Magnesium sulfate therapy of preeclampsia: an old tool with new mechanism of action and prospect in management and prophylaxis

Magnesium sulfate in preeclampsia: Broad indications, not only in neurological symptoms

The role of magnesium sulfate for treatment of eclampsia is well established. The medication proved to be superior to other anticonvulsants to reduce the incidence of recurrent convulsions among women with eclampsia. Additionally, magnesium sulfate has been indicated for women with preeclampsia with different severe features. However, despite these recommendations, many clinicians are still not confident with the use of magnesium sulfate, even in settings with high incidence of preeclampsia and unacceptable rates of maternal mortality. This review brings basic science and clinical information to endorse recommendations to encourage clinicians to use magnesium sulfate for patients with all severe features of preeclampsia, not only for women with neurological symptoms. Additionally, other benefits of magnesium sulfate in anesthesia and fetal neuroprotection are also presented. Finally, a comprehensive algorithm presents recommendations to manage patients with preeclampsia with severe features between 34 and 36+6 weeks.

Cochlear pathology in preeclamptic rats: protective effects of vitamin D and magnesium sulfate

Background/aim

This study investigated the possible degeneration in cochlear morphology induced by preeclampsia (PE) and the therapeutic/preventive effect of vitamin D (Vit D) and magnesium sulfate (MgSO4) used separately and together on feto-maternal outcomes.

Materials and methods

We created PE in rats using a reduced uterine perfusion pressure (RUPP) animal model and recorded blood pressure (BP), embryonic survival (ES), and embryonic weight (EW) and evaluated cochlear morphology by electron microscopy.

Results

The PE group had elevated BP, a decreased number and weight of live pups, and significant degeneration in the cochlea compared to the sham group. In the PEV group, we observed significant beneficial effects of Vit D supplementation at 14.5 and 19.5 dpc in terms of BP (p < 0.05), EW (p < 0.001), and cochlear degeneration compared to the PE group. In the PEM group, BP (p < 0.05) and cochlear degeneration nearly reached the level found in the sham group. However, although the EW was statistically different in the PE group, it did not reach sham group levels. We also observed that BP returned to sham level (p < 0.01) and noticed significant increases in the EW (p < 0.0001) and ES (p = 0.017) in the PEMV group compared to the PE group. According to the scanning electron microscope results, combined administration of VitD and MgSO4 is more effective than separate administration in improving cochlear degeneration induced by PE.

Conclusion

The administration of Vit D and MgSO4 during pregnancy has beneficial effects on PE pathology and may play a significant role in preventing PE-related complications, including cochlear degeneration.

Differences in epidemiology of patients with preeclampsia between China and the US (Review)

Preeclampsia (PE) is a complex complication that occurs during pregnancy. Studies indicated that morbidity from PE exhibits marked variations among geographical areas. Disparities in the incidence of PE between China and the US may be due to differences in ethnicity and genetic susceptibility, maternal age, sexual culture, body mass index, diet, exercise, multiple pregnancies and educational background. These epidemiological differences may give rise to differences between the two countries in terms of diagnostic and therapeutic criteria for PE. PE may be largely attributed to susceptibility genes and lifestyles, such as diet, body mass index and cultural norms regarding sexual relationships. The epidemiologic differences of patients with PE between the two countries indicated that appropriate prevention plans for PE require to be developed according to local conditions.

'Magnesium'-the master cation-as a drug-possibilities and evidences

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.

Efficacy and safety of low dose aspirin and magnesium sulfate in the treatment of pregnancy induced hypertension: A protocol for systematic review and meta-analysis

BACKGROUND

Magnesium sulfate combined with low-dose aspirin can significantly reduce adverse reactions and effectively lower blood pressure in patients with pregnancy induced hypertension, but the overall efficacy and safety of the combination of drugs are not clear. The purpose of this study was to evaluate the efficacy and safety of magnesium sulfate combined with low-dose aspirin in the treatment of pregnancy induced hypertension.

METHODS

Randomized controlled trials focusing on the administration of magnesium sulfate combined with low-dose aspirin for pregnancy induced hypertension were searched from PubMed, EMbase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), WanFang, and the Chongqing VIP Chinese Science and Technology Periodical Database. Two researchers independently screened titles, abstracts, and full texts, and extracted relevant data. The RevMan 5.3 software and Stata 14 software were used for statistical analysis.

RESULTS

The effect and safety of magnesium sulfate combined with low-dose aspirin in the treatment of pregnancy induced hypertension were assessed by summarizing the related randomized controlled trials.

CONCLUSION

This article provides theoretical support for the clinical application of magnesium sulfate combined with low-dose aspirin in the treatment of pregnancy induced hypertension.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/SZFGB.

Animal Models of Preeclampsia: Causes, Consequences, and Interventions

Preeclampsia is a common pregnancy complication, affecting 2% to 8% of pregnancies worldwide, and is an important cause of both maternal and fetal morbidity and mortality. Importantly, although aspirin and calcium are able to prevent preeclampsia in some women, there is no cure apart from delivery of the placenta and fetus, often necessitating iatrogenic preterm birth. Preclinical models of preeclampsia are widely used to investigate the causes and consequences of preeclampsia and to evaluate safety and efficacy of potential preventative and therapeutic interventions. In this review, we provide a summary of the published preclinical models of preeclampsia that meet human diagnostic criteria, including the development of maternal hypertension, together with new-onset proteinuria, maternal organ dysfunction, and uteroplacental dysfunction. We then discuss evidence from preclinical models for multiple causal factors of preeclampsia, including those implicated in early-onset and late-onset preeclampsia. Next, we discuss the impact of exposure to a preeclampsia-like environment for later maternal and progeny health. The presence of long-term impairment, particularly cardiovascular outcomes, in mothers and progeny after an experimentally induced preeclampsia-like pregnancy, implies that later onset or reduced severity of preeclampsia will improve later maternal and progeny health. Finally, we summarize published intervention studies in preclinical models and identify gaps in knowledge that we consider should be targets for future research.

Magnesium sulfate versus esomeprazole impact on the neonates of preeclamptic rats

OBJECTIVE

Preeclampsia represents a major complication of pregnancy, associated with greater maternal and fetal complications. We compared the effects of esomeprazole (a proton pump inhibitor) and magnesium sulfate (MgSO4) on the deleterious effects observed on the mother and neonates in experimentally induced preeclampsia in rats.

STUDY DESIGN

Preeclampsia was induced in pregnant rats with NG-nitro-l-arginine methyl ester (L-NAME) starting from day 10-till end of pregnancy. Pregnant rats were divided into four groups: control pregnant; untreated preeclampsia; preeclamptic rats treated with MgSO4 and preeclamptic treated with esomeprazole. Treatment was started on day 14 and continued until end of pregnancy. Systolic blood pressure, gestation duration, the total number of pups/fetal resorption, pups birth weight, and histopathology examination of the pup's organs were recorded.

RESULTS

In comparison with the L-NAME group, the MgSO4 and esomeprazole treatment reduced the values of systolic blood pressure; MgSO4 normalized gestational duration while esomeprazole prolonged it (post-term pregnancy); both restored number of delivered pups; with no statistical differences between the numbers of died pups between the four groups studied while with esomeprazole, out of 10 pregnant females, 2 of them had complete intrauterine fetal resorption; esomeprazole normalized birth weight and histological structure of fetal liver, kidney, and brain. On the other side, MgSO4 treatment gave rise to lower than normal birth weight and minimal tissue damage.

CONCLUSION

Esomeprazole and MgSO4 improved systolic blood pressure, prevented preterm labor and restored numbers of pups delivered and fetal weight. Esomeprazole prolonged gestational period post-term with subsequent improving reproductive outcome.

Magnesium sulfate and ophthalmic artery Doppler velocimetry in patients with severe preeclampsia: a case series

Background

In the present study, we used Doppler velocimetry in the ophthalmic artery to evaluate the hemodynamic status of the intracranial vasculature. This is the first time in the literature that indices of ophthalmic artery Doppler sonography of women with preeclampsia were evaluated before and after the use of magnesium sulfate to prevent eclampsia.

Case presentation

Indices of ophthalmic artery Doppler sonography of six women with severe preeclampsia at 27 to 33 weeks of gestational age were evaluated before and after the use of magnesium sulfate (10 minutes, 30 minutes, and 60 minutes after the magnesium sulfate loading dosage. The patients’ ages were 26 years (patient 01), 29 years (patient 02), 20 years (patient 03), 21 years (patient 04), 20 years (patient 05), and 19 years (patient 06). The ethnic group of patients 01 and 04 was white and the ethnic group of patients 02, 03, 05 and 06 was mulatto.

Conclusions

The apparent increase in resistance index and pulsatility index values, although there is no statistical significance in this series of cases, and the decrease in peak ratio values after the administration of magnesium sulfate reflect an increase in the impedance to flow in the ophthalmic artery and consequently a reduction in cerebral perfusion after the use of magnesium sulfate. This may explain how magnesium sulfate protects women with severe preeclampsia against cerebral damage and prevents acute convulsions in these patients. We believe that this case series report may have a broader clinical impact across medicine because the mechanism of how magnesium sulfate can protect patients and prevent acute convulsions is controversial.

Magnesium in obstetric anesthesia and intensive care

Magnesium, one of the essential elements in the human body, has numerous favorable effects that offer a variety of possibilities for its use in obstetric anesthesia and intensive care. Administered as a single intravenous bolus dose or a bolus followed by continuous infusion during surgery, magnesium attenuates stress response to endotracheal intubation, and reduces intraoperative anesthetic and postoperative analgesic requirements, while at the same time preserving favorable hemodynamics. Applied as part of an intrathecal or epidural anesthetic mixture, magnesium prolongs the duration of anesthesia and diminishes total postoperative analgesic consumption with no adverse maternal or neonatal effects. In obstetric intensive care, magnesium represents a first-choice medication in the treatment and prevention of eclamptic seizures. If used in recommended doses with close monitoring, magnesium is a safe and effective medication.

Magnesium sulphate can prolong pregnancy in patients with severe early-onset preeclampsia

OBJECTIVE

To assess whether long-term use of magnesium sulphate prolongs pregnancy in patients with severe early-onset preeclampsia.

METHODS

Retrospective cohort study included all singleton pregnancies with severe early-onset preeclampsia, expectantly managed in our institution between 2005 and 2013. Obstetric and perinatal outcomes were compared between patients managed using a current protocol that tolerates long-term (over 48 h) use of magnesium sulphate (long-term group, n = 26) and a historical control group (control group, n = 15) that underwent conventional treatment (up to 48 h use of magnesium sulphate).

RESULTS

Long-term group showed significant prolongation of pregnancy compared with the control group (9.2 ± 7.9 versus 16.6 ± 9.3 d, log-rank test, p = 0.021), which was also observed in patients with severe preeclampsia occurring before 28 weeks' gestation (n = 11, 4.5 ± 5.2 versus 13.2 ± 6.8 d, log-rank test, p = 0.035). In contrast to a progressive decrease of platelet count in patients managed without magnesium sulphate, administration of magnesium sulphate for 7 d prevented the decrease of platelet count (p = 0.001). Thirty two percent of patients (13/41) experienced a major complication irrespective of duration of magnesium sulphate use.

CONCLUSIONS

Long-term use of magnesium sulphate prolonged pregnancy in patients with severe early-onset preeclampsia and can help alleviate progression of preeclampsia.

Tanshinone II-A is protective against human umbilical vein endothelial cell injury after exposure to serum from preeclampsia patients

BACKGROUND/AIMS

Preeclampsia (PE) is one of the most common and dangerous complications during pregnancy and is characterized by high blood pressure and significant amounts of protein in the urine. Vascular endothelial cell dysfunction is the major pathology in PE. This study was designed to assay the effects of tanshinone II-A (TII-A) on human umbilical vein endothelial cell (HUVEC) injury after incubation with serum from PE patients and to determine the underlying mechanism.

METHODS

After treating HUVECs with different TII-A concentrations, cell viability, apoptosis and CD40/CD40 ligand (CD40L) mRNA and protein expression levels were measured.

RESULTS

Incubation of HUVECs with serum from PE patients induced morphological alterations, caused decreased cell viability and increased the rate of apoptosis. However, TII-A (5-40 μg/ml) significantly reversed these injuries. Importantly, preapplication of TII-A attenuated PE sera-induced expression of CD40 and CD40L mRNA and protein.

CONCLUSION

TII-A has a protective effect against PE sera, likely through regulation of the CD40/CD40L signal transduction pathway.

Is ethnicity a risk factor for developing preeclampsia? An analysis of the prevalence of preeclampsia in China

Preeclampsia is a major complication of pregnancy. Risk factors for preeclampsia include population and regional ethnicity. Chinese women living outside the Chinese mainland have a lower prevalence of preeclampsia than resident Caucasians. We performed a retrospective study to identify potential factors that may be associated with developing preeclampsia in China. A total of 67,746 pregnant women were included in this study from 2002 to 2011. Data included maternal age, maternal body mass index (BMI), age at marriage, parity, gestation and blood pressure at diagnosis, proteinuria, and birth weight. In the study period, 1301 (1.92%) nulliparous women developed preeclampsia. The prevalence of mild or severe preeclampsia was 1.42% or 0.49%, respectively. The average BMI was 21.61 kg m(-2). On the basis of the WHO BMI classification, 78.8% of women were of normal BMI, 18.3% were overweight and 2.9% were obese. A total of 37.8% of preeclamptic women had lived with the same partner for less than 1 year, which was significantly higher than those healthy pregnant women who did not develop preeclampsia (24.2%). The prevalence of preeclampsia in China is low compared with Caucasians, and the contribution to this lower prevalence may be dependent on BMI or lifestyle including period of cohabitation with the partner. Our data suggest that Chinese ethnicity may be a factor responsible for the low risk of developing preeclampsia in the populations studied.