, Italy
| | - Chiara Sueri
- Regional Epilepsy Centre, Great Metropolitan Hospital, Via Melacrino, Reggio Calabria, Italy
| | - Vittoria Cianci
- Regional Epilepsy Centre, Great Metropolitan Hospital, Via Melacrino, Reggio Calabria, Italy
| | - Michele Ascoli
- Regional Epilepsy Centre, Great Metropolitan Hospital, Via Melacrino, Reggio Calabria, Italy
| | - Salvatore M Cavalli
- Regional Epilepsy Centre, Great Metropolitan Hospital, Via Melacrino, Reggio Calabria, Italy
| | - Ettore Beghi
- Department of Neuroscience, IRCCS, Istituto di Ricerche Farmacologiche "Mario Negri", Milan, Italy
| | | | - Amedeo Bianchi
- Department of Neurology and Epilepsy Centre, San Donato Hospital, Arezzo, Italy
| | - Paolo Benna
- Department of Neurosciences and Mental Health, Città della Salute e della Scienza University Hospital, Torino, Italy
| | - Roberto Cantello
- Neurology Unit, Department of Health Sciences, University of Piemonte Orientale, Novara, Italy
| | | | | | | | - Antonio Gambardella
- Medical and Surgical Sciences Department, School of Medicine, Magna Græcia University of Catanzaro, Viale Europa, Catanzaro, Italy.,Institute of Molecular Bioimaging and Physiology, National Research Council, Viale Europa, Catanzaro, Italy
| | - Gian Luigi Gigli
- Neurology Unit, Department of Medicine (DAME), University of Udine Medical School, Udine, Italy
| | - Alfonso Iudice
- Department of Clinical and Experimental Medicine, Section of Neurology, University of Pisa, Pisa, Italy
| | - Angelo Labate
- Medical and Surgical Sciences Department, School of Medicine, Magna Græcia University of Catanzaro, Viale Europa, Catanzaro, Italy.,Institute of Molecular Bioimaging and Physiology, National Research Council, Viale Europa, Catanzaro, Italy
| | - Roberto Michelucci
- IRCCS Institute of Neurological Sciences, Neurology Unit, Bellaria Hospital, Bologna, Italy
| | - Maurizio Paciaroni
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | | | - Alberto Primavera
- Clinical Neurology, Department of Neuroscience (DINOGMI), University of Genoa, IRCCS AOU San Martino-IST, Genoa, Italy
| | - Ferdinando Sartucci
- Department of Clinical and Experimental Medicine, Section of Neurology, University of Pisa, Pisa, Italy
| | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, "G. Gaslini" Institute, Genoa, Italy
| | - Flavio Villani
- Department of Diagnostics and Applied Technology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Emilio Russo
- Science of Health Department, School of Medicine, University "Magna Graecia" of Catanzaro, Viale Europa, Catanzaro, Italy
| | - Giovambattista De Sarro
- Science of Health Department, School of Medicine, University "Magna Graecia" of Catanzaro, Viale Europa, Catanzaro, Italy
| | - Umberto Aguglia
- Medical and Surgical Sciences Department, School of Medicine, Magna Græcia University of Catanzaro, Viale Europa, Catanzaro, Italy. .,Regional Epilepsy Centre, Great Metropolitan Hospital, Via Melacrino, Reggio Calabria, Italy. .,Institute of Molecular Bioimaging and Physiology, National Research Council, Viale Europa, Catanzaro, Italy. .,Regional Epilepsy Centre, Magna Graecia University of Catanzaro, Riuniti Hospital, Via Melacrino, Reggio Calabria, Italy.
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Abstract
The 4 categories of hypertensive disorders of pregnancy are chronic hypertension, gestational hypertension, preeclampsia-eclampsia, and chronic hypertension with superimposed preeclampsia. These disorders are among the leading causes of maternal and fetal morbidity and mortality. Proper diagnosis in the emergency department is crucial in order to initiate appropriate treatment to reduce the potential harm to the mother and the fetus. Prompt management should be undertaken when the blood pressure is greater than 160/110 mm Hg or there are other severe features such as acute kidney injury, elevated liver function tests, severe abdominal pain, pulmonary edema, and central nervous system disturbances.
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Affiliation(s)
- R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, Suite 200; 6th Floor, Baltimore, MD 21201, USA.
| | - Adeolu C Ogunbodede
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, Suite 200; 6th Floor, Baltimore, MD 21201, USA; Department of Internal Medicine, University of Maryland School of Medicine, 110 South Paca Street, Suite 200; 6th Floor, Baltimore, MD 21201, USA
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Management of Adult Patients in the Pediatric Emergency Department. Pediatr Clin North Am 2018; 65:1167-1190. [PMID: 30446055 DOI: 10.1016/j.pcl.2018.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Adult patients often present to the pediatric emergency department (ED) for treatment of a wide variety of diseases. However, pediatric emergency medicine physicians are primarily trained to provide specialized care for children. Studies have shown that the number of adult patients presenting to pediatric EDs has increased significantly since the introduction of the Emergency Medicine Transfer and Active Labor Act in 1986. This article discusses the management of common adult complaints presenting to the pediatric ED. The focus is on stabilization in the pediatric ED and safe transfer to a more appropriate facility.
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Leetheeragul J, Boriboonhirunsarn D, Reesukumal K, Srisaimanee N, Horrasith S, Wataganara T. A retrospective review of on-admission factors on attainment of therapeutic serum concentrations of magnesium sulfate in women treated for a diagnosis of preeclampsia. J Matern Fetal Neonatal Med 2018; 33:258-266. [PMID: 29898629 DOI: 10.1080/14767058.2018.1489531] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Introduction: There is little information on the effect of maternal characteristics and on-admission laboratory parameters to the therapeutic serum magnesium sulfate (MgSO4) levels in women with preeclampsia (PE). We sought to identify factors that may predict timely attainment of therapeutic serum magnesium levels after intravenous administration for seizure prophylaxis.Materials and methods: On-admission factors of 360 women with PE who received intravenous MgSO4 (4-g loading and 2-g/h maintenance) for seizure prophylaxis were retrospectively reviewed. Parameters of those who attained therapeutic serum concentrations (4.8-8.4 mg/dL) within 2 h (Group A) and those who did not (Group B) were compared.Results: There was no seizure or magnesium toxicity in this cohort. Median (min-max) level of serum magnesium was 4.3 (2.5-8.4) mg/dL. Women in Group A (n = 105) had lower gestational age, body mass index (BMI), and platelets count, higher blood urea nitrogen (BUN), serum creatinine, uric acid, direct bilirubin, aspartate aminotransferase, alanine aminotransferase, lactate dehydrogenase, prothrombin, and partial thromboplastin times than those in Group B (n = 255) (p < .05). Women with mild PE were less likely to attain therapeutic serum magnesium levels compared with those with severe phenotypes (adjusted OR 23.57, 95% CI 8.20-67.76 versus adjusted OR 14.72, 95% CI 3.56-60.89, respectively; p < .05), which may be explained by their significantly lower serum BUN and uric acid (p < .05).Conclusions: On-admission factors, especially BMI and renal clearance indices, of women with PE may affect timely attainment of therapeutic serum magnesium levels. Validation of its clinical impact requires further study focusing on women with severe PE.
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Affiliation(s)
- Jarunee Leetheeragul
- Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | | | - Kanit Reesukumal
- Department of Clinical Pathology, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | - Nusara Srisaimanee
- Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | - Siriluck Horrasith
- Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | - Tuangsit Wataganara
- Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
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Vigil-DeGracia P, Ludmir J, Ng J, Reyes-Tejada O, Nova C, Beltré A, Yuen-Chon V, Collantes J, Turcios E, Lewis R, Cabrera S. Is there benefit to continue magnesium sulphate postpartum in women receiving magnesium sulphate before delivery? A randomised controlled study. BJOG 2018; 125:1304-1311. [DOI: 10.1111/1471-0528.15320] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2018] [Indexed: 11/27/2022]
Affiliation(s)
- P Vigil-DeGracia
- Hospital de la Caja de Seguro Social; Investigador distinguido del Sistema Nacional de Investigación; SENACYT; Panamá City Panama
| | - J Ludmir
- Thomas Jefferson University; Philadelphia PA USA
| | - J Ng
- Hospital José Domingo de Obaldía; Chiriquí Panama
| | - O Reyes-Tejada
- Hospital Santo Tomas; Miembro del Sistema Nacional de Investigacion; SENACYT; Panamá City Panama
| | - C Nova
- Hospital Nuestra Señora de Alta Gracia; Santo Domingo Dominican Republic
| | - A Beltré
- Hospital Las minas; Santo Domingo Dominican Republic
| | - V Yuen-Chon
- Hospital Teodoro Maldonado Carbo; Guayaquil Ecuador
| | | | - E Turcios
- Hospital Primero de Mayo; Seguridad Social; San Salvador El Salvador
| | - R Lewis
- Complejo Hospitalario de la Caja de Seguro Social; Panamá Panama
| | - S Cabrera
- Hospital Nacional Docente Madre Niño; San Bartolomé Lima Peru
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Mohammadzadeh A, Towfighi F, Jafari N. Effect of magnesium on arrhythmia incidence in patients undergoing coronary artery bypass grafting. ANZ J Surg 2018; 88:612-615. [PMID: 28544600 DOI: 10.1111/ans.14056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Revised: 02/13/2017] [Accepted: 04/05/2017] [Indexed: 01/27/2023]
Abstract
BACKGROUND Cardiac arrhythmia after coronary artery bypass grafting (CABG) surgery is a common complication of cardiac surgery. The effect of serum magnesium, hypomagnesaemia treatment and prophylactic administration of magnesium in the development and prevention of arrhythmias is controversial and there are many different ideas. This study evaluates the therapeutic effects of magnesium in cardiac arrhythmia after CABG surgery. METHODS The clinical trial enrolled 250 patients who underwent CABG. Based on the initial serum levels of magnesium, patients were divided into two groups: hypomagnesium and normomagnesium. Based on bioethics committee requirements, patients in the hypo-magnesium group received magnesium treatments until they attained normal magnesium blood levels. Both groups underwent CABG with normal blood levels of magnesium. After surgery, each group was randomly divided into two subgroups: one subgroup received a bolus dose of magnesium sulphate (30 mg/kg in 5 min) and the other subgroup received a placebo. Subgroups were under observation in the intensive care unit for 3 days and arrhythmias were recorded. Data from all four subgroups were analysed statistically and interpreted. RESULTS The results of this study showed that the occurrence of arrhythmia was not significantly different among subgroups (P > 0.05). There was no significant relationship between blood levels of magnesium and arrhythmia during the 3 days post-surgery (P > 0.05). CONCLUSION The results of this study showed that magnesium sulphate administration did not significantly improve the incidence of arrhythmias in hypo- and normo-magnesium patients after CABG. There was no significant correlation between post-operative serum levels of magnesium and arrhythmia during 3 days.
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Affiliation(s)
- Alireza Mohammadzadeh
- Department of Cardiothoracic, Imam Khomeini Hospital, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Farshad Towfighi
- Department of Cardiothoracic, Imam Khomeini Hospital, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Naser Jafari
- Department of Cardiothoracic, Imam Khomeini Hospital, Ardabil University of Medical Sciences, Ardabil, Iran
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Odigboegwu O, Pan LJ, Chatterjee P. Use of Antihypertensive Drugs During Preeclampsia. Front Cardiovasc Med 2018; 5:50. [PMID: 29896480 PMCID: PMC5987086 DOI: 10.3389/fcvm.2018.00050] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 05/04/2018] [Indexed: 01/13/2023] Open
Abstract
Treatment of pregnancy-related hypertensive disorders, such as preeclampsia (PE), remain a challenging problem in obstetrics. Typically, aggressive antihypertensive drug treatment options are avoided to prevent pharmacological-induced hypotension. Another major concern of administering antihypertensive drugs during pregnancy is possible adverse fetal outcome. In addition, management of hypertension during pregnancy in chronic hypertensive patients or in patients with prior kidney problems are carefully considered. Recent studies suggest that PE patients are at increased cardiovascular risk postpartum. Therefore, these patients need to be monitored postpartum for the subsequent development of other cardiovascular diseases. In this review article, we review the antihypertensive drugs currently being used to treat patients with PE and the advantages or disadvantages of using these drugs during pregnancy.
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Affiliation(s)
- Obinnaya Odigboegwu
- Department of Internal Medicine, Scott and White Medical Center-Temple, Texas A&M Health Science Center, Temple, TX, United States
| | - Lu J Pan
- Department of Internal Medicine, Scott and White Medical Center-Temple, Texas A&M Health Science Center, Temple, TX, United States
| | - Piyali Chatterjee
- Department of Internal Medicine, Scott and White Medical Center-Temple, Texas A&M Health Science Center, Temple, TX, United States
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Bergman L, Zetterberg H, Kaihola H, Hagberg H, Blennow K, Åkerud H. Blood-based cerebral biomarkers in preeclampsia: Plasma concentrations of NfL, tau, S100B and NSE during pregnancy in women who later develop preeclampsia - A nested case control study. PLoS One 2018; 13:e0196025. [PMID: 29719006 PMCID: PMC5931625 DOI: 10.1371/journal.pone.0196025] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 03/23/2018] [Indexed: 11/26/2022] Open
Abstract
Objective To evaluate if concentrations of the neuronal proteins neurofilament light chain and tau are changed in women developing preeclampsia and to evaluate the ability of a combination of neurofilament light chain, tau, S100B and neuron specific enolase in identifying neurologic impairment before diagnosis of preeclampsia. Methods A nested case-control study within a longitudinal study cohort was performed. 469 healthy pregnant women were enrolled between 2004–2007 and plasma samples were collected at gestational weeks 10, 25, 28, 33 and 37. Plasma concentrations of tau and neurofilament light chain were analyzed in 16 women who eventually developed preeclampsia and 36 controls throughout pregnancy with single molecule array (Simoa) method and compared within and between groups. S100B and NSE had been analyzed previously in the same study population. A statistical model with receiving characteristic operation curve was constructed with the four biomarkers combined. Results Plasma concentrations of neurofilament light chain were significantly increased in women who developed preeclampsia in gestational week 33 (11.85 ng/L, IQR 7.48–39.93 vs 6.80 ng/L, IQR 5.65–11.40) and 37 (22.15 ng/L, IQR 10.93–35.30 vs 8.40 ng/L, IQR 6.40–14.30) and for tau in gestational week 37 (4.33 ng/L, IQR 3.97–12.83 vs 3.77 ng/L, IQR 1.91–5.25) in contrast to healthy controls. A combined model for preeclampsia with tau, neurofilament light chain, S100B and neuron specific enolase in gestational week 25 displayed an area under the curve of 0.77, in week 28 it was 0.75, in week 33 it was 0.89 and in week 37 it was 0.83. Median week for diagnosis of preeclampsia was at 38 weeks of gestation. Conclusion Concentrations of both tau and neurofilament light chain are increased in the end of pregnancy in women developing preeclampsia in contrast to healthy pregnancies. Cerebral biomarkers might reflect cerebral involvement before onset of disease.
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Affiliation(s)
- Lina Bergman
- Department for Women’s and Children’s health, Uppsala University, Uppsala, Sweden
- Center for Clinical Research, Falun, Sweden
- * E-mail:
| | - Henrik Zetterberg
- Institute of Neuroscience and Physiology, Department of Psychiatry and Neurochemistry, Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- UCL Institute of Neurology, Queen Square, London, United Kingdom
- UK Dementia Research Institute, London, United Kingdom
| | - Helena Kaihola
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Henrik Hagberg
- Perinatal Center, Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Centre for the Developing Brain, King's College, London, United Kingdom
| | - Kaj Blennow
- Institute of Neuroscience and Physiology, Department of Psychiatry and Neurochemistry, Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Helena Åkerud
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
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Garber A, Rao PM, Rajakumar C, Dumitrascu GA, Rousseau G, Posner GD. Postpartum Magnesium Sulfate Overdose: A Multidisciplinary and Interprofessional Simulation Scenario. Cureus 2018; 10:e2446. [PMID: 29888150 PMCID: PMC5991930 DOI: 10.7759/cureus.2446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
This case is one of an eight-case multidisciplinary curriculum designed and implemented at the University of Ottawa by simulation educators with specialty training in obstetrics and gynecology (OB/GYN) and anesthesiology. Consultation with a nurse educator maintained the quality and relevance of objectives for nursing participants. The curriculum was prepared to train OB/GYN and anesthesiology residents and labor and delivery nurses to hone crisis resource management skills and to recognize and manage rare/critical medical events in an obstetrical setting. Obstetricians, anesthesiologists, and nurses often work together in acute, high-stakes situations and this curriculum provides a safe environment to practice team-based management of such emergencies. Over an eight-year period, this curriculum has been executed in scenario couplets in a four-year cycle to allow OB/GYN and anesthesiology residents exposure to all scenarios during a five-year residency, beginning in their second year. Prospective evaluative data has been positive. For example, over 90% of participants rated these simulations to be 5 out of 5 for “Was an effective use of my educational time” and “Will influence/enhance my future practice.” In this scenario, participants must evaluate and treat a postpartum preeclamptic woman who is being treated with magnesium sulfate for the purpose of seizure prophylaxis. The patient experiences magnesium sulfate toxicity and subsequent respiratory arrest. Any mannequin that can display vital signs can be used for this scenario. This simulation case includes a case template, critical actions checklist, debriefing guide, summary of key medical content, and an evaluation form for learners to provide feedback.
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Affiliation(s)
- Adam Garber
- Department of Obstetrics & Gynecology, The Ottawa Hospital / University of Ottawa
| | - Purnima M Rao
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital / University of Ottawa
| | | | - George A Dumitrascu
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital / University of Ottawa
| | - Genevieve Rousseau
- Department of Obstetrics & Gynecology, The Ottawa Hospital / University of Ottawa
| | - Glenn D Posner
- Department of Innovation in Medical Education, University of Ottawa
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Long-term impact of intrauterine neuroinflammation and treatment with magnesium sulphate and betamethasone: Sex-specific differences in a preterm labor murine model. Sci Rep 2017; 7:17883. [PMID: 29263436 PMCID: PMC5738437 DOI: 10.1038/s41598-017-18197-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 12/06/2017] [Indexed: 11/17/2022] Open
Abstract
Preterm infants are at significantly increased risk for lifelong neurodevelopmental disability with male offspring disproportionately affected. Corticosteroids (such as betamethasone) and magnesium sulphate (MgSO4) are administered to women in preterm labor to reduce neurologic morbidity. Despite widespread use of MgSO4 in clinical practice, its effects on adult offspring are not well known nor have sex-specific differences in therapeutic response been explored. The objective of our study was to examine the long-term effects of perinatal neuroinflammation and the effectiveness of prenatal MgSO4/betamethasone treatments between males and females in a murine model via histologic and expression analyses. Our results demonstrate that male but not female offspring exposed to intrauterine inflammation demonstrated impaired performance in neurodevelopmental testing in early life assessed via negative geotaxis, while those exposed to injury plus treatment fared better. Histologic analysis of adult male brains identified a significant reduction in hippocampal neural density in the injured group compared to controls. Evaluation of key neural markers via qRT-PCR demonstrated more profound differences in gene expression in adult males exposed to injury and treatment compared to female offspring, which largely showed resistance to injury. Prenatal treatment with MgSO4/betamethasone confers long-term benefits beyond cerebral palsy prevention with sex-specific differences in response.
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Shah RR. Anti-Angiogenic Tyrosine Kinase Inhibitors and Reversible Posterior Leukoencephalopathy Syndrome: Could Hypomagnesaemia Be the Trigger? Drug Saf 2017; 40:373-386. [PMID: 28181126 DOI: 10.1007/s40264-017-0508-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Reversible posterior leukoencephalopathy syndrome (RPLS), also known frequently as posterior reversible encephalopathy syndrome (PRES), is a characteristic acute neuro-radiology syndrome with clinical presentation that typically includes acute hypertension, seizures and other neurological symptoms and signs. Many patients with RPLS have (a history of) pre-existing hypertension and in receipt of diuretics. It is being diagnosed more frequently and in association with an increasing number of morbidities and medications. Drugs most frequently implicated are immunosuppressant drugs and anticancer agents, including a number of anti-angiogenic tyrosine kinase inhibitors (TKIs). Hypomagnesaemia is a frequent finding at presentation in RPLS patients, which is known to lead to or aggravate hypertension. Pre-eclampsia, a variant of RPLS, responds effectively to intravenous magnesium. Cyclosporin, tacrolimus and some TKIs that induce RPLS are also known to give rise to both hypertension and hypomagnesaemia. This raises an interesting hypothesis that hypomagnesaemia may play a contributory role in triggering RPLS in some patients by acutely raising the blood pressure further. Additional systematic studies are required to test this hypothesis. If the hypothesis is confirmed, hypomagnesaemia offers an effective target for risk mitigation and prevention of RPLS in patients identified at risk.
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Affiliation(s)
- Rashmi R Shah
- Pharmaceutical Consultant, 8 Birchdale, Gerrards Cross, Buckinghamshire, UK.
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Keepanasseril A, Maurya DK, Manikandan K, Suriya J Y, Habeebullah S, Raghavan SS. Prophylactic magnesium sulphate in prevention of eclampsia in women with severe preeclampsia: randomised controlled trial (PIPES trial). J OBSTET GYNAECOL 2017; 38:305-309. [DOI: 10.1080/01443615.2017.1351931] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Anish Keepanasseril
- Department of Obstetrics and Gynecology, Jawaharlal Institute of Post-graduate Medical Education and Research, Puducherry, India
| | - Dilip Kumar Maurya
- Department of Obstetrics and Gynecology, Jawaharlal Institute of Post-graduate Medical Education and Research, Puducherry, India
| | - K. Manikandan
- Department of Obstetrics and Gynecology, Jawaharlal Institute of Post-graduate Medical Education and Research, Puducherry, India
| | - Yavana Suriya J
- Department of Obstetrics and Gynecology, Jawaharlal Institute of Post-graduate Medical Education and Research, Puducherry, India
| | - Syed Habeebullah
- Department of Obstetrics and Gynecology, Jawaharlal Institute of Post-graduate Medical Education and Research, Puducherry, India
| | - S. Soundara Raghavan
- Department of Obstetrics and Gynecology, Jawaharlal Institute of Post-graduate Medical Education and Research, Puducherry, India
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Magnesium sulfate for 6 vs 24 hours post delivery in patients who received magnesium sulfate for less than 8 hours before birth: a randomized clinical trial. BMC Pregnancy Childbirth 2017; 17:241. [PMID: 28738788 PMCID: PMC5525206 DOI: 10.1186/s12884-017-1424-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 07/18/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To compare the benefits of magnesium sulfate for 24 h (h) postpartum versus 6 h postpartum in patients who received magnesium sulfate (Mg) for less than 8 h before birth. METHODS A randomized, multicenter, open study was conducted between November 2013 and October 2016 in three teaching maternity hospitals in Panama. Pregnant women diagnosed with severe pre-eclampsia or pre-eclampsia with severe features at more than 20 weeks gestation were invited to participate. They were randomized to the following groups in a 1:1 ratio: A- continue Mg for 24 h after birth (control group); and B- receive Mg for 6 h after birth (experimental group). The primary endpoint and variable was seizure (eclampsia) in the first 72 h postpartum. RESULTS During the study period, 284 patients agreed to participate in the study; 143 were randomized to receive Mg for 24 h postpartum and 141 to receive Mg for 6 h postpartum. There were no significant differences in the baseline characteristics of the two groups studied. There was no eclampsia in the entire population; therefore, there was no significant difference in the primary variable. Two secondary variables showed a significant difference: time to onset of ambulation, which was 14 h shorter (p = 0.0001) in the group that received 6 h of postpartum Mg, and time to initiation of breastfeeding, which was 11 h earlier (p = 0.0001) in the group that received 6 h of postpartum Mg. There were not significant differences between the groups with respect to total complications or any particular complication. There were no cases of maternal death. CONCLUSION Maintaining Mg for 6 h postpartum is equally effective in preventing eclampsia as receiving Mg for 24 h postpartum in patients with severe pre-eclampsia who receive less than 8 h of Mg treatment before birth. The onset of maternal ambulation and initiation of breastfeeding are faster in patients who only receive Mg for 6 h postpartum. TRIAL REGISTRATION The study was registered at clinical-trials.gov, number NCT02317146 . Date of registration: December 11, 2014. This study was registered at clinical trials after the beginning of recruitment of patients.
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Yeh DD, Chokengarmwong N, Chang Y, Yu L, Arsenault C, Rudolf J, Lee-Lewandrowski E, Lewandrowski K. Total and ionized magnesium testing in the surgical intensive care unit - Opportunities for improved laboratory and pharmacy utilization. J Crit Care 2017; 42:147-151. [PMID: 28732315 DOI: 10.1016/j.jcrc.2017.07.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 06/29/2017] [Accepted: 07/10/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE Ionized fraction (iMg) is the physiologically active form of magnesium (Mg); total Mg may not accurately reflect iMg status. Erroneously "low" Mg levels may result in unnecessary repetitive testing. MATERIALS AND METHODS From 11/2015 to 01/2016, patients ordered for Mg from a pilot ICU also had iMg tested. Weighted kappa statistic was used to assess agreement between Mg categories (low, normal, high). Predictors of unnecessary repeated Mg testing and repletion using data were explored through logistic regression models using GEE techniques to account for repeated measurements in both bivariate and multivariable analyses. RESULTS There were 470Mg/iMg paired measurements from 173 patients. The weighted kappa statistic was 0.35 (95%CI 0.27-0.43) indicating poor agreement in assessment of magnesium status. Of the 34Mg samples reported as "low", only 6 (18%) were considered "low" using concurrent iMg testing. In the multivariable models, history of atrial fibrillation (aOR=1.61, 95%CI 1.16-2.21, p=0.004) and concomitant metoclopramide (aOR=1.71, 95%CI 1.03-2.81, p=0.036) were significant predictors of unnecessary repeat Mg testing. CONCLUSIONS In the surgical ICU, categorical agreement (low, normal, high) was poor between Mg and iMg. Over 80% of "low" total Mg values are erroneous and may result in unnecessary additional measurements and repletion.
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Affiliation(s)
- Daniel Dante Yeh
- Massachusetts General Hospital, Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, United States.
| | - Nalin Chokengarmwong
- Massachusetts General Hospital, Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, United States
| | - Yuchiao Chang
- Massachusetts General Hospital, Department of Medicine, United States
| | - Liyang Yu
- Massachusetts General Hospital, Department of Medicine, United States
| | - Colleen Arsenault
- Massachusetts General Hospital, Surgical Intensive Care Unit, United States
| | - Joseph Rudolf
- Massachusetts General Hospital, Department of Pathology, United States
| | | | - Kent Lewandrowski
- Massachusetts General Hospital, Department of Pathology, United States
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Malachias MVB, Figueiredo CEP, Sass N, Antonello IC, Torloni MR, Bortolotto MRFL. 7th Brazilian Guideline of Arterial Hypertension: Chapter 9 - Arterial Hypertension in pregnancy. Arq Bras Cardiol 2017; 107:49-52. [PMID: 27819388 PMCID: PMC5319470 DOI: 10.5935/abc.20160159] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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Clinical and laboratory markers in the recovery from severe preeclampsia. Pregnancy Hypertens 2017; 8:46-50. [PMID: 28501279 DOI: 10.1016/j.preghy.2017.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Revised: 01/17/2017] [Accepted: 03/04/2017] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To examine the recovery from severe Preeclampsia toxemia (PET) in women treated with magnesium sulfate (MgSO4) during the first 24h postpartum as reflected by the changes in various clinical and laboratory markers. STUDY DESIGN The study population included all women diagnosed with severe PET that gave birth at the Soroka University Medical center between 2013 and 2014, and were treated with MgSO4 in the first 24h postpartum. Data were collected from the institutional computerized records. The different parameters were examined in 6h intervals and were compared using appropriate statistical tests. MAIN OUTCOMES MEASURES Change in various postpartum laboratory and clinical parameters. RESULTS During the study period there were 132 singleton deliveries with severe PET treated with a 24-hours postpartum MgSO4 regimen. Most of the women were primigravida and delivered vaginally. Both mean systolic and mean diastolic blood pressure values have shown recovery to normal values after the first 6h of treatment (P<0.001). Urine output and proteinuria have demonstrated later recovery (after 12h). CONCLUSIONS When assessing the natural recovery of severe PET features, the earliest parameter to recover during the first 24h postpartum is hypertension followed by urine output and the proteinuria. Further larger studies are needed in order to confirm these results. Moreover, the use of these parameters may allow using shorter MgSO4 treatment regimens for appropriate women showing earlier recovery and facilitating quicker mother-baby bonding and emotional recovery.
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Effects of Pharmacological Agents on Human Amniotic Fluid-Derived Stem Cells in Culture. Stem Cells Dev 2016; 25:1570-1579. [DOI: 10.1089/scd.2016.0141] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Berhan Y, Endeshaw G. Clinical and Biomarkers Difference in Prepartum and Postpartum Eclampsia. Ethiop J Health Sci 2016; 25:257-66. [PMID: 26633929 PMCID: PMC4650881 DOI: 10.4314/ejhs.v25i3.9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background There is a large body of literature which assessed the incidence and risk factors of eclampsia, but little was done in assessing the association of clinical features and biological markers with prepartum and postpartum eclampsia. Methods A total of 361 eclamptic women admitted to three teaching hospitals between 2008 and 2013 were included in this analysis. A comparative analysis was done for several clinical and biological variables to assess their association with prepartum and postpartum eclampsia. Results The overall incidence of eclampsia was 1.2% (prepartum 71% and postpartum 29%). The majority of women with prepartum eclampsia were young, primigravida, more hypertensive, symptomatic and proteinuric. Conversely, the majoritys of the women with post-partum eclampsia were adult, multiparous, carrying pregnancy to term, anemic, thrombocytopenic, and with hepatic dysfunction. The commonest severity symptom (headache) was less common in postpartum eclamptic women. Conclusion The incidence of eclampsia was among the highest in the world. And, the analysis has shown that the clinical and biochemical spectrum of prepartum and postpartum eclampsia were apparently different. The majority of the women who developed postpartum eclampsia were multiparous and adult. Derangement of biomarkers was also more common in women with postpartum eclampsia.
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Affiliation(s)
- Yifru Berhan
- College of Medicine and Health Sciences, Hawassa University, Ethiopia
| | - Gezahegn Endeshaw
- College of Medicine and Health Sciences, Hawassa University, Ethiopia
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