1
|
Tated RCP, Maheta D, Agrawal SP, Frishman WH, Aronow WS. Ischemic Heart Disease in Pregnancy: Current Understanding and Management Strategies. Cardiol Rev 2024:00045415-990000000-00310. [PMID: 39140736 DOI: 10.1097/crd.0000000000000774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/15/2024]
Abstract
Ischemic heart disease (IHD) during pregnancy poses a rare but significant risk to maternal and fetal health, with global incidence rates ranging from 0.7 to 10 cases per 100,000 pregnancies. This review synthesizes current literature on the epidemiology, pathophysiology, clinical presentation, diagnosis, management, and outcomes of IHD in pregnancy. Pregnancy-related IHD encompasses various conditions, including coronary artery disease, spontaneous coronary artery dissection, myocardial infarction with nonobstructive coronary arteries, coronary embolism, and coronary vasospasm. The pathophysiology is multifactorial, involving hemodynamic changes, hormonal influences, and increased hypercoagulability. Clinical presentation may mimic typical pregnancy symptoms, necessitating a high index of suspicion for timely diagnosis. A multidisciplinary strategy is needed for management, taking into account the hazards to the mother and fetus while also taking drug safety and procedural treatments such coronary artery bypass grafting and percutaneous coronary intervention into account. Careful observation and timely management are necessary for complications such as cardiogenic shock, arrhythmias, and thromboembolic events following myocardial infarction. With advancements in treatment techniques and early discovery, the prognosis has improved, although maternal mortality is still a worry. For the purpose of improving results and directing future research endeavors, knowledge and comprehension of IHD during pregnancy are essential.
Collapse
Affiliation(s)
| | - Darshilkumar Maheta
- From the Department of Public Health, New York Medical College, Valhalla, NY
| | - Siddharth Pravin Agrawal
- Department of Internal Medicine, New York Medical College/Landmark Medical Center, Woonsocket, RI
| | | | - Wilbert S Aronow
- Department of Cardiology and Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
| |
Collapse
|
2
|
Tegenge MA, Mahmood I, Struble EB, Sauna Z. Pharmacokinetics of antibodies during pregnancy: General pharmacokinetics and pregnancy related physiological changes (Part 1). Int Immunopharmacol 2023; 117:109914. [PMID: 36841154 DOI: 10.1016/j.intimp.2023.109914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/15/2023] [Accepted: 02/16/2023] [Indexed: 02/27/2023]
Abstract
Pharmacokinetics (PK) studies are important to determine a safe and effective dose of both small and large molecule drugs. Intrinsic factors such as pregnancy can substantially alter the PK of a drug. Several PK studies have been published for small molecules administered during pregnancy, but such investigations are scarce for macromolecules including monoclonal and polyclonal antibodies. In this part 1 of 2 reviews, we first provide a general description of macromolecule drugs, the PK differences with small molecules, and current knowledge on their absorption, distribution, metabolism and elimination in non-pregnant subjects. We then review in detail the physiological changes during pregnancy. While some of the physiologic adaptions of pregnancy, for example increased plasma volume and cardiac output, are expected to impact PK of antibody therapeutics, the effects of others, such as increased GFR and altered immune responses are not fully understood. We conclude that further investigations are needed to fully elucidate how pregnancy can impact PK properties of macromolecules.
Collapse
Affiliation(s)
- Million A Tegenge
- Division of Clinical Evaluation and Pharmacology/Toxicology, Office of Tissue and Advanced Therapies, Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA.
| | - Iftekhar Mahmood
- Mahmood Clinical Pharmacology Consultancy LLC, Rockville, MD, USA
| | - Evi B Struble
- Division of Plasma Protein Therapeutics, Office of Tissue and Advanced Therapies, Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Zuben Sauna
- Division of Plasma Protein Therapeutics, Office of Tissue and Advanced Therapies, Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| |
Collapse
|
3
|
Patel P, Balanchivadze N. Hematologic Findings in Pregnancy: A Guide for the Internist. Cureus 2021; 13:e15149. [PMID: 34164247 PMCID: PMC8214837 DOI: 10.7759/cureus.15149] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2021] [Indexed: 12/25/2022] Open
Abstract
Hematologic changes in pregnancy are common and can potentially lead to maternal and fetal morbidity. Here, we present various hematologic manifestations seen in pregnant women. Iron deficiency anemia (IDA) is the most common cause of anemia in pregnancy. Physiologically, the state of pregnancy results in increased iron demand. Iron deficiency is important to diagnose and treat early for better maternal and fetal outcomes. An algorithmic approach is used for the repletion of iron storage, starting with oral elemental iron daily and escalating to intravenous iron if necessary. Folate and cobalamin are necessary elements for deoxyribonucleic acid (DNA) synthesis, fetal growth, and maternal tissue development, and deficiency in these elements can be a cause for anemia in pregnancy. Thrombocytopenia is currently the second most common hematologic condition in pregnancy after anemia. There is a wide range of etiology for thrombocytopenia in pregnancy from benign to life-threatening causes that require prompt diagnosis and treatment. These conditions include gestational thrombocytopenia, thrombotic thrombocytopenic purpura, pregnancy-associated atypical hemolytic-uremic syndrome, and immune thrombocytopenia. Acquired bleeding disorders that can cause major complications in pregnancy include von Willebrand disease (vWD) and coagulation factor deficiencies. Women with vWD are at increased risk of pregnancy bleeding and postpartum hemorrhage. Pregnancy can also produce a physiologic hypercoagulable state, leading to life-threatening conditions like thromboembolism. Diagnosis, treatment options, and guidelines for the management of these conditions will be explored in this review.
Collapse
Affiliation(s)
- Pooja Patel
- Internal Medicine, Grand Strand Medical Center, Myrtle Beach, USA
| | | |
Collapse
|
4
|
Spratt DI, Buchsbaum RJ. COVID-19 and Hypercoagulability: Potential Impact on Management with Oral Contraceptives, Estrogen Therapy and Pregnancy. Endocrinology 2020; 161:5874354. [PMID: 32725207 PMCID: PMC7454527 DOI: 10.1210/endocr/bqaa121] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/14/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Daniel I Spratt
- The Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Maine Medical Center, Portland ME
- Corresponding author: Daniel Spratt, MD, Division of Reproductive Endocrinology and Infertility, Maine Medical Center, Portland, ME 04102, Phone: 207-771-5549,
| | - Rachel J Buchsbaum
- Division of Hematology/Oncology, Tufts University School of Medicine, Boston MA (RB)
| |
Collapse
|
5
|
Xu Y, Liang Y, Parunov L, Despres D, Eckhaus M, Scott D, Ovanesov M, Struble EB. Combined thrombogenic effects of vessel injury, pregnancy and procoagulant immune globulin administration in mice. Thromb J 2020; 18:32. [PMID: 33292285 PMCID: PMC7648396 DOI: 10.1186/s12959-020-00245-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 10/26/2020] [Indexed: 11/25/2022] Open
Abstract
Background Pregnant women are at increased risk of thrombotic adverse events. Plasma derived immune globulin (IG) products, which are used in pregnancy for various indications, may contain procoagulant impurity activated coagulation factor XI (FXIa). Procoagulant IG products have been associated with increased thrombogenicity but their effect in pregnancy is unknown. Methods Late pregnant (gestation days 17–20) or early lactation (days 1–3) and control female mice were treated with IGs supplemented with human FXIa then subjected to ferric chloride (FeCl3) vessel injury. Occlusion of blood vessel was assessed by recording blood velocity in the femoral vein for 20 min using doppler ultrasound laser imaging. FXIa dose was selected by the ability to increase thrombin generation in mouse plasma in vitro. Results FXIa produced robust thrombin generation in mouse plasma ex vivo. Following FeCl3 injury, pregnant and non-pregnant mice receiving IG + FXIa exhibited faster reduction of blood velocity in femoral vein compared to IG alone or untreated controls. In vitro, thrombin generation in plasma samples collected after thrombosis in FXIa-treated animals was elevated and could be reduced by anti-FXI antibody. Conclusions Our results suggest that intravenously-administered FXIa may contribute to thrombosis at the site of vascular injury in both pregnant and non-pregnant animals. Supplementary Information Supplementary information accompanies this paper at 10.1186/s12959-020-00245-8.
Collapse
Affiliation(s)
- Yanqun Xu
- Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, 10903 New Hampshire Ave, Silver Spring, MD, 20993-0002, USA
| | - Yideng Liang
- Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, 10903 New Hampshire Ave, Silver Spring, MD, 20993-0002, USA
| | - Leonid Parunov
- Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, 10903 New Hampshire Ave, Silver Spring, MD, 20993-0002, USA
| | - Daryl Despres
- Mouse Imaging Facility, National Institutes of Health, Bethesda, MD, USA
| | - Michael Eckhaus
- Pathology Service, Division of Veterinary Resources, National Institutes of Health, Bethesda, MD, USA
| | - Dorothy Scott
- Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, 10903 New Hampshire Ave, Silver Spring, MD, 20993-0002, USA
| | - Mikhail Ovanesov
- Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, 10903 New Hampshire Ave, Silver Spring, MD, 20993-0002, USA.
| | - Evi B Struble
- Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, 10903 New Hampshire Ave, Silver Spring, MD, 20993-0002, USA.
| |
Collapse
|
6
|
Deems NP, Leuner B. Pregnancy, postpartum and parity: Resilience and vulnerability in brain health and disease. Front Neuroendocrinol 2020; 57:100820. [PMID: 31987814 PMCID: PMC7225072 DOI: 10.1016/j.yfrne.2020.100820] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 11/25/2019] [Accepted: 01/21/2020] [Indexed: 02/07/2023]
Abstract
Risk and resilience in brain health and disease can be influenced by a variety of factors. While there is a growing appreciation to consider sex as one of these factors, far less attention has been paid to sex-specific variables that may differentially impact females such as pregnancy and reproductive history. In this review, we focus on nervous system disorders which show a female bias and for which there is data from basic research and clinical studies pointing to modification in disease risk and progression during pregnancy, postpartum and/or as a result of parity: multiple sclerosis (MS), depression, stroke, and Alzheimer's disease (AD). In doing so, we join others (Shors, 2016; Galea et al., 2018a) in aiming to illustrate the importance of looking beyond sex in neuroscience research.
Collapse
Affiliation(s)
- Nicholas P Deems
- The Ohio State University, Department of Psychology, Columbus, OH, USA
| | - Benedetta Leuner
- The Ohio State University, Department of Psychology, Columbus, OH, USA.
| |
Collapse
|