Altered platelet calcium metabolism as an early predictor of increased peripheral vascular resistance and preeclampsia in urban black women

Immunoreactive circulating endothelin-1 in normal and hypertensive pregnancies

OBJECTIVE

The purpose of this study was to measure the circulatory levels of endothelin-1 in the serum of pregnant women with hypertension.

STUDY DESIGN

Endothelin-1 levels were measured by means of radioimmunoassay in the serum of 26 pregnant women with hypertension (14 with pregnancy-induced preeclamptic toxemia, 12 with chronic hypertension) and in the serum of 17 control pregnant women and 18 control nonpregnant women. The mean levels in the different groups were subject to statistical analysis with the analysis of variance.

RESULTS

The mean level among the women with preeclampsia (29.9 +/- 13.2 fmol/ml) was significantly higher than those of the chronically hypertensive women (16.1 +/- 7.3 fmol/ml, p = 0.002) and of the control pregnant women (19.7 +/- 9.2 fmol/ml, p = 0.011). The mean level of the control nonpregnant women (26.9 +/- 9.3) was significantly higher than that of the control pregnant women (p = 0.029). Among the patients with preeclampsia there was no correlation between endothelin-1 levels and the mean arterial blood pressure. Six to 10 weeks after delivery the mean levels of 15 studied patients (7 with preeclampsia, 8 with chronic hypertension) were similar to the levels of the nonpregnant control women.

CONCLUSION

We conclude that increased endothelin-1 production may play a role in the pathogenesis of preeclampsia.

Severe post-partum eclampsia: response to plasma exchange

In their severest forms, pre-eclampsia and eclampsia may be life-threatening complications of pregnancy. We describe a patient with severe post-partum eclampsia characterized by seizures, deep coma, hypertension, renal insufficiency, coagulopathy, and microangiopathic hemolysis. The patient responded to treatment that included intensive plasma exchange, and she achieved full recovery. Our case supports the use of plasma exchange in patients with severe pre-eclampsia and eclampsia.

Modulation of platelet Ca2+ homeostasis by hypertensive plasma factor(s) derived from patients with early-stage renal disease

To determine whether blood-borne factors in hypertension accompanying early-stage kidney disease might be responsible for altered cellular calcium homeostasis, we measured changes in cytosolic calcium before and after incubating platelets in plasma ultrafiltrates from normotensive and hypertensive renal patients. With the use of the chelating agent quin 2, we found the free-calcium concentrations in platelets to be higher in the hypertensive than in the normotensive group. When both groups of participants were combined, a direct correlation was found between arterial pressure and cytosolic calcium. The cytosolic calcium concentration in platelets of normotensive renal patients increased after incubation with plasma from patients with untreated renal hypertension, but it was unchanged after incubation with plasma from normotensive subjects. These data indicate that the total cell burden of calcium is increased in platelets of hypertensive patients with early-stage renal disease, and that plasma from these patients contains a substance that is capable of increasing the cytosolic calcium concentration in platelets. If the plasma factor (or factors) acts not only on platelets, but also on vascular smooth muscle cells, it may contribute to the increased peripheral vascular resistance associated with hypertension of renal origin.

Rise and fall of agonist-evoked platelet Ca2+ in hypertensive rats

We previously reported an enhanced peak response of intracellular free Ca2+ to thrombin in platelets of spontaneously hypertensive rats in comparison with normotensive Wistar-Kyoto rats. In the present study, we compared the platelet intracellular Ca2+ response to the receptor-linked agonist thrombin with the response to the Ca2+ ionophore ionomycin. Basal intracellular Ca2+ was higher in hypertensive platelets as was leakage of fura-2. We confirmed the previous finding that the thrombin-induced intracellular Ca2+ peak is greater in platelets of hypertensive rats and noted that the rate of recovery from peak intracellular Ca2+ is significantly greater in this model. In contrast, the peak platelet intracellular Ca2+ response to ionomycin (50 nM and 5 microM) was not different between the two strains, and the rate of recovery from the peak response was only slightly depressed in hypertensive rats after the low dose of ionomycin. Internal Ca2+ discharge capacity, assessed by the intracellular Ca2+ response to a maximal dose of ionomycin in Ca(2+)-free medium, was not different between platelets of the two strains. Thus, activated platelet intracellular Ca2+ is not altered in the hypertensive rat when the nonphysiological ionophore ionomycin is used as agonist. However, a heightened intracellular Ca2+ response is observed when the receptor-mediated agonist thrombin is used. These results are consistent with the hypothesis that differences in receptor-linked second messenger pathways underlie the altered intracellular Ca2+ response in platelets of genetically hypertensive rats and may contribute to differences both in the mobilization of Ca2+ and in its fall.

Calcium supplementation to prevent hypertensive disorders of pregnancy

BACKGROUND

Calcium supplementation has been reported to reduce blood pressure in pregnant and nonpregnant women. We undertook this prospective study to determine the effect of calcium supplementation on the incidence of hypertensive disorders of pregnancy (gestational hypertension and preeclampsia) and to determine the value of urinary calcium levels as a predictor of the response.

METHODS

We studied 1194 nulliparous women who were in the 20th week of gestation at the beginning of the study. The women were randomly assigned to receive 2 g per day of elemental calcium in the form of calcium carbonate (593 women) or placebo (601 women). Urinary excretion of calcium and creatinine was measured before calcium supplementation was begun. The women were followed to the end of their pregnancies, and the incidence of hypertensive disorders of pregnancy was determined.

RESULTS

The rates of hypertensive disorders of pregnancy were lower in the calcium group than in the placebo group (9.8 percent vs. 14.8 percent; odds ratio, 0.63; 95 percent confidence interval, 0.44 to 0.90). The risk of these disorders was lower at all times during gestation, particularly after the 28th week of gestation (P = 0.01 by life-table analysis), in the calcium group than in the placebo group, and the risk of both gestational hypertension and preeclampsia was also lower in the calcium group. Among the women who had low ratios of urinary calcium to urinary creatinine (less than or equal to 0.62 mmol per millimole) during the 20th week of gestation, those in the calcium group had a lower risk of hypertensive disorders of pregnancy (odds ratio, 0.56; 95 percent confidence interval, 0.29 to 1.09) and less of an increase in diastolic and systolic blood pressure than the placebo group. The pattern of response was similar among the women who had a high ratio of urinary calcium to urinary creatinine during the 20th week of gestation, but the differences were smaller.

CONCLUSIONS

Pregnant women who receive calcium supplementation after the 20th week of pregnancy have a reduced risk of hypertensive disorders of pregnancy.

Prevention and treatment of pregnancy-associated hypertension: what have we learned in the last 10 years?

High blood pressure (BP) complicates approximately 10% of all pregnancies. Hypertension in pregnancy falls into four categories: (1) preeclampsia-eclampsia, (2) chronic hypertension of whatever cause, (3) preeclampsia-eclampsia superimposed to chronic hypertension or renal disease, and (4) transient or late hypertension (gestational hypertension). Preeclampsia, the association of hypertension, proteinuria, and edema, accounts for more than 50% of all the hypertensive disorders of pregnancy and is a major cause of fetal and maternal morbidity and mortality. Unfortunately, distinguishing between preeclampsia and other causes of hypertension on clinical grounds can be difficult because of the lack of specific tests for differential diagnosis. Increased vascular resistance has been claimed as the primary cause of preeclampsia; however, a variable hemodynamic profile with relatively high cardiac outputs, normal filling pressures, and inappropriately high systemic vascular resistances is now reported by most investigators. Imbalance between vasodilator and vasoconstrictor eicosanoids may account for platelet activation and increased responsiveness to pressor peptides. Altered prostacyclin (PGI2) to thromboxane A2 (TxA2) ratio in maternal uteroplacental vascular bed may favor local platelet activation and vasoconstriction contributing to placental insufficiency and fetal distress. Alternatively, recent evidence seems to suggest that fetal umbilical placental circulation may be the site of the primary vascular injury. Whether low-dose aspirin prevents preeclampsia because it inhibits the excessive maternal TxA2 or whether the partial inhibition of fetal TxA2 is also of therapeutic value remains to be established. Treatment of severe hypertension in pregnancy is probably important to prevent cardiac failure or cerebrovascular accidents in the mother. The need for pharmacological therapy of mild to moderate hypertension is still debated, since no formal studies are available to clarify whether pharmacological treatment in such instances effectively reduces maternal or fetal risk. For the treatment of preeclampsia, hydralazine and nifedipine may be used when delivery is not applicable. Labetalol and diazoxide are effective for hypertensive emergencies. Life-threatening hypertension that does not respond to more conventional therapy is an indication for the use of sodium nitroprusside. For chronic hypertension, alpha-methyldopa remains the treatment of choice; if ineffective, hydralazine or beta-blockers are suitable. Effectiveness and safety of other molecules remain elusive.

Early detection of preeclampsia

The signs and symptoms of preeclampsia are usually apparent at a relatively late stage in pregnancy (late second to early third trimester). However, the disorder results from abnormal interaction between fetal and maternal tissue much earlier in pregnancy, between 8 and 18 weeks' gestation. During the past two decades numerous clinical, biophysical, and biochemical tests have been proposed for the early detection of preeclampsia. Some of these tests are simple, whereas others are invasive; some have been studied extensively, while others are still under clinical investigation. A review of the literature indicates considerable disagreement regarding the sensitivity and predictive values of the various tests studied. The reported differences in the predictive values of these tests may be attributed to one or more of the following: populations studied, definition and prevalence of the disorder, techniques and methodology used in performing these tests, etc. As a result, there is disagreement regarding the ideal screening test to be used for identifying patients for clinical trials dealing with prevention of the disorder.