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Kovo M, Berman E, Odeh H, Luria O, Beloosesky R, Bar J. The effects of inflammation and acidosis on placental blood vessels reactivity. Placenta 2023; 144:8-12. [PMID: 37949032 DOI: 10.1016/j.placenta.2023.10.012] [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: 05/01/2023] [Revised: 10/04/2023] [Accepted: 10/26/2023] [Indexed: 11/12/2023]
Abstract
INTRODUCTION Inflammation and acidosis are two stress stimuli that correspond to pathophysiological processes occurring in placental-mediated vascular disorders. We aimed to investigate the effects of these stimuli on placental chorionic blood vessels reactivity using the ex-vivo placental perfusion model. METHODS Term placentas were obtained immediately after cesarean deliveries, and selected cotyledons were cannulated and dually perfused ex-vivo. Placentas were perfused with three different protocols: culture medium (M199-controls, n = 5), culture medium with lipopolysaccharide (inflammatory stimuli) (LPS,1 μg/ml, n = 7), and acidotic culture medium (M - 199, pH: 6.9-7, n = 6). Each perfusion experiment was maintained for 180 min. Fetal perfusion pressure was continuously measured. Measurements in response to angiotensin II (AT II) at the end of the perfusion were compared between the treatment groups, including amplitude of the contraction response, relaxation factor, time to maximal constriction and the area under the pressure curve (AUC). RESULTS In response to ATII there was a significant difference in the amplitude of the contraction and the AUC between the treatment groups, (p = 0.049, p = 0.015, respectively). As compared with control perfused cotyledon, the inflammatory stimuli significantly increased the vasoconstriction response to ATII in fetal placental blood vessels, as expressed by increased AUC - median (IQR): 555 (235-1184) vs. 133 (118-207), respectively, p = 0.017. The time to maximal constriction and the relaxation factor did not differ between the groups. DISCUSSION Inflammatory stimuli but not acidosis impact fetal-placental vasculature in response to ATII, suggesting that inflammation can compromise vascular function.
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Affiliation(s)
- Michal Kovo
- Meir Medical Center, Kfar Saba, Israel; Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel.
| | - Erez Berman
- Wolfson Medical Center, Holon, Israel; Institute for Drug Research, School of Pharmacy, The Hebrew University of Jerusalem, Israel
| | - Hind Odeh
- Wolfson Medical Center, Holon, Israel
| | - Oded Luria
- Faculty of Biomedical Engineering, Tel Aviv University, Tel-Aviv, Israel
| | | | - Jacob Bar
- Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel; Wolfson Medical Center, Holon, Israel
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2
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Tropea T, Mavichak W, Evangelinos A, Brennan-Richardson C, Cottrell EC, Myers JE, Johnstone ED, Brownbill P. Fetoplacental vascular effects of maternal adrenergic antihypertensive and cardioprotective medications in pregnancy. J Hypertens 2023; 41:1675-1687. [PMID: 37694528 PMCID: PMC10552840 DOI: 10.1097/hjh.0000000000003532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 06/07/2023] [Accepted: 07/24/2023] [Indexed: 09/12/2023]
Abstract
Maternal cardiovascular diseases, including hypertension and cardiac conditions, are associated with poor fetal outcomes. A range of adrenergic antihypertensive and cardioprotective medications are often prescribed to pregnant women to reduce major maternal complications during pregnancy. Although these treatments are not considered teratogenic, they may have detrimental effects on fetal growth and development, as they cross the fetoplacental barrier, and may contribute to placental vascular dysregulation. Medication risk assessment sheets do not include specific advice to clinicians and women regarding the safety of these therapies for use in pregnancy and the potential off-target effects of adrenergic medications on fetal growth have not been rigorously conducted. Little is known of their effects on the fetoplacental vasculature. There is also a dearth of knowledge on adrenergic receptor activation and signalling within the endothelium and vascular smooth muscle cells of the human placenta, a vital organ in the maintenance of adequate blood flow to satisfy fetal growth and development. The fetoplacental circulation, absent of sympathetic innervation, and unique in its reliance on endocrine, paracrine and autocrine influence in the regulation of vascular tone, appears vulnerable to dysregulation by adrenergic antihypertensive and cardioprotective medications compared with the adult peripheral circulation. This semi-systematic review focuses on fetoplacental vascular expression of adrenergic receptors, associated cell signalling mechanisms and predictive consequences of receptor activation/deactivation by antihypertensive and cardioprotective medications.
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Affiliation(s)
- Teresa Tropea
- Maternal & Fetal Health Research Centre, Division of Developmental Biology & Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester
- St Mary's Hospital, Manchester University Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Weerawaroon Mavichak
- Maternal & Fetal Health Research Centre, Division of Developmental Biology & Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester
- St Mary's Hospital, Manchester University Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Angelos Evangelinos
- Maternal & Fetal Health Research Centre, Division of Developmental Biology & Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester
- St Mary's Hospital, Manchester University Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Charlotte Brennan-Richardson
- Maternal & Fetal Health Research Centre, Division of Developmental Biology & Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester
- St Mary's Hospital, Manchester University Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Elizabeth C. Cottrell
- Maternal & Fetal Health Research Centre, Division of Developmental Biology & Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester
- St Mary's Hospital, Manchester University Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Jenny E. Myers
- Maternal & Fetal Health Research Centre, Division of Developmental Biology & Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester
- St Mary's Hospital, Manchester University Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Edward D. Johnstone
- Maternal & Fetal Health Research Centre, Division of Developmental Biology & Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester
- St Mary's Hospital, Manchester University Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Paul Brownbill
- Maternal & Fetal Health Research Centre, Division of Developmental Biology & Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester
- St Mary's Hospital, Manchester University Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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3
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de Queiroz DV, Velarde LGC, Alves RL, Verçosa N, Cavalcanti IL. Incidence of bradycardia during noradrenaline or phenylephrine bolus treatment of postspinal hypotension in cesarean delivery: A randomized double-blinded controlled trial. Acta Anaesthesiol Scand 2023; 67:797-803. [PMID: 36866963 DOI: 10.1111/aas.14225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 01/27/2023] [Accepted: 02/15/2023] [Indexed: 03/04/2023]
Abstract
The treatment of choice for spinal anesthesia-induced hypotension during cesarean section is phenylephrine. As this vasopressor can cause reflex bradycardia, noradrenaline is a suggested alternative. This randomized double-blinded controlled trial included 76 parturients undergoing elective cesarean delivery under spinal anesthesia. Women received noradrenaline in bolus doses of 5 mcg or phenylephrine in bolus doses of 100 mcg. These drugs were used intermittently and therapeutically to maintain systolic blood pressure ≥ 90% of its baseline value. The primary study outcome was bradycardia incidence (<60 bpm) with intermittent bolus administration of these drugs. Secondary outcomes included extreme bradycardia (<40 bpm), number of bradycardia episodes, hypertension (systolic blood pressure > 120% of baseline value), and hypotension (systolic blood pressure < 90% of baseline value and requiring vasopressor use). Neonatal outcomes per the Apgar scale and umbilical cord blood gas analysis were also compared. The incidence of bradycardia in both groups (51.4% and 70.3%, respectively; p = 0.16) were not significantly different. No neonates had umbilical vein or artery pH values below 7.20. The noradrenaline group required more boluses than phenylephrine group (8 vs. 5; p = 0.01). There was no significant intergroup difference in any of the other secondary outcomes. When administered in intermittent bolus doses for the treatment of postspinal hypotension in elective cesarean delivery, noradrenaline, and phenylephrine have a similar incidence of bradycardia. When treating hypotension related to spinal anesthesia in obstetric cases, strong vasopressors are commonly administered, thought these can also have side effects. This trial assessed bradycardia after bolus administration of noradrenaline or phenylephrine, and found no difference in risk for clinically meaningful bradycardia.
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Affiliation(s)
- Daniel Vieira de Queiroz
- Department of Anesthesiology, Servidores do Estado Federal Hospital (Hospital Federal dos Servidores do Estado), Rio de Janeiro, Brazil
- Medical Sciences Postgraduate Program, Fluminense Federal University (Universidade Federal Fluminense), Niteroi, Brazil
| | - Luis Guillermo Coca Velarde
- Department of Statistics, Medical Sciences Postgraduate Program, Fluminense Federal University (Universidade Federal Fluminense), Niteroi, Brazil
| | - Rodrigo Leal Alves
- Department of Postgraduate Program in Anesthesiology, Botucatu School of Medicine, São Paulo State University (Universidade Estadual Paulista), São Paulo, Brazil
| | - Nubia Verçosa
- Department of Surgery, Anesthesiology, Surgical Sciences Postgraduate Program, Federal University of Rio de Janeiro (Universidade Federal do Rio de Janeiro), Rio de Janeiro, Brazil
| | - Ismar Lima Cavalcanti
- Medical Sciences Postgraduate Program, Fluminense Federal University (Universidade Federal Fluminense), Niteroi, Brazil
- Department of General and Specialized Surgery, Anesthesiology, Fluminense Federal University (Universidade Federal Fluminense), Niteroi, Brazil
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Zabel RR, Favaro RR, Groten T, Brownbill P, Jones S. Ex vivo perfusion of the human placenta to investigate pregnancy pathologies. Placenta 2022; 130:1-8. [DOI: 10.1016/j.placenta.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 08/26/2022] [Accepted: 10/08/2022] [Indexed: 11/07/2022]
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Beighley A, Glynn R, Scullen T, Mathkour M, Werner C, Berry JF, Carr C, Abou-Al-Shaar H, Aysenne A, Nerva JD, Dumont AS. Aneurysmal subarachnoid hemorrhage during pregnancy: a comprehensive and systematic review of the literature. Neurosurg Rev 2021; 44:2511-2522. [PMID: 33409763 DOI: 10.1007/s10143-020-01457-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 11/10/2020] [Accepted: 12/07/2020] [Indexed: 11/30/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) is an emergent condition requiring rapid intervention and prolonged monitoring. There are few recommendations regarding the management of aSAH in pregnancy. We identified all available literature and compiled management decisions as well as reported outcomes through a systematic literature review without meta-analysis to provide recommendations for management of aSAH during pregnancy. We included a total of 23 articles containing 54 cases of pregnancy-related aSAH in our review. From these reports and other literature, we evaluated information on aSAH pathophysiology, diagnosis, and management with respect to pregnancy. Early transfer to an appropriate facility with neurocritical care, a high-risk obstetric service, and a neurosurgery team available is crucial for the management of aSAH in pregnancy. Intensive monitoring and a multidisciplinary approach remain fundamental to ensure maternal and fetal health.
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Affiliation(s)
- Adam Beighley
- Department of Neurological Surgery, Tulane University, New Orleans, LA, USA
| | - Ryan Glynn
- Department of Neurological Surgery, Tulane University, New Orleans, LA, USA.,Department of Neurological Surgery, Ochsner Medical Center, New Orleans, LA, USA
| | - Tyler Scullen
- Department of Neurological Surgery, Tulane University, New Orleans, LA, USA.,Department of Neurological Surgery, Ochsner Medical Center, New Orleans, LA, USA
| | - Mansour Mathkour
- Department of Neurological Surgery, Tulane University, New Orleans, LA, USA. .,Department of Neurological Surgery, Ochsner Medical Center, New Orleans, LA, USA. .,Neurosurgery Division, Surgery Department, Jazan University, Jazan, Kingdom of Saudi Arabia.
| | - Cassidy Werner
- Department of Neurological Surgery, Tulane University, New Orleans, LA, USA
| | - John F Berry
- Department of Neurological Surgery, Tulane University, New Orleans, LA, USA.,Department of Neurological Surgery, Ochsner Medical Center, New Orleans, LA, USA
| | - Christopher Carr
- Department of Neurological Surgery, Tulane University, New Orleans, LA, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Aimee Aysenne
- Department of Neurological Surgery, Tulane University, New Orleans, LA, USA.,Department of Neurocritical Care, Tulane Medical Center, New Orleans, LA, USA
| | - John D Nerva
- Department of Neurological Surgery, Tulane University, New Orleans, LA, USA
| | - Aaron S Dumont
- Department of Neurological Surgery, Tulane University, New Orleans, LA, USA. .,Department of Neurological Surgery, Ochsner Medical Center, New Orleans, LA, USA.
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A randomised dose-response study of prophylactic Methoxamine infusion for preventing spinal-induced hypotension during Cesarean delivery. BMC Anesthesiol 2020; 20:198. [PMID: 32787783 PMCID: PMC7422554 DOI: 10.1186/s12871-020-01119-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 08/06/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND α-receptor agonists have been reported to be safe and effective for treating or preventing spinal-induced hypotension during cesarean delivery. As a pure α1 adrenergic agonist, methoxamine has potential advantages of reducing myocardial oxygen consumption and protecting the heart in obstetric patients compared to phenylephrine. The aim of this study was to determine the optimal prophylactic methoxamine infusion dose that would be effective for preventing spinal-induced hypotension in 50% (ED50) and 95% (ED95) of parturients. METHODS Eighty parturients with a singleton pregnancy scheduled for elective cesarean delivery were randomly allocated to receive prophylactic methoxamine infusion at one of four different fixed-rates: 1 μg/kg/min (group M1), 2 μg/kg/min (group M2), 3 μg/kg/min (group M3), or 4 μg/kg/min (group M4). An adequate response was defined as absence of hypotension (maternal SBP < 80% of baseline or SBP < 90 mmHg). The values for ED50 and ED95 of prophylactic methoxamine infusion were determined by probit regression model. The outcomes of maternal hemodynamics and fetal status were compared among the groups. RESULTS The calculated ED50 and ED95 (95% confidence interval) of prophylactic methoxamine infusion dose were 2.178 (95% CI 1.564 to 2.680) μg/kg/min and 4.821 (95% CI 3.951 to 7.017) μg/kg/min, respectively. The incidence of hypotension decreased with increasing methoxamine infusion dose (15/20, 11/20, 7/20 and 2/20 in group M1, M2, M3 and M4 respectively, P < 0.001). 1-min Apgar scores and umbilical arterial PaO2 were lower but umbilical arterial PaCO2 was higher in Group M1. No difference was found in the other incidence of adverse effects and neonatal outcomes among groups. CONCLUSIONS Under the conditions of this study, when prophylactic methoxamine infusion was given at a fixed-rate based on body weight for preventing spinal-induced hypotension in obstetric patients, the values for ED50 and ED95 were 2.178 μg/kg/min and 4.821 μg/kg/min respectively. CLINICAL TRIAL REGISTRATION Chinese Clinical Trial Registry (ChiCTR), registry number of clinical trial: ChiCTR-1,800,018,988 , date of registration: October 20, 2018.
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7
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Xu S, Mao M, Zhang S, Qian R, Shen X, Shen J, Wang X. A randomized double-blind study comparing prophylactic norepinephrine and ephedrine infusion for preventing maternal spinal hypotension during elective cesarean section under spinal anesthesia: A CONSORT-compliant article. Medicine (Baltimore) 2019; 98:e18311. [PMID: 31860981 PMCID: PMC6940128 DOI: 10.1097/md.0000000000018311] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Studies have shown the efficacy of norepinephrine in the treatment of maternal hypotension during cesarean section by comparing it to treatment with phenylephrine. However, few studies have compared the efficacy of norepinephrine to ephedrine. METHODS Ninety-seven women undergoing elective cesarean section were administered norepinephrine at 4 μg/minute (group N; n = 48) or ephedrine at 4 mg/minute (group E; n = 49) immediately postspinal anesthesia, with an on-off titration to maintain systolic blood pressure (SBP) at 80% to 120% of baseline. A rescue bolus of 8 μg norepinephrine was given whenever SBP reached the predefined lower limit. Our primary outcome was the incidence of tachycardia. Secondary outcomes included the incidence of bradycardia, hypertension, hypotension, severe hypotension, hypotensive episodes, number of rescue top-ups, hemodynamic performance error including median performance error (MDPE), and median absolute performance error (MDAPE). Neonatal Apgar scores and umbilical arterial (UA) blood gas data were also collected. RESULTS Women in group N experienced fewer cases of tachycardia (4.2% vs 30.6%, P = .002, odds ratio: 0.11 [95% confidence interval, CI: 0.02-0.47]), a lower standardized heart rate (HR) (70.3 ± 11 vs 75 ± 11, P = .04, difference: 4.7 ± 2.2 [95% CI: 0.24-9.1]), and a lower MDPE for HR (1.3 ± 9.6 vs 8.4 ± 13.5 bpm, P = .003, difference: 3.1 ± 1.8 [95% CI: -0.6-6.7]). In addition, the lowest or the highest HR was lower in group N compared to group E (both P < .05). Meanwhile, the standardized SBP in group N was lower than that in group E (P = .04). For neonates, the UA blood gas showed a higher base excess (BE) and a lower lactate level in group N compared to E (both P < .001). Other hemodynamic variables, maternal, and neonatal outcomes were similar. CONCLUSION Infusion of 4 μg/minute norepinephrine presented fewer cases of tachycardia, less fluctuation and a lower HR compared to baseline values, as well as a less stressed fetal status compared to ephedrine infusion at 4 mg/minute. In addition, norepinephrine infusion presented a lower standardized SBP compared to ephedrine.
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Affiliation(s)
- Shiqin Xu
- Department of Anesthesiology, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital
| | - Mao Mao
- Department of Anesthesiology, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital
| | - Susu Zhang
- Department of Anesthesiology, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital
| | - Ruifeng Qian
- Department of Anesthesiology, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital
| | - Xiaofeng Shen
- Department of Anesthesiology, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital
| | - Jinchun Shen
- Department of Anesthesiology, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, P.R. China
| | - Xian Wang
- Department of Anesthesiology, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital
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Wang X, Mao M, Liu S, Xu S, Yang J. A Comparative Study of Bolus Norepinephrine, Phenylephrine, and Ephedrine for the Treatment of Maternal Hypotension in Parturients with Preeclampsia During Cesarean Delivery Under Spinal Anesthesia. Med Sci Monit 2019; 25:1093-1101. [PMID: 30738019 PMCID: PMC6377586 DOI: 10.12659/msm.914143] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background This study aimed to compare the efficacy and safety of bolus norepinephrine, phenylephrine, and ephedrine in parturient with preeclampsia who had hypotension during cesarean delivery under spinal anesthesia. Material/Methods One hundred and sixty-six parturient women with preeclampsia who had a baseline systolic blood pressure (SBP) <80% during spinal anesthesia for cesarean section were divided into three treatment groups; bolus norepinephrine 4 μg (group N) (n=56), phenylephrine 50 μg (group P) (n=55), and ephedrine 4 mg (group E) (n=55). Primary outcomes included overall SBP and heart rate (HR) until delivery. Secondary outcomes included the incidence of tachycardia (HR >120 bpm), bradycardia (HR <60 bpm), hypertension (SBP >120% baseline), number of boluses of vasopressor required and episodes of hypotension, maternal side effects, and neonatal outcome. Results Overall HR in group N was significantly increased compared with group P (80.5±12 vs. 76.6±6.9 bpm; P=0.04), and significantly lower compared with group E (80.5±12 vs. 84.9±7.1 bpm; P=0.02). Parturients in group N had fewer episodes of bradycardia compared with group P (3.6% vs. 21.8%; RR=0.26l; 95% CI, 0.07–0.73; P=0.004) and fewer episodes of tachycardia compared with group E (16.1% vs. 36.4%; RR 0.54; 95% CI, 0.29–0.90; P=0.02). Conclusions A bolus dose of norepinephrine showed similar efficacy to phenylephrine but improved maternal and neonatal safety in parturients with preeclampsia with hypotension during cesarean section under spinal anesthesia.
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Affiliation(s)
- Xian Wang
- Department of Anesthesiology, Obstetrics and Gynecology Hospital Affiliated to Nanjing Medical University, Nanjing, Jiangsu, China (mainland)
| | - Mao Mao
- Department of Anesthesiology, Obstetrics and Gynecology Hospital Affiliated to Nanjing Medical University, Nanjing, Jiangsu, China (mainland)
| | - Shijiang Liu
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China (mainland)
| | - Shiqin Xu
- Department of Anesthesiology, Obstetrics and Gynecology Hospital Affiliated to Nanjing Medical University, Nanjing, Jiangsu, China (mainland)
| | - Jianjun Yang
- Department of Anesthesiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China (mainland).,Department of Anesthesiology, Jinling Hospital Affiliated to Nanjing Medical University, Nanjing, Jiangsu, China (mainland)
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9
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Hassani V, Movaseghi G, Safaeeyan R, Masghati S, Ghorbani Yekta B, Farahmand Rad R. Comparison of Ephedrine vs. Norepinephrine in Treating Anesthesia-Induced Hypotension in Hypertensive Patients: Randomized Double-Blinded Study. Anesth Pain Med 2018; 8:e79626. [PMID: 30271750 PMCID: PMC6150924 DOI: 10.5812/aapm.79626] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 08/08/2018] [Accepted: 08/08/2018] [Indexed: 12/04/2022] Open
Abstract
Background Hypotension is a common problem in general anesthesia. Maintaining the mean arterial pressure by choosing a vasopressor with minimal complications is still discussed in various surgeries. Objectives The aim of this study is comparison of ephedrine versus norepinephrine in treating anesthesia-induced hypotension in hypertensive patients in spinal surgery in a randomized double-blinded study. Methods This randomized, double-blinded study was approved by Iran University of Medical Sciences, operating room of medical center. Data collection was completed between Jan to Dec 2017. Inclusion criteria included age between 20 and 75 years, history of high blood pressure (a patient who has been treated for maximum 5 years with a anti hypertensive medication), and patients under general anesthesia in spinal surgery. The exclusion criteria were based on American Society of Anesthesiologists physical status of 3 or higher, history of arrhythmia, heart valve disease, cerebrovascular disease, kidney failure, beta-blocker use and diabetes, as well as intra operative massive blood loss. After initiation of anesthesia, when the pressure reaches less than 60, the patient entered the protocol and simultaneously administration of 5 mL/kg serum crystalloid and vasopressor. Patients were randomized to the ephedrine group (n = 28) who received 5 mg ephedrine intravenous (i.v.) or norepinephrine Group (n = 28) who received 10 µg (i.v.) bolus norepinephrine at anesthesia-induced hypotension. The administration of 5 mL/kg serum crystalloid and vasopressor was simultaneous. If the mean arterial pressure (MAP) had not reached 60 mmHg, the same dose should be repeated at a maximum of three or more times at five-minute intervals in the ephedrine group and at two minutes intervals in the norepinephrine group. All parameters were collected before and at the end of administration anesthesia drug and during episodes of hypotension. Hemodynamic variables, frequency of hypotension, and total number of vasopressors doses during anesthesia were recorded and analyzed. Results The mean number of hypotension times, the number of vasopressors doses in the first hypotension, the total number of doses consumed during the anesthesia, and heart rate at the end of anesthesia were lower in the norepinephrine group (P) respectively. MAP, 5 minutes after the first episode of hypotension and MAP at the end of anesthesia were higher in norepinephrine group. Conclusions Norepinephrine is more effective than ephedrine in maintenance of MAP in hypertensive patients undergoing spinal surgery under general anesthesia.
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Affiliation(s)
- Valiollah Hassani
- Pain Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Gholamreza Movaseghi
- Department of Anesthesiology, Hasheminezhad Hospital, Iran University of Medical Sciences, Tehran,
Iran
| | - Reza Safaeeyan
- Pain Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Sahar Masghati
- Iran University of Medical Sciences (IUMS), Tehran, Iran
- Corresponding Author: Iran University of Medical Sciences (IUMS), Tehran, Iran. Tel: +98-9111931972,
| | - Batool Ghorbani Yekta
- Young Researchers and Elite Club, Tehran Medical Sciences Branch, Islamic Azad University, Tehran,
Iran
- Herbal Pharmacology Research Center, Tehran Medical Sciences Branch, Islamic Azad University, Tehran, Iran
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10
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Burlinson CEG, Sirounis D, Walley KR, Chau A. Sepsis in pregnancy and the puerperium. Int J Obstet Anesth 2018; 36:96-107. [PMID: 29921485 DOI: 10.1016/j.ijoa.2018.04.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 04/27/2018] [Accepted: 04/30/2018] [Indexed: 12/30/2022]
Abstract
Sepsis remains a leading cause of maternal morbidity and mortality. Recognition and treatment of maternal sepsis are often delayed due to the physiological adaptations of pregnancy and vague or absent signs and symptoms during its initial presentation. Over the past decade, our understanding of sepsis has evolved and maternal early warning systems have been developed in an effort to help providers promptly identify and stratify parturients who are at risk. In addition, new consensus definitions and care bundles have recently been published by the World Health Organization and the Surviving Sepsis Campaign to facilitate earlier recognition and timely management of sepsis. In this narrative review, we summarize the available evidence about sepsis and provide an overview of the research efforts focused on maternal sepsis to date. Controversies and challenges surrounding the anesthetic management of parturients with sepsis or at risk of developing sepsis during pregnancy or the puerperium will be highlighted.
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Affiliation(s)
- C E G Burlinson
- Department of Anesthesia, British Columbia Women's Hospital, Vancouver, BC, Canada
| | - D Sirounis
- Division of Critical Care Medicine, Department of Medicine, St. Paul's Hospital, Vancouver, BC, Canada; Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - K R Walley
- Division of Critical Care Medicine, Department of Medicine, St. Paul's Hospital, Vancouver, BC, Canada; Centre for Heart Lung Innovation, University of British Columbia, Vancouver, BC, Canada
| | - A Chau
- Department of Anesthesia, British Columbia Women's Hospital, Vancouver, BC, Canada; Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada.
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11
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Ali Elnabtity AM, Selim MF. Norepinephrine versus Ephedrine to Maintain Arterial Blood Pressure during Spinal Anesthesia for Cesarean Delivery: A Prospective Double-blinded Trial. Anesth Essays Res 2018; 12:92-97. [PMID: 29628561 PMCID: PMC5872901 DOI: 10.4103/aer.aer_204_17] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background: Ephedrine was conventionally regarded as the first-choice drug to maintain maternal blood pressure during spinal anesthesia for cesarean delivery, due to its stimulant activity on α- and β-adrenergic receptors. Norepinephrine is a weak β-adrenergic and potent α-adrenergic receptor agonist. Therefore, it may be suitable for maintaining blood pressure with less chronotropic effects compared to ephedrine. Patients and Methods: One hundred and forty healthy patients having cesarean delivery under spinal anesthesia were randomized to Group N (n = 61) who received a prophylactic bolus of norepinephrine 5 μg intravenous (i.v.) at the time of intrathecal block or Group E (n = 61) who received a prophylactic bolus of i.v. ephedrine 10 mg. Rescue i.v. bolus interventions of norepinephrine 5 μg or ephedrine 10 mg were given as required to maintain systolic blood pressure. Maternal and fetal hemodynamic variables, Apgar score, and number of boluses of vasopressors used were recorded. Results: The numbers of maternal hypotension and hypertension episodes and the frequency of bradycardia and tachycardia were significantly lower in Group N compared with Group E (P = 0.02, 0.003, 0.0002, and 0.008, respectively). The number of boluses of vasopressors used was also lower in Group N (P = 0.005). Uterine artery pulsatility index was lower in Group N compared to Group E (P = 0.01) when measured 5 min after spinal anesthesia. Moreover, it was higher at 5 min in Group E when compared with the baseline readings in the same group (P = 0.001). Conclusions: Norepinephrine is a suitable and potent drug to counterbalance the hemodynamic effects of spinal anesthesia during cesarean delivery.
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Affiliation(s)
| | - Mohamed Foad Selim
- Professor of Gynecology and Obstetrics, Faculty of Medicine, Zagazig University, Zagazig, Egypt
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James JL, Chamley LW, Clark AR. Feeding Your Baby In Utero: How the Uteroplacental Circulation Impacts Pregnancy. Physiology (Bethesda) 2017; 32:234-245. [DOI: 10.1152/physiol.00033.2016] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 12/20/2016] [Accepted: 12/22/2016] [Indexed: 11/22/2022] Open
Abstract
The utero-placental circulation links the maternal and fetal circulations during pregnancy, ensuring adequate gas and nutrient exchange, and consequently fetal growth. However, our understanding of this circulatory system remains incomplete. Here, we discuss how the utero-placental circulation is established, how it changes dynamically during pregnancy, and how this may impact on pregnancy success, highlighting how we may address knowledge gaps through advances in imaging and computational modeling approaches.
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Affiliation(s)
- Joanna L. James
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand; and
| | - Lawrence W. Chamley
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand; and
| | - Alys R. Clark
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
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Plante LA. Management of Sepsis and Septic Shock for the Obstetrician–Gynecologist. Obstet Gynecol Clin North Am 2016; 43:659-678. [DOI: 10.1016/j.ogc.2016.07.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Bottiger BA, Bezinover DS, Mets B, Dalal PG, Prozesky J, Ural S, Vaida S. Phenylephrine infusion for spinal-induced hypotension in elective cesarean delivery: Does preload make a difference? J Anaesthesiol Clin Pharmacol 2016; 32:319-24. [PMID: 27625478 PMCID: PMC5009836 DOI: 10.4103/0970-9185.168159] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background and Aims: Patients undergoing elective cesarean delivery (CD) have a high-risk of spinal-induced hypotension (SIH). We hypothesized that a colloid preload would further reduce SIH when compared with a crystalloid preload. Material and Methods: Eighty-two healthy parturients undergoing elective CD were included in the study. Patients were randomly assigned to two groups (41 patients in each group) to receive either Lactated Ringer's solution (1500 ml) or hydroxyethyl starch (6% in normal saline, 500 ml) 30 min prior to placement of spinal anesthesia. All patients were treated with a phenylephrine infusion (100 mcg/min), titrated during the study. Results: There was no statistical difference between groups with regards to the incidence of hypotension (10.8% in the colloid group vs. 27.0% in the crystalloid group, P = 0.12). There was also no difference between groups with respect to bradycardia, APGAR scores, and nausea and vomiting. Significantly less phenylephrine (1077.5 ± 514 mcg) was used in the colloid group than the crystalloid group (1477 ± 591 mcg, P = 0.003). Conclusion: The preload with 6% of hydroxyethyl starch before CD might be beneficial for the prevention of SIH.
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Affiliation(s)
- Brandi A Bottiger
- Department of Anesthesiology, Duke University Medical Center, Durham, USA
| | - Dmitri S Bezinover
- Department of Anesthesiology, Penn State Milton S Hershey Medical Center, PA 17033, USA
| | - Berend Mets
- Department of Anesthesiology, Penn State Milton S Hershey Medical Center, PA 17033, USA
| | - Priti G Dalal
- Department of Anesthesiology, Penn State Milton S Hershey Medical Center, PA 17033, USA
| | - Jansie Prozesky
- Department of Anesthesiology, Penn State Milton S Hershey Medical Center, PA 17033, USA
| | - Serdar Ural
- Department of Maternal Fetal Medicine, Penn State Milton S Hershey Medical Center, PA 17033, USA
| | - Sonia Vaida
- Department of Anesthesiology, Penn State Milton S Hershey Medical Center, PA 17033, USA
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Downing JW, Baysinger CL, Johnson RF, Paschall RL, Shotwell MS. The Effects of Vasopressin and Oxytocin on the Fetoplacental Distal Stem Arteriolar Vascular Resistance of the Dual-Perfused, Single, Isolated, Human Placental Cotyledon. Anesth Analg 2016; 123:698-702. [DOI: 10.1213/ane.0000000000001449] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
PURPOSE OF REVIEW This review assesses the maternal and fetal effects of vasopressor administration during spinal anaesthesia for caesarean delivery, with emphasis on recent findings. RECENT FINDINGS Maternal heart rate is a good surrogate for cardiac output. The initial hypotensive effect of spinal anaesthesia is caused by a rapid decrease in systemic vascular resistance, which makes α-agonists the logical first-line therapy. Effective prophylactic phenylephrine administration can be associated with reduced maternal cardiac output, but this has not been associated with adverse maternal or fetal effects. Prophylactic phenylephrine infusion can cause hypertension if increasing arterial pressure does not trigger a timely reduction in the rate of administration. Phenylephrine has been used safely in mothers with cardiac disease and in pregnancies with suspected fetal compromise. Fetal genotype may increase resistance to ephedrine-induced acidosis. The combination of vagolytics and vasopressors has caused maternal hypertensive crises with serious adverse outcome. SUMMARY Phenylephrine is the current vasopressor of choice for the prevention of maternal hypotension and nausea. Phenylephrine regimens need to be developed that can reliably and safely be used with noninvasive blood pressure cycle times less frequent than every minute. Further vasopressor should be used with caution when vagolytic therapy is, quite rightly, used to treat bradycardia associated with hypotension.
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Luria O, Bar J, Barnea O, Golan A, Kovo M. Reactivity of blood vessels in response to prostaglandin E2 in placentas from pregnancies complicated by fetal growth restriction. Prenat Diagn 2012; 32:417-22. [PMID: 22495578 DOI: 10.1002/pd.3827] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The authors aimed to study the contractility responses of normal and fetal growth restriction (FGR) placentas to prostaglandin E(2) (PGE(2) ) and to correlate the results to subsequent placental histological analysis. METHOD A dual-perfused single cotyledon model was used. Placentas from pregnancies complicated by FGR and from normal pregnancies were obtained. Selected cotyledons were cannulated and dually perfused. Following stabilization, three concentrations of PGE(2) (0.05, 0.1, and 0.15 mg/mL) were administered to the fetal arterial side causing contraction/relaxation response. Fetal perfusion pressure was measured continuously during these contraction and relaxation phases. Following the perfusion experiments, the placentas were analyzed for fetal or maternal origin vascular lesions. RESULTS A total of 21 complete experiments were performed (16 normal, 5 FGR). In response to PGE(2) , FGR placentas exhibited lower change in the perfusion pressure and lower relaxation time constant. Basal perfusion pressure did not differ significantly between the two groups. Placental histopathology lesions, fetal or maternal origin, were more common in the FGR compared with the controls placentas, 80% versus 25%, respectively, P= 0.047. CONCLUSIONS The lower vascular reactivity in response to PGE(2) and the presence of fetal and maternal vascular placental lesions suggest a mechanism explaining the altered vascular supply in FGR.
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Affiliation(s)
- Oded Luria
- Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
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Current World Literature. Curr Opin Anaesthesiol 2011; 24:463-5. [DOI: 10.1097/aco.0b013e3283499d5a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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