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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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Joglar JA, Kapa S, Saarel EV, Dubin AM, Gorenek B, Hameed AB, Lara de Melo S, Leal MA, Mondésert B, Pacheco LD, Robinson MR, Sarkozy A, Silversides CK, Spears D, Srinivas SK, Strasburger JF, Tedrow UB, Wright JM, Zelop CM, Zentner D. 2023 HRS expert consensus statement on the management of arrhythmias during pregnancy. Heart Rhythm 2023; 20:e175-e264. [PMID: 37211147 DOI: 10.1016/j.hrthm.2023.05.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 05/12/2023] [Indexed: 05/23/2023]
Abstract
This international multidisciplinary expert consensus statement is intended to provide comprehensive guidance that can be referenced at the point of care to cardiac electrophysiologists, cardiologists, and other health care professionals, on the management of cardiac arrhythmias in pregnant patients and in fetuses. This document covers general concepts related to arrhythmias, including both brady- and tachyarrhythmias, in both the patient and the fetus during pregnancy. Recommendations are provided for optimal approaches to diagnosis and evaluation of arrhythmias; selection of invasive and noninvasive options for treatment of arrhythmias; and disease- and patient-specific considerations when risk stratifying, diagnosing, and treating arrhythmias in pregnant patients and fetuses. Gaps in knowledge and new directions for future research are also identified.
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Affiliation(s)
- José A Joglar
- The University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Elizabeth V Saarel
- St. Luke's Health System, Boise, Idaho, and Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio
| | | | | | | | | | | | | | - Luis D Pacheco
- The University of Texas Medical Branch at Galveston, Galveston, Texas
| | | | - Andrea Sarkozy
- University Hospital of Antwerp, University of Antwerp, Antwerp, Belgium
| | | | - Danna Spears
- University Health Network, Toronto, Ontario, Canada
| | - Sindhu K Srinivas
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | | | | | - Carolyn M Zelop
- The Valley Health System, Ridgewood, New Jersey; New York University Grossman School of Medicine, New York, New York
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Liu C, Pace S, Bromley R, Dobson R. Exposure to medication for neurological disease in pregnancy - time to consider the long-term implications? EClinicalMedicine 2023; 63:102157. [PMID: 37662523 PMCID: PMC10474373 DOI: 10.1016/j.eclinm.2023.102157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 09/05/2023] Open
Abstract
A range of long-term neurological conditions may be diagnosed in young adulthood. These conditions are generally not curable, and most people need to take ongoing treatment for symptom control and/or disease modification. When chronic diseases are diagnosed before people have completed their families, there is a need to balance the potential benefits of treatment for the mother against potential risk(s) to the fetus from exposure to medications during pregnancy. Whilst available data regarding short-term fetal outcomes following treatment exposures during pregnancy is rapidly increasing, information regarding longer-term outcomes is more limited. The association of fetal exposure to valproate with serious long-term neurodevelopmental outcomes has highlighted the importance of capturing and evaluating long-term data. In this review we examine available evidence around the long-term effects of treatments used for the most common long-term neurological conditions diagnosed in early adulthood, namely epilepsy, migraine and neuroinflammatory disorders. We draw from existing literature across a range of diseases and discuss strategies to improve future knowledge.
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Affiliation(s)
- Chen Liu
- Preventive Neurology Unit, Wolfson Institute of Population Health, QMUL, UK
| | - Samuel Pace
- Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Rebecca Bromley
- Division of Neuroscience, School of Biological Sciences, Faculty of Medicine, Biology and Health, University of Manchester, UK
- Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, UK
| | - Ruth Dobson
- Preventive Neurology Unit, Wolfson Institute of Population Health, QMUL, UK
- Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK
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Kalam MN, Rasool MF, Rehman AU, Ahmed N. Clinical Pharmacokinetics of Propranolol Hydrochloride: A Review. Curr Drug Metab 2021; 21:89-105. [PMID: 32286940 DOI: 10.2174/1389200221666200414094644] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 02/06/2020] [Accepted: 03/02/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Nobel laureate Sir James Black's molecule, propranolol, still has broad potential in cardiovascular diseases, infantile haemangiomas and anxiety. A comprehensive and systematic review of the literature for the summarization of pharmacokinetic parameters would be effective to explore the new safe uses of propranolol in different scenarios, without exposing humans and using virtual-human modeling approaches. OBJECTIVE This review encompasses physicochemical properties, pharmacokinetics and drug-drug interaction data of propranolol collected from various studies. METHODS Clinical pharmacokinetic studies on propranolol were screened using Medline and Google Scholar databases. Eighty-three clinical trials, in which pharmacokinetic profiles and plasma time concentration were available after oral or IV administration, were included in the review. RESULTS The study depicts that propranolol is well absorbed after oral administration. It has dose-dependent bioavailability, and a 2-fold increase in dose results in a 2.5-fold increase in the area under the curve, a 1.3-fold increase in the time to reach maximum plasma concentration and finally, 2.2 and 1.8-fold increase in maximum plasma concentration in both immediate and long-acting formulations, respectively. Propranolol is a substrate of CYP2D6, CYP1A2 and CYP2C19, retaining potential pharmacokinetic interactions with co-administered drugs. Age, gender, race and ethnicity do not alter its pharmacokinetics. However, in renal and hepatic impairment, it needs a dose adjustment. CONCLUSION Physiochemical and pooled pharmacokinetic parameters of propranolol are beneficial to establish physiologically based pharmacokinetic modeling among the diseased population.
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Affiliation(s)
| | - Muhammad Fawad Rasool
- Pharmacy Practice Department, Faculty of Pharmacy, Bahauddin Zakariya University, Multan, Pakistan
| | - Asim Ur Rehman
- Department of Pharmacy, Quaid-i-Azam University, 45320, Islamabad, Pakistan
| | - Naveed Ahmed
- Department of Pharmacy, Quaid-i-Azam University, 45320, Islamabad, Pakistan
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Propranolol during pregnancy for large chorioangioma. Med Hypotheses 2015; 85:513-4. [DOI: 10.1016/j.mehy.2015.06.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 06/12/2015] [Accepted: 06/28/2015] [Indexed: 11/21/2022]
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Abstract
Migraine is common during pregnancy, but fortunately this combination of conditions obviously exists for only a finite period. The greatest frequency of migraine attacks occurs during the first trimester. Accurate diagnosis is a sine qua non in this setting as in any headache patient. It is in the first trimester that the fetus is at greatest risk from abortifacient and teratogenic drugs, and when very early pregnancy may be undiagnosed. Ergot alkaloids (including methysergide) should be avoided during pregnancy because of their teratogenicity, and most other drug classes should be used only when unavoidable. The use of prophylactic agents during pregnancy should be the exception, not the rule, and preferably only during the second and third trimesters; propranolol is probably safest in this situation. De novo headache during pregnancy usually requires expert review of the patient. Treatment tactics for uncomplicated migraine in pregnancy depend on the concurrent clinical situation. Paracetamol (acetaminophen) is the mainstay for the patient whose typical attacks continue into the first trimester. If paracetamol is insufficient, then partial agonist opioids may be used if typical migraine attacks persist in the second and third trimesters (which is uncommon). 'Chronic migraine' in pregnancy, i.e. >or=15 headache days per month, is rare, and is the greatest therapeutic challenge. Co-morbidities such as depression or epilepsy require specialised approaches. The complexities associated with these tactics are discussed in this article, and it is emphasised that none has the specific approval of regulatory authorities. Heightened pharmacovigilance will better inform the future pregnant migraineur. However, this type of information is less likely to be available for novel classes of neuropharmacological agents than for existing ones.
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Oudijk MA, Ruskamp JM, Ambachtsheer BE, Ververs TFF, Stoutenbeek P, Visser GHA, Meijboom EJ. Drug treatment of fetal tachycardias. Paediatr Drugs 2002; 4:49-63. [PMID: 11817986 DOI: 10.2165/00128072-200204010-00006] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The pharmacological treatment of fetal tachycardia (FT) has been described in various publications. We present a study reviewing the necessity for treatment of FT, the regimens of drugs used in the last two decades and their mode of administration. The absence of reliable predictors of fetal hydrops (FH) has led most centers to initiate treatment as soon as the diagnosis of FT has been established, although a small minority advocate nonintervention. As the primary form of pharmacological intervention, oral maternal transplacental therapy is generally preferred. Digoxin is the most common drug used to treat FT; however, effectiveness remains a point of discussion. After digoxin, sotalol seems to be the most promising agent, specifically in atrial flutter and nonhydropic supraventricular tachycardia (SVT). Flecainide is a very effective drug in the treatment of fetal SVT, although concerns about possible pro-arrhythmic effects have limited its use. Amiodarone has been described favorably, but is frequently excluded due to its poor tolerability. Verapamil is contraindicated as it may increase mortality. Conclusions on other less frequently used drugs cannot be drawn. In severely hydropic fetuses and/or therapy-resistant FT, direct fetal therapy is sometimes initiated. To minimize the number of invasive procedures, fetal intramuscular or intraperitoneal injections that provide a more sustained release are preferred. Based on these data we propose a drug protocol of sotalol 160 mg twice daily orally, increased to a maximum of 480 mg daily. Whenever sinus rhythm is not achieved, the addition of digoxin 0.25 mg three times daily is recommended, increased to a maximum of 0.5 mg three times daily. Only in SVT complicated by FH, either maternal digoxin 1 to 2mg IV in 24 hours, and subsequently 0.5 to 1 mg/day IV, or flecainide 200 to 400 mg/day orally is proposed. Initiating direct fetal therapy may follow failure of transplacental therapy.
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Affiliation(s)
- Martijn A Oudijk
- Department of Obstetrics, University Medical Center, Utrecht 3508 AB, 3584 EA, The Netherlands
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Abstract
Drugs administered to mothers have the potential to cross the placenta and reach the fetus. Under particular circumstances, the comparison of the drug concentration in the maternal and fetal plasma may give an idea of the exposure of the fetus to the maternally administered drugs. In this review drugs are classified according to their type of transfer across the placenta. Several drugs rapidly cross the placenta and pharmacologically significant concentrations equilibrate in maternal and fetal plasma. Their transfer is termed 'complete'. Other drugs cross the placenta incompletely, and their concentrations are lower in the fetal than in maternal plasma. The majority of drugs fit into 1 of these 2 groups. A limited number of drugs reach greater concentrations in fetal than maternal plasma. It is said that these drugs have an 'exceeding' transfer. The impression prevails that suxamethonium chloride (succinylcholine chloride) and doxorubicin do not cross the placenta. However, a careful analysis of the literature suggests that this impression is wrong and that all drugs cross the placenta, although the extent transfer varies considerably. The following parameters were considered as possible factors determining the extent of placental transfer: (i) the molecular weight of the drug; (ii) the pKa (pH at which the drug is 50% ionised); and (iii) the extent of drug binding to the plasma protein. Drugs with molecular weights greater than 500D have an incomplete transfer across the human placenta. Strongly dissociated acid drug molecules should have an incomplete transfer, but this does not seem to be an absolute rule. For example, ampicillin and methicillin transfer completely and they are strongly dissociated at physiological pH. The extent of drug binding to plasma protein does not influence the type of drug transfer across the human placenta.
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Affiliation(s)
- G M Pacifici
- Department of Biomedicine, University of Pisa, Medical School, Italy
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Buttar HS, Moffatt JH, Bura C. Transplacental and mammary passage of radioactivity in rats treated vaginally and orally with [14C]propranolol. JOURNAL OF TOXICOLOGY AND ENVIRONMENTAL HEALTH 1988; 24:1-18. [PMID: 3373560 DOI: 10.1080/15287398809531137] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The milk transfer, maternal-fetal distribution, and disposition of the antihypertensive/spermicidal agent propranolol were studied in pregnant and lactating rats. Single doses (10 mg/kg) of an aqueous solution of [14C]propranolol were administered either orally (po) or intravaginally (ivg) on gestational d 15, or on postpartum d 7-10. Upon ivg administration, [14C]propranolol was quickly transferred to systemic circulation and the mean blood [14C] concentrations were significantly greater during the first 0.25-2 h than in po dosed counterparts. About 98% of the ivg applied dose was absorbed after 6 h in gravid rats, and the combined 6-h excretions of radioactivity in the urine (ivg = 24.6%; po = 22.9%) and feces (ivg = 16.8%; po = 14.6%) were equivalent in both groups. At the end of 6 h, the levels of [14C] in the urinary bladder, adrenal, uterus, ovary, spleen, skeletal muscle, brain, heart, lung and fat were significantly higher in ivg treated rats than po dosed animals. Compared with the maternal plasma (ivg = 0.76; po = 0.88 microgram/ml), the mean concentrations of [14C] in the placentas were similar in both groups, while the amounts of [14C] were three to five times lower in the amniotic fluids and the fetuses of both po and ivg treated dams. In lactating rats, over 99% of the administered radioactivity was absorbed from the vagina within 6 h. The blood concentrations of [14C] were significantly elevated at 0.5 and 1 h in the per vaginam treated animals, and afterward the disappearance rate of [14C] followed a similar course in both groups. Following ivg application, the milk radioactivity peaked at 0.5 h and declined rapidly. However, the appearance of [14C] in milk was rather slow after oral dosing: the milk [14C] peaked between 2 and 3 h posttreatment and remained steady thereafter. The milk to blood (M/B) [14C] concentration ratios were markedly greater during 0.5 to 1 h in the ivg group than in their po dosed counterparts. At 6 h, the [14C] levels in the whole blood, plasma, milk, and mammary gland were virtually equivalent in the ivg and po treated females. Comparison of the areas under the milk [14C] concentration-time curves (AUCs) indicated that the milk availability of [14C] was about 31% more in dams dosed vaginally. These data suggest that route of administration alters the disposition and milk excretion of [14C]propranolol-derived radioactivity in pregnant and lactating rats.
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Affiliation(s)
- H S Buttar
- Drug Toxicology Division, Health and Welfare Canada, Ottawa
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Affiliation(s)
- E Perucca
- Department of Internal Medicine and Therapeutics, University of Pavia, Italy
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O'Hare MF, Kinney CD, Murnaghan GA, McDevitt DG. Pharmacokinetics of propranolol during pregnancy. Eur J Clin Pharmacol 1984; 27:583-7. [PMID: 6519163 DOI: 10.1007/bf00556896] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Propranolol, a beta-adrenoceptor blocking drug, was administered to 6 healthy pregnant volunteers between 32 and 36 weeks gestation and when at least 6 weeks postpartum. On both occasions, subjects were given propranolol 120 mg orally or 10 mg intravenously in randomised order with a minimum washout period of 1 week. Propranolol was assayed in plasma by gas-liquid chromatography with electron-capture detection and the pharmacokinetic parameters were investigated. There were no significant alterations in elimination half-life, clearance or apparent volume of distribution per kilogram antenatally compared with postnatally: bioavailability was also unchanged. It is concluded that the disposition of propranolol is not altered during pregnancy.
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