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Mowafy SMS, Medhat MM. Evaluation of intravenous infusion of labetalol versus magnesium sulfate on cerebral hemodynamics of preeclampsia patients with severe features using transcranial doppler. J Clin Monit Comput 2023:10.1007/s10877-023-01006-4. [PMID: 37074522 PMCID: PMC10372116 DOI: 10.1007/s10877-023-01006-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 04/01/2023] [Indexed: 04/20/2023]
Abstract
PURPOSE It is essential to understand the underlying pathophysiological mechanisms of preeclampsia cerebral complications. This study aimed to compare the cerebral hemodynamic effects of magnesium sulfate (MgSO4) and labetalol in pre-eclampsia patients with severe features. METHODS Singleton pregnant women who suffered from late onset preeclampsia with severe features were enrolled and subjected to baseline Transcranial doppler (TCD) evaluation and then randomly assigned to either the magnesium sulfate group or labetalol group. TCD to measure middle cerebral artery (MCA) blood flow indices including mean flow velocity (cm/s), mean end-diastolic velocity (DIAS), and pulsatility index (PI) and to estimate CPP and MCA velocity were performed as basal measurements before study drug administration and at post-treatment one and six hours after administration. The occurrence of seizures and any adverse effects were recorded for each group. RESULTS Sixty preeclampsia patients with severe features were included and randomly allocated into two equal groups. In group M the PI was 0.77 ± 0.04 at baseline versus 0.66 ± 0.05 at 1hour and 0.66 ± 0.05 at 6 hours after MgSO4 administration (p value < 0.001) also the calculated CPP was significantly decreased from 103.3 ± 12.7mmHg to 87.8 ± 10.6mmHg and 89.8 ± 10.9mmHg (p value < 0.001) at 1 and 6 hours respectively. Similarly, in group L the PI was significantly decreased from 0.77 ± 0.05 at baseline to 0.67 ± 0.05 and 0.67 ± 0.06 at 1 and 6 hours (p value < 0.001) after labetalol administration. Moreover, the calculated CPP was significantly decreased from 103.6 ± 12.6 mmHg to 86.2 ± 13.02mmHg at 1 hour and to 83.7 ± 14.6mmHg at 6 hours (p value < 0.001). In terms of changes in blood pressure and the heart rate, they were significantly lower in the labetalol group. CONCLUSION Both magnesium sulfate and labetalol reduce CPP while maintaining cerebral blood flow (CBF) in preeclampsia patients with severe features. TRIAL REGISTRATION The institutional review board of the Faculty of Medicine, Zagazig University approved this study with the reference number (ZU-IRB#: 6353-23-3-2020) and it was registered at clinicaltrials.gov (NCT04539379).
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Affiliation(s)
- Sherif M S Mowafy
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Marwa M Medhat
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Zagazig University, Zagazig, Egypt.
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Jitsinthunun T, Raksakietisak M, Pantubtim C, Mahatnirunkul P. Effects of Magnesium Sulfate on Intraoperative Blood Loss and Anesthetic Requirement in Meningioma Patients Undergoing Craniotomy with Tumor Removal: A Prospective Randomized Study. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2022. [DOI: 10.1055/s-0042-1750692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
Abstract
Background Meningioma brain tumor is associated with significant blood loss. Magnesium (Mg), a calcium blocker, can facilitate blood pressure control during surgery. This study aimed to evaluate effects of magnesium on blood loss, anesthetic requirement, and its neuroprotective effect in meningioma patients undergoing craniotomy.
Methods Eighty patients aged between 18 and 70, American Society of Anesthesiologists physical status I and II, diagnosed with meningioma and scheduled for craniotomy tumor removal were randomized into two groups. Group M (Mg) received intravenous magnesium sulfate 40 mg/kg over 30 minutes initiated at skin incision and followed by continuous infusion of 10 mg/kg/h until dura closure. Group N (NSS) received 0.9% NaCl as placebo. Anesthesiologists in charge, surgeons, and patients were all blinded. The assessed outcomes were perioperative blood loss, anesthetic requirement, and pre- and postoperative neurocognitive functions assessed by Montreal Cognitive Assessment (MoCA).
Results Thirty-eight patients in each group were analyzed. In group M, the intraoperative blood losses were 500 (70, 2300) mL, and 510 (100, 1600) mL in group N (p = 0.315). Patients who received blood within 24 hours were 39.5% in group M and 47.4% in group N (p = 0.644). No differences were observed in anesthetic requirement, intraoperative mean arterial pressure, hypotensive episodes, and vasopressor usages. There were no significant differences in postoperative MoCA score. Magnesium levels did not exceed acceptable levels.
Conclusions Magnesium administration in meningioma patients had no significant effects on blood loss, anesthetic requirement, and postoperative cognitive function.
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Affiliation(s)
- Thanawut Jitsinthunun
- Department of Anaesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Manee Raksakietisak
- Department of Anaesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chanitda Pantubtim
- Department of Anaesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Porntip Mahatnirunkul
- Department of Anaesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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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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Pergialiotis V, Bellos I, Constantinou T, Voskos A, Papapanagiotou A, Loutradis D, Daskalakis G. Magnesium sulfate and risk of postpartum uterine atony and hemorrhage: A meta-analysis. Eur J Obstet Gynecol Reprod Biol 2020; 256:158-164. [PMID: 33246200 DOI: 10.1016/j.ejogrb.2020.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 11/05/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Magnesium sulfate (MgSO4) is among the most commonly used medications in labor and delivery units. It has been used as a mean to protect against eclampsia and a neuroprotective agent for fetuses at risk of preterm birth. In the present study we investigated its impact in the occurrence of postpartum uterine atony and hemorrhage. METHODS We searched the Medline, Scopus, EMBASE, Cochrane Central Register of Controlled Trials CENTRAL, Clinicaltrials.gov and Google Scholar databases for randomized trials and observational studies. Statistical analysis was performed with the Hartung-Knapp-Sidik-Jonkman model in RStudio using the meta package. RESULTS Twelve studies fitted the predetermined criteria and these involved 41,190 women of whom 10,565 (25.6 %) received MgSO4. The meta-analysis revealed that the risk of postpartum uterine atony was similar among patients that received MgSO4 and those that did not (OR 1.93, 95 % CI 0.78, 4.81). Estimated blood loss (SMD 0.04, 95 % CI -0.10, 0.18) as well as the risk of postpartum hemorrhage (OR 1.82, 95 % CI 0.99, 3.35) also did not differ. Subgroup analysis revealed that evidence drawn from observational studies indicates a significant effect of MgSO4 on the odds of postpartum uterine atony and hemorrhage; however, randomized trials do not support this. CONCLUSIONS The results of our meta-analysis suggest that it is reasonable to consider MgSO4 in women at risk of delivering before the completion of its elimination half-life. However, physicians should be vigilant in cases at risk of postpartum hemorrhage as current data are very heterogeneous and should not be considered as definitive.
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Affiliation(s)
- Vasilios Pergialiotis
- Laboratory of Experimental Surgery and Surgical Research N.S Christeas, National and Kapodistrian University of Athens, Greece; 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Greece.
| | - Ioannis Bellos
- Laboratory of Experimental Surgery and Surgical Research N.S Christeas, National and Kapodistrian University of Athens, Greece
| | - Therapon Constantinou
- Laboratory of Experimental Surgery and Surgical Research N.S Christeas, National and Kapodistrian University of Athens, Greece
| | - Andreas Voskos
- Laboratory of Experimental Surgery and Surgical Research N.S Christeas, National and Kapodistrian University of Athens, Greece
| | - Angeliki Papapanagiotou
- Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Loutradis
- 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Greece
| | - George Daskalakis
- 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Greece
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Cha HH, Hwang JR, Sung JH, Choi SJ, Oh SY, Roh CR. Changes in calcium channel proteins according to magnesium sulfate administration in placentas from pregnancies with pre-eclampsia or fetal growth restriction. J Investig Med 2018; 67:319-326. [PMID: 30415221 PMCID: PMC6581081 DOI: 10.1136/jim-2018-000844] [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] [Accepted: 09/07/2018] [Indexed: 11/06/2022]
Abstract
We aimed to evaluate the changes in plasma membrane Ca2+-ATPase (PMCA) and sarcoendoplasmic reticulum CA2+-ATPase (SERCA-2) according to the antepartal magnesium sulfate (MgSO4) administration in the placentas from pregnancies with pre-eclampsia (PE) or fetal growth restriction (FGR). Pregnant women were classified as follows: (group 1) pregnancies without PE or FGR (n=16), (group 2) pregnancies with PE or FGR but without MgSO4 administration (n=14), and (group 3) pregnancies with PE or FGR and with MgSO4 administration (n=28). We observed the localization of PMCA and SERCA-2 in placentas and compared its expression among 3 groups. And we observed its expression in BeWo cells following treatment with MgSO4 and CoCl2. PMCA staining was more observed in the basal membrane, whereas SERCA-2 staining was observed predominantly under the microvillous membrane. SERCA-2 expression was significantly increased in group 3 compared with that in group 1. Considering the gestational age at delivery, PMCA expression was increased in group 2 and group 3 compared with that in group 1 after 36 weeks of gestation. SERCA-2 was increased in group 3, but not in group 2 compared with that in group 1 after 36 weeks of gestation. In BeWo cells, MgSO4 treatment increased PMCA and SERCA-2 expression. PMCA expression was influenced by gestational age at delivery, and SERCA-2 expression was increased in the presence of PE and antepartal MgSO4 administration. This indicates that antepartal MgSO4 administration has a greater influence on SERCA-2 than PMCA.
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Affiliation(s)
- Hyun-Hwa Cha
- Department of Obstetrics and Gynecology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jae-Ryoung Hwang
- Sungkynkwan University School of Medicine, Samsung Biomedical Research Institute, Samsung Medical Center, Seoul, Korea
| | - Ji Hee Sung
- Department of Obstetrics and Gynecology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Suk-Joo Choi
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Soo-Young Oh
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Cheong-Rae Roh
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Kane SC, Brennecke SP, da Silva Costa F. Ophthalmic artery Doppler analysis: a window into the cerebrovasculature of women with pre-eclampsia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 49:15-21. [PMID: 27485824 DOI: 10.1002/uog.17209] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 07/22/2016] [Indexed: 05/27/2023]
Affiliation(s)
- S C Kane
- University of Melbourne, Department of Obstetrics and Gynaecology, The Royal Women's Hospital, Parkville, Victoria, Australia
- Pregnancy Research Centre, Department of Maternal Fetal Medicine, The Royal Women's Hospital, Parkville, Victoria, Australia
| | - S P Brennecke
- University of Melbourne, Department of Obstetrics and Gynaecology, The Royal Women's Hospital, Parkville, Victoria, Australia
- Pregnancy Research Centre, Department of Maternal Fetal Medicine, The Royal Women's Hospital, Parkville, Victoria, Australia
| | - F da Silva Costa
- University of Melbourne, Department of Obstetrics and Gynaecology, The Royal Women's Hospital, Parkville, Victoria, Australia
- Perinatal Services, Monash Health, Clayton, Victoria, Australia
- Monash Ultrasound for Women, Clayton, Victoria, Australia
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Abstract
Hypertensive disorders of pregnancy complicate approximately 10% of all deliveries in the United States and are a leading cause of maternal and fetal morbidity and mortality. Preeclampsia is defined as hypertension in association with proteinuria, thrombocytopenia, impaired liver function, renal insufficiency, pulmonary edema, or new-onset cerebral or visual disturbances. The greatest risk factor for the development of preeclampsia is a history of preeclampsia. There currently is no effective means for the prevention of preeclampsia. Approximately 39% of patients diagnosed with preeclampsia have hypertension and approximately 20% have proteinuria 3 months postpartum. Preeclampsia increases the risk of patients developing hypertension later in life.
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Affiliation(s)
- Nerlyne K Dhariwal
- Department of Anesthesiology, Emory University, 1354 Clifton Road Northeast, Atlanta, GA 30322, USA
| | - Grant C Lynde
- Department of Anesthesiology, Emory University, 1354 Clifton Road Northeast, Atlanta, GA 30322, USA.
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Cerebral oximetry assessed by near-infrared spectrometry during preeclampsia: an observational study: impact of magnesium sulfate administration. Crit Care Med 2014; 42:2379-86. [PMID: 25072763 DOI: 10.1097/ccm.0000000000000519] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To determine the regional cerebral oxygen saturation of hemoglobin (rcSO2) in severe preeclamptic parturients exhibiting neurologic symptoms compared with healthy pregnant women (control) and to describe the effects of MgSO4 infusion on rcSO2 and cerebral and systemic hemodynamic variables. DESIGN Prospective, observational study. SETTING Obstetric critical care unit in a university-affiliated hospital. PATIENTS Twenty severe preeclamptic parturients presenting with neurologic signs before any administration of MgSO4, and 20 control parturients. INTERVENTION Infusion of MgSO4 in severe preeclamptic patients. MEASUREMENTS AND MAIN RESULTS We measured rcSO2 using near-infrared spectroscopy, blood flow velocities of the middle cerebral artery, and cardiac output at baseline, 5 minutes, 1 hour, and 6 hours after the MgSO4 bolus (4 g), followed by continuous MgSO4 infusion (1 g/h). These measurements were also obtained in 20 control parturients at baseline and 6 hours. Baseline rcSO2 was significantly lower in the severe preeclamptic group: 61% (56-69) vs 66% (63-71) (p = 0.037). At inclusion, blood pressures were significantly higher in the severe preeclamptic group compared with the control group, whereas cardiac output and transcranial Doppler readings were similar. Five minutes after the MgSO4 bolus infusion, a median increase of 8.6% (3.2-18.1) in rcSO2 was observed (p = 0.007), reaching values of the control group that were maintained up to 6 hours. Blood pressures and systolic velocities of the middle cerebral artery significantly decreased (p < 0.01) after the MgSO4 bolus, whereas cardiac output did not change. The percentage increase in rcSO2 was negatively correlated to the mean blood pressure (r = 0.60, p < 0.0001). CONCLUSION Cerebral oxygenation impairment can be detected by near-infrared spectroscopy monitoring in severe preeclamptic parturients. These results suggested the presence of disorders in cerebral microcirculation and/or changes in cerebral oxygenation. MgSO4 infusion in patients with severe preeclampsia restored rcSO2 to control levels with no systemic side effects. Further studies are needed to confirm the usefulness of near-infrared spectroscopy monitoring in patients with preeclampsia and to assess the action of other antihypertensive therapies on rcSO2.
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Farshchian N, Rezavand N, Mohammadi S. Effect of magnesium sulfate on Doppler parameters of fetal umbilical and middle cerebral arteries in women with severe preeclampsia. J Clin Imaging Sci 2012; 2:85. [PMID: 23393641 PMCID: PMC3551494 DOI: 10.4103/2156-7514.105269] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Accepted: 11/08/2012] [Indexed: 12/02/2022] Open
Abstract
Objective: To assess the effect of injecting magnesium sulfate on Doppler parameters of fetal umbilical and middle cerebral arteries (MCA) in women with severe preeclampsia. Materials and Methods: A total of 21 patients with severe preeclampsia admitted to Imam Reza Hospital, Kermanshah (Iran), were evaluated. Before and after administration of magnesium sulfate, Doppler ultrasound scan was carried out to measure fetal middle cerebral artery and umbilical artery blood flow. Paired t-test was used for statistical analysis. Results: After injection of magnesium sulfate, the mean resistivity index (RI)-umbilical, and pulsatility index (PI)-cerebral showed a statistically significant reduction (P < 0.001). The cerebroumbilical C/U ratio increased after the intervention (P < 0.001). The PI-umbilical (P = 0.1) and pre- and post-RI-cerebral (P = 0.96) did not have statistically significant changes. Conclusions: Infusion of magnesium sulfate significantly decreases the flow in the fetus RI-umbilical and PI-MCA, and it increases C/U ratio indices in color Doppler ultrasound.
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Affiliation(s)
- Nazanin Farshchian
- Department of Radiology, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Wareing M. Effects of oxygenation and luminal flow on human placenta chorionic plate blood vessel function. J Obstet Gynaecol Res 2011; 38:185-91. [DOI: 10.1111/j.1447-0756.2011.01666.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
BACKGROUND AND PURPOSE Magnesium sulfate is used extensively for prevention of eclamptic seizures. Empirical and clinical evidence supports the effectiveness of magnesium sulfate; however, questions remain as to its safety and mechanism. This review summarizes current evidence supporting the possible mechanisms of action and several controversies for magnesium sulfate treatment. SUMMARY OF REVIEW Several mechanisms are presented, including the effects of magnesium sulfate on peripheral and cerebral vasodilation, blood-brain barrier protection, and as an anticonvulsant. CONCLUSIONS Though the specific mechanisms of action remain unclear, the effect of magnesium sulfate in the prevention of eclampsia is likely multi-factorial. Magnesium sulfate may act as a vasodilator, with actions in the peripheral vasculature or the cerebrovasculature, to decrease peripheral vascular resistance or relieve vasoconstriction. Additionally, magnesium sulfate may also protect the blood-brain barrier and limit cerebral edema formation, or it may act through a central anticonvulsant action.
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Affiliation(s)
- Anna G Euser
- Department of Neurology, University of Vermont, Burlington, VT 05405, USA
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Euser AG, Bullinger L, Cipolla MJ. Magnesium sulphate treatment decreases blood-brain barrier permeability during acute hypertension in pregnant rats. Exp Physiol 2007; 93:254-61. [PMID: 17933863 DOI: 10.1113/expphysiol.2007.039966] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Eclampsia is associated with increased blood-brain barrier (BBB) permeability and formation of cerebral oedema. Magnesium sulphate is used to treat eclampsia despite an unclear mechanism of action. This study was to determine the effect of magnesium sulphate on in vivo BBB permeability and formation of cerebral oedema during acute hypertension and on brain aquaporin-4 (AQP4) protein expression. An in vivo model of hypertensive encephalopathy was used in late-pregnant (LP) rats following magnesium sulphate treatment, 270 mg kg(-1) i.p. injection every 4 h for 24 h. Permeability of the BBB was determined by in situ brain perfusion of Evan's Blue (EB) and sodium fluorescein (NaFl), and dye clearance determined by fluorescence spectrophotometry. Cerebral oedema was determined following acute hypertension by measuring brain water content. The effect of magnesium treatment on AQP4 expression was determined by Western blot analysis. Acute hypertension with autoregulatory breakthrough increased BBB permeability to EB in both brain regions studied (P < 0.05). Magnesium attenuated BBB permeability to EB during acute hypertension by 41% in the posterior cerebrum (P < 0.05) but had no effect in the anterior cerebrum (P > 0.05). Treatment with magnesium did not change NaFl permeability, cerebral oedema formation or AQP4 expression. In summary, BBB permeability to Evan's Blue was increased by acute hypertension in LP rats, and this was attenuated by treatment with magnesium sulphate. The greatest effect on BBB permeability to EB was in the posterior cerebrum, an area particularly susceptible to oedema formation during eclampsia.
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Affiliation(s)
- Anna G Euser
- University of Vermont, Department of Neurology, 89 Beaumont Avenue, Given C454, Burlington, VT 05405, USA
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Belfort MA, Clark SL, Sibai B. Cerebral Hemodynamics in Preeclampsia: Cerebral Perfusion and the Rationale for an Alternative to Magnesium Sulfate. Obstet Gynecol Surv 2006; 61:655-65. [PMID: 16978425 DOI: 10.1097/01.ogx.0000238670.29492.84] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
UNLABELLED Preeclampsia and eclampsia continue to be major causes of maternal death. Currently, approximately 18% of U.S. maternal deaths are attributed to hypertensive disorders and eclampsia, and several hundred women die from eclampsia and its complications every year. In the United States, preeclamptic women have received magnesium sulfate as a seizure prophylaxis agent for 3 decades, and this practice is becoming more widely accepted internationally. In addition to a recognized failure rate, there are financial, logistic, and safety concerns associated with the universal administration of magnesium sulfate. Many institutions in the developing world lack the necessary equipment and expertise to administer the medication, and many preeclamptic patients thus do not receive magnesium sulfate before their first seizure. As effective as it has been in reducing mortality from eclampsia, magnesium sulfate is also associated with appreciable morbidity and mortality from administration errors and magnesium toxicity. The availability of an easily administered, cheap, safe, and orally administered alternative to magnesium sulfate would be welcomed in the developing world and would provide an extremely useful alternative therapy to the current standard of care. Recent advances in the understanding of the pathophysiology of preeclampsia and eclampsia, primarily related to cerebral perfusion and blood flow, could allow us to reduce the seizure rate in treated preeclamptic women even further than what is currently reported. This article deals with the rationale behind the use of labetalol as an alternative to magnesium sulfate for the prevention of eclampsia. TARGET AUDIENCE Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES After completion of this article, the reader should be able to recall that hypertensive diseases of pregnancy contribute a significant portion of today's maternal mortality, explain that methods of preventing eclampsia are not applicable worldwide, and state that understanding of the pathophysiology of preeclampsia/eclampsia may assist in developing safe and effective medications that can be used universally.
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Affiliation(s)
- Michael A Belfort
- St. Marks Hospital and University of Utah School of Medicine, Salt Lake City, Utah 84124, USA.
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