Preeclampsia was formerly defined as a multisystemic disorder characterized by new onset of hypertension (i.e. systolic blood pressure (SBP) ≥ 140 mmHg and/or diastolic blood pressure (DBP) ≥ 90 mmHg) and proteinuria (> 300 mg/24 h) arising after 20 weeks of gestation in a previously normotensive woman. Recently, the American College of Obstetricians and Gynecologists has stated that proteinuria is no longer required for the diagnosis of preeclampsia. This complication of pregnancy remains a leading cause of maternal morbidity and mortality. Clinical signs appear in the second half of pregnancy, but initial pathogenic mechanisms arise much earlier. The cytotrophoblast fails to remodel spiral arteries, leading to hypoperfusion and ischemia of the placenta. The fetal consequence is growth restriction. On the maternal side, the ischemic placenta releases factors that provoke a generalized maternal endothelial dysfunction. The endothelial dysfunction is in turn responsible for the symptoms and complications of preeclampsia. These include hypertension, proteinuria, renal impairment, thrombocytopenia, epigastric pain, liver dysfunction, hemolysis-elevated liver enzymes-low platelet count (HELLP) syndrome, visual disturbances, headache, and seizures. Despite a better understanding of preeclampsia pathophysiology and maternal hemodynamic alterations during preeclampsia, the only curative treatment remains placenta and fetus delivery. At the time of diagnosis, the initial objective is the assessment of disease severity. Severe hypertension (SBP ≥ 160 mm Hg and/or DBP ≥ 110 mmHg), thrombocytopenia < 100.000/μL, liver transaminases above twice the normal values, HELLP syndrome, renal failure, persistent epigastric or right upper quadrant pain, visual or neurologic symptoms, and acute pulmonary edema are all severity criteria. Medical treatment depends on the severity of preeclampsia, and relies on antihypertensive medications and magnesium sulfate. Medical treatment does not alter the course of the disease, but aims at preventing the occurrence of intracranial hemorrhages and seizures. The decision of terminating pregnancy and perform delivery is based on gestational age, maternal and fetal conditions, and severity of preeclampsia. Delivery is proposed for patients with preeclampsia without severe features after 37 weeks of gestation and in case of severe preeclampsia after 34 weeks of gestation. Between 24 and 34 weeks of gestation, conservative management of severe preeclampsia may be considered in selected patients. Antenatal corticosteroids should be administered to less than 34 gestation week preeclamptic women to promote fetal lung maturity. Termination of pregnancy should be discussed if severe preeclampsia occurs before 24 weeks of gestation. Maternal end organ dysfunction and non-reassuring tests of fetal well-being are indications for delivery at any gestational age. Neuraxial analgesia and anesthesia are, in the absence of thrombocytopenia, strongly considered as first line anesthetic techniques in preeclamptic patients. Airway edema and tracheal intubation-induced elevation in blood pressure are important issues of general anesthesia in those patients. The major adverse outcomes associated with preeclampsia are related to maternal central nervous system hemorrhage, hepatic rupture, and renal failure. Preeclampsia is also a risk factor for developing cardiovascular disease later in life, and therefore mandates long-term follow-up.

Preeclampsia: an update.

Dexmedetomidine is an alpha 2 adrenergic receptor agonist, even ten times more selective than clonidine. It is a very versatile drug in anaesthesia practice, finding place in increasing number of clinical scenarios and is no more limited to intensive care unit (ICU) sedation. It is analgesic, has anaesthetic sparing effect, sympatholytic property, useful in other procedural sedation and also has cardiovascular stabilizing property. It reduces delirium and preserves respiratory function which adds benefits to its uses. The aim of this review is to make awareness of its role in present anaesthesia and discuss its limitations at the same time.

Dexmedetomidine in current anaesthesia practice- a review.

The introduction of newer more selective α−2 adrenergic agonist, dexmedetomidine has made a revolution in the field of anesthesia owing to its varied application. The aim of the current review is to highlight the various clinical and pharmacological aspects of dexmedetomidine in daily routine practice of anesthesiology and intensive care besides its potential role in other clinical specialties. This review of dexmedetomidine was carried out after searching the medical literature in Pubmed, Science direct, Scopus, Google scholar and various text books and journal articles using keywords anesthesia, dexmedetomidine, neurosurgery, pediatric surgery, regional dexmedetomidine, anesthesia, regional, neurosurgery, and pediatric surgery. Dexmedetomidine has made its application from a novel sedating agent in the intensive care unit to its use as an adjuvant in various regional anesthetic techniques because of its “cooperative sedation” without any respiratory depression. It has a favorable pharmacokinetic profile suitable to be used in the perioperative period to reduce the requirements of opioids and anesthetic drugs. There are few sideâÂÂeffects of dexmedetomidine, which should always be kept in mind before choosing the patients for its use. The various sideâÂÂeffects associated with dexmedetomidine include, but are not limited to hypotension, bradycardia, worsening of heart block, dry mouth, and nausea. However, large scale randomized controlled trials are still needed to establish various effects of dexmedetomidine and to clearly define its safety profile.

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Dexmedetomidine: An adjuvant making large inroads into clinical practice

Objective Primary studies and systematic reviews provide estimates of varying accuracy for different factors in the prediction of pre-eclampsia. The aim of this study was to review published systematic reviews to collate evidence on the ability of available tests to predict pre-eclampsia, to identify high-value avenues for future research and to minimize future research waste in this field. Methods MEDLINE, EMBASE and The Cochrane Library including DARE (Database of Abstracts of Reviews of Effects) databases, from database inception to March 2017, and bibliographies of relevant articles were searched, without language restrictions, for systematic reviews and meta-analyses on the prediction of pre-eclampsia. The quality of the included reviews was assessed using the AMSTAR tool and a modified version of the QUIPS tool. We evaluated the comprehensiveness of search, sample size, tests and outcomes evaluated, data synthesis methods, predictive ability estimates, risk of bias related to the population studied, measurement of predictors and outcomes, study attrition and adjustment for confounding. Results From 2444 citations identified, 126 reviews were included, reporting on over 90 predictors and 52 prediction models for pre-eclampsia. Around a third (n = 37 (29.4%)) of all reviews investigated solely biochemical markers for predicting pre-eclampsia, 31 (24.6%) investigated genetic associations with pre-eclampsia, 46 (36.5%) reported on clinical characteristics, four (3.2%) evaluated only ultrasound markers and six (4.8%) studied a combination of tests; two (1.6%) additional reviews evaluated primary studies investigating any screening test for pre-eclampsia. Reviews included between two and 265 primary studies, including up to 25 356 688 women in the largest review. Only approximately half (n = 67 (53.2%)) of the reviews assessed the quality of the included studies. There was a high risk of bias in many of the included reviews, particularly in relation to population representativeness and study attrition. Over 80% (n = 106 (84.1%)) summarized the findings using meta-analysis. Thirty-two (25.4%) studies lacked a formal statement on funding. The predictors with the best test performance were body mass index (BMI) > 35 kg/m2 , with a specificity of 92% (95% CI, 89-95%) and a sensitivity of 21% (95% CI, 12-31%); BMI > 25 kg/m2 , with a specificity of 73% (95% CI, 64-83%) and a sensitivity of 47% (95% CI, 33-61%); first-trimester uterine artery pulsatility index or resistance index > 90th centile (specificity 93% (95% CI, 90-96%) and sensitivity 26% (95% CI, 23-31%)); placental growth factor (specificity 89% (95% CI, 89-89%) and sensitivity 65% (95% CI, 63-67%)); and placental protein 13 (specificity 88% (95% CI, 87-89%) and sensitivity 37% (95% CI, 33-41%)). No single marker had a test performance suitable for routine clinical use. Models combining markers showed promise, but none had undergone external validation. Conclusions This review of reviews calls into question the need for further aggregate meta-analysis in this area given the large number of published reviews subject to the common limitations of primary predictive studies. Prospective, well-designed studies of predictive markers, preferably randomized intervention studies, and combined through individual-patient data meta-analysis are needed to develop and validate new prediction models to facilitate the prediction of pre-eclampsia and minimize further research waste in this field. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Prediction of pre-eclampsia : review of reviews

Angiogenic and antiangiogenic factors have proven to be an accurate predictive means of preeclampsia. Echocardiographic studies have shown that women with preeclampsia exhibit significant cardiovascular strain, especially early-onset preeclampsia. The aim of this study is to determine preeclampsia risk with soluble fms-like tyrosin kinase 1/placental growth factor ratio, serum NT-proBNP (N-terminal pro B-type natriuretic peptide), and biophysical markers of cardiovascular function in a prospective case–control study. We examined a cohort of 110 pregnant women with uneventful pregnancy outcome (controls) and 129 with hypertensive pregnancy disorders, including 77 with preeclampsia and 52 with pregnancy-induced hypertension. Cardiac indices were obtained with a USCOM-1A monitor, and soluble fms-like tyrosin kinase 1, placental growth factor, and NT-proBNP were measured in serum samples on automated platforms. Logistic regression, as well as Cox proportional hazard analysis, was performed. There were significant contributions from all variables tested, except for heart rate, stroke volume index, and cardiac index to the prediction model. When testing accuracy of respective markers in combination (full model) versus individual markers (soluble fms-like tyrosin kinase 1/placental growth factor ratio and total peripheral resistance) was compared. The soluble fms-like tyrosin kinase 1/placental growth factor ratio and total peripheral resistance performed as good as the full model, except for hypertensive pregnancy disorders and pregnancy-induced hypertension, where the full model performed better. The additional assessment of biophysical and biochemical markers of cardiovascular strain in pregnancy increases the detection of the composite group of hypertensive pregnancy disorders, while not significantly improving detection of preeclampsia alone. This offers a more precise insight into the pathogenesis of the disease, as well as offering a window for intervention, possibly decreasing cardiovascular mortality in these women.

Angiogenic Markers and Cardiovascular Indices in the Prediction of Hypertensive Disorders of Pregnancy.

https://www.clevelandclinic.org/outcomesresearch/viewpdf.aspx?orArticleID=846

Utility of B-type natriuretic peptides in preeclampsia: a systematic review

Dexmedetomidine is a highly selective and potent alpha2-adrenoreceptor (AR) agonist offering dosedependent sedation, anxiolysis and analgesia. It is a relatively new drug, approved for sedation for up to 24 hours in mechanically ventilated post-cardiac surgery patients. Yet, because of its unique drug profile, it has been increasingly studied and used in various clinical settings, albeit off label, with promising results. The purpose of this review is to discuss dexmedetomidine in terms of its pharmacokinetics and pharmacodynamics, and to focus on its various clinical applications. A PubMed search, using the keyword “dexmedetomidine”, identified approximately 1,000 articles, the earliest being animal studies published in 1988.

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Clinical application of dexmedetomidine

SummaryBackground
NP is a biomarker that has been used in the diagnosis, management, and prognostication of a number of cardiovascular disorders in the pediatric population. The physiological role of this hormone is to allow the myocardium to adapt to stress or strain imposed by a volume and/or pressure load.

Objective
The aim of this study was to determine the utility of preoperative and postoperative NP to predict outcome in pediatric patients undergoing cardiac surgery for structural congenital heart disease.

Method
We conducted a systematic review by searching three electronic databases using the search terms ‘paediatric’ or ‘pediatric’ and ‘B-type natriuretic peptide’. Twenty peer-reviewed papers were included in the study.

Results
Preoperative NP levels were associated with the severity of cardiac failure in several studies. Preoperative NPs also correlated with early postoperative outcome measures such as duration of cardiopulmonary bypass, duration of mechanical ventilation, presence of low cardiac output syndrome, length of stay in the intensive care unit and in one study, death. Early (within 24 h) postoperative NPs showed a stronger correlation than preoperative NPs to early postoperative adverse events.

Conclusion
NPs provide a simple, noninvasive and complementary tool to echocardiography that can be used to assist clinicians in the assessment and management of pediatric patients with congenital heart disease in the perioperative period.

Clinical utility of B‐type natriuretic peptide (NP) in pediatric cardiac surgery – a systematic review

Biomarkers are important in diagnosis, assessment of disease severity, risk stratification and therapeutic decision-making. Recent studies strongly suggest that there is a role for B-type natriuretic peptide (BtNP) as a powerful prognostic predictor in both the preoperative and postoperative setting. An understanding is required of the specific statistical methodology that is used to assess the value of biomarkers. The main aim of this paper was to discuss the current role that BtNP plays in perioperative risk prediction.

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The role of biomarkers and B-type natriuretic peptide in diagnosis and perioperative risk prediction

Abstract Biomarkers are important in diagnosis, assessment of disease severity, risk stratification and therapeutic decision-making. Recent studies strongly suggest that there is a role for B-type natriuretic peptide (BtNP) as a powerful prognostic predictor in both the preoperative and postoperative setting. An understanding is required of the specific statistical methodology that is used to assess the value of biomarkers. The main aim of this paper was to discuss the current role that BtNP plays in perioperative risk prediction.

Nura Afshani

Papers

Utility of B-type natriuretic peptides in preeclampsia: a systematic review

Clinical application of dexmedetomidine

Clinical utility of B‐type natriuretic peptide (NP) in pediatric cardiac surgery – a systematic review

The role of biomarkers and B-type natriuretic peptide in diagnosis and perioperative risk prediction

The role of biomarkers and B-type natriuretic peptide in diagnosis and perioperative risk prediction : review article