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Ramlakhan KP, Roos-Hesselink JW, Basso T, Greenslade J, Flint RB, Krieger EV, Shotan A, Budts W, De Backer J, Hall R, Johnson MR, Parsonage WA. Perinatal outcomes after in-utero exposure to beta-blockers in women with heart disease: Data from the ESC EORP registry of pregnancy and cardiac disease (ROPAC). Int J Cardiol 2024; 410:132234. [PMID: 38844094 DOI: 10.1016/j.ijcard.2024.132234] [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: 01/24/2024] [Revised: 05/20/2024] [Accepted: 06/03/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND Beta-blockers are commonly used drugs during pregnancy, especially in women with heart disease, and are regarded as relatively safe although evidence is sparse. Differences between beta-blockers are not well-studied. METHODS In the Registry of Pregnancy And Cardiac disease (ROPAC, n = 5739), a prospective global registry of pregnancies in women with structural heart disease, perinatal outcomes (small for gestational age (SGA), birth weight, neonatal congenital heart disease (nCHD) and perinatal mortality) were compared between women with and without beta-blocker exposure, and between different beta-blockers. Multivariable regression analysis was used for the effect of beta-blockers on birth weight, SGA and nCHD (after adjustment for maternal and perinatal confounders). RESULTS Beta-blockers were used in 875 (15.2%) ROPAC pregnancies, with metoprolol (n = 323, 37%) and bisoprolol (n = 261, 30%) being the most frequent. Women with beta-blocker exposure had more SGA infants (15.3% vs 9.3%, p < 0.001) and nCHD (4.7% vs 2.7%, p = 0.001). Perinatal mortality rates were not different (1.4% vs 1.9%, p = 0.272). The adjusted mean difference in birth weight was -177 g (-5.8%), the adjusted OR for SGA was 1.7 (95% CI 1.3-2.1) and for nCHD 2.3 (1.6-3.5). With metoprolol as reference, labetalol (0.2, 0.1-0.4) was the least likely to cause SGA, and atenolol (2.3, 1.1-4.9) the most. CONCLUSIONS In women with heart disease an association was found between maternal beta-blocker use and perinatal outcomes. Labetalol seems to be associated with the lowest risk of developing SGA, while atenolol should be avoided.
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Affiliation(s)
- Karishma P Ramlakhan
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands; Department of Obstetrics and Gynaecology, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jolien W Roos-Hesselink
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Thomas Basso
- Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Jaimi Greenslade
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Australia; Australian Centre for Health Services Innovation, School of Public Health and Social Work, Centre for Healthcare Transformation, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Robert B Flint
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands; Department of Neonatology, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Eric V Krieger
- Division of Cardiology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Avraham Shotan
- Heart Institute, Laniado Medical Center, Netanya, Adelson School of Medicine, Ariel University, Israel
| | - Werner Budts
- Congenital and Structural Cardiology, University Hospitals Leuven, and Department of Cardiovascular Sciences, Catholic University of Leuven, Leuven, Belgium
| | - Julie De Backer
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Roger Hall
- Department of Cardiology, University of East Anglia, Norwich, United Kingdom
| | - Mark R Johnson
- Department of Obstetric Medicine, Imperial College London, Chelsea and Westminster Hospital, London, United Kingdom
| | - William A Parsonage
- Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia; Australian Centre for Health Services Innovation, School of Public Health and Social Work, Centre for Healthcare Transformation, Faculty of Health, Queensland University of Technology, Brisbane, Australia
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2
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Avalos LA, Neugebauer RS, Nance N, Badon SE, Cheetham TC, Easterling TR, Reynolds K, Idu A, Bider-Canfield Z, Holt VL, Dublin S. Maternal and neonatal outcomes associated with treating hypertension in pregnancy at different thresholds. Pharmacotherapy 2023; 43:381-390. [PMID: 36779861 PMCID: PMC10849892 DOI: 10.1002/phar.2778] [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: 07/14/2022] [Revised: 11/07/2022] [Accepted: 01/04/2023] [Indexed: 02/14/2023]
Abstract
INTRODUCTION In the United States, there has been controversy over whether treatment of mild-to-moderate hypertension during pregnancy conveys more benefit than risk. OBJECTIVE The objective of the study was to compare risks and benefits of treatment of mild-to-moderate hypertension during pregnancy. METHODS This retrospective cohort study included 11,871 pregnant women with mild-to-moderate hypertension as defined by blood pressure (BP) values from three Kaiser Permanente regions between 2005 and 2014. Data were extracted from electronic health records. Dynamic marginal structural models with inverse probability weighting and informative censoring were used to compare risks of adverse outcomes when beginning antihypertensive medication treatment at four BP thresholds (≥155/105, ≥150/100, ≥145/95, ≥140/90 mm Hg) compared with the recommended threshold in the United States at that time, ≥160/110 mm Hg. Outcomes included preeclampsia, preterm birth, small-for-gestational-age (SGA), Neonatal Intensive Care Unit (NICU) care, and stillbirth. Primary analyses allowed 2 weeks for medication initiation after an elevated BP. Several sensitivity and subgroup (i.e., race/ethnicity and pre-pregnancy body mass index) analyses were also conducted. RESULTS In primary analyses, medication initiation at lower BP thresholds was associated with greater risk of most outcomes. Comparing the lowest (≥140/90 mm Hg) to the highest BP threshold (≥160/110 mm Hg), we found an excess risk of preeclampsia (adjusted Risk Difference (aRD) 38.6 per 100 births, 95% Confidence Interval (CI): 30.6, 46.6), SGA (aRD: 10.2 per 100 births, 95% CI: 2.6, 17.8), NICU admission (aRD: 20.2 per 100 births, 95% CI: 12.6, 27.9), and stillbirth (1.18 per 100 births, 95% CI: 0.27, 2.09). The findings did not reach statistical significance for preterm birth (aRD: 2.5 per 100 births, 95% CI: -0.4, 5.3). These relationships were attenuated and did not always reach statistically significance when comparing higher BP treatment thresholds to the highest threshold (i.e., ≥160/110 mm Hg). Sensitivity and subgroup analyses produced similar results. CONCLUSIONS Initiation of antihypertensive medication at mild-to-moderate BP thresholds (140-155/90-105 mm Hg; with the largest risk consistently associated with treatment at 140/90 mm Hg) may be associated with adverse maternal and neonatal outcomes. Limitations include inability to measure medication adherence.
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Affiliation(s)
- Lyndsay A Avalos
- Kaiser Permanente Northern California Division of Research, Oakland, California, USA
| | - Romain S Neugebauer
- Kaiser Permanente Northern California Division of Research, Oakland, California, USA
| | - Nerissa Nance
- Kaiser Permanente Northern California Division of Research, Oakland, California, USA
| | - Sylvia E Badon
- Kaiser Permanente Northern California Division of Research, Oakland, California, USA
| | | | - Thomas R Easterling
- Department of Obstetrics & Gynecology, University of Washington, Seattle, Washington, USA
| | - Kristi Reynolds
- Kaiser Permanente Southern California Department of Research and Evaluation, California, USA
| | - Abisola Idu
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Zoe Bider-Canfield
- Kaiser Permanente Southern California Department of Research and Evaluation, California, USA
| | - Victoria L Holt
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Sascha Dublin
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
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3
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Al Khalaf S, Khashan AS, Chappell LC, O'Reilly ÉJ, McCarthy FP. Role of Antihypertensive Treatment and Blood Pressure Control in the Occurrence of Adverse Pregnancy Outcomes: a Population-Based Study of Linked Electronic Health Records. Hypertension 2022; 79:1548-1558. [PMID: 35502665 DOI: 10.1161/hypertensionaha.122.18920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Chronic hypertension (CH) adversely impacts pregnancy. It remains unclear whether antihypertensive treatment alters these risks. We examined the role of antihypertensive treatment in the association between CH and adverse pregnancy outcomes. METHODS Electronic health records from the UK Caliber and Clinical Practice Research Datalink were used to define a cohort of women delivering between 1997 and 2016. Primary outcomes were preeclampsia, preterm birth (PTB), and fetal growth restriction (FGR). We used multivariable logistic regression to compare outcomes in women with CH to women without CH and propensity score matching to compare antihypertensive agents. RESULTS The study cohort consisted of 1 304 679 women and 1 894 184 births. 14 595 (0.77%) had CH, and 6786 (0.36%) were prescribed antihypertensive medications in pregnancy. Overall, women with CH (versus no CH), had higher odds of preeclampsia (adjusted odds ratio [aOR], 5.74 [95% CI, 5.44-6.07]); PTB (aOR, 2.53 [2.39-2.67]); and FGR (aOR, 2.51 [2.31-2.72]). Women with CH prescribed treatment (versus untreated women) had higher odds of preeclampsia (aOR, 1.17 [1.05-1.30]), PTB (1.25 [1.12-1.39]), and FGR (1.80 [1.51-2.14]). Women prescribed methyldopa (versus β-blockers) had higher odds of preeclampsia (aOR, 1.43 [1.19-1.73]); PTB (1.59 [1.30-1.93]), but lower odds of FGR (aOR, 0.66 [0.48-0.90]). Odds of adverse outcomes were similar in relation to calcium channel blockers (versus β-blockers) except for PTB (aOR, 1.94 [1.15-3.27]). Among women prescribed treatment, lower average blood pressure (<135/85 mm Hg) was associated with better pregnancy outcomes. CONCLUSIONS Treatment with antihypertensive agents and control of hypertension ameliorates some effects but higher risks of adverse outcomes persist. β-Blockers versus methyldopa may be associated with better pregnancy outcomes except for FGR. Powered trials are needed to inform optimal treatment of CH during pregnancy.
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Affiliation(s)
- Sukainah Al Khalaf
- School of Public Health (S.A.K., A.S.K., E.J.O.), University College Cork, Ireland.,INFANT Research Centre (S.A.K., A.S.K., F.P.M.), University College Cork, Ireland
| | - Ali S Khashan
- School of Public Health (S.A.K., A.S.K., E.J.O.), University College Cork, Ireland.,INFANT Research Centre (S.A.K., A.S.K., F.P.M.), University College Cork, Ireland
| | - Lucy C Chappell
- Department of Women and Children's Health, King's College London (L.C.C.)
| | - Éilis J O'Reilly
- School of Public Health (S.A.K., A.S.K., E.J.O.), University College Cork, Ireland.,Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA (E.J.O.).,Environmental Research Institute, University College Cork, Ireland (E.J.O.).,Environmental Research Institute, University College Cork, Ireland (E.J.O.)
| | - Fergus P McCarthy
- INFANT Research Centre (S.A.K., A.S.K., F.P.M.), University College Cork, Ireland.,Department of Obstetrics and Gynaecology, Cork University Hospital, Ireland (F.P.M.)
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Reddy R, Baijnath S, Moodley R, Moodley J, Naicker T, Govender N. South African medicinal plants displaying angiotensin-converting enzyme inhibition: Potential use in the management of preeclampsia. J Ayurveda Integr Med 2022; 13:100562. [PMID: 35675745 PMCID: PMC9178479 DOI: 10.1016/j.jaim.2022.100562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 03/01/2022] [Accepted: 03/04/2022] [Indexed: 01/13/2023] Open
Abstract
In resource-limited settings, such as South Africa, hypertensive disorders of pregnancy such as preeclampsia, is the most common direct cause of maternal deaths. Current management strategies of preeclampsia primarily involve the use of pharmaceutical drugs, which are frequently associated with undesirable side-effects. Moreover, these drugs are often not easily accessible due to financial and economic constraints. Consequently, many patients rely on traditional medicine obtained from medicinal plants to manage health-related conditions. Angiotensin-converting enzyme inhibitors are widely used drugs for the management of preeclampsia. This narrative review aims to highlight the use of indigenous medicinal plants from South Africa with Angiotensin-converting enzyme inhibitory activity whilst also evaluating their potential use in the treatment of hypertension in pregnancy. This information will influence traditional healers and sangomas in their patient management. Furthermore, the antihypertensive potential of these plants will be unraveled thus facilitating the development of new naturally occurring pharmaceutical products to reduce maternal and neonatal mortality and morbidity.
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Affiliation(s)
- Rebecca Reddy
- Department of Basic Medical Science, Faculty of Health Sciences, Durban University of Technology, Durban, South Africa
| | - Sooraj Baijnath
- Catalysis and Peptide Research Unit, Discipline of Pharmaceutical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Roshila Moodley
- School of Chemistry and Physics, University of KwaZulu-Natal, Durban, South Africa
| | - Jagidesa Moodley
- Women's Health and HIV Research Group, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Thajasvarie Naicker
- Discipline of Optics and Imaging, Doris Duke Medical Research Institute, College of Health Sciences, University of KwaZulu-Natal, Durban, KwaZulu-Natal, 4001, South Africa
| | - Nalini Govender
- Department of Basic Medical Science, Faculty of Health Sciences, Durban University of Technology, Durban, South Africa.
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5
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Kerr S, Heinke D, Yazdy MM, Mitchell AA, Darling AM, Lin A, Nestoridi E, Werler MM. Use of vasoactive medications in pregnancy and the risk of stillbirth among birth defect cases. Birth Defects Res 2022; 114:277-294. [PMID: 35238183 PMCID: PMC9798591 DOI: 10.1002/bdr2.1996] [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: 11/04/2021] [Revised: 02/11/2022] [Accepted: 02/15/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Many previous studies have identified risk factors for stillbirth, but few examine stillbirth among pregnancies affected with birth defects. Because many hypothesized etiologies of stillbirth work through vascular pathologies of the placenta, we examined maternal use of vasoactive medications in relation to stillbirth among pregnancies affected with birth defects. METHODS Data were analyzed from the National Birth Defects Prevention Study (1997-2011). We examined use of nonsteroidal anti-inflammatory drugs (NSAIDs), decongestants, short- or long-acting beta-agonists (SABA/LABA), and antihypertensive medications in relation to pregnancies affected by birth defects ending in stillbirth compared to live birth. Associations were measured with odds ratios (ORs) for early pregnancy use and hazard ratios (HRs) for time-varying late pregnancy use. RESULTS Among all birth defects (n = 12,394), the risk of stillbirth was associated with use of antihypertensive medications in early (odds ratio [OR]: 1.8; 95% confidence interval [CI]: 1.0, 3.1) and late pregnancy (HR: 2.0; 95% CI: 1.1, 3.6). Other vasoactive medications were not associated with increased risk of stillbirth. Of 27 specific defect groups, increased risks were observed for only one medication/defect pair: early decongestant use was more common among mothers of stillbirth versus live birth cases with spina bifida (OR: 2.4; 95% CI: 0.9, 6.5). CONCLUSION This exploratory analysis of vasoactive medication use suggests that use of NSAIDs, decongestants, and SABA/LABA is not associated with increased risk of stillbirth among pregnancies affected with birth defects. Our finding of increased risks associated with antihypertensive medication use raises questions of confounding by indication, which we were not able to fully address.
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Affiliation(s)
- Stephen Kerr
- Slone Epidemiology Center, Boston University, Boston, Massachusetts, USA
| | - Dominique Heinke
- Center for Birth Defects Research and Prevention, Massachusetts Department of Public Health, Boston, Massachusetts, USA
| | - Mahsa M. Yazdy
- Center for Birth Defects Research and Prevention, Massachusetts Department of Public Health, Boston, Massachusetts, USA
| | - Allen A. Mitchell
- Slone Epidemiology Center, Boston University, Boston, Massachusetts, USA
| | - Anne Marie Darling
- Center for Birth Defects Research and Prevention, Massachusetts Department of Public Health, Boston, Massachusetts, USA
| | - Angela Lin
- Center for Birth Defects Research and Prevention, Massachusetts Department of Public Health, Boston, Massachusetts, USA
- Medical Genetics Unit, Mass General Hospital for Children, Harvard Medical School, Boston, Massachusetts, USA
| | - Eirini Nestoridi
- Center for Birth Defects Research and Prevention, Massachusetts Department of Public Health, Boston, Massachusetts, USA
| | - Martha M. Werler
- Department of Epidemiology, Boston University, Boston, Massachusetts, USA
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6
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Clinical outcomes of hypertensive disorders in pregnancy in the offspring during perinatal period, childhood, and adolescence. J Hum Hypertens 2021; 35:1063-1073. [PMID: 33986467 DOI: 10.1038/s41371-021-00550-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 04/23/2021] [Accepted: 04/29/2021] [Indexed: 02/03/2023]
Abstract
Hypertensive disorders during pregnancy (HDP) could have significant clinical impact not only on the mother's, but also on the offspring's health. The clinical impact of HDP may be evident early in the perinatal period or during childhood and adolescence. The cardiovascular system seems to be primarily affected with higher rates of congenital heart defects reported from cohort studies in the offspring of mothers with HDP. HDP are associated with alterations in cardiac and vascular structure and higher BP during childhood. HDP may also affect brain development and could result in increased prevalence of adverse cognitive outcomes and neuropsychiatric disorders in children and adolescents. The kidney, immune, endocrine, and gastrointestinal system abnormalities could also have their origin in exposure to HDP. The aim of this narrative review is to examine the clinical impact of HDP on the offspring with a focus on the perinatal period, childhood, and adolescence.
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7
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Fu J, Tomlinson G, Feig DS. Increased risk of major congenital malformations in early pregnancy use of angiotensin-converting-enzyme inhibitors and angiotensin-receptor-blockers: a meta-analysis. Diabetes Metab Res Rev 2021; 37:e3453. [PMID: 33779043 DOI: 10.1002/dmrr.3453] [Citation(s) in RCA: 12] [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: 12/03/2020] [Revised: 02/04/2021] [Accepted: 02/26/2021] [Indexed: 12/31/2022]
Abstract
AIMS To evaluate the risk of adverse fetal outcomes after exposure to angiotensin converting enzyme inhibitors (ACE-Is) or angiotensin receptor blockers (ARBs) in first trimester of pregnancy, by conducting a systematic review and meta-analysis. MATERIALS AND METHODS A systematic literature search was conducted using Medline, Embase, Cochrane and PubMed from inception to 25 November 2019. Studies were included if they evaluated pregnancies exposed to ACE-Is or ARBs, reported fetal outcomes, and compared these outcomes with a control group. Pooled odds ratios (ORs) were estimated using inverse variance-weighted random effects model. The protocol was registered with the PROSPERO International Prospective Register of Systematic Reviews (CRD42020160566). RESULTS Studies reporting on 6234 pregnancies exposed to ACE-Is or ARBs, 4104 pregnancies exposed to other oral antihypertensives, and 1,872,733 pregnancies without exposure were included in the meta-analysis. ACE-I or ARB exposed pregnancies, compared to non-exposed controls, had higher risk of major congenital malformations (OR 1.82; 95% confidence interval [CI]: 1.42-2.34), cardiovascular malformations (OR 2.50; 95% CI: 1.62-3.87) and stillbirths (OR 1.75; 95% CI: 1.21-2.53). There was no difference in congenital malformations observed between pregnancies exposed to other antihypertensives compared to non-exposed controls (OR 0.96; 95% CI: 0.69-1.33). CONCLUSIONS Women exposed to ACE-Is or ARBs during early pregnancy had higher risk of adverse fetal outcomes, including malformations and stillbirths, than non-exposed controls. This increased risk was independent of underlying maternal hypertension, as those exposed to other antihypertensives did not exhibit a higher risk than healthy controls. Women planning for pregnancy using these medications, including those with diabetic nephropathy, should be counselled appropriately.
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Affiliation(s)
- Jennifer Fu
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - George Tomlinson
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
| | - Denice S Feig
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Leadership Sinai Centre for Diabetes, Mount Sinai Hospital, Sinai Health System, Toronto, Ontario, Canada
- Lunenfeld-Tanenbaum Research Institute, Toronto, Ontario, Canada
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8
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Al Khalaf SY, O'Reilly ÉJ, Barrett PM, B Leite DF, Pawley LC, McCarthy FP, Khashan AS. Impact of Chronic Hypertension and Antihypertensive Treatment on Adverse Perinatal Outcomes: Systematic Review and Meta-Analysis. J Am Heart Assoc 2021; 10:e018494. [PMID: 33870708 PMCID: PMC8200761 DOI: 10.1161/jaha.120.018494] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Maternal chronic hypertension is associated with adverse pregnancy outcomes. Previous studies examined the association between either chronic hypertension or antihypertensive treatment and adverse pregnancy outcomes. We aimed to synthesize the evidence on the effect of chronic hypertension/antihypertensive treatment on adverse pregnancy outcomes. Methods and Results Medline/PubMed, EMBASE, and Web of Science were searched; we included observational studies and assessed the effect of race/ethnicity, where possible, following a registered protocol (CRD42019120088). Random-effects meta-analyses were used. A total of 81 studies were identified on chronic hypertension, and a total of 16 studies were identified on antihypertensive treatment. Chronic hypertension was associated with higher odds of preeclampsia (adjusted odd ratio [aOR], 5.43; 95% CI, 3.85-7.65); cesarean section (aOR, 1.87; 95% CI, 1.6-2.16); maternal mortality (aOR, 4.80; 95% CI, 3.04-7.58); preterm birth (aOR, 2.23; 95% CI, 1.96-2.53); stillbirth (aOR, 2.32; 95% CI, 2.22-2.42); and small for gestational age (SGA) (aOR, 1.96; 95% CI, 1.6-2.40). Subgroup analyses indicated that maternal race/ethnicity does not influence the observed associations. Women with chronic hypertension on antihypertensive treatment (versus untreated) had higher odds of SGA (aOR, 1.86; 95% CI, 1.38-2.50). Conclusions Chronic hypertension is associated with adverse pregnancy outcomes, and these associations appear to be independent of maternal race/ethnicity. In women with chronic hypertension, those on treatment had a higher risk of SGA, although the number of studies was limited. This could result from a direct effect of the treatment or because severe hypertension during pregnancy is a risk factor for SGA and women with severe hypertension are more likely to be treated. The effect of antihypertensive treatment on SGA needs to be further tested with large randomized controlled trials.
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Affiliation(s)
- Sukainah Y Al Khalaf
- School of Public Health University College Cork Cork Ireland.,INFANT Research Centre University College Cork Ireland
| | - Éilis J O'Reilly
- School of Public Health University College Cork Cork Ireland.,Department of Nutrition Harvard T.H. Chan School of Public Health Boston MA
| | - Peter M Barrett
- School of Public Health University College Cork Cork Ireland.,INFANT Research Centre University College Cork Ireland
| | | | - Lauren C Pawley
- Department of Anatomy and Neuroscience University College Cork Cork Ireland
| | - Fergus P McCarthy
- INFANT Research Centre University College Cork Ireland.,Department of Obstetrics and Gynaecology University College Cork Cork Ireland
| | - Ali S Khashan
- School of Public Health University College Cork Cork Ireland.,INFANT Research Centre University College Cork Ireland
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9
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Fitton CA, Fleming M, Aucott L, Pell JP, Mackay DF, McLay JS. Congenital defects and early childhood outcomes following in-utero exposure to antihypertensive medication. J Hypertens 2021; 39:581-588. [PMID: 33044380 DOI: 10.1097/hjh.0000000000002670] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hypertensive disorders during pregnancy are an important risk to mother and fetus, frequently necessitating antihypertensive treatment. Data describing the safety of in-utero exposure to antihypertensive treatment is conflicting with many studies suffering from significant methodological issues. METHOD We conducted a retrospective cohort study using linked routinely collected healthcare records for 268 711 children born 2010-2014 in Scotland to assess outcomes following in-utero exposure to antihypertensive medication. RESULTS We identified a cohort of 265 488 eligible mother-child pairs born over the study period; of which, 2433 were exposed in utero to antihypertensive medication, 4391 exposed to treated late-onset hypertension and 6066 exposed to untreated hypertension during pregnancy. In-utero antihypertensive exposure was associated with an increased risk of circulatory defects (aOR 2.29; 99% CI 1.14-4.59) compared with normal controls and the untreated hypertensive group. We report no increased odds of any developmental outcomes at 2.5 years of age following exposure to antihypertensive medication during pregnancy, untreated hypertension or late-onset hypertension. CONCLUSION Although circulatory defects may be associated with antihypertensive medication exposure during pregnancy, the mechanisms underlying this process are unclear.
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Affiliation(s)
- Catherine A Fitton
- Division of Applied Health Sciences, University of Aberdeen, Royal Aberdeen Children's Hospital, Aberdeen
| | - Michael Fleming
- The Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland
| | - Lorna Aucott
- Division of Applied Health Sciences, University of Aberdeen, Royal Aberdeen Children's Hospital, Aberdeen
| | - Jill P Pell
- The Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland
| | - Daniel F Mackay
- The Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland
| | - James S McLay
- Division of Applied Health Sciences, University of Aberdeen, Royal Aberdeen Children's Hospital, Aberdeen
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10
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Tsepokina A, Shmulevich S, Ponasenko A, Shabaldin A. Genetic predisposition to the development of congenital heart diseases: Role of xenobiotic biotransformation genes. Birth Defects Res 2020; 113:579-588. [PMID: 33174399 DOI: 10.1002/bdr2.1841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 10/02/2020] [Accepted: 10/31/2020] [Indexed: 01/10/2023]
Abstract
Congenital heart diseases are one of the most common multi-factorial fetal abnormalities caused by a complex of endo- and exogenous factors. It is known that mutations in xenobiotic biotransformation genes can be associated with the pathogenesis of congenital heart diseases. In the presented research, 131 children with congenital heart diseases and 101 women having children with this pathology were included in the study group. In control group, 103 healthy children and their mothers were included. Single-nucleotide polymorphisms in the xenobiotic biotransformation genes CYP1A1 (rs1048943), CYP1A2 (rs762551), GSTP1 (rs6591256, rs1871042 and rs17593068) were detected by the real-time polymerase chain reaction. Gene-gene interactions were determined using the Multifactor Dimensionality Reduction method. We obtained no difference in the frequency of CYP1A1, CYP1A2 and GSTP1 between the study and control groups. At the same time, the genetic combinations GSTP1 (rs6591256)-GSTP1 (rs1871042) and GSTP1 (rs6591256)-GSTP1 (rs1871042)-CYP1A1 (rs1048943) in women; and GSTP1 (rs1793068)-GSTP1 (rs6591256)-GSTP1 (rs1871042)-CYP1A1 (rs1048943)-CYP1A2 (rs762551) in children contribute to the pathogenesis of congenital heart diseases.
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Affiliation(s)
- Anna Tsepokina
- Laboratory of Genome Medicine, Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russian Federation
| | - Svetlana Shmulevich
- Laboratory of Congenital Heart Diseases, Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russian Federation
| | - Anastasia Ponasenko
- Laboratory of Genome Medicine, Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russian Federation
| | - Andrey Shabaldin
- Laboratory of Congenital Heart Diseases, Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russian Federation
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11
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Wu Y, Yao JW, Xu LJ, Chen M, Wan L. Risk of congenital malformations in offspring of women using β-blockers during early pregnancy: An updated meta-analysis of observational studies. Br J Clin Pharmacol 2020; 87:806-815. [PMID: 32978831 DOI: 10.1111/bcp.14561] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 09/03/2020] [Accepted: 09/12/2020] [Indexed: 01/11/2023] Open
Abstract
AIMS Beta-blockers are commonly used to treat hypertension that arises during pregnancy. However, reproductive safety concerns have been expressed. Here, we investigated whether the use of β-blockers during early pregnancy increased the risk of congenital malformations. METHODS A systematic literature search was performed in PubMed, Embase and Cochrane Library to identify relevant studies published from database inception until February 2020. Observational studies evaluating associations between maternal β-blocker use and congenital malformations were included in this meta-analysis. Two reviewers independently extracted data and assessed study quality. Meta-analysis of outcomes was performed and a summary odds ratio (OR) was calculated with consideration of heterogeneity. RESULTS Twenty observational studies were identified. Beta-blocker use during early pregnancy was not associated with an increased risk of congenital malformations (OR = 1.01, 95% confidence interval [CI] = 0.93-1.09). Subgroup analysis of organ-specific malformations revealed that β-blocker use was associated with an increased risk of heart malformations (OR = 1.29, 95% CI = 1.02-1.63) and an increased risk of cleft lip or palate (OR = 1.5, 95% CI = 1.18-1.91); however, these associations (OR = 1.11, 95% CI = 0.94-1.32 for heart malformations; OR = 1.34, 95% CI = 0.98-1.85 for cleft lip or palate) disappeared when the adjusted data were pooled. Beta-blocker use was not associated with increased risks of central nervous system malformations, neural tube defects or hypospadias. CONCLUSION Exposure to β-blockers during early pregnancy does not appear to be associated with congenital malformations or heart malformations in offspring. Other organ-specific congenital malformations should be evaluated in further studies.
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Affiliation(s)
- Yin Wu
- Department of Oral Diseases, Ningbo Urology and Nephrology Hospital, Ningbo, Zhejiang, China
| | - Jiang-Wei Yao
- Department of Oral Diseases, Tongxiang Dental Hospital, Tongxiang, Zhejiang, China
| | - Li-Jie Xu
- Department of Oral Diseases, Tongxiang First People's Hospital, Tongxiang, Zhejiang, China
| | - Miao Chen
- Tianshi Dental Clinic of Huzhou, Huzhou, Zhejiang, China
| | - Long Wan
- Department of Oral Diseases, Tongxiang First People's Hospital, Tongxiang, Zhejiang, China
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12
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Buawangpong N, Teekachunhatean S, Koonrungsesomboon N. Adverse pregnancy outcomes associated with first-trimester exposure to angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers: A systematic review and meta-analysis. Pharmacol Res Perspect 2020; 8:e00644. [PMID: 32815286 PMCID: PMC7438312 DOI: 10.1002/prp2.644] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 07/21/2020] [Accepted: 07/22/2020] [Indexed: 12/11/2022] Open
Abstract
This study aimed to determine the effects of prenatal exposure to angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs), particularly when exposure is limited to the first trimester of pregnancy, on adverse maternal and neonatal outcomes. A systematic search was performed on four databases, that is, PubMed, Scopus, Web of Science, and Cochrane Library, to identify relevant articles published up to December 31, 2019. Included studies were limited to original investigations assessing the association between prenatal exposure to ACEIs/ARBs and adverse pregnancy outcomes. Odds ratios were used as a summary effect measure. Pooled-effect estimates of each outcome were calculated by the random-effects meta-analysis. The main outcomes included overall and specific congenital malformations, low birth weight, miscarriage, elective termination of pregnancy, stillbirth, and preterm delivery. Of 19 included articles involving a total of 4 163 753 pregnant women, 13 studies reported an increased risk of, at least, one adverse pregnancy outcome in pregnant women who were exposed to ACEIs/ARBs. Meta-analysis revealed a significant association between overall congenital malformations and first trimester-only exposure to ACEIs/ARBs (OR = 1.94, 95% CI = 1.71-2.21, P < .0001). Cardiovascular malformations, miscarriage, and stillbirth also provided a significant relation with ACEI/ARB exposure. In conclusion, prenatal exposure to ACEIs/ARBs in the first trimester of pregnancy was found to be associated with an increased risk of adverse pregnancy outcomes. Women of reproductive age should be aware of the potential teratogenic risks of these drugs if they become pregnant.
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Affiliation(s)
- Nida Buawangpong
- Department of Family MedicineFaculty of MedicineChiang Mai UniversityChiang MaiThailand
| | | | - Nut Koonrungsesomboon
- Department of PharmacologyFaculty of MedicineChiang Mai UniversityChiang MaiThailand
- Musculoskeletal Science and Translational Research CenterChiang Mai UniversityChiang MaiThailand
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13
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Romeo AN, Običan SG. Teratogen update: Antithyroid medications. Birth Defects Res 2020; 112:1150-1170. [PMID: 32738035 DOI: 10.1002/bdr2.1771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/30/2020] [Accepted: 07/01/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Thyroid disorders including hyperthyroidism are common during pregnancy. Untreated hyperthyroidism can result in adverse outcomes for pregnancy. METHODS Iodine, propylthiouracil (PTU), carbimazole (CMZ), and methimazole (MMI) are common medications for hyperthyroidism treatment. The literature regarding antithyroid medication use in pregnancy and breastfeeding is reviewed. RESULTS Animal studies for PTU have suggested congenital anomalies while animal studies for MMI have only indicated adverse outcomes at higher doses than used in humans. Epidemiological studies have noted an increased risk of congenital anomalies for PTU less often than CMZ or MMI but the epidemiological evidence remains mixed. A pattern of anomalies has been described for CMZ and MMI, from both case and epidemiological studies, including choanal atresia, aplasia cutis congenita, and other facial, heart, gastrointestinal, and skin anomalies. Closer examination of cases indicates that a few cases of the anomalies have occurred without exposure to CMZ or MMI and outside of the proposed critical period. PTU has a small risk of hepatotoxicity which rarely results in liver transplantation and death. Some authors have suggested that PTU be prescribed in early pregnancy and switched to MMI in late pregnancy. Untreated hyperthyroidism, from either a lack of medications or switching medications during the first trimester, may also increase the chance of congenital anomalies. Multiple case studies and larger epidemiological studies have failed to provide clear, consistent outcomes for the use of PTU, CMZ, and MMI in pregnancy. MMI and PTU both enter the breastmilk in small amounts. CONCLUSION Additional research is needed to assist in the medical management and exposure counseling of pregnant and breastfeeding women with hyperthyroidism.
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Affiliation(s)
- Alfred N Romeo
- MotherToBaby Utah, Utah Department of Health, Salt Lake City, Utah, USA
| | - Sarah G Običan
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
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14
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Battarbee AN, Sinkey RG, Harper LM, Oparil S, Tita AT. Chronic hypertension in pregnancy. Am J Obstet Gynecol 2020; 222:532-541. [PMID: 31715148 DOI: 10.1016/j.ajog.2019.11.1243] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 10/31/2019] [Accepted: 11/02/2019] [Indexed: 01/25/2023]
Abstract
Chronic hypertension and associated cardiovascular disease are among the leading causes of maternal and perinatal morbidity and death in the United States. Chronic hypertension in pregnancy is associated with a host of adverse outcomes that include preeclampsia, cesarean delivery, cerebrovascular accidents, fetal growth restriction, preterm birth, and maternal and perinatal death. There are several key issues related to the diagnosis and management of chronic hypertension in pregnancy where data are limited and further research is needed. These challenges and recent guidelines for the management of chronic hypertension are reviewed. Well-timed pregnancies are of utmost importance to reduce the risks of chronic hypertension; long-acting reversible contraceptive options are preferred. Research to determine optimal blood pressure thresholds for diagnosis and treatment to optimize short- and long-term maternal and perinatal outcomes should be prioritized along with interventions to reduce extant racial and ethnic disparities.
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15
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Chen L, Shortreed SM, Easterling T, Cheetham TC, Reynolds K, Avalos LA, Kamineni A, Holt V, Neugebauer R, Akosile M, Nance N, Bider-Canfield Z, Walker RL, Badon SE, Dublin S. Identifying hypertension in pregnancy using electronic medical records: The importance of blood pressure values. Pregnancy Hypertens 2020; 19:112-118. [PMID: 31954339 DOI: 10.1016/j.preghy.2020.01.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 10/24/2019] [Accepted: 01/01/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To incorporate blood pressure (BP), diagnoses codes, and medication fills from electronic medical records (EMR) to identify pregnant women with hypertension. STUDY DESIGN A retrospective cohort study of singleton pregnancies at three US integrated health delivery systems during 2005-2014. MAIN OUTCOME MEASURES Women were considered hypertensive if they had any of the following: (1) ≥2 high BPs (≥140/90 mmHg) within 30 days during pregnancy (High BP); (2) an antihypertensive medication fill in the 120 days before pregnancy and a hypertension diagnosis from 1 year prior to pregnancy through 20 weeks gestation (Treated Chronic Hypertension); or (3) a high BP, a hypertension diagnosis, and a prescription fill within 7 days during pregnancy (Rapid Treatment). We described characteristics of these pregnancies and conducted medical record review to understand hypertension presence and severity. RESULTS Of 566,624 pregnancies, 27,049 (4.8%) met our hypertension case definition: 24,140 (89.2%) with High BP, 5,409 (20.0%) with Treated Chronic Hypertension, and 5,363 (19.8%) with Rapid Treatment (not mutually exclusive). Of hypertensive pregnancies, 19,298 (71.3%) received a diagnosis, 9,762 (36.1%) received treatment and 11,226 (41.5%) had a BP ≥ 160/110. In a random sample (n = 55) of the 7,559 pregnancies meeting the High BP criterion with no hypertension diagnosis, clinical statements about hypertension were found in medical records for 58% of them. CONCLUSION Incorporating EMR BP identified many pregnant women with hypertension who would have been missed by using diagnosis codes alone. Future studies should seek to incorporate BP to study treatment and outcomes of hypertension in pregnancy.
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Affiliation(s)
- Lu Chen
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States.
| | - Susan M Shortreed
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States; University of Washington, Seattle, WA, United States
| | | | - T Craig Cheetham
- Kaiser Permanente Southern California, Department of Research & Evaluation, Pasadena, CA, United States; Chapman University, School of Pharmacy, Irvine, CA, United States
| | - Kristi Reynolds
- Kaiser Permanente Southern California, Department of Research & Evaluation, Pasadena, CA, United States
| | - Lyndsay A Avalos
- Kaiser Permanente Northern California, Division of Research, Oakland, CA, United States
| | - Aruna Kamineni
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
| | - Victoria Holt
- University of Washington, Seattle, WA, United States
| | - Romain Neugebauer
- Kaiser Permanente Northern California, Division of Research, Oakland, CA, United States
| | - Mary Akosile
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
| | - Nerissa Nance
- Kaiser Permanente Northern California, Division of Research, Oakland, CA, United States
| | - Zoe Bider-Canfield
- Kaiser Permanente Southern California, Department of Research & Evaluation, Pasadena, CA, United States
| | - Rod L Walker
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
| | - Sylvia E Badon
- Kaiser Permanente Northern California, Division of Research, Oakland, CA, United States
| | - Sascha Dublin
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States; University of Washington, Seattle, WA, United States
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16
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Fitton CA, Fleming M, Steiner MFC, Aucott L, Pell JP, Mackay DF, Mclay JS. In Utero Antihypertensive Medication Exposure and Neonatal Outcomes: A Data Linkage Cohort Study. Hypertension 2019; 75:628-633. [PMID: 31884860 PMCID: PMC8032216 DOI: 10.1161/hypertensionaha.119.13802] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Hypertensive disorders during pregnancy are an important risk to mother and fetus, frequently necessitating antihypertensive treatment. Data describing the safety of in utero exposure to antihypertensive treatment is conflicting, with many studies suffering from significant methodological issues, such as inappropriate study design, small sample sizes, and no untreated control group. We conducted a retrospective cohort study using linked routinely collected healthcare records for 268 711 children born 2010-2014 in Scotland to assess outcomes following in utero exposure to antihypertensive medication. We identified a cohort of 265 488 eligible children born over the study period; of which, 2350 were exposed to in utero antihypertensive medication, 4391 exposed to treated late-onset hypertension, and 7971 exposed to untreated hypertension during pregnancy. Untreated hypertension was associated with increased risk of preterm birth (adjusted risk ratio [aRR], 1.15 [99% CI, 1.01-1.30]), low birth weight (aRR, 2.01 [99% CI, 1.72-2.36]) and being small for gestational age (aRR, 1.50 [99% CI, 1.35-1.66]), while in utero antihypertensive exposure was also associated with preterm birth (aRR, 3.12 [99% CI, 2.68-3.64]), low birth weight (aRR, 2.23 [99% CI, 1.79-2.78]), and being small for gestational age (aRR, 2.13 [99% CI, 1.81-2.52]). Late-onset hypertension was also associated with preterm birth (aRR, 2.21 [99% CI, 1.86-2.62]), low birth weight (aRR, 2.06 [99% CI, 1.74-2.43]), and being small for gestational age (aRR, 1.90 [99% CI, 1.68-2.16]). Our results suggest that hypertension is a key risk factor for low birth weight and preterm birth. Although preterm birth may be associated with antihypertensive medication exposure during pregnancy, these associations may reflect increasing hypertension severity necessitating treatment.
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Affiliation(s)
- Catherine A Fitton
- From the Department of Child Health, Division of Applied Health Sciences, University of Aberdeen, Royal Aberdeen Children's Hospital, Scotland (C.A.F., M.F.C.S., L.A., J.S.M.)
| | - Michael Fleming
- The Institute of Health and Wellbeing, University of Glasgow, Scotland (M.F., J.P.P., D.F.M.)
| | - Markus F C Steiner
- From the Department of Child Health, Division of Applied Health Sciences, University of Aberdeen, Royal Aberdeen Children's Hospital, Scotland (C.A.F., M.F.C.S., L.A., J.S.M.)
| | - Lorna Aucott
- From the Department of Child Health, Division of Applied Health Sciences, University of Aberdeen, Royal Aberdeen Children's Hospital, Scotland (C.A.F., M.F.C.S., L.A., J.S.M.)
| | - Jill P Pell
- The Institute of Health and Wellbeing, University of Glasgow, Scotland (M.F., J.P.P., D.F.M.)
| | - Daniel F Mackay
- The Institute of Health and Wellbeing, University of Glasgow, Scotland (M.F., J.P.P., D.F.M.)
| | - James S Mclay
- From the Department of Child Health, Division of Applied Health Sciences, University of Aberdeen, Royal Aberdeen Children's Hospital, Scotland (C.A.F., M.F.C.S., L.A., J.S.M.)
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17
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Use of Prescribed Psychotropics during Pregnancy: A Systematic Review of Pregnancy, Neonatal, and Childhood Outcomes. Brain Sci 2019; 9:brainsci9090235. [PMID: 31540060 PMCID: PMC6770670 DOI: 10.3390/brainsci9090235] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 09/03/2019] [Accepted: 09/09/2019] [Indexed: 12/27/2022] Open
Abstract
This paper reviews the findings from preclinical animal and human clinical research investigating maternal/fetal, neonatal, and child neurodevelopmental outcomes following prenatal exposure to psychotropic drugs. Evidence for the risks associated with prenatal exposure was examined, including teratogenicity, neurodevelopmental effects, neonatal toxicity, and long-term neurobehavioral consequences (i.e., behavioral teratogenicity). We conducted a comprehensive review of the recent results and conclusions of original research and reviews, respectively, which have investigated the short- and long-term impact of drugs commonly prescribed to pregnant women for psychological disorders, including mood, anxiety, and sleep disorders. Because mental illness in the mother is not a benign event, and may itself pose significant risks to both mother and child, simply discontinuing or avoiding medication use during pregnancy may not be possible. Therefore, prenatal exposure to psychotropic drugs is a major public health concern. Decisions regarding drug choice, dose, and duration should be made carefully, by balancing severity, chronicity, and co-morbidity of the mental illness, disorder, or condition against the potential risk for adverse outcomes due to drug exposure. Globally, maternal mental health problems are considered as a major public health challenge, which requires a stronger focus on mental health services that will benefit both mother and child. More preclinical and clinical research is needed in order to make well-informed decisions, understanding the risks associated with the use of psychotropic medications during pregnancy.
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18
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Pregnancy outcome after first trimester exposure to bisoprolol: an observational cohort study. J Hypertens 2019; 36:2109-2117. [PMID: 29985206 DOI: 10.1097/hjh.0000000000001818] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVES Beta-blockers are frequently used during pregnancy, with labetalol and metoprolol being considered as drugs of choice. As there are no prospective pregnancy studies for bisoprolol yet, our aim was to analyze pregnancy outcomes after bisoprolol exposure. METHODS Pregnancies exposed to bisoprolol during the first trimester were retrieved from the German Embryotox pharmacovigilance database. Pregnancy outcomes of prospectively ascertained pregnancies were compared with women neither exposed to beta-blockers nor other antihypertensives. In addition, retrospective reports on adverse drug reactions were screened for patterns of birth defects. RESULTS Inclusion criteria for the prospective study were met by 339 bisoprolol-treated women and 678 patients in the comparison cohort. Neither the risk for spontaneous abortions [adjusted hazard ratio (HRadj.) 1.06; 95% confidence interval (CI) 0.66-1.70] nor for major congenital malformations [adjusted odds ratio (ORadj.) 0.77; 95% CI 0.34-1.75] was increased after first trimester bisoprolol treatment. However, higher rates of preterm births [ORadj. 1.90; 95% CI 1.17-3.11] and reduced birthweights in singleton pregnancies (adjusted standard deviation score difference -0.48; 95% CI -0.62 to -0.34) were noted. Continued treatment with beta-blockers until birth was found to be associated with a higher risk for growth restriction than first trimester exposure only. A sensitivity analysis did not suggest higher rates of adverse pregnancy outcomes in hypertensive women on bisoprolol compared with nonhypertensive bisoprolol-exposed women. CONCLUSION Our study supports the hypothesis that first trimester bisoprolol treatment does not increase the risk for spontaneous abortions or major birth defects. However, an influence of prolonged bisoprolol exposure on fetal growth cannot be ruled out.
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19
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20
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Mito A, Murashima A, Wada Y, Miyasato-Isoda M, Kamiya CA, Waguri M, Yoshimatsu J, Yakuwa N, Watanabe O, Suzuki T, Arata N, Mikami M, Ito S. Safety of Amlodipine in Early Pregnancy. J Am Heart Assoc 2019; 8:e012093. [PMID: 31345083 PMCID: PMC6761676 DOI: 10.1161/jaha.119.012093] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Background Amlodipine is used for the treatment of hypertension, but reports on its use in early pregnancy are limited. Methods and Results In the present study, we recruited 231 women with chronic hypertension, including those who received amlodipine or other antihypertensives during early pregnancy, and investigated frequencies of morphologic abnormalities in their 231 offspring. Specifically, we evaluated 48 neonates exposed to amlodipine in the first trimester (amlodipine group, Group A), 54 neonates exposed to antihypertensives other than amlodipine (other antihypertensive group, Group O), and 129 neonates not exposed to antihypertensives (no‐antihypertensive group, Group N). The number of morphologic abnormalities of offspring in each group were 2 in Group A (4.2%; 95% CI, 0.51–14.25); 3 in Group O (5.6%; 95% CI, 1.16–15.39) and 6 in Group N (4.7%; 95% CI, 1.73–9.85). The odds ratio of the primary outcome comparing Group A and Group O was 0.74 (95% CI: 0.118–4.621) and Group A and Group N was 0.89 (95% CI: 0.174–4.575). Conclusions The odds of birth defects in Group A in the first trimester were not significantly different from those with or without other antihypertensives. See Editorial Malha and August
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Affiliation(s)
- Asako Mito
- Drug Information Institute in Pregnancy Tokyo Japan.,Division of Maternal Medicine Center for Maternal-Fetal-Neonatal and Reproductive Medicine National Center for Child Health and Development Tokyo Japan
| | - Atsuko Murashima
- Drug Information Institute in Pregnancy Tokyo Japan.,Division of Maternal Medicine Center for Maternal-Fetal-Neonatal and Reproductive Medicine National Center for Child Health and Development Tokyo Japan
| | - Yoshinao Wada
- Department of Obstetric Medicine Osaka Women's and Children's Hospital Osaka Japan
| | | | - Chizuko A Kamiya
- Department of Perinatology and Gynecology National Cerebral and Cardiovascular Center Osaka Japan
| | - Masako Waguri
- Department of Obstetric Medicine Osaka Women's and Children's Hospital Osaka Japan
| | - Jun Yoshimatsu
- Department of Perinatology and Gynecology National Cerebral and Cardiovascular Center Osaka Japan
| | - Naho Yakuwa
- Drug Information Institute in Pregnancy Tokyo Japan
| | - Omi Watanabe
- Drug Information Institute in Pregnancy Tokyo Japan
| | - Tomo Suzuki
- Drug Information Institute in Pregnancy Tokyo Japan.,Division of Obstetrics Center for Maternal-Fetal-Neonatal and Reproductive Medicine National Center for Child Health and Development Tokyo Japan
| | - Naoko Arata
- Drug Information Institute in Pregnancy Tokyo Japan.,Division of Maternal Medicine Center for Maternal-Fetal-Neonatal and Reproductive Medicine National Center for Child Health and Development Tokyo Japan
| | - Masashi Mikami
- Division of Biostatistics Clinical Research Center National Center for Child Health and Development Tokyo Japan
| | - Shinya Ito
- Motherisk Program Division of Clinical Pharmacology and Toxicology Department of Paediatrics The Hospital for Sick Children University of Toronto Toronto Canada
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21
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Leavitt K, Običan S, Yankowitz J. Treatment and Prevention of Hypertensive Disorders During Pregnancy. Clin Perinatol 2019; 46:173-185. [PMID: 31010554 DOI: 10.1016/j.clp.2019.02.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
This article reviews the pharmacology of the most commonly used antihypertensive medications during pregnancy; their mechanism of action; and the effects on the mother, the fetus, and lactation. Each class of antihypertensive pharmacologic agents have specific mechanisms of action by which they exert their antihypertensive effect. β-Adrenoreceptor antagonists block these receptors in the peripheral circulation. Calcium channel blockers result in arterial vasodilation. α-Agonists inhibit vasoconstriction. Methyldopa is a centrally acting adrenoreceptor antagonist. Vasodilators have a direct effect on vascular smooth muscle. Diuretics decrease intravascular volume. Medications acting on the angiotensin pathway are avoided during pregnancy because of fetotoxic effects.
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Affiliation(s)
- Karla Leavitt
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of South Florida, Morsani College of Medicine, 2 Tampa General Circle, 6th Floor, Tampa, FL 33606, USA.
| | - Sarah Običan
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of South Florida, Morsani College of Medicine, 2 Tampa General Circle, 6th Floor, Tampa, FL 33606, USA
| | - Jerome Yankowitz
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of South Florida, Morsani College of Medicine, 2 Tampa General Circle, 6th Floor, Tampa, FL 33606, USA
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22
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Grześk G, Wołowiec Ł, Walukiewicz M, Rogowicz D, Gilewski W, Banach J. The importance and safety of calcium antagonists in the treatment of hypertension in pregnant women. Pregnancy Hypertens 2019; 16:85-88. [PMID: 31056164 DOI: 10.1016/j.preghy.2019.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 03/05/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Grzegorz Grześk
- 2nd Department of Cardiology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Poland
| | - Łukasz Wołowiec
- 2nd Department of Cardiology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Poland
| | - Marcin Walukiewicz
- 2nd Department of Cardiology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Poland.
| | - Daniel Rogowicz
- 2nd Department of Cardiology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Poland
| | - Wojciech Gilewski
- 2nd Department of Cardiology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Poland
| | - Joanna Banach
- 2nd Department of Cardiology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Poland
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Braunthal S, Brateanu A. Hypertension in pregnancy: Pathophysiology and treatment. SAGE Open Med 2019; 7:2050312119843700. [PMID: 31007914 PMCID: PMC6458675 DOI: 10.1177/2050312119843700] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 03/22/2019] [Indexed: 12/14/2022] Open
Abstract
Hypertensive disorders of pregnancy, an umbrella term that includes preexisting and gestational hypertension, preeclampsia, and eclampsia, complicate up to 10% of pregnancies and represent a significant cause of maternal and perinatal morbidity and mortality. Despite the differences in guidelines, there appears to be consensus that severe hypertension and non-severe hypertension with evidence of end-organ damage need to be controlled; yet the ideal target ranges below 160/110 mmHg remain a source of debate. This review outlines the definition, pathophysiology, goals of therapy, and treatment agents used in hypertensive disorders of pregnancy.
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Affiliation(s)
| | - Andrei Brateanu
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
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24
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Tamargo J, Caballero R, Delpón E. Pharmacotherapy for hypertension in pregnant patients: special considerations. Expert Opin Pharmacother 2019; 20:963-982. [PMID: 30943045 DOI: 10.1080/14656566.2019.1594773] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Hypertensive disorders of pregnancy (HDP) represent a major cause of maternal, fetal and neonatal morbidity and mortality and identifies women at risk for cardiovascular and other chronic diseases later in life. When antihypertensive drugs are used during pregnancy, their benefit and harm to both mother and fetus should be evaluated. AREAS COVERED This review summarizes the pharmacological characteristics of the recommended antihypertensive drugs and their impact on mother and fetus when administered during pregnancy and/or post-partum. Drugs were identified using MEDLINE and the main international Guidelines for the management of HDP. EXPERT OPINION Although there is a consensus that severe hypertension should be treated, treatment of mild hypertension without end-organ damage (140-159/90-109 mmHg) remains controversial and there is no agreement on when to initiate therapy, blood pressure targets or recommended drugs in the absence of robust evidence for the superiority of one drug over others. Furthermore, the long-term outcomes of in-utero antihypertensive exposure remain uncertain. Therefore, evidence-based data regarding the treatment of HDP is lacking and well designed randomized clinical trials are needed to resolve all these controversial issues related to the management of HDP.
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Affiliation(s)
- Juan Tamargo
- a Department of Pharmacology and Toxicology, School of Medicine , Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, CIBERCV , Madrid , Spain
| | - Ricardo Caballero
- a Department of Pharmacology and Toxicology, School of Medicine , Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, CIBERCV , Madrid , Spain
| | - Eva Delpón
- a Department of Pharmacology and Toxicology, School of Medicine , Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, CIBERCV , Madrid , Spain
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Sarwar A. Drugs in renal disease and pregnancy. Best Pract Res Clin Obstet Gynaecol 2019; 57:106-119. [PMID: 31031053 DOI: 10.1016/j.bpobgyn.2019.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 11/12/2018] [Accepted: 03/27/2019] [Indexed: 01/06/2023]
Abstract
This review aims to summarise historic and the latest evidence of commonly used drugs in pregnant women with chronic kidney disease (CKD). Data regarding safety of drugs in breastfeeding are also described. Practical recommendations are made on the use of newer agents that have limited information of use in pregnant women with CKD. Pharmacokinetic and dynamic issues are outlined, and general principles for prescribing drugs in pregnant women with CKD are listed. Resources to investigate drug safety are presented.
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Affiliation(s)
- Asif Sarwar
- Advanced Clinical Pharmacist - Electronic Prescribing, Pharmacy Department, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2TH, England, United Kingdom.
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26
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Bateman BT, Heide-Jørgensen U, Einarsdóttir K, Engeland A, Furu K, Gissler M, Hernandez-Diaz S, Kieler H, Lahesmaa-Korpinen AM, Mogun H, Nørgaard M, Reutfors J, Selmer R, Huybrechts KF, Zoega H. β-Blocker Use in Pregnancy and the Risk for Congenital Malformations: An International Cohort Study. Ann Intern Med 2018; 169:665-673. [PMID: 30326014 PMCID: PMC6854680 DOI: 10.7326/m18-0338] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND β-Blockers are a class of antihypertensive medications that are commonly used in pregnancy. OBJECTIVE To estimate the risks for major congenital malformations associated with first-trimester exposure to β-blockers. DESIGN Cohort study. SETTING Health registries in the 5 Nordic countries and the U.S. Medicaid database. PATIENTS Pregnant women with a diagnosis of hypertension and their offspring. MEASUREMENTS First-trimester exposure to β-blockers was assessed. Outcomes were any major congenital malformation, cardiac malformations, cleft lip or palate, and central nervous system (CNS) malformations. Propensity score stratification was used to control for potential confounders. RESULTS Of 3577 women with hypertensive pregnancies in the Nordic cohort and 14 900 in the U.S. cohort, 682 (19.1%) and 1668 (11.2%), respectively, were exposed to β-blockers in the first trimester. The pooled adjusted relative risk (RR) and risk difference per 1000 persons exposed (RD1000) associated with β-blockers were 1.07 (95% CI, 0.89 to 1.30) and 3.0 (CI, -6.6 to 12.6), respectively, for any major malformation; 1.12 (CI, 0.83 to 1.51) and 2.1 (CI, -4.3 to 8.4) for any cardiac malformation; and 1.97 (CI, 0.74 to 5.25) and 1.0 (CI, -0.9 to 3.0) for cleft lip or palate. For CNS malformations, the adjusted RR was 1.37 (CI, 0.58 to 3.25) and the RD1000 was 1.0 (CI, -2.0 to 4.0) (based on U.S. cohort data only). LIMITATION Analysis was restricted to live births, exposure was based on dispensed medication, and cleft lip or palate and CNS malformations had few outcomes. CONCLUSION The results suggest that maternal use of β-blockers in the first trimester is not associated with a large increase in the risk for overall malformations or cardiac malformations, independent of measured confounders. PRIMARY FUNDING SOURCE The Eunice Kennedy Shriver National Institute of Child Health and Human Development and the Söderström König Foundation.
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Affiliation(s)
- Brian T Bateman
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (B.T.B., K.F.H.)
| | | | | | - Anders Engeland
- Norwegian Institute of Public Health, Oslo, and University of Bergen, Bergen, Norway (A.E.)
| | - Kari Furu
- Norwegian Institute of Public Health, Oslo, Norway (K.F., R.S.)
| | - Mika Gissler
- University of Turku, Turku, Finland, and Karolinska Institutet, Stockholm, Sweden (M.G., H.K., J.R.)
| | | | - Helle Kieler
- University of Turku, Turku, Finland, and Karolinska Institutet, Stockholm, Sweden (M.G., H.K., J.R.)
| | | | - Helen Mogun
- Karolinska Institutet, Stockholm, Sweden; National Institute for Health and Welfare, Helsinki, Finland; Brigham and Women's Hospital, Boston, Massachusetts (H.M.)
| | - Mette Nørgaard
- Aarhus University Hospital, Aarhus, Denmark (U.H., M.N.)
| | - Johan Reutfors
- University of Turku, Turku, Finland, and Karolinska Institutet, Stockholm, Sweden (M.G., H.K., J.R.)
| | - Randi Selmer
- Norwegian Institute of Public Health, Oslo, Norway (K.F., R.S.)
| | - Krista F Huybrechts
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (B.T.B., K.F.H.)
| | - Helga Zoega
- University of Iceland, Reykjavik, Iceland, and University of New South Wales, Sydney, New South Wales, Australia (H.Z.)
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Ahmed B, Tran DT, Zoega H, Kennedy SE, Jorm LR, Havard A. Maternal and perinatal outcomes associated with the use of renin-angiotensin system (RAS) blockers for chronic hypertension in early pregnancy. Pregnancy Hypertens 2018; 14:156-161. [PMID: 30527105 DOI: 10.1016/j.preghy.2018.09.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 09/18/2018] [Accepted: 09/30/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Previous research reported greater risk of adverse perinatal outcomes associated with first trimester exposure to angiotensin converting enzyme inhibitors (ACEIs) in comparison to unexposed pregnancies among non-hypertensive women. We examined the relationship between first trimester exposure to ACEIs and angiotensin receptor blockers (ARBs), and maternal and perinatal outcomes, whilst controlling for the underlying hypertension. STUDY DESIGN We performed a population-based cohort study among 130,061 pregnancies resulting in birth in NSW, Australia between 2005 and 2012. Birth data were linked to hospital discharge and pharmaceutical dispensing records. After restricting to women with chronic hypertension, 67 and 73 pregnancies exposed to ACEIs and ARBs respectively during the first trimester were compared with 316 pregnancies exposed to methyldopa. STUDY OUTCOMES Preterm delivery, caesarean section, low birth weight, small for gestational age and Apgar score <7. RESULTS Compared to pregnancies exposed to methyldopa, the adjusted odds ratio (aOR) for ACEI exposure was 0.5 (95% CI: 0.2-1.1) for preterm delivery, 1.6 (0.8-3.1) for caesarean section, 0.6 (0.2-1.3) for LBW and 0.8 (0.4-1.9) for SGA. The corresponding aORs and confidence intervals for ARB exposure were 0.7 (0.3-1.5), 1.2 (0.6-2.6), 1.3 (0.7-2.6), and 1.2 (0.6-2.4). CONCLUSION No association between early pregnancy exposure to ACEIs and ARBs and perinatal outcomes was observed, however, the possibility of an association cannot be ruled out due to limited power. Nonetheless, this study suggests that the magnitude of risk is smaller than that reported previously.
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Affiliation(s)
- Bilal Ahmed
- Centre for Big Data Research in Health, University of New South Wales, Sydney, Australia.
| | - Duong T Tran
- Centre for Big Data Research in Health, University of New South Wales, Sydney, Australia
| | - Helga Zoega
- Centre for Big Data Research in Health, University of New South Wales, Sydney, Australia; Centre of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavk, Iceland
| | - Sean E Kennedy
- School of Women's & Children's Health, University of New South Wales (NSW), Sydney, Australia
| | - Louisa R Jorm
- Centre for Big Data Research in Health, University of New South Wales, Sydney, Australia
| | - Alys Havard
- Centre for Big Data Research in Health, University of New South Wales, Sydney, Australia
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Beta-Blocker Use in Pregnancy and Risk of Specific Congenital Anomalies: A European Case-Malformed Control Study. Drug Saf 2018; 41:415-427. [PMID: 29230691 PMCID: PMC5878198 DOI: 10.1007/s40264-017-0627-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Introduction The prevalence of chronic hypertension is increasing in pregnant women. Beta-blockers are among the most prevalent anti-hypertensive agents used in early pregnancy. Objective The objective of this study was to investigate whether first-trimester use of beta-blockers increases the risk of specific congenital anomalies in offspring. Methods A population-based case-malformed control study was conducted in 117,122 registrations of congenital anomalies from 17 European Concerted Action on Congenital Anomalies and Twins (EUROCAT) registries participating in EUROmediCAT with data for all or part of the period between 1995 and 2013. Associations previously reported in the literature (signals) were tested and an exploratory analysis was performed to identify new signals. Odds ratios of exposure to any beta-blocker or to a beta-blocker subgroup were calculated for each signal anomaly compared with two control groups (non-chromosomal, non-signal anomalies and chromosomal anomalies). The exploratory analyses were performed for each non-signal anomaly compared with all the other non-signal anomalies. Results The signals from the literature (congenital heart defects, oral clefts, neural tube defects and hypospadias) were not confirmed. Our exploratory analysis revealed that multi-cystic renal dysplasia had significantly increased odds of occurring after maternal exposure to combined alpha- and beta-blockers (adjusted odds ratio 3.8; 95% confidence interval 1.3–11.0). Conclusion Beta-blocker use in the first trimester of pregnancy was not found to be associated with a higher risk of specific congenital anomalies in the offspring, but a new signal between alpha- and beta-blockers and multi-cystic renal dysplasia was found. Future large epidemiological studies are needed to confirm or refute our findings. Electronic supplementary material The online version of this article (10.1007/s40264-017-0627-x) contains supplementary material, which is available to authorized users.
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Fisher SC, Van Zutphen AR, Werler MM, Romitti PA, Cunniff C, Browne ML. Maternal antihypertensive medication use and selected birth defects in the National Birth Defects Prevention Study. Birth Defects Res 2018; 110:1433-1442. [PMID: 30260586 PMCID: PMC10064868 DOI: 10.1002/bdr2.1372] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 06/25/2018] [Accepted: 06/26/2018] [Indexed: 11/06/2022]
Abstract
BACKGROUND There are limited data on the relationship between antihypertensive medication use in early pregnancy and risk of birth defects. METHODS Using data from the National Birth Defects Prevention Study, we examined associations between specific antihypertensive medication classes and 28 noncardiac birth defects. We analyzed self-reported data on 17,038 case and 11,477 control pregnancies with estimated delivery dates during 1997-2011. We used multivariable logistic regression to estimate odds ratios (ORs) and 95% confidence intervals, adjusted for maternal age, race/ethnicity, body mass index, parity, pregestational diabetes, and study site, for associations between individual birth defects and antihypertensive medication use during the first trimester of pregnancy. We compared risk among women reporting early pregnancy antihypertensive medication use to normotensive women. RESULTS Hypertensive women who reported early pregnancy antihypertensive medication use were more likely to be at least 35 years old, non-Hispanic Black, obese, multiparous, and to report pregestational diabetes than normotensive women. Compared to normotensive women, early pregnancy antihypertensive medication use was associated with increased risk of small intestinal atresia (adjusted OR 2.4, 95% CI 1.2-4.7) and anencephaly (adjusted OR 1.9, 95% CI 1.0-3.5). Risk of these defects was not specific to any particular medication class. CONCLUSIONS Maternal antihypertensive medication use was not associated with the majority of birth defects we analyzed, but was associated with an increased risk for some birth defects. Because we cannot entirely rule out confounding by the underlying hypertension and most ORs were based on small numbers, the increased risks observed should be interpreted with caution.
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Affiliation(s)
- Sarah C Fisher
- New York State Department of Health, Congenital Malformations Registry, Albany, New York
| | - Alissa R Van Zutphen
- New York State Department of Health, Congenital Malformations Registry, Albany, New York.,Department of Epidemiology and Biostatistics, School of Public Health, University at Albany, Rensselaer, New York
| | - Martha M Werler
- Department of Epidemiology, School of Public Health, Boston University, Boston, Massachusetts
| | - Paul A Romitti
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa
| | | | - Marilyn L Browne
- New York State Department of Health, Congenital Malformations Registry, Albany, New York.,Department of Epidemiology and Biostatistics, School of Public Health, University at Albany, Rensselaer, New York
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30
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Increased rate of birth defects after first trimester use of angiotensin converting enzyme inhibitors – Treatment or hypertension related? An observational cohort study. Pregnancy Hypertens 2018; 13:65-71. [DOI: 10.1016/j.preghy.2018.04.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 04/07/2018] [Accepted: 04/28/2018] [Indexed: 11/19/2022]
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Wolgast E, Josefsson A, Josefsson M, Lilliecreutz C, Reis M. Drug use in pregnant women-a pilot study of the coherence between reported use of drugs and presence of drugs in plasma. Eur J Clin Pharmacol 2017; 74:535-539. [PMID: 29264642 PMCID: PMC5849659 DOI: 10.1007/s00228-017-2402-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 12/08/2017] [Indexed: 02/06/2023]
Abstract
Purpose In Sweden, information on drug use during pregnancy is obtained through an interview and recorded in a standardized medical record at every visit to the antenatal care clinic throughout the pregnancy. Antenatal, delivery, and neonatal records constitute the basis for the Swedish Medical Birth Register (MBR). The purpose of this exploratory study was to investigate the reliability of reported drug use by simultaneous screening for drug substances in the blood stream of the pregnant woman and thereby validate self-reported data in the MBR. Methods Plasma samples from 200 women were obtained at gestational weeks 10–12 and 25 and screened for drugs by using ultra-high performance liquid chromatography with time of flight mass spectrometry (UHPLC-TOF-MS). The results from the analysis were then compared to medical records. Results At the first sampling occasion, the drugs found by screening had been reported by 86% of the women and on the second sampling, 85.5%. Missed reported information was clearly associated with drugs for occasional use. The most common drugs in plasma taken in early and mid-pregnancy were meclizine and paracetamol. Two types of continuously used drugs, selective serotonin reuptake inhibitors and propranolol, were used. All women using them reported it and the drug screening revealed a 100% coherence. Conclusions This study shows good coherence between reported drug intake and the drugs found in plasma samples, which in turn positively validates the MBR.
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Affiliation(s)
- Emelie Wolgast
- Department of Obstetrics and Gynecology and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Ann Josefsson
- Department of Obstetrics and Gynecology and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Martin Josefsson
- Department of Forensic Genetics and Forensic Toxicology, National Board of Forensic Medicine, Linköping, Sweden.,Department of Physics, Chemistry and Biology, Linköping University, Linköping, Sweden
| | - Caroline Lilliecreutz
- Department of Obstetrics and Gynecology and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Margareta Reis
- Department of Clinical Pharmacology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
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Fitton CA, Steiner MF, Aucott L, Pell JP, Mackay DF, Fleming M, McLay JS. In-utero exposure to antihypertensive medication and neonatal and child health outcomes: a systematic review. J Hypertens 2017; 35:2123-2137. [PMID: 28661961 PMCID: PMC5625961 DOI: 10.1097/hjh.0000000000001456] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 05/30/2017] [Accepted: 06/01/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although medication is generally avoided wherever possible during pregnancy, pharmacotherapy is required for the treatment of pregnancy associated hypertension, which remains a leading cause of maternal and fetal morbidity and mortality. The long-term effects to the child of in-utero exposure to antihypertensive agents remains largely unknown. OBJECTIVE The aim of this study was to systematically review published studies on adverse outcomes to the child associated with in-utero exposure to antihypertensive medications. METHODS OVID, Scopus, EBSCO Collections, the Cochrane Library, and Web of Science databases were searched for relevant publications published between January 1950 and October 2016 and a total of 688 potentially eligible studies were identified. RESULTS Following review, 47 primary studies were eligible for inclusion. The Critical Appraisal Skills Programme checklist was used to assess study quality. Five studies were of excellent quality; the remainder were either mediocre or poor. Increased risk of low birth weight, low size for gestational age, preterm birth, and congenital defects following in-utero exposure to all antihypertensive agents were identified. Two studies reported an increased risk of attention deficit hyperactivity disorder following exposure to labetalol, and an increased risk of sleep disorders following exposure to methyldopa and clonidine. CONCLUSION The current systematic review demonstrates a paucity of relevant published high-quality studies. A small number of studies suggest possible increased risk of adverse child health outcomes; however, most published studies have methodological weaknesses and/or lacked statistical power thus preventing any firm conclusions being drawn.
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Affiliation(s)
- Catherine A. Fitton
- The Department of Child Health, University of Aberdeen, Royal Aberdeen Children's Hospital, Aberdeen
| | - Markus F.C. Steiner
- The Department of Child Health, University of Aberdeen, Royal Aberdeen Children's Hospital, Aberdeen
| | - Lorna Aucott
- The Department of Child Health, University of Aberdeen, Royal Aberdeen Children's Hospital, Aberdeen
| | - Jill P. Pell
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Daniel F. Mackay
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Michael Fleming
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - James S. McLay
- The Department of Child Health, University of Aberdeen, Royal Aberdeen Children's Hospital, Aberdeen
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Hoeltzenbein M, Beck E, Fietz AK, Wernicke J, Zinke S, Kayser A, Padberg S, Weber-Schoendorfer C, Meister R, Schaefer C. Pregnancy Outcome After First Trimester Use of Methyldopa: A Prospective Cohort Study. Hypertension 2017; 70:201-208. [PMID: 28533329 DOI: 10.1161/hypertensionaha.117.09110] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 02/01/2017] [Accepted: 04/20/2017] [Indexed: 01/23/2023]
Abstract
Published experience on first trimester exposure to methyldopa is still limited, although it is recommended as first-line treatment for hypertensive disorders in pregnancy in most countries. The primary aim of this prospective observational cohort study was to analyze the rate of major birth defects and spontaneous abortions in women with methyldopa therapy for chronic hypertension. Outcomes of 261 pregnancies with first trimester exposure to methyldopa and 526 comparison pregnancies without chronic hypertension reported to the German Embryotox pharmacovigilance institute were evaluated. The rate of major birth defects in the exposed cohort was not significantly increased compared with the comparison cohort (3.7% versus 2.5%; adjusted odds ratio, 1.24; 95% confidence interval, 0.4-4.0). There was a tendency toward a higher rate of spontaneous abortions in exposed women. The risk of preterm birth was significantly higher, and adjusted birth weight scores were significantly lower in the methyldopa group. Head circumferences were significantly reduced in exposed boys only. There was neither evidence for an increased risk for birth defects or increase in early pregnancy loss nor evidence for growth restriction or a reduced head circumference in a sensitivity analysis comparing monotherapies with methyldopa to metoprolol. However, the significantly increased risk of preterm birth in methyldopa-treated pregnancies was confirmed. In conclusion, our study does not indicate a teratogenic risk of methyldopa. Further studies are needed to confirm its safety in the first trimester and clarify the influence of hypertension and methyldopa on preterm birth and intrauterine growth. CLINICAL TRIAL REGISTRATION URL: https://drks-neu.uniklinik-freiburg.de/drks_web/. Unique identifier: DRKS00010502.
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Affiliation(s)
- Maria Hoeltzenbein
- From the Pharmakovigilanzzentrum Embryonaltoxikologie, Institut für Klinische Pharmakologie und Toxikologie, Charité-Universitätsmedizin Berlin, Germany (M.H., E.B., A.-K.F., J.W., S.Z., A.K., S.P., C.W.-S., C.S.); and Department of Mathematics, Beuth Hochschule für Technik Berlin, University of Applied Sciences, Germany (A.-K.F., R.M.).
| | - Evelin Beck
- From the Pharmakovigilanzzentrum Embryonaltoxikologie, Institut für Klinische Pharmakologie und Toxikologie, Charité-Universitätsmedizin Berlin, Germany (M.H., E.B., A.-K.F., J.W., S.Z., A.K., S.P., C.W.-S., C.S.); and Department of Mathematics, Beuth Hochschule für Technik Berlin, University of Applied Sciences, Germany (A.-K.F., R.M.)
| | - Anne-Katrin Fietz
- From the Pharmakovigilanzzentrum Embryonaltoxikologie, Institut für Klinische Pharmakologie und Toxikologie, Charité-Universitätsmedizin Berlin, Germany (M.H., E.B., A.-K.F., J.W., S.Z., A.K., S.P., C.W.-S., C.S.); and Department of Mathematics, Beuth Hochschule für Technik Berlin, University of Applied Sciences, Germany (A.-K.F., R.M.)
| | - Juliane Wernicke
- From the Pharmakovigilanzzentrum Embryonaltoxikologie, Institut für Klinische Pharmakologie und Toxikologie, Charité-Universitätsmedizin Berlin, Germany (M.H., E.B., A.-K.F., J.W., S.Z., A.K., S.P., C.W.-S., C.S.); and Department of Mathematics, Beuth Hochschule für Technik Berlin, University of Applied Sciences, Germany (A.-K.F., R.M.)
| | - Sandra Zinke
- From the Pharmakovigilanzzentrum Embryonaltoxikologie, Institut für Klinische Pharmakologie und Toxikologie, Charité-Universitätsmedizin Berlin, Germany (M.H., E.B., A.-K.F., J.W., S.Z., A.K., S.P., C.W.-S., C.S.); and Department of Mathematics, Beuth Hochschule für Technik Berlin, University of Applied Sciences, Germany (A.-K.F., R.M.)
| | - Angela Kayser
- From the Pharmakovigilanzzentrum Embryonaltoxikologie, Institut für Klinische Pharmakologie und Toxikologie, Charité-Universitätsmedizin Berlin, Germany (M.H., E.B., A.-K.F., J.W., S.Z., A.K., S.P., C.W.-S., C.S.); and Department of Mathematics, Beuth Hochschule für Technik Berlin, University of Applied Sciences, Germany (A.-K.F., R.M.)
| | - Stephanie Padberg
- From the Pharmakovigilanzzentrum Embryonaltoxikologie, Institut für Klinische Pharmakologie und Toxikologie, Charité-Universitätsmedizin Berlin, Germany (M.H., E.B., A.-K.F., J.W., S.Z., A.K., S.P., C.W.-S., C.S.); and Department of Mathematics, Beuth Hochschule für Technik Berlin, University of Applied Sciences, Germany (A.-K.F., R.M.)
| | - Corinna Weber-Schoendorfer
- From the Pharmakovigilanzzentrum Embryonaltoxikologie, Institut für Klinische Pharmakologie und Toxikologie, Charité-Universitätsmedizin Berlin, Germany (M.H., E.B., A.-K.F., J.W., S.Z., A.K., S.P., C.W.-S., C.S.); and Department of Mathematics, Beuth Hochschule für Technik Berlin, University of Applied Sciences, Germany (A.-K.F., R.M.)
| | - Reinhard Meister
- From the Pharmakovigilanzzentrum Embryonaltoxikologie, Institut für Klinische Pharmakologie und Toxikologie, Charité-Universitätsmedizin Berlin, Germany (M.H., E.B., A.-K.F., J.W., S.Z., A.K., S.P., C.W.-S., C.S.); and Department of Mathematics, Beuth Hochschule für Technik Berlin, University of Applied Sciences, Germany (A.-K.F., R.M.)
| | - Christof Schaefer
- From the Pharmakovigilanzzentrum Embryonaltoxikologie, Institut für Klinische Pharmakologie und Toxikologie, Charité-Universitätsmedizin Berlin, Germany (M.H., E.B., A.-K.F., J.W., S.Z., A.K., S.P., C.W.-S., C.S.); and Department of Mathematics, Beuth Hochschule für Technik Berlin, University of Applied Sciences, Germany (A.-K.F., R.M.)
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Fisher SC, Van Zutphen AR, Werler MM, Lin AE, Romitti PA, Druschel CM, Browne ML. Maternal Antihypertensive Medication Use and Congenital Heart Defects: Updated Results From the National Birth Defects Prevention Study. Hypertension 2017; 69:798-805. [PMID: 28373593 PMCID: PMC9976617 DOI: 10.1161/hypertensionaha.116.08773] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 12/18/2016] [Accepted: 02/22/2017] [Indexed: 11/16/2022]
Abstract
Previous NBDPS (National Birth Defects Prevention Study) findings from 1997 to 2003 suggested that maternal antihypertensive use was associated with congenital heart defects (CHDs). We re-examined associations between specific antihypertensive medication classes and specific CHDs with additional NBDPS data from 2004 to 2011. After excluding mothers missing hypertension information or who reported pregestational diabetes mellitus, a multiple birth, or antihypertensive use but no hypertension, we compared self-reported maternal exposure data on 10 625 CHD cases and 11 137 nonmalformed controls. We calculated adjusted odds ratios [95% confidence intervals] to estimate the risk of specific CHDs associated with antihypertensive use during the month before conception through the third month of pregnancy, controlling for maternal age, race/ethnicity, body mass index, first trimester cigarette smoking, and NBDPS site. Overall, 164 (1.5%) case mothers and 102 (0.9%) control mothers reported early pregnancy antihypertensive use for their hypertension. We observed increased risk of 4 CHD phenotypes, regardless of antihypertensive medication class reported: coarctation of the aorta (2.50 [1.52-4.11]), pulmonary valve stenosis (2.19 [1.44-3.34]), perimembranous ventricular septal defect (1.90 [1.09-3.31]), and secundum atrial septal defect (1.94 [1.36-2.79]). The associations for these phenotypes were statistically significant for mothers who reported β-blocker use or renin-angiotensin system blocker use; estimates for other antihypertensive medication classes were generally based on fewer exposed cases and were less stable but remained elevated. Our results support and expand on earlier NBDPS findings that antihypertensive medication use may be associated with increased risk of specific CHDs, although we cannot completely rule out confounding by underlying disease characteristics.
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Affiliation(s)
- Sarah C. Fisher
- Congenital Malformations Registry, New York State Department of Health, Albany, NY
| | - Alissa R. Van Zutphen
- Congenital Malformations Registry, New York State Department of Health, Albany, NY,Department of Epidemiology and Biostatistics, School of Public Health, University at Albany, Rensselaer, NY
| | - Martha M. Werler
- Department of Epidemiology, School of Public Health, Boston University, Boston, MA
| | - Angela E. Lin
- Genetics Unit, MassGeneral Hospital for Children, Boston, Massachusetts,Massachusetts Center for Birth Defects Prevention, Massachusetts Department of Public Health
| | - Paul A. Romitti
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA
| | - Charlotte M. Druschel
- Congenital Malformations Registry, New York State Department of Health, Albany, NY,Department of Epidemiology and Biostatistics, School of Public Health, University at Albany, Rensselaer, NY
| | - Marilyn L. Browne
- Congenital Malformations Registry, New York State Department of Health, Albany, NY,Department of Epidemiology and Biostatistics, School of Public Health, University at Albany, Rensselaer, NY
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Nembhard WN, Tang X, Hu Z, MacLeod S, Stowe Z, Webber D. Maternal and infant genetic variants, maternal periconceptional use of selective serotonin reuptake inhibitors, and risk of congenital heart defects in offspring: population based study. BMJ 2017; 356:j832. [PMID: 28264803 PMCID: PMC6283388 DOI: 10.1136/bmj.j832] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Objective To evaluate whether the association between maternal periconceptional use of selective serotonin reuptake inhibitors (SSRIs) and increased risk of congenital heart defects in offspring is modified by maternal or infant genetic variants in folate, homocysteine, or transsulfuration pathways.Design Population based study. DNA from mothers, fathers, and infants was genotyped with an Illumina GoldenGate custom single nucleotide polymorphism panel. A hybrid design based on a log linear model was used to calculate relative risks and Bayesian false discovery probabilities (BFDP) to identify polymorphisms associated with congenital heart defects modified by SSRI use.Data sources Data from the US National Birth Defects Prevention Study on 1180 liveborn infants with congenital heart defects and 1644 controls, born 1997-2008.Main outcome measures Cases included infants with selected congenital heart defects and control infants had no major defects. SSRI use was obtained from telephone interviews with mothers.Results For women who reported taking SSRIs periconceptionally, maternal SHMT1 (rs9909104) GG and AGgenotypes were associated with a 5.9 and 2.4 increased risk of select congenital heart defects in offspring, respectively, versus the AA genotype (BFDP=0.69). Compared with the AA genotype, BHMT (rs492842 and rs542852) GG and AG genotypes were associated with twice the riskof congenital heart defects (BFDP=0.74 and 0.79, respectively). MGST1 (rs2075237) CC and ACgenotypes were associated with an increased risk compared with the GG genotype (8.0 and 2.8, respectively; BFDP=0.79). Single nucleotide polymorphism in infant genes in the folate (MTHFS rs12438477), homocysteine (TRDMT1 rs6602178 and GNMT rs11752813) and transsulfuration (GSTP1 rs7941395 and MGST1 rs7294985) pathways were also associated with an increased risk of congenital heart defects.Conclusions Common maternal or infant genetic variants in folate, homocysteine, or transsulfuration pathways are associated with an increased risk of certain congenital heart defects among children of women taking SSRIs during cardiogenesis.
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Affiliation(s)
- Wendy N Nembhard
- Division of Birth Defects Research, Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences and Arkansas Children's Research Institute, Little Rock, AR, 72202, USA
| | - Xinyu Tang
- Division of Biostatistics, Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Arkansas Children's Research Institute, Little Rock, AR, 72202 USA
| | - Zhuopei Hu
- Division of Biostatistics, Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Arkansas Children's Research Institute, Little Rock, AR, 72202 USA
| | - Stewart MacLeod
- Division of Birth Defects Research, Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences and Arkansas Children's Research Institute, Little Rock, AR, 72202, USA
| | - Zachary Stowe
- Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, 72205, USA
| | - Daniel Webber
- Division of Birth Defects Research, Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences and Arkansas Children's Research Institute, Little Rock, AR, 72202, USA
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Bellizzi S, Ali MM, Abalos E, Betran AP, Kapila J, Pileggi-Castro C, Vogel JP, Merialdi M. Are hypertensive disorders in pregnancy associated with congenital malformations in offspring? Evidence from the WHO Multicountry cross sectional survey on maternal and newborn health. BMC Pregnancy Childbirth 2016; 16:198. [PMID: 27473210 PMCID: PMC4966715 DOI: 10.1186/s12884-016-0987-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Accepted: 07/23/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Annually, around 7.9 million children are born with birth defects and the contribution of congenital malformations to neonatal mortality is generally high. Congenital malformations in children born to mothers with hypertensive disorders during pregnancy has marginally been explored. METHODS Country incidence of congenital malformations was estimated using data on the 310 401 livebirths of the WHO Multicountry Survey which reported information from 359 facilities across 29 countries. A random-effect logistic regression model was utilized to explore the associations between six broad categories of congenital malformations and the four maternal hypertensive disorders "Chronic Hypertension", "Preeclampsia" and "Eclampsia" and "Chronic hypertension with superimposed preeclampsia". RESULTS The occupied territories of Palestine presented the highest rates in all groups of malformation except for the "Lip/Cleft/Palate" category. Newborns of women with chronic maternal hypertension were associated with a 3.7 (95 % CI 1.3-10.7), 3.9 (95 % CI 1.7-9.0) and 4.2 (95 % CI 1.5-11.6) times increase in odds of renal, limb and lip/cleft/palate malformations respectively. Chronic hypertension with superimposed preeclampsia was associated with a 4.3 (95 % CI 1.3-14.4), 8.7 (95 % CI 2.5-30.2), 7.1 (95 % CI 2.1-23.5) and 8.2 (95 % CI 2.0-34.3) times increase in odds of neural tube/central nervous system, renal, limb and Lip/Cleft/Palate malformations. CONCLUSIONS This study shows that chronic hypertension in the maternal period exposes newborns to a significant risk of developing renal, limb and lip/cleft/palate congenital malformations, and the risk is further exacerbate by superimposing eclampsia. Additional research is needed to identify shared pathways of maternal hypertensive disorders and congenital malformations.
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Affiliation(s)
- S Bellizzi
- World Health Organization, Eastern Mediterranean Regional Office, P.O. Box 7608, Nasr City, Cairo, 11371, Egypt
| | - M M Ali
- World Health Organization, Eastern Mediterranean Regional Office, P.O. Box 7608, Nasr City, Cairo, 11371, Egypt.
| | - E Abalos
- Centro Rosarino de Estudios Perinatales (CREP) Moreno 878, 6° Piso. (S2000DKR), Rosario, Argentina
| | - A P Betran
- Department of Reproductive Health and Research, World Health Organization, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Avenue Appia 20, Geneva, Switzerland
| | - J Kapila
- Maternal & Child Morbidity & Mortality Surveillance Unit, Family Health Bureau - Ministry of Health, 231 De Saram Place, Colombo, 10, Sri Lanka
| | - C Pileggi-Castro
- Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - J P Vogel
- Department of Reproductive Health and Research, World Health Organization, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Avenue Appia 20, Geneva, Switzerland
| | - M Merialdi
- , BD. 1 Becton Drive, MC 374, Franklin Lakes, NJ, 07417-1885, USA
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Propranolol treatment of infantile hemangioma (IH) is not associated with developmental risk or growth impairment at age 4 years. J Am Acad Dermatol 2016; 75:59-63.e1. [DOI: 10.1016/j.jaad.2016.02.1218] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Revised: 02/19/2016] [Accepted: 02/21/2016] [Indexed: 11/19/2022]
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Bailey G, Vaughan L, Rose C, Krambeck A. Perinatal Outcomes with Tamsulosin Therapy for Symptomatic Urolithiasis. J Urol 2016; 195:99-103. [DOI: 10.1016/j.juro.2015.06.097] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2015] [Indexed: 11/26/2022]
Affiliation(s)
- George Bailey
- Department of Urology, Mayo Clinic, Rochester, Minnesota
| | - Lisa Vaughan
- Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Carl Rose
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota
| | - Amy Krambeck
- Department of Urology, Mayo Clinic, Rochester, Minnesota
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Reversible Fetal Renal Impairment following Angiotensin Receptor Blocking Treatment during Third Trimester of Pregnancy: Case Report and Review of the Literature. Case Rep Obstet Gynecol 2016; 2016:2382031. [PMID: 27672462 PMCID: PMC5031874 DOI: 10.1155/2016/2382031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 08/17/2016] [Accepted: 08/22/2016] [Indexed: 11/23/2022] Open
Abstract
Background. Late pregnancy usage of angiotensin converting enzyme inhibitors (ACE-I) and angiotensin II receptor blockers (ARB) may cause severe oligohydramnios due to fetal renal impairment. Affected neonates will often suffer from fatal, renal, and respiratory failure. Case. A 39-year-old multigravida admitted due to anhydramnios secondary to valsartan (ARB) exposure at 30 weeks' gestation. Following secession of treatment amniotic fluid volume returned to normal. Delivery was induced at 34 weeks' gestation following premature rupture of membranes and maternal fever. During the two-year follow-up, no signs of renal insufficiency were noted. Conclusions. This description of reversible fetal renal damage due to ARB intake during pregnancy is the first to show no adverse renal function in a two-year follow-up period. This case may help clinicians counsel patients with pregnancies complicated by exposure to these drugs.
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Prete A, Paragliola RM, Salvatori R, Corsello SM. MANAGEMENT OF CATECHOLAMINE-SECRETING TUMORS IN PREGNANCY: A REVIEW. Endocr Pract 2015; 22:357-70. [PMID: 26536138 DOI: 10.4158/ep151009.ra] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Catecholamine-secreting tumors (pheochromocytomas and paragangliomas) presenting during pregnancy are extremely rare, but they can be fatal to both mother and fetus. Recent discoveries in the genetic background of these tumors are expected to address an increasing number of at-risk women to prenatal diagnosis. METHODS The literature was reviewed in order to provide clinicians with a practical and updated guide on how to manage this life-threatening condition. RESULTS The clinical presentation of catecholamine-secreting tumors can be deceptive and mimic common disorders of pregnancy. Silent catecholamine-secreting tumors can become evident during pregnancy, and hypertension cannot be considered a hallmark for this condition: some women may be normotensive or develop orthostatic hypotension. Biochemical screening includes measurement of plasma free metanephrines or urinary fractioned metanephrines. Measurement of catecholamines, dopamine, and methoxytyramine can provide further information on tumor biology, location, and prognosis. Diagnostic imaging is limited, and medical treatment requires a cautious balance between hemodynamic control and effects on the fetoplacental unit. Several genes have been associated with syndromes including catecholamine-secreting tumors, and positive genetic testing can correlate with tumor behavior. Timing and modalities for tumor removal and delivery, including anesthetic management, depend on gestational age, maternal and fetal wellbeing, control of catecholamine excess, suspicion of multiple or malignant disease, and surgical accessibility to the tumor. CONCLUSION A timely diagnosis and a multidisciplinary approach are the keys to improve pregnancy outcomes in patients with a catecholamine-secreting tumor; each case should be managed in a tertiary referral center.
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Abstract
The risk of arrhythmia development or recurrence is increased during pregnancy. For those arrhythmias that are unresponsive to conservative therapy, such as vagal maneuvers or life style interventions, or that present a higher risk to the mother or fetus, medical therapy may be necessary. In each case, the patient and provider must carefully consider the risks and benefits of a particular therapy. This requires an understanding of the data regarding the safety and efficacy of any particular drug, which in some cases may be extensive and in others quite limited. Fortunately, options exist for the treatment of arrhythmias during pregnancy.
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Affiliation(s)
- Jennifer M Wright
- a Cardiovascular Division, Department of Medicine , University of Wisconsin School of Medicine and Public Health , Madison , WI , USA
| | - Richard L Page
- a Cardiovascular Division, Department of Medicine , University of Wisconsin School of Medicine and Public Health , Madison , WI , USA
| | - Michael E Field
- a Cardiovascular Division, Department of Medicine , University of Wisconsin School of Medicine and Public Health , Madison , WI , USA
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Cragan JD, Young BA, Correa A. Renin-Angiotensin System Blocker Fetopathy. J Pediatr 2015; 167:792-4. [PMID: 26254838 PMCID: PMC4627591 DOI: 10.1016/j.jpeds.2015.07.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 07/14/2015] [Indexed: 01/09/2023]
Affiliation(s)
- Janet D Cragan
- Division of Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Bessie A Young
- Veterans Affairs Puget Sound, Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
| | - Adolfo Correa
- Departments of Medicine and Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi.
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Ramakrishnan A, Lee LJ, Mitchell LE, Agopian AJ. Maternal Hypertension During Pregnancy and the Risk of Congenital Heart Defects in Offspring: A Systematic Review and Meta-analysis. Pediatr Cardiol 2015; 36:1442-51. [PMID: 25951814 PMCID: PMC4573362 DOI: 10.1007/s00246-015-1182-9] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 04/29/2015] [Indexed: 10/23/2022]
Abstract
Maternal hypertension is common during pregnancy, and multiple studies have reported on an association between maternal hypertension and congenital heart defects (CHDs) in offspring; however, there is variability in the quality of these studies. A systematic review and meta-analysis was conducted on the associations between untreated and treated maternal hypertension and the risk of CHDs, evaluating CHDs overall as well as specific CHD subtypes. A systematic search of peer-reviewed articles published before August 2013 identified 16 studies evaluating the associations between untreated and treated maternal hypertension and CHDs. Summary relative risk (RR) estimates were calculated using fixed-effects models and random-effects models. Significant associations were observed between maternal hypertension and overall CHDs, for both treated [RR 2.0; 95 % confidence interval (CI) 1.5, 2.7] and untreated (RR 1.4; 95 % CI 1.2, 1.7) hypertension, as well as for overall hypertension regardless of treatment status (RR 1.8; 95 % CI 1.5, 2.2). The magnitude of effect was similar for the majority of CHD subtypes evaluated. The effects were also similar among women with hypertension who used one of multiple specific hypertension medications. There was no evidence of publication bias, and our results were robust to several factors considered in sensitivity analyses (e.g., source of exposure data, adjustment for potential confounders, and study design). Maternal hypertension was associated with CHDs. By understanding the specific mechanisms involved, appropriate strategies may be developed to reduce this risk, in order to prevent CHDs.
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Affiliation(s)
- Anushuya Ramakrishnan
- Division of Epidemiology, Human Genetics and Environmental Sciences, University of Texas School of Public Health, 1200 Herman Pressler, Houston, TX, USA
| | - Laura J. Lee
- Division of Epidemiology, Human Genetics and Environmental Sciences, University of Texas School of Public Health, 1200 Herman Pressler, Houston, TX, USA
| | - Laura E. Mitchell
- Division of Epidemiology, Human Genetics and Environmental Sciences, University of Texas School of Public Health, 1200 Herman Pressler, Houston, TX, USA
| | - A. J. Agopian
- Division of Epidemiology, Human Genetics and Environmental Sciences, University of Texas School of Public Health, 1200 Herman Pressler, Houston, TX, USA
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Maternal caffeine consumption and small for gestational age births: results from a population-based case-control study. Matern Child Health J 2015; 18:1540-51. [PMID: 24288144 DOI: 10.1007/s10995-013-1397-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Caffeine is consumed in various forms during pregnancy, has increased half-life during pregnancy and crosses the placental barrier. Small for gestational age (SGA) is an important perinatal outcome and has been associated with long term complications. We examined the association between maternal caffeine intake and SGA using National Birth Defects Prevention Study data. Non-malformed live born infants with an estimated date of delivery from 1997-2007 (n = 7,943) were included in this analysis. Maternal caffeine exposure was examined as total caffeine intake and individual caffeinated beverage type (coffee, tea, and soda); sex-, race/ethnic-, and parity-specific growth curves were constructed to estimate SGA births. Crude and adjusted odds ratios (aORs) and 95% confidence intervals were estimated using unconditional logistic regression. Interaction with caffeine exposures was assessed for maternal smoking, vasoconstrictor medication use, and folic acid. Six hundred forty-eight infants (8.2%) were found to be SGA in this analysis. Increasing aORs were observed for increasing intakes of total caffeine and for each caffeinated beverage with aORs (adjusting for maternal education, high blood pressure, and smoking) ranging from 1.3 to 2.1 for the highest intake categories (300+ mg/day total caffeine and 3+ servings/day for each beverage type). Little indication of additive interaction by maternal smoking, vasoconstrictor medication use, or folic acid intake was observed. We observed an increase in SGA births for mothers with higher caffeine intake, particularly for those consuming 300+ mg of caffeine per day. Increased aORs were also observed for tea intake but were more attenuated for coffee and soda intake.
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Bateman BT, Huybrechts KF, Fischer MA, Seely EW, Ecker JL, Oberg AS, Franklin JM, Mogun H, Hernandez-Diaz S. Chronic hypertension in pregnancy and the risk of congenital malformations: a cohort study. Am J Obstet Gynecol 2015; 212:337.e1-14. [PMID: 25265405 PMCID: PMC4346443 DOI: 10.1016/j.ajog.2014.09.031] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 08/20/2014] [Accepted: 09/25/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Chronic hypertension is a common medical condition in pregnancy. The purpose of the study was to examine the association between maternal chronic hypertension and the risk of congenital malformations in the offspring. STUDY DESIGN We defined a cohort of 878,126 completed pregnancies linked to infant medical records using the Medicaid Analytic Extract. The risk of congenital malformations was compared between normotensive controls and those with treated and untreated chronic hypertension. Confounding was addressed using propensity score matching. RESULTS After matching, compared with normotensive controls, pregnancies complicated by treated chronic hypertension were at increased risk of congenital malformations (odds ratio [OR], 1.3; 95% confidence interval [CI], 1.2-1.5), as were pregnancies with untreated chronic hypertension (OR 1.2; 95% CI, 1.1-1.3). In our analysis of organ-specific malformations, both treated and untreated chronic hypertension was associated with a significant increase in the risk of cardiac malformations (OR, 1.6; 95% CI, 1.4-1.9 and OR, 1.5; 95% CI, 1.3-1.7, respectively). These associations persisted across a range of sensitivity analyses. CONCLUSION There is a similar increase in the risk of congenital malformations (particularly cardiac malformations) associated with treated and untreated chronic hypertension that is independent of measured confounders. Studies evaluating the teratogenic potential of antihypertensive medications must control for confounding by indication. Fetuses and neonates of mothers with chronic hypertension should be carefully evaluated for potential malformations, particularly cardiac defects.
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Affiliation(s)
- Brian T Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| | - Krista F Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Michael A Fischer
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ellen W Seely
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jeffrey L Ecker
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Anna S Oberg
- Department of Epidemiology, Harvard School of Public Health, Boston, MA
| | - Jessica M Franklin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Helen Mogun
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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S. Mukherjee M, Coppenrath VA, Dallinga BA. Pharmacologic Management of Types 1 and 2 Diabetes Mellitus and Their Complications in Women of Childbearing Age. Pharmacotherapy 2015; 35:158-74. [DOI: 10.1002/phar.1535] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
| | | | - Bree A. Dallinga
- Edward M. Kennedy Community Health Center; Framingham Massachusetts
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Pucci M, Sarween N, Knox E, Lipkin G, Martin U. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in women of childbearing age: risks versus benefits. Expert Rev Clin Pharmacol 2015; 8:221-31. [DOI: 10.1586/17512433.2015.1005074] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Ueki N, Takeda S, Koya D, Kanasaki K. The relevance of the Renin-Angiotensin system in the development of drugs to combat preeclampsia. Int J Endocrinol 2015; 2015:572713. [PMID: 26000015 PMCID: PMC4426891 DOI: 10.1155/2015/572713] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 03/28/2015] [Accepted: 03/28/2015] [Indexed: 12/14/2022] Open
Abstract
Preeclampsia is a hypertensive disorder that occurs during pregnancy. It has an unknown etiology and affects approximately 5-8% of pregnancies worldwide. The pathophysiology of preeclampsia is not yet known, and preeclampsia has been called "a disease of theories." The central symptom of preeclampsia is hypertension. However, the etiology of the hypertension is unknown. In this review, we analyze the molecular mechanisms of preeclampsia with a particular focus on the pathogenesis of the hypertension in preeclampsia and its association with the renin-angiotensin system. In addition, we propose potential alternative strategies to target the renin-angiotensin system, which is enhanced during pregnancy.
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Affiliation(s)
- Norikazu Ueki
- Department of Diabetology and Endocrinology, Kanazawa Medical University, Ishikawa 920-0293, Japan
- Department of Obstetrics and Gynecology, Juntendo University, Tokyo 113-8431, Japan
| | - Satoru Takeda
- Department of Obstetrics and Gynecology, Juntendo University, Tokyo 113-8431, Japan
| | - Daisuke Koya
- Department of Diabetology and Endocrinology, Kanazawa Medical University, Ishikawa 920-0293, Japan
- Division of Anticipatory Molecular Food Science and Technology, Medical Research Institute, Kanazawa Medical University, Ishikawa 920-0293, Japan
| | - Keizo Kanasaki
- Department of Diabetology and Endocrinology, Kanazawa Medical University, Ishikawa 920-0293, Japan
- Division of Anticipatory Molecular Food Science and Technology, Medical Research Institute, Kanazawa Medical University, Ishikawa 920-0293, Japan
- *Keizo Kanasaki:
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Sullo MG, Perri D, Sibilio M, Rafaniello C, Fucile A, Rossi F, Capuano A. Hypoglycemia, polycythemia and hyponatremia in a newborn exposed to nebivolol during pregnancy. J Pharmacol Pharmacother 2015; 6:45-8. [PMID: 25709355 PMCID: PMC4319251 DOI: 10.4103/0976-500x.149148] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 03/15/2014] [Accepted: 06/28/2014] [Indexed: 11/22/2022] Open
Abstract
Nebivolol is a third-generation beta blocker that exerts selective antagonistic activity on β1 receptors. It has vasodilating properties that result from direct stimulation of endothelial nitric oxide synthase. Nebivolol is indicated for the treatment of hypertension and heart failure, and is generally well tolerated. In this article, we report a case of an infant who was admitted to the Pediatrics and Neonatology Unit of the Moscati Hospital (Aversa, Italy) about 24 hours after birth. The reason for hospitalization was persistent severe hypoglycemia (blood glucose = 30 mg/dL) and jaundice (total bilirubin = 12.5 mg/dL, indirect bilirubin 11.75 mg/dL). He was born by spontaneous delivery after a normal term pregnancy. Birth weight was 3040 g and the Apgar score was 6-9. The mother reported taking nebivolol 5 mg/day for unspecified tachycardia in the last 4 months of pregnancy. Clinical and instrumental investigations carried out during hospitalization did not reveal any congenital or perinatal abnormalities. After treatment for metabolic and electrolyte imbalance, he was discharged on the 10th day of hospitalization, in good clinical condition and with normalization of clinical and laboratory parameters. Currently, there are no specific studies on nebivolol tolerability during pregnancy. Our data suggest that the risk profile of nebivolol during pregnancy is the same as that of other β-blockers. Therefore, further studies are required to determine the safety of β-blockers during pregnancy and the risks to the unborn child.
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Affiliation(s)
- Maria Giuseppa Sullo
- Department of Experimental Medicine, Section of Pharmacology, Pharmacoepidemiology and Pharmacovigilance Centre of the Campania Region, Second University of Naples, Naples, Italy
| | - Domenico Perri
- Department of Pediatric, Moscati Hospital, Aversa, Italy
| | | | - Concetta Rafaniello
- Department of Experimental Medicine, Section of Pharmacology, Pharmacoepidemiology and Pharmacovigilance Centre of the Campania Region, Second University of Naples, Naples, Italy
| | | | - Francesco Rossi
- Department of Experimental Medicine, Section of Pharmacology, Pharmacoepidemiology and Pharmacovigilance Centre of the Campania Region, Second University of Naples, Naples, Italy
| | - Annalisa Capuano
- Department of Experimental Medicine, Section of Pharmacology, Pharmacoepidemiology and Pharmacovigilance Centre of the Campania Region, Second University of Naples, Naples, Italy
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van Gelder MMHJ, Van Bennekom CM, Louik C, Werler MM, Roeleveld N, Mitchell AA. Maternal hypertensive disorders, antihypertensive medication use, and the risk of birth defects: a case-control study. BJOG 2014; 122:1002-9. [DOI: 10.1111/1471-0528.13138] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2014] [Indexed: 12/01/2022]
Affiliation(s)
- MMHJ van Gelder
- Department for Health Evidence; Radboud University Medical Center; Nijmegen the Netherlands
| | - CM Van Bennekom
- Slone Epidemiology Center at Boston University; Boston MA USA
| | - C Louik
- Slone Epidemiology Center at Boston University; Boston MA USA
| | - MM Werler
- Slone Epidemiology Center at Boston University; Boston MA USA
| | - N Roeleveld
- Department for Health Evidence; Radboud University Medical Center; Nijmegen the Netherlands
- Department of Paediatrics; Radboud University Medical Center; Nijmegen the Netherlands
| | - AA Mitchell
- Slone Epidemiology Center at Boston University; Boston MA USA
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