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Kaur B, Bakshi RK, Siwatch S. A Narrative Review of Oxidative Stress and Liver Disease in Pregnancy: The Role of Antioxidants. Cureus 2024; 16:e64714. [PMID: 39156333 PMCID: PMC11327959 DOI: 10.7759/cureus.64714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2024] [Indexed: 08/20/2024] Open
Abstract
Pregnancy brings numerous physiological changes to the body of the pregnant woman. Liver diseases in pregnancy contribute to increased oxidative stress, disrupting the delicate balance between reactive oxygen species and antioxidant defence. Antioxidant supplementation may have potential benefits in addressing pregnancy-related liver disorders, such as HELLP (haemolysis, elevated liver enzymes, low platelet count) and preeclampsia-associated liver dysfunction in pregnancy. The purpose of this narrative review is to review the evidence regarding oxidative stress in liver disorders during pregnancy and the role of antioxidants in alleviating oxidative stress and its effect on maternal and foetal outcomes. A narrative review study design involved a comprehensive search across three scientific databases: PubMed, Embase, and MEDLINE, published in the last 20 years. The searches were performed up to January 2024. Thirty-two studies were included in the narrative review. The most studied antioxidants were vitamins (vitamin C and E) for their role in clinical treatment, prophylaxis, and clearing surrogate oxidative stress markers. The majority of studies were on preeclampsia. Though the existing literature is not robust, available evidence suggests that antioxidant supplementation may have potential benefits in addressing pregnancy-related liver disorders, such as HELLP and preeclampsia-associated liver dysfunction in pregnancy. However, there is a need to establish consistent protocols, ethical standards, and well-designed clinical trials to clarify the timing and dosage of antioxidants in pregnancy. Antioxidants may alleviate the oxidative stress in various liver disorders during pregnancy, which still needs to be studied further for their clinical relevance.
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Affiliation(s)
- Bandhanjot Kaur
- Department of Obstetrics and Gynaecology, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Ravleen K Bakshi
- Department of Health Research, Division of Reproductive Biology, Maternal, and Child Health, Indian Council of Medical Research, Ministry of Health and Family Welfare, New Delhi, IND
| | - Sujata Siwatch
- Department of Obstetrics and Gynaecology, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
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Alves PRMM, Fragoso MBT, Tenório MCS, Bueno NB, Goulart MOF, Oliveira ACM. The role played by oral antioxidant therapies in preventing and treating preeclampsia: An updated meta-analysis. Nutr Metab Cardiovasc Dis 2023; 33:1277-1292. [PMID: 37246073 DOI: 10.1016/j.numecd.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 01/10/2023] [Accepted: 02/06/2023] [Indexed: 02/26/2023]
Abstract
AIMS Performing an up-to-date meta-analysis of oral antioxidant therapies and determining whether they are effective in preventing and/or treating preeclampsia (PE). DATA SYNTHESIS Search was performed in PubMed, CENTRAL, LILACS, Web of Science, and ScienceDirect databases. The risk of bias was assessed based on using Cochrane Collaboration's tool. A funnel plot was created, and Egger's and Peter's test was carried out to assess publication bias in the primary outcome of prevention studies. The overall quality of the evidence was assessed based on using the Grading of Recommendations Assessment, Developing and Evaluation (GRADE) tool; a formal protocol was published in the PROSPERO database (registration number CRD42022348992). In total, 32 studies were taken into consideration for analysis purposes; 22 studies focused on investigating preeclampsia prevention methods, whereas 10 focused on its treatment. Significant results associated with the incidence of preeclampsia were observed in prevention studies comprising 11,198 subjects and 1106 events in the control groups, as well as 11,156 subjects and 1048 events in the intervention groups (relative risk [RR]: 0.86, 95% confidence interval [CI]: [0.75, 0.99], P = 0.03; I2 = 44%, P = 0.02). With respect to outcomes associated with treatment studies, only intrauterine growth restriction has shown significant effects. Egger's and Peter's test has evidenced publication bias. Six outcomes in prevention studies were classified as having low quality and two as having moderate quality, whereas all three outcomes assessed in treatment studies were classified as having moderate quality. CONCLUSIONS Antioxidant therapy has shown beneficial effects on preeclampsia prevention; moreover, the positive impact of this therapy on intrauterine growth restriction was observed during the disease treatment.
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Affiliation(s)
- Palloma R M M Alves
- Faculdade de Nutrição, Universidade Federal de Alagoas, Campus A. C. Simões, BR 104 Norte, Km 96,7, Tabuleiro dos Martins, CEP 57.072-970, Maceió, Alagoas, Brazil.
| | - Marilene B T Fragoso
- Instituto de Química e Biotecnologia (IQB/UFAL), Universidade Federal de Alagoas, Campus A. C. Simões, BR 104 Norte, Km 96,7, Tabuleiro dos Martins, CEP 57.072-970, Maceió, Alagoas, Brazil; Rede Nordeste de Biotecnologia (RENORBIO), Universidade Federal de Alagoas, Campus A. C. Simões, BR 104 Norte, Km 96,7, Tabuleiro dos Martins, CEP 57.072-970, Maceió, Alagoas, Brazil.
| | - Micaely C S Tenório
- Instituto de Química e Biotecnologia (IQB/UFAL), Universidade Federal de Alagoas, Campus A. C. Simões, BR 104 Norte, Km 96,7, Tabuleiro dos Martins, CEP 57.072-970, Maceió, Alagoas, Brazil; Rede Nordeste de Biotecnologia (RENORBIO), Universidade Federal de Alagoas, Campus A. C. Simões, BR 104 Norte, Km 96,7, Tabuleiro dos Martins, CEP 57.072-970, Maceió, Alagoas, Brazil.
| | - Nassib B Bueno
- Faculdade de Nutrição, Universidade Federal de Alagoas, Campus A. C. Simões, BR 104 Norte, Km 96,7, Tabuleiro dos Martins, CEP 57.072-970, Maceió, Alagoas, Brazil.
| | - Marília O F Goulart
- Instituto de Química e Biotecnologia (IQB/UFAL), Universidade Federal de Alagoas, Campus A. C. Simões, BR 104 Norte, Km 96,7, Tabuleiro dos Martins, CEP 57.072-970, Maceió, Alagoas, Brazil; Rede Nordeste de Biotecnologia (RENORBIO), Universidade Federal de Alagoas, Campus A. C. Simões, BR 104 Norte, Km 96,7, Tabuleiro dos Martins, CEP 57.072-970, Maceió, Alagoas, Brazil.
| | - Alane C M Oliveira
- Faculdade de Nutrição, Universidade Federal de Alagoas, Campus A. C. Simões, BR 104 Norte, Km 96,7, Tabuleiro dos Martins, CEP 57.072-970, Maceió, Alagoas, Brazil.
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Malnourishment-Associated Acetaminophen Toxicity in Pregnancy. Obstet Gynecol 2021; 137:877-880. [PMID: 33831932 DOI: 10.1097/aog.0000000000004351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 02/04/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Although acetaminophen is commonly used in pregnancy, it can deplete glutathione concentrations and cause accumulation of 5-oxoproline, with subsequent metabolic acidosis. CASE A malnourished 25-year-old woman, G2P1001, with chronic acetaminophen use presented with abdominal pain and high anion gap metabolic acidosis. After ruling out other potential causes, her urine 5-oxoproline level was found to be elevated. She received N-acetylcysteine, with resolution of the acidosis. CONCLUSION Those who care for pregnant patients should remain alert to 5-oxoprolinemia as a cause of metabolic acidosis during pregnancy. Care must be taken when using acetaminophen in states of malnutrition. N-acetylcysteine seems to be an effective antidote.
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Tenório MCDS, Graciliano NG, Moura FA, de Oliveira ACM, Goulart MOF. N-Acetylcysteine (NAC): Impacts on Human Health. Antioxidants (Basel) 2021; 10:967. [PMID: 34208683 PMCID: PMC8234027 DOI: 10.3390/antiox10060967] [Citation(s) in RCA: 142] [Impact Index Per Article: 47.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/11/2021] [Accepted: 06/14/2021] [Indexed: 02/06/2023] Open
Abstract
N-acetylcysteine (NAC) is a medicine widely used to treat paracetamol overdose and as a mucolytic compound. It has a well-established safety profile, and its toxicity is uncommon and dependent on the route of administration and high dosages. Its remarkable antioxidant and anti-inflammatory capacity is the biochemical basis used to treat several diseases related to oxidative stress and inflammation. The primary role of NAC as an antioxidant stems from its ability to increase the intracellular concentration of glutathione (GSH), which is the most crucial biothiol responsible for cellular redox imbalance. As an anti-inflammatory compound, NAC can reduce levels of tumor necrosis factor-alpha (TNF-α) and interleukins (IL-6 and IL-1β) by suppressing the activity of nuclear factor kappa B (NF-κB). Despite NAC's relevant therapeutic potential, in several experimental studies, its effectiveness in clinical trials, addressing different pathological conditions, is still limited. Thus, the purpose of this chapter is to provide an overview of the medicinal effects and applications of NAC to human health based on current therapeutic evidence.
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Affiliation(s)
| | - Nayara Gomes Graciliano
- Institute of Biological and Health Sciences, Federal University of Alagoas, Maceió 57072-970, Alagoas, Brazil; (N.G.G.); (A.C.M.d.O.)
| | - Fabiana Andréa Moura
- College of Nutrition, Federal University of Alagoas, Maceió 57072-970, Alagoas, Brazil;
- College of Medicine, Federal University of Alagoas, Maceió 57072-970, Alagoas, Brazil
| | - Alane Cabral Menezes de Oliveira
- Institute of Biological and Health Sciences, Federal University of Alagoas, Maceió 57072-970, Alagoas, Brazil; (N.G.G.); (A.C.M.d.O.)
- College of Nutrition, Federal University of Alagoas, Maceió 57072-970, Alagoas, Brazil;
| | - Marília Oliveira Fonseca Goulart
- Institute of Chemistry and Biotechnology, Federal University of Alagoas, Maceió 57072-970, Alagoas, Brazil;
- Institute of Biological and Health Sciences, Federal University of Alagoas, Maceió 57072-970, Alagoas, Brazil; (N.G.G.); (A.C.M.d.O.)
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Lofthouse EM, Manousopoulou A, Cleal JK, O'Kelly IM, Poore KR, Garbis SD, Lewis RM. N-acetylcysteine, xCT and suppression of Maxi-chloride channel activity in human placenta. Placenta 2021; 110:46-55. [PMID: 34120018 DOI: 10.1016/j.placenta.2021.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/04/2021] [Accepted: 05/26/2021] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Placental oxidative stress features in pregnancy pathologies but in clinical trials antioxidant supplementation has not improved outcomes. N-acetylcysteine (NAC) stimulates glutathione production and is proposed as a therapeutic agent in pregnancy. However, key elements of N-acetylcysteine biology, including its cellular uptake mechanism, remains unclear. This study explores how the cystine/glutamate transporter xCT may mediate N-acetylcysteine uptake and how N-acetylcysteine alters placental redox status. METHODS The involvement of xCT in NAC uptake by the human placenta was studied in perfused placenta and Xenopus oocytes. The effect of short-term N-acetylcysteine exposure on the placental villous proteome was determined using LC-MS. The effect of N-acetylcysteine on Maxi-chloride channel activity was investigated in perfused placenta, villous fragments and cell culture. RESULTS Maternoplacental N-acetylcysteine administration stimulated intracellular glutamate efflux suggesting a role of the exchange transporter xCT, which was localised to the microvillous membrane of the placental syncytiotrophoblast. Placental exposure to a bolus of N-acetylcysteine inhibited subsequent activation of the redox sensitive Maxi-chloride channel independently of glutathione synthesis. Stable isotope quantitative proteomics of placental villi treated with N-acetylcysteine demonstrated changes in pathways associated with oxidative stress, apoptosis and the acute phase response. DISCUSSION This study suggests that xCT mediates N-acetylcysteine uptake into the placenta and that N-acetylcysteine treatment of placental tissue alters the placental proteome while regulating the redox sensitive Maxi-chloride channel. Interestingly N-acetylcysteine had antioxidant effects independent of the glutathione pathway. Effective placental antioxidant therapy in pregnancy may require maintaining the balance between normalising redox status without inhibiting physiological redox signalling.
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Affiliation(s)
- Emma M Lofthouse
- Faculty of Medicine, University of Southampton, UK; Institute for Life Sciences, University of Southampton, UK.
| | - Antigoni Manousopoulou
- Faculty of Medicine, University of Southampton, UK; Institute for Life Sciences, University of Southampton, UK; Beckman Research Institute, City of Hope National Medical Center, Duarte, CA, USA
| | - Jane K Cleal
- Faculty of Medicine, University of Southampton, UK; Institute for Life Sciences, University of Southampton, UK
| | | | | | - Spiros D Garbis
- Faculty of Medicine, University of Southampton, UK; Institute for Life Sciences, University of Southampton, UK; Proteome Exploration Laboratory, Beckman Institute, Division of Biology and Biological Engineering, California Institute of Technology, Pasadena, CA, USA
| | - Rohan M Lewis
- Faculty of Medicine, University of Southampton, UK; Institute for Life Sciences, University of Southampton, UK
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Guerby P, Tasta O, Swiader A, Pont F, Bujold E, Parant O, Vayssiere C, Salvayre R, Negre-Salvayre A. Role of oxidative stress in the dysfunction of the placental endothelial nitric oxide synthase in preeclampsia. Redox Biol 2021; 40:101861. [PMID: 33548859 PMCID: PMC7873691 DOI: 10.1016/j.redox.2021.101861] [Citation(s) in RCA: 104] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 12/30/2020] [Accepted: 01/05/2021] [Indexed: 12/25/2022] Open
Abstract
Preeclampsia (PE) is a multifactorial pregnancy disease, characterized by new-onset gestational hypertension with (or without) proteinuria or end-organ failure, exclusively observed in humans. It is a leading cause of maternal morbidity affecting 3–7% of pregnant women worldwide. PE pathophysiology could result from abnormal placentation due to a defective trophoblastic invasion and an impaired remodeling of uterine spiral arteries, leading to a poor adaptation of utero-placental circulation. This would be associated with hypoxia/reoxygenation phenomena, oxygen gradient fluctuations, altered antioxidant capacity, oxidative stress, and reduced nitric oxide (NO) bioavailability. This results in part from the reaction of NO with the radical anion superoxide (O2•−), which produces peroxynitrite ONOO-, a powerful pro-oxidant and inflammatory agent. Another mechanism is the progressive inhibition of the placental endothelial nitric oxide synthase (eNOS) by oxidative stress, which results in eNOS uncoupling via several events such as a depletion of the eNOS substrate L-arginine due to increased arginase activity, an oxidation of the eNOS cofactor tetrahydrobiopterin (BH4), or eNOS post-translational modifications (for instance by S-glutathionylation). The uncoupling of eNOS triggers a switch of its activity from a NO-producing enzyme to a NADPH oxidase-like system generating O2•−, thereby potentiating ROS production and oxidative stress. Moreover, in PE placentas, eNOS could be post-translationally modified by lipid peroxidation-derived aldehydes such as 4-oxononenal (ONE) a highly bioreactive agent, able to inhibit eNOS activity and NO production. This review summarizes the dysfunction of placental eNOS evoked by oxidative stress and lipid peroxidation products, and the potential consequences on PE pathogenesis. Physiological ROS production is enhanced during pregnancy. eNOS is one of the main target of oxidative stress in PE placenta. eNOS is S-glutathionylated in PE placentas. eNOS is modified by lipid oxidation products in PE placentas.
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Affiliation(s)
- Paul Guerby
- Inserm U1048, Université de Toulouse, France; Gynecology and Obstetrics Department, Paule-de-Viguier Hospital, Toulouse University Hospital, France; Pôle Technologique du CRCT, Toulouse, France
| | - Oriane Tasta
- Inserm U1048, Université de Toulouse, France; Gynecology and Obstetrics Department, Paule-de-Viguier Hospital, Toulouse University Hospital, France
| | | | | | - Emmanuel Bujold
- Reproduction, Mother and Child Health Unit, CHU de Québec - Université Laval Research Centre, Université Laval, Québec, Canada
| | - Olivier Parant
- Gynecology and Obstetrics Department, Paule-de-Viguier Hospital, Toulouse University Hospital, France
| | - Christophe Vayssiere
- Gynecology and Obstetrics Department, Paule-de-Viguier Hospital, Toulouse University Hospital, France
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The effects of N-acetylcysteine on inflammatory and oxidative stress biomarkers: A systematic review and meta-analysis of controlled clinical trials. Eur J Pharmacol 2020; 884:173368. [DOI: 10.1016/j.ejphar.2020.173368] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 07/08/2020] [Accepted: 07/13/2020] [Indexed: 01/08/2023]
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Prenatal Amino Acid Supplementation to Improve Fetal Growth: A Systematic Review and Meta-Analysis. Nutrients 2020; 12:nu12092535. [PMID: 32825593 PMCID: PMC7551332 DOI: 10.3390/nu12092535] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 08/16/2020] [Accepted: 08/19/2020] [Indexed: 12/12/2022] Open
Abstract
Aberrant fetal growth remains a leading cause of perinatal morbidity and mortality and is associated with a risk of developing non-communicable diseases later in life. We performed a systematic review and meta-analysis combining human and animal studies to assess whether prenatal amino acid (AA) supplementation could be a promising approach to promote healthy fetal growth. PubMed, Embase, and Cochrane libraries were searched to identify studies orally supplementing the following AA groups during gestation: (1) arginine family, (2) branched chain (BCAA), and (3) methyl donors. The primary outcome was fetal/birth weight. Twenty-two human and 89 animal studies were included in the systematic review. The arginine family and, especially, arginine itself were studied the most. Our meta-analysis showed beneficial effects of arginine and (N-Carbamyl) glutamate (NCG) but not aspartic acid and citrulline on fetal/birth weight. However, no effects were reported when an isonitrogenous control diet was included. BCAA and methyl donor supplementation did not affect fetal/birth weight. Arginine family supplementation, in particular arginine and NCG, improves fetal growth in complicated pregnancies. BCAA and methyl donor supplementation do not seem to be as promising in targeting fetal growth. Well-controlled research in complicated pregnancies is needed before ruling out AA supplements or preferring arginine above other AAs.
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Can Endothelial Glycocalyx Be a Major Morphological Substrate in Pre-Eclampsia? Int J Mol Sci 2020; 21:ijms21093048. [PMID: 32357469 PMCID: PMC7246531 DOI: 10.3390/ijms21093048] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 04/21/2020] [Accepted: 04/23/2020] [Indexed: 02/06/2023] Open
Abstract
Today pre-eclampsia (PE) is considered as a disease of various theories; still all of them agree that endothelial dysfunction is the leading pathogenic factor. Endothelial dysfunction is a sequence of permanent immune activation, resulting in the change of both the phenotype and the functions of an endothelial cell and of the extracellular layer associated with the cell membrane—endothelial glycocalyx (eGC). Numerous studies demonstrate that eGC mediates and regulates the key functions of endothelial cells including regulation of vascular tone and thromboresistance; and these functions are disrupted during PE. Taking into account that eGC and its components undergo alterations under pathological conditions leading to endothelial activation, it is supposed that eGC plays a certain role in pathogenesis of PE. Envisaging the eGC damage as a key factor of PE, might be a new approach to prevention, treatment, and rehabilitation of patients with PE. This approach could include the development of drugs protecting eGC and promoting regeneration of this structure. Since the issue of PE is far from being solved, any effort in this direction might be valuable.
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Hitzerd E, Broekhuizen M, Neuman RI, Colafella KMM, Merkus D, Schoenmakers S, Simons SHP, Reiss IKM, Danser AHJ. Human Placental Vascular Reactivity in Health and Disease: Implications for the Treatment of Pre-eclampsia. Curr Pharm Des 2020; 25:505-527. [PMID: 30950346 DOI: 10.2174/1381612825666190405145228] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 03/29/2019] [Indexed: 12/17/2022]
Abstract
Adequate development of the placenta is essential for optimal pregnancy outcome. Pre-eclampsia (PE) is increasingly recognized to be a consequence of placental dysfunction and can cause serious maternal and fetal complications during pregnancy. Furthermore, PE increases the risk of neonatal problems and has been shown to be a risk factor for cardiovascular disease of the mother later in life. Currently, there is no adequate treatment for PE, mainly because its multifactorial pathophysiology remains incompletely understood. It originates in early pregnancy with abnormal placentation and involves a cascade of dysregulated systems in the placental vasculature. To investigate therapeutic strategies it is essential to understand the regulation of vascular reactivity and remodeling of blood vessels in the placenta. Techniques using human tissue such as the ex vivo placental perfusion model provide insight in the vasoactive profile of the placenta, and are essential to study the effects of drugs on the fetal vasculature. This approach highlights the different pathways that are involved in the vascular regulation of the human placenta, changes that occur during PE and the importance of focusing on restoring these dysfunctional systems when studying treatment strategies for PE.
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Affiliation(s)
- Emilie Hitzerd
- Department of Pediatrics, Division of Neonatology, Erasmus MC University Medical Center, Rotterdam, Netherlands.,Department of Internal Medicine; Division of Pharmacology and Vascular Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Michelle Broekhuizen
- Department of Pediatrics, Division of Neonatology, Erasmus MC University Medical Center, Rotterdam, Netherlands.,Department of Internal Medicine; Division of Pharmacology and Vascular Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands.,Department of Cardiology; Division of Experimental Cardiology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Rugina I Neuman
- Department of Internal Medicine; Division of Pharmacology and Vascular Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands.,Department of Gynecology and Obstetrics, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Katrina M Mirabito Colafella
- Department of Internal Medicine; Division of Pharmacology and Vascular Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands.,Cardiovascular Program, Monash Biomedicine Discovery Institute, Monash University, Melbourne, Australia.,Department of Physiology, Monash University, Melbourne, Australia
| | - Daphne Merkus
- Department of Cardiology; Division of Experimental Cardiology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Sam Schoenmakers
- Department of Gynecology and Obstetrics, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Sinno H P Simons
- Department of Pediatrics, Division of Neonatology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Irwin K M Reiss
- Department of Pediatrics, Division of Neonatology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - A H Jan Danser
- Department of Internal Medicine; Division of Pharmacology and Vascular Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands
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Terstappen F, Clarke SM, Joles JA, Ross CA, Garrett MR, Minnion M, Feelisch M, van Goor H, Sasser JM, Lely AT. Sodium Thiosulfate in the Pregnant Dahl Salt-Sensitive Rat, a Model of Preeclampsia. Biomolecules 2020; 10:biom10020302. [PMID: 32075042 PMCID: PMC7072460 DOI: 10.3390/biom10020302] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 02/12/2020] [Indexed: 11/16/2022] Open
Abstract
Aberrant production of hydrogen sulfide (H2S) has been linked to preeclampsia. We hypothesized that sodium thiosulfate (STS), a H2S donor, reduces hypertension and proteinuria, and diminishes fetal growth restriction in the Dahl salt-sensitive (S) rat, a spontaneous model of superimposed preeclampsia. In addition to a control group (n = 13), two groups received STS via drinking water at a dose of 2 g (n = 9) or 3 g per kg body weight per day (n = 8) from gestational day (GD) 10 to 20. Uterine artery resistance index was measured (GD18), urinary protein excretion rate was determined (GD19), and blood pressure and fetal outcomes were evaluated (GD20). At 2 g, STS had no effect on preeclamptic symptoms or fetal outcome. At 3 g, STS reduced maternal hypertension (121.8 ± 3.0 vs. 136.3 ± 2.9), but increased proteinuria (89 ± 15 vs. 56 ± 5 mg/24h), and relative kidney weight (0.86 ± 0.04 vs. 0.73 ± 0.02%). Fetal/placental weight ratio was reduced (3.83 ± 0.07 vs. 4.31 ± 0.08) without affecting litter size. No differences in uterine artery flow or renal histological damage were noted across treatment groups. While these data suggest a promising antihypertensive effect that could imply prolongation of preeclamptic pregnancies, the unfavorable effects on proteinuria, kidney weight, and fetal/placental weight ratio implies that clinical implementation of STS is contra-indicated until safety for mother and child can be verified.
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Affiliation(s)
- Fieke Terstappen
- Department of Obstetrics, Wilhelmina Children’s Hospital, University Medical Center Utrecht, 3508GA Utrecht, The Netherlands; (S.M.C.); (A.T.L.)
- Department of Developmental Origins of Disease (DDOD), Wilhelmina Children’s Hospital, University Medical Center Utrecht, 3508GA Utrecht, The Netherlands
- Correspondence: ; Tel.: +31-88-757-7251
| | - Sinéad M. Clarke
- Department of Obstetrics, Wilhelmina Children’s Hospital, University Medical Center Utrecht, 3508GA Utrecht, The Netherlands; (S.M.C.); (A.T.L.)
| | - Jaap A. Joles
- Department of Nephrology and Hypertension, University Medical Center Utrecht, 3508GA Utrecht, The Netherlands;
| | - Courtney A Ross
- Department of Pharmacology and Toxicology, University of Mississippi Medical Center, Jackson, MS 39216-4505, USA; (C.A.R.); (M.R.G.); (J.M.S.)
| | - Michael R. Garrett
- Department of Pharmacology and Toxicology, University of Mississippi Medical Center, Jackson, MS 39216-4505, USA; (C.A.R.); (M.R.G.); (J.M.S.)
| | - Magdalena Minnion
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK; (M.M.); (M.F.)
- NIHR Southampton Biomedical Research Center, Southampton General Hospital, Southampton SO16 6YD, UK
| | - Martin Feelisch
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK; (M.M.); (M.F.)
- NIHR Southampton Biomedical Research Center, Southampton General Hospital, Southampton SO16 6YD, UK
| | - Harry van Goor
- Department of Pathology and Medical Biology, University Medical Center Groningen, University of Groningen, 9713GZ Groningen, The Netherlands;
| | - Jennifer M. Sasser
- Department of Pharmacology and Toxicology, University of Mississippi Medical Center, Jackson, MS 39216-4505, USA; (C.A.R.); (M.R.G.); (J.M.S.)
| | - A. Titia Lely
- Department of Obstetrics, Wilhelmina Children’s Hospital, University Medical Center Utrecht, 3508GA Utrecht, The Netherlands; (S.M.C.); (A.T.L.)
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Alcala M, Gutierrez-Vega S, Castro E, Guzman-Gutiérrez E, Ramos-Álvarez MP, Viana M. Antioxidants and Oxidative Stress: Focus in Obese Pregnancies. Front Physiol 2018; 9:1569. [PMID: 30459642 PMCID: PMC6232303 DOI: 10.3389/fphys.2018.01569] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 10/19/2018] [Indexed: 12/12/2022] Open
Abstract
The prevalence of obesity in women of childbearing age around the globe has dramatically increased in the last decades. Obesity is characterized by a low-state chronic inflammation, metabolism impairment and oxidative stress, among other pathological changes. Getting pregnant in this situation involves that gestation will occur in an unhealthy environment, that can potentially jeopardize both maternal and fetal health. In this review, we analyze the role of maternal obesity-induced oxidative stress as a risk factor to develop adverse outcomes during gestation, including reduced fertility, spontaneous abortion, teratogenesis, preeclampsia, and intrauterine growth restriction. Evidences of macromolecule oxidation increase in reactive oxygen species generation and antioxidant defense alterations are commonly described in maternal and fetal tissues. Thus, antioxidant supplementation become an interesting prophylactic and therapeutic tool, that yields positive results in cellular, and animal models. However, the results from most meta-analysis studying the effect of these therapies in complicated gestations in humans are not really encouraging. It is still to be analyzed whether these therapies could work if applied to cohorts of patients at a high risk, such as those with low concentration of antioxidants or obese pregnant women.
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Affiliation(s)
- Martin Alcala
- Department of Chemistry and Biochemistry, Facultad de Farmacia, CEU San Pablo University – CEU Universities, Madrid, Spain
- Red Iberoamericana de Alteraciones Vasculares Asociadas a TRastornos del EMbarazo (RIVA-TREM), Chillán, Chile
| | - Sebastián Gutierrez-Vega
- Red Iberoamericana de Alteraciones Vasculares Asociadas a TRastornos del EMbarazo (RIVA-TREM), Chillán, Chile
- Molecular Medicine Laboratory, School of Medical Technology, Faculty of Health Sciences, Universidad San Sebastián, Concepción, Chile
| | - Erica Castro
- Red Iberoamericana de Alteraciones Vasculares Asociadas a TRastornos del EMbarazo (RIVA-TREM), Chillán, Chile
- Faculty of Medicine, Universidad San Sebastián, Concepción, Chile
| | - Enrique Guzman-Gutiérrez
- Red Iberoamericana de Alteraciones Vasculares Asociadas a TRastornos del EMbarazo (RIVA-TREM), Chillán, Chile
- Molecular Medicine Laboratory, School of Medical Technology, Faculty of Health Sciences, Universidad San Sebastián, Concepción, Chile
| | - Maria Pilar Ramos-Álvarez
- Department of Chemistry and Biochemistry, Facultad de Farmacia, CEU San Pablo University – CEU Universities, Madrid, Spain
- Red Iberoamericana de Alteraciones Vasculares Asociadas a TRastornos del EMbarazo (RIVA-TREM), Chillán, Chile
| | - Marta Viana
- Department of Chemistry and Biochemistry, Facultad de Farmacia, CEU San Pablo University – CEU Universities, Madrid, Spain
- Red Iberoamericana de Alteraciones Vasculares Asociadas a TRastornos del EMbarazo (RIVA-TREM), Chillán, Chile
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Tenório MB, Ferreira RC, Moura FA, Bueno NB, Goulart MOF, Oliveira ACM. Oral antioxidant therapy for prevention and treatment of preeclampsia: Meta-analysis of randomized controlled trials. Nutr Metab Cardiovasc Dis 2018; 28:865-876. [PMID: 30111493 DOI: 10.1016/j.numecd.2018.06.002] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 05/18/2018] [Accepted: 06/04/2018] [Indexed: 12/15/2022]
Abstract
AIMS To determine whether oral antioxidant therapies, of various types and doses, are able to prevent or treat women with preeclampsia. DATA SYNTHESIS The following databases were searched: MEDLINE, CENTRAL, LILACS, and Web of Science. Inclusion criteria were: a) randomized clinical trials; b) oral antioxidant supplementation; c) study in pregnant women; d) control group, treated or not with placebo. Papers were excluded if they evaluated antioxidant nutrient supplementation associated with other non-antioxidant therapies. Data were extracted and the risk of bias of each study was assessed. Heterogeneity was analyzed using the Cochran Q test, and I2 statistics and pre-specified sensitivity analyses were performed. Meta-analyses were conducted on prevention and treatment studies, separately. The primary outcome was the incidence of preeclampsia in prevention trials, and of perinatal death in treatment trials. Twenty-nine studies were included in the analysis, 19 for prevention and 10 for treatment. The antioxidants used in these studies were vitamins C and E, selenium, l-arginine, allicin, lycopene and coenzyme Q10, none of which showed beneficial effects on the prevention of preeclampsia (RR: 0.89, CI 95%: [0.79-1.02], P = 0.09; I2 = 39%, P = 0.04) and other outcomes. The antioxidants used in the treatment studies were vitamins C and E, N-acetylcysteine, l-arginine, and resveratrol. A beneficial effect was found in intrauterine growth restriction. CONCLUSIONS Antioxidant therapy had no effects in the prevention of preeclampsia but did show beneficial effects in intrauterine growth restriction, when used in the treatment of this condition.
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Affiliation(s)
- M B Tenório
- Faculdade de Nutrição, Universidade Federal de Alagoas, Campus A. C. Simões, BR 104 Norte, Km 96,7, Tabuleiro dos Martins, CEP 57.072-970, Maceió, Alagoas, Brazil
| | - R C Ferreira
- Faculdade de Nutrição, Universidade Federal de Alagoas, Campus A. C. Simões, BR 104 Norte, Km 96,7, Tabuleiro dos Martins, CEP 57.072-970, Maceió, Alagoas, Brazil
| | - F A Moura
- Faculdade de Nutrição, Universidade Federal de Alagoas, Campus A. C. Simões, BR 104 Norte, Km 96,7, Tabuleiro dos Martins, CEP 57.072-970, Maceió, Alagoas, Brazil
| | - N B Bueno
- Faculdade de Nutrição, Universidade Federal de Alagoas, Campus A. C. Simões, BR 104 Norte, Km 96,7, Tabuleiro dos Martins, CEP 57.072-970, Maceió, Alagoas, Brazil
| | - M O F Goulart
- Instituto de Química e Biotecnologia (IQB/UFAL), Rede Nordeste de Biotecnologia (RENORBIO), Universidade Federal de Alagoas, Campus A. C. Simões, BR 104 Norte, Km 96,7, Tabuleiro dos Martins, CEP 57.072-970, Maceió, Alagoas, Brazil
| | - A C M Oliveira
- Faculdade de Nutrição, Universidade Federal de Alagoas, Campus A. C. Simões, BR 104 Norte, Km 96,7, Tabuleiro dos Martins, CEP 57.072-970, Maceió, Alagoas, Brazil.
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Abstract
Preeclampsia (PE) is one of the leading causes of maternal morbidity and mortality worldwide. This disease is believed to occur in two stages with placental dysfunction in early pregnancy leading to maternal clinical findings after 20 weeks of gestation, as consequence of systemic inflammation, oxidative stress, and endothelial dysfunction. Much evidence suggests that PE women display an overshooting inflammatory response throughout pregnancy due to an unbalanced regulation of innate and adaptive immune responses. Recently, it has been suggested that dysregulation of endogenous protective pathways might be associated with PE etiopathogenesis. Resolution of inflammation is an active process coordinated by mediators from diverse nature that regulate key cellular events to restore tissue homeostasis. Inadequate or insufficient resolution of inflammation is believed to play an important role in the development of chronic inflammatory diseases, like PE. In this narrative review, we discuss possible pro-resolution pathways that might be compromised in PE women, which could be targets to novel therapeutic strategies in this disease.
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Groom KM, David AL. The role of aspirin, heparin, and other interventions in the prevention and treatment of fetal growth restriction. Am J Obstet Gynecol 2018; 218:S829-S840. [PMID: 29229321 DOI: 10.1016/j.ajog.2017.11.565] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 10/20/2017] [Accepted: 11/08/2017] [Indexed: 11/24/2022]
Abstract
Fetal growth restriction and related placental pathologies such as preeclampsia, stillbirth, and placental abruption are believed to arise in early pregnancy when inadequate remodeling of the maternal spiral arteries leads to persistent high-resistance and low-flow uteroplacental circulation. The consequent placental ischaemia, reperfusion injury, and oxidative stress are associated with an imbalance in angiogenic/antiangiogenic factors. Many interventions have centered on the prevention and/or treatment of preeclampsia with results pertaining to fetal growth restriction and small-for-gestational-age pregnancy often included as secondary outcomes because of the common pathophysiology. This renders the study findings less reliable for determining clinical significance. For the prevention of fetal growth restriction, a recent large-study level meta-analysis and individual patient data meta-analysis confirm that aspirin modestly reduces small-for-gestational-age pregnancy in women at high risk (relative risk, 0.90, 95% confidence interval, 0.81-1.00) and that a dose of ≥100 mg should be recommended and to start at or before 16 weeks of gestation. These findings support national clinical practice guidelines. In vitro and in vivo studies suggest that low-molecular-weight heparin may prevent fetal growth restriction; however, evidence from randomized control trials is inconsistent. A meta-analysis of multicenter trial data does not demonstrate any positive preventative effect of low-molecular-weight heparin on a primary composite outcome of placenta-mediated complications including fetal growth restriction (18% vs 18%; absolute risk difference, 0.6%; 95% confidence interval, 10.4-9.2); use of low-molecular-weight heparin for the prevention of fetal growth restriction should remain in the research setting. There are even fewer treatment options once fetal growth restriction is diagnosed. At present the only management option if the risk of hypoxia, acidosis, and intrauterine death is high is iatrogenic preterm birth, with the use of peripartum maternal administration of magnesium sulphate for neuroprotection and corticosteroids for fetal lung maturity, to prevent adverse neonatal outcomes. The pipeline of potential therapies use different strategies, many aiming to increase fetal growth by improving poor placentation and uterine blood flow. Phosphodiesterase type 5 inhibitors that potentiate nitric oxide availability such as sildenafil citrate have been extensively researched both in preclinical and clinical studies; results from the Sildenafil Therapy In Dismal Prognosis Early-Onset Intrauterine Growth Restriction consortium of randomized control clinical trials are keenly awaited. Targeting the uteroplacental circulation with novel therapeutics is another approach, the most advanced being maternal vascular endothelial growth factor gene therapy, which is being translated into the clinic via the doEs Vascular endothelial growth factor gene therapy safEly impRove outcome in seveRe Early-onset fetal growth reSTriction consortium. Other targeting approaches include nanoparticles and microRNAs to deliver drugs locally to the uterine arterial endothelium or trophoblast. In vitro and in vivo studies and animal models have demonstrated effects of nitric oxide donors, dietary nitrate, hydrogen sulphide donors, statins, and proton pump inhibitors on maternal blood pressure, uteroplacental resistance indices, and angiogenic/antiangiogenic factors. Data from human pregnancies and, in particular, pregnancies with fetal growth restriction remain very limited. Early research into melatonin, creatine, and N-acetyl cysteine supplementation in pregnancy suggests they may have potential as neuro- and cardioprotective agents in fetal growth restriction.
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Duffy JMN, Hirsch M, Kawsar A, Gale C, Pealing L, Plana MN, Showell M, Williamson PR, Khan KS, Ziebland S, McManus RJ. Outcome reporting across randomised controlled trials evaluating therapeutic interventions for pre-eclampsia. BJOG 2017; 124:1829-1839. [DOI: 10.1111/1471-0528.14702] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2017] [Indexed: 02/05/2023]
Affiliation(s)
- JMN Duffy
- Nuffield Department of Primary Care Health Sciences; University of Oxford; Oxford UK
| | - M Hirsch
- Women's Health Research Unit; Barts and the London School of Medicine and Dentistry; London UK
- Royal Free London NHS Trust; London UK
| | - A Kawsar
- Royal Free London NHS Trust; London UK
| | - C Gale
- Neonatal Medicine; Faculty of Medicine; Imperial College London; London UK
| | - L Pealing
- Nuffield Department of Primary Care Health Sciences; University of Oxford; Oxford UK
| | - MN Plana
- Clinical Biostatistics Unit; Ramon y Cajal Institute of Research and Centro de Investigación Biomédica en Red Epidemiology and Public Health; Madrid Spain
| | - M Showell
- Cochrane Gynaecology and Fertility Group; University of Auckland; Auckland New Zealand
| | - PR Williamson
- MRC North West Hub for Trials Methodology Research; Institute of Translational Medicine; University of Liverpool; Liverpool UK
| | - KS Khan
- Women's Health Research Unit; Barts and the London School of Medicine and Dentistry; London UK
| | - S Ziebland
- Nuffield Department of Primary Care Health Sciences; University of Oxford; Oxford UK
| | - RJ McManus
- Nuffield Department of Primary Care Health Sciences; University of Oxford; Oxford UK
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Implication du stress oxydant dans la physiopathologie de la pré-éclampsie : mise au point. ACTA ACUST UNITED AC 2015; 43:751-6. [DOI: 10.1016/j.gyobfe.2015.09.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 09/15/2015] [Indexed: 11/19/2022]
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Oyston CJ, Stanley JL, Baker PN. Potential targets for the treatment of preeclampsia. Expert Opin Ther Targets 2015; 19:1517-30. [DOI: 10.1517/14728222.2015.1088004] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Sánchez-Aranguren LC, Prada CE, Riaño-Medina CE, Lopez M. Endothelial dysfunction and preeclampsia: role of oxidative stress. Front Physiol 2014; 5:372. [PMID: 25346691 PMCID: PMC4193194 DOI: 10.3389/fphys.2014.00372] [Citation(s) in RCA: 257] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 09/09/2014] [Indexed: 01/22/2023] Open
Abstract
Preeclampsia (PE) is an often fatal pathology characterized by hypertension and proteinuria at the 20th week of gestation that affects 5-10% of the pregnancies. The problem is particularly important in developing countries in where the incidence of hypertensive disorders of pregnancy is higher and maternal mortality rates are 20 times higher than those reported in developed countries. Risk factors for the development of PE include obesity, insulin resistance and hyperlipidemia that stimulate inflammatory cytokine release and oxidative stress leading to endothelial dysfunction (ED). However, how all these clinical manifestations concur to develop PE is still not very well understood. The related poor trophoblast invasion and uteroplacental artery remodeling described in PE, increases reactive oxygen species (ROS), hypoxia and ED. Here we aim to review current literature from research showing the interplay between oxidative stress, ED and PE to the outcomes of current clinical trials aiming to prevent PE with antioxidant supplementation.
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Affiliation(s)
- Lissette C. Sánchez-Aranguren
- Translational Biomedical Research Group, Biotechnology, Innovation and Technology Development, Cardiovascular Foundation of ColombiaFloridablanca, Colombia
- Graduate Program in Biomedical Sciences, Faculty of Health, Universidad del ValleCali, Colombia
| | - Carlos E. Prada
- Translational Biomedical Research Group, Biotechnology, Innovation and Technology Development, Cardiovascular Foundation of ColombiaFloridablanca, Colombia
- Center for Genomic Medicine and Metabolism, Instituto del Corazón de Floridablanca, Cardiovascular Foundation of ColombiaFloridablanca, Colombia
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of MedicineCincinnati, OH, USA
| | - Carlos E. Riaño-Medina
- Translational Biomedical Research Group, Biotechnology, Innovation and Technology Development, Cardiovascular Foundation of ColombiaFloridablanca, Colombia
- Maternal-Fetal Medicine Program, Cardiovascular Foundation of ColombiaFloridablanca, Colombia
| | - Marcos Lopez
- Translational Biomedical Research Group, Biotechnology, Innovation and Technology Development, Cardiovascular Foundation of ColombiaFloridablanca, Colombia
- Graduate Program in Biomedical Sciences, Faculty of Health, Universidad del ValleCali, Colombia
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Spencer RN, Carr DJ, David AL. Treatment of poor placentation and the prevention of associated adverse outcomes--what does the future hold? Prenat Diagn 2014; 34:677-84. [PMID: 24799349 PMCID: PMC4265258 DOI: 10.1002/pd.4401] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 04/29/2014] [Accepted: 04/29/2014] [Indexed: 12/14/2022]
Abstract
Poor placentation, which manifests as pre-eclampsia and fetal growth restriction, is a major pregnancy complication. The underlying cause is a deficiency in normal trophoblast invasion of the spiral arteries, associated with placental inflammation, oxidative stress, and an antiangiogenic state. Peripartum therapies, such as prenatal maternal corticosteroids and magnesium sulphate, can prevent some of the adverse neonatal outcomes, but there is currently no treatment for poor placentation itself. Instead, management relies on identifying the consequences of poor placentation in the mother and fetus, with iatrogenic preterm delivery to minimise mortality and morbidity. Several promising therapies are currently under development to treat poor placentation, to improve fetal growth, and to prevent adverse neonatal outcomes. Interventions such as maternal nitric oxide donors, sildenafil citrate, vascular endothelial growth factor gene therapy, hydrogen sulphide donors, and statins address the underlying pathology, while maternal melatonin administration may provide fetal neuroprotection. In the future, these may provide a range of synergistic therapies for pre-eclampsia and fetal growth restriction, depending on the severity and gestation of onset.
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Affiliation(s)
- RN Spencer
- Institute for Women's Health, University College LondonLondon, UK
| | - DJ Carr
- Institute for Women's Health, University College LondonLondon, UK
| | - AL David
- Institute for Women's Health, University College LondonLondon, UK
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Holwerda KM, Faas MM, van Goor H, Lely AT. Gasotransmitters: a solution for the therapeutic dilemma in preeclampsia? Hypertension 2013; 62:653-9. [PMID: 23959552 DOI: 10.1161/hypertensionaha.113.01625] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Kim M Holwerda
- Department of Obstetrics and Gynecology, Hanzeplein 1, PO Box 30001, 9713 GZ Groningen, The Netherlands.
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Abstract
BACKGROUND Very high blood pressure during pregnancy poses a serious threat to women and their babies. The aim of antihypertensive therapy is to lower blood pressure quickly but safety, to avoid complications. Antihypertensive drugs lower blood pressure but their comparative effectiveness and safety, and impact on other substantive outcomes is uncertain. OBJECTIVES To compare different antihypertensive drugs for very high blood pressure during pregnancy. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group Trials Register (9 January 2013). SELECTION CRITERIA Studies were randomised trials. Participants were women with severe hypertension during pregnancy. Interventions were comparisons of one antihypertensive drug with another. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and assessed trial quality. Two review authors extracted data and checked them for accuracy. MAIN RESULTS Thirty-five trials (3573 women) with 15 comparisons were included. Women allocated calcium channel blockers were less likely to have persistent high blood pressure compared to those allocated hydralazine (six trials, 313 women; 8% versus 22%; risk ratio (RR) 0.37, 95% confidence interval (CI) 0.21 to 0.66). Ketanserin was associated with more persistent high blood pressure than hydralazine (three trials, 180 women; 27% versus 6%; RR 4.79, 95% CI 1.95 to 11.73), but fewer side-effects (three trials, 120 women; RR 0.32, 95% CI 0.19 to 0.53) and a lower risk of HELLP (haemolysis, elevated liver enzymes and lowered platelets) syndrome (one trial, 44 women; RR 0.20, 95% CI 0.05 to 0.81).Labetalol was associated with a lower risk of hypotension compared to diazoxide (one trial 90 women; RR 0.06, 95% CI 0.00 to 0.99) and a lower risk of caesarean section (RR 0.43, 95% CI 0.18 to 1.02), although both were borderline for statistical significance.Both nimodipine and magnesium sulphate were associated with a high incidence of persistent high blood pressure, but this risk was lower for nimodipine compared to magnesium sulphate (one trial, 1650 women; 47% versus 65%; RR 0.84, 95% CI 0.76 to 0.93). Nimodipine was associated with a lower risk of respiratory difficulties (RR 0.28, 95% CI 0.08 to 0.99), fewer side-effects (RR 0.68, 95% CI 0.55 to 0.85) and less postpartum haemorrhage (RR 0.41, 95% CI 0.18 to 0.92) than magnesium sulphate. Stillbirths and neonatal deaths were not reported.There are insufficient data for reliable conclusions about the comparative effects of any other drugs. AUTHORS' CONCLUSIONS Until better evidence is available the choice of antihypertensive should depend on the clinician's experience and familiarity with a particular drug; on what is known about adverse effects; and on women's preferences. Exceptions are nimodipine, magnesium sulphate (although this is indicated for women who require an anticonvulsant for prevention or treatment of eclampsia), diazoxide and ketanserin, which are probably best avoided.
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Affiliation(s)
- Lelia Duley
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, Nottingham, UK.
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Magee L, Yong P, Espinosa V, Côté A, Chen I, von Dadelszen P. Expectant Management of Severe Preeclampsia Remote from Term: A Structured Systematic Review. Hypertens Pregnancy 2009; 28:312-47. [DOI: 10.1080/10641950802601252] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
Pregnancy could be associated with a state of oxidative stress that could initiate and propagate a cascade of changes that may lead to pregnancy wastage. This process of oxidative stress may be suppressed by the antioxidant effect of N-acetyl cysteine (NAC). The current study aimed to evaluate the effect of NAC therapy in patients diagnosed with unexplained recurrent pregnancy loss (RPL). The study was a prospective controlled study performed in the Women's Health Centre, Assiut University, Egypt. A group of 80 patients with history of recurrent unexplained pregnancy loss were treated with NAC 0.6 g + folic acid 500 microg/day and compared with an aged-matched group of 86 patients treated with folic acid 500 microg/day alone. NAC + folic acid compared with folic acid alone caused a significantly increased rate of continuation of a living pregnancy up to and beyond 20 weeks [P < 0.002, relative risk (RR) 2.9, 95% confidence interval (CI) 1.5-5.6]. NAC + folic acid was associated with a significant increase in the take-home baby rate as compared with folic acid alone (P < 0.047, RR 1.98, 95% CI 1.3-4.0). In conclusion, NAC is a well-tolerated drug that could be a potentially effective treatment in patients with unexplained RPL.
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Shahin AY, Hassanin IMA, Ismail AM, Kruessel JS, Hirchenhain J. Effect of oral N-acetyl cysteine on recurrent preterm labor following treatment for bacterial vaginosis. Int J Gynaecol Obstet 2008; 104:44-8. [PMID: 18851855 DOI: 10.1016/j.ijgo.2008.08.026] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2008] [Revised: 08/13/2008] [Accepted: 08/26/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To evaluate the effect of N-acetyl cysteine (NAC) on gestational age at delivery in women with previous preterm labor and bacterial vaginosis. METHODS A randomized, double-blind, placebo-controlled trial with 280 women between 16 and 18 weeks of pregnancy who had 1 previous preterm birth and had just been successfully treated for bacterial vaginosis with metronidazole for 1 week. The women were randomized to receive 0.6 g of NAC per day plus 17-hydroxyprogesterone caproate (17-OHPC) or placebo plus 17-OHPC until 36 completed weeks of pregnancy or active labor. A vaginal swab was taken during labor. RESULTS Reaching 36 weeks of pregnancy was more frequent (P<0.05) and gestational age at delivery was significantly higher in the NAC than in the placebo group (37.4 weeks+/-0.4 weeks vs 34.1 weeks+/-1.2 weeks, P<0.05). The discontinuation rate was 11.4% in the NAC group. CONCLUSIONS Oral NAC was found to reduce the recurrence of preterm birth in patients with bacterial vaginosis.
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Affiliation(s)
- Ahmed Y Shahin
- Department of Obstetrics and Gynecology, Women's Health Centre, Assiut University, Egypt.
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Reference. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2008. [DOI: 10.1016/s1701-2163(16)32783-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Abstract
BACKGROUND Oxidative stress has been proposed as a key factor involved in the development of pre-eclampsia. Supplementing women with antioxidants during pregnancy may help to counteract oxidative stress and thereby prevent or delay the onset of pre-eclampsia. OBJECTIVES To determine the effectiveness and safety of any antioxidant supplementation during pregnancy and the risk of developing pre-eclampsia and its related complications. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (May 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 3), MEDLINE (1950 to October 2007) and Current Contents (1998 to August 2004). SELECTION CRITERIA All randomised trials comparing one or more antioxidants with either placebo or no antioxidants during pregnancy for the prevention of pre-eclampsia, and trials comparing one or more antioxidants with another, or with other interventions. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and trial quality and extracted data. MAIN RESULTS Ten trials, involving 6533 women, were included in this review, five trials were rated high quality. For the majority of trials, the antioxidant assessed was combined vitamin C and E therapy. There was no significant difference between antioxidant and control groups for the relative risk (RR) of pre-eclampsia (RR 0.73, 95% confidence intervals (CI) 0.51 to 1.06; nine trials, 5446 women) or any other primary outcome: severe pre-eclampsia (RR 1.25, 95% CI 0.89 to 1.76; two trials, 2495 women), preterm birth (before 37 weeks) (RR 1.10, 95% CI 0.99 to 1.22; five trials, 5198 women), small-for-gestational-age infants (RR 0.83, 95% CI 0.62 to 1.11; five trials, 5271 babies) or any baby death (RR 1.12, 95% CI 0.81 to 1.53; four trials, 5144 babies). Women allocated antioxidants were more likely to self-report abdominal pain late in pregnancy (RR 1.61, 95% CI 1.11 to 2.34; one trial, 1745 women), require antihypertensive therapy (RR 1.77, 95% CI 1.22 to 2.57; two trials, 4272 women) and require an antenatal hospital admission for hypertension (RR 1.54, 95% CI 1.00 to 2.39; one trial, 1877 women). However, for the latter two outcomes, this was not clearly reflected in an increase in any other hypertensive complications. AUTHORS' CONCLUSIONS Evidence from this review does not support routine antioxidant supplementation during pregnancy to reduce the risk of pre-eclampsia and other serious complications in pregnancy.
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Affiliation(s)
- A Rumbold
- Menzies School of Health Research, PO Box 41096, Casuarina, NT, Australia, 0820.
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Abstract
BACKGROUND Very high blood pressure during pregnancy poses a serious threat to women and their babies. Antihypertensive drugs lower blood pressure. Their comparative effects on other substantive outcomes, however, is uncertain. OBJECTIVES To compare different antihypertensive drugs for very high blood pressure during pregnancy. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group Trials Register (28 February 2006) and CENTRAL (The Cochrane Library 2006, Issue 2). SELECTION CRITERIA Studies were randomised trials. Participants were women with severe hypertension during pregnancy. Interventions were comparisons of one antihypertensive drug with another. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data. MAIN RESULTS Twenty-four trials (2949 women) with 12 comparisons were included. Women allocated calcium channel blockers rather than hydralazine were less likely to have persistent high blood (five trials, 263 women; 6% versus 18%; relative risk (RR) 0.33, 95% confidence interval (CI) 0.15 to 0.70). Ketanserin was associated with more persistent high blood pressure than hydralazine (four trials, 200 women; 27% versus 6%; RR 4.79, 95% CI 1.95 to 11.73), but fewer side-effects (three trials, 120 women; RR 0.32, 95% CI 0.19 to 0.53) and a lower risk of HELLP (Haemolysis, Elevated Liver enzymes and Lowered Platelets) syndrome (one trial, 44 women, RR 0.20, 95% CI 0.05 to 0.81). Labetalol was associated with a higher risk of hypotension (one trial 90 women; RR 0.06, 95% CI 0.00 to 0.99) and caesarean section (RR 0.43, 95% CI 0.18 to 1.02) than diazoxide. Data were insufficient for reliable conclusions about other outcomes. The risk of persistent high blood pressure was greater for nimodipine compared to magnesium sulphate (two trials 1683 women; 47% versus 65%; RR 0.84, 95% CI 0.76 to 0.93). Nimodipine was also associated with a higher risk of eclampsia (RR 2.24, 95% CI 1.06 to 4.73) and respiratory difficulties (RR 0.28, 95% CI 0.08 to 0.99), but fewer side-effects (RR 0.68, 95% CI 0.54 to 0.86) and less postpartum haemorrhage (RR 0.41, 95% CI 0.18 to 0.92) than magnesium sulphate. Stillbirths and neonatal deaths were not reported. There are insufficient data for reliable conclusions about the comparative effects of any other drugs. AUTHORS' CONCLUSIONS Until better evidence is available, the choice of antihypertensive should depend on the clinician's experience and familiarity with a particular drug, and on what is known about adverse effects. Exceptions are diazoxide, ketanserin, nimodipine and magnesium sulphate, which are probably best avoided.
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Affiliation(s)
- L Duley
- University of Oxford, Nuffield Department of Medicine, Room 5609, Level 5, John Radcliffe Hospital, Headington, Oxford, UK OX3 9DU.
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