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Wang T, Jiang R, Yao Y, Xu T, Li N. Anti-hypertensive therapy for preeclampsia: a network meta-analysis and systematic review. Hypertens Pregnancy 2024; 43:2329068. [PMID: 38488570 DOI: 10.1080/10641955.2024.2329068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 03/05/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND Preeclampsia (PE) is a pregnancy disorder that represents a major cause of maternal and perinatal morbidity and mortality. METHODS This network meta-analysis was registered with PROSPERO. We searched the PubMed, ClinicalTrials.gov. and Embase databases for studies published from inception to the 31st of March 2023. RevMan5.3 software provided by the Cochrane Collaboration was used for direct meta-analysis (DMA) statistical analysis. Funnel maps, network meta-analysis (NMA), the surface under the cumulative ranking curve (SUCRA) to rank the different interventions and publication bias were generated by STATA 17.0 software. RESULTS We included eight randomized controlled trials (RCTs) involving a total of 1192 women with PE; two studies were of high quality and six were of moderate quality. Eight interventions were addressed in the NMA. In the DMA, we found that blood pressure in the Ketanserin group were significantly higher than those in the Nicardipine group. NMA showed that blood pressure in the Dihydralazine group was significantly higher than that in the Methyldopa, Labetalol, Nicardipine and Diltiazem groups. And the blood pressure in the Labetalol group was significantly lower than that in the Nicardipine group. SUCRA values showed that Diltiazem was more effective in lowering blood pressure than other drugs looked at in this study. CONCLUSION According to the eight RCTs included in this study, Diltiazem was the most effective in reducing blood pressure in PE patients; Labetalol and Nicardipine also had good effects. Diltiazem is preferred for the treatment of patients with severe PE and high blood pressure.
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Affiliation(s)
- Ting Wang
- Department of Obstetrics and Gynecology, Women's Hospital Zhejiang University School of Medicine, Hangzhou, China
| | - Ruoan Jiang
- Department of Obstetrics and Gynecology, Women's Hospital Zhejiang University School of Medicine, Hangzhou, China
- Zhejiang Provincial Clinical Research Center for Obstetrics and Gynecology, Hangzhou, China
- Traditional Chinese Medicine for Reproductive Health Key Laboratory of Zhejiang Province, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yingsha Yao
- Department of Obstetrics and Gynecology, Women's Hospital Zhejiang University School of Medicine, Hangzhou, China
| | - Ting Xu
- Department of Obstetrics and Gynecology, Women's Hospital Zhejiang University School of Medicine, Hangzhou, China
| | - Na Li
- Department of Obstetrics and Gynecology, Women's Hospital Zhejiang University School of Medicine, Hangzhou, China
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2
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Kubota K, Inai K, Shimada E, Shinohara T. α/β- and β-Blocker Exposure in Pregnancy and the Risk of Neonatal Hypoglycemia and Small for Gestational Age. Circ J 2023; 87:569-577. [PMID: 36823100 DOI: 10.1253/circj.cj-22-0647] [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] [Indexed: 02/25/2023]
Abstract
BACKGROUND α/β- and β-blockers are essential in pregnant women's perinatal congenital heart disease management. Nevertheless, data on the effects of α/β- and β-blockers on pregnant women and fetuses are limited. We examined the risks of neonatal hypoglycemia and small for gestational age (SGA) associated with maternal exposure to α/β- and β-blockers.Methods and Results: All consecutive pregnant women with heart disease admitted to our hospital between January 2014 and October 2020 were included. Of 306 pregnancies (267 women), 32 were in the α/β-blocker group, 11 were in the β-blocker group, and 263 were in the control group. All 32 pregnancies in the α/β-blocker group were treated with carvedilol. In the β-blocker group, 4 women were treated with bisoprolol, 3 were treated with propranolol, 2 were treated with atenolol, 1 was treated with metoprolol, and 1 was treated nadolol. The incidence of neonatal hypoglycemia was higher in pregnant women taking carvedilol than in the control group (P=0.025). SGA was observed significantly more frequently in pregnant women taking β-blockers than in the carvedilol and control groups (P<0.001). CONCLUSIONS Carvedilol administration during pregnancy was associated with neonatal hypoglycemia; however, it did not occur in a time- or dose-dependent manner. Routine monitoring of blood glucose levels in newborns exposed to α/β- and β-blockers is essential.
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Affiliation(s)
- Kana Kubota
- Department of Pediatric Cardiology and Adult Congenital Cardiology, Tokyo Women's Medical University.,Division of Cardiovascular Medicine, Department of Internal Medicine, Jichi Medical University
| | - Kei Inai
- Department of Pediatric Cardiology and Adult Congenital Cardiology, Tokyo Women's Medical University
| | - Eriko Shimada
- Department of Pediatric Cardiology and Adult Congenital Cardiology, Tokyo Women's Medical University
| | - Tokuko Shinohara
- Department of Pediatric Cardiology and Adult Congenital Cardiology, Tokyo Women's Medical University
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3
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Chen Z, Wang J, Carru C, Chen Y, Li Z. Treatment for mild hypertension in pregnancy with different strategies: A systematic review and meta-analysis. Int J Gynaecol Obstet 2022; 162:202-210. [PMID: 36528834 DOI: 10.1002/ijgo.14634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 12/09/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To synthesize the evidence from randomized controlled trials (RCTs) of antihypertensive treatment for mild pregnancy hypertension. METHODS We searched various databases from inception to June 2022, using keywords including hypertension; pregnancy; therapy; treatment; pregnancy outcomes; maternal outcomes; and perinatal outcomes. Only RCTs of antihypertensive treatment for mild hypertension in pregnancy comparing placebo/no therapy were included. We used Review Manager version 5.3 for statistical analyses. RESULTS In all, eight studies were eligible, with a total of 4211 participants. Compared with control, the active treatment significantly prevented preeclampsia (OR 0.55; 95%CI, 0.39-0.78), placental abruption (OR 0.39; 95%CI, 0.17-0.91), severe hypertension (OR 0.35; 95%CI, 0.17-0.71), end-organ dysfunction (OR 0.34; 95%CI, 0.19-0.62) and preterm birth (OR 0.69; 95%CI, 0.59-0.82), with no increased risk of small for gestational age (SGA) (OR 1.25; 95%CI, 0.78-2.00), or admission to the NICU (OR 0.83; 95%CI, 0.54-1.28). Subgroup analyses demonstrated that the tight control group did not show an advantage over the less-tight control group in improving pregnancy outcomes. CONCLUSION In pregnant women with mild pregnancy-induced hypertension or chronic hypertension, antihypertensive treatment still provided precise benefits of improving pregnancy outcomes without increased risk in fetal outcomes.
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Affiliation(s)
- Zhichao Chen
- University of Sassari, Sassari, Italy
- Department of Life Science and Biotechnology, Second Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Jing Wang
- University of Sassari, Sassari, Italy
- Department of Life Science and Biotechnology, Second Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Ciriaco Carru
- University of Sassari, Sassari, Italy
- Department of Biomedical Sciences, Second Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Youren Chen
- Department of Cardiology, Second Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Zhi Li
- Department of Cardiology, Second Affiliated Hospital of Shantou University Medical College, Shantou, China
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The Risk for Neonatal Hypoglycemia and Bradycardia after Beta-Blocker Use during Pregnancy or Lactation: A Systematic Review and Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19159616. [PMID: 35954977 PMCID: PMC9368631 DOI: 10.3390/ijerph19159616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 12/10/2022]
Abstract
Beta-blockers are often used during pregnancy to treat cardiovascular diseases. The described neonatal side effects of maternal beta-blocker use are hypoglycemia and bradycardia, but the evidence base for these is yet to be evaluated comprehensively. Hence, this systematic review and meta-analysis was performed to evaluate the potential increased risk for hypoglycemia and bradycardia in neonates exposed to beta-blockers in utero or during lactation. A systematic search of English-language human studies was conducted until 21 April 2021. Both observational studies and randomized controlled trials investigating hypoglycemia and/or bradycardia in neonates following beta-blocker exposure during pregnancy and lactation were included. All articles were screened by two authors independently and eligible studies were included. Pair-wise and proportion-based meta-analysis was conducted and the certainty of evidence (CoE) was performed by standard methodologies. Of the 1.043 screened articles, 55 were included in this systematic review. Our meta-analysis showed a probable risk of hypoglycemia (CoE—Moderate) and possible risk of bradycardia (CoE—Low) in neonates upon fetal beta-blocker exposure. Therefore, we suggest the monitoring of glucose levels in exposed neonates until 24 h after birth. Due to the limited clinical implication, monitoring of the heart rate could be considered for 24 h. We call for future studies to substantiate our findings.
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Kahramanoglu Ö, Schiattarella A, Demirci O, Sisti G, Ammaturo FP, Trotta C, Ferrari F, Rapisarda AMC. Preeclampsia: state of art and future perspectives. A special focus on possible preventions. J OBSTET GYNAECOL 2022; 42:766-777. [PMID: 35469530 DOI: 10.1080/01443615.2022.2048810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Preeclampsia (PE) is characterised by the new onset of hypertension after the 20th week of pregnancy, with or without proteinuria or hypertension that leads to end-organ dysfunction. Since the only definitive treatment is delivery, PE still represents one of the leading causes of preterm birth and perinatal mobility and mortality. Therefore, any strategies that aim to reduce adverse outcomes are based on early primary prevention, prenatal surveillance and prophylactic interventions. In the last decade, intense research has been focussed on the study of predictive models in order to identify women at higher risk accurately. To date, the most effective screening model is based on the combination of anamnestic, demographic, biophysical and maternal biochemical factors. In this review, we provide a detailed discussion about the current and future perspectives in the field of PE. We will examine pathogenesis, risk factors and clinical features. Moreover, recent developments in screening and prevention strategies, novel therapies and healthcare management strategies will be discussed.
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Affiliation(s)
- Özge Kahramanoglu
- Department of Perinatology, Zeynep Kamil Education and Research Hospital, İstanbul, Turkey
| | - Antonio Schiattarella
- Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Oya Demirci
- Department of Perinatology, Zeynep Kamil Education and Research Hospital, İstanbul, Turkey
| | - Giovanni Sisti
- Department of Obstetrics and Gynecology, New York Health and Hospitals/Lincoln, Bronx, NY, USA
| | - Franco Pietro Ammaturo
- Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Carlo Trotta
- Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Federico Ferrari
- Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Agnese Maria Chiara Rapisarda
- Department of General Surgery and Medical Surgical Specialties, Obstetrics and Gynecology Unit, University of Catania, Catania, Italy
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Bone JN, Sandhu A, Abalos ED, Khalil A, Singer J, Prasad S, Omar S, Vidler M, von Dadelszen P, Magee LA. Oral Antihypertensives for Nonsevere Pregnancy Hypertension: Systematic Review, Network Meta- and Trial Sequential Analyses. Hypertension 2022; 79:614-628. [PMID: 35138877 PMCID: PMC8823910 DOI: 10.1161/hypertensionaha.121.18415] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND We aimed to address which antihypertensives are superior to placebo/no therapy or another antihypertensive for controlling nonsevere pregnancy hypertension and provide future sample size estimates for definitive evidence. METHODS Randomized trials of antihypertensives for nonsevere pregnancy hypertension were identified from online electronic databases, to February 28, 2021 (registration URL: https://www.crd.york.ac.uk/PROSPERO/; unique identifier: CRD42020188725). Our outcomes were severe hypertension, proteinuria/preeclampsia, fetal/newborn death, small-for-gestational age infants, preterm birth, and admission to neonatal care. A Bayesian random-effects model generated estimates of direct and indirect treatment comparisons. Trial sequential analysis informed future trials needed. RESULTS Of 1246 publications identified, 72 trials were included; 61 (6923 women) were informative. All commonly prescribed antihypertensives (labetalol, other β-blockers, methyldopa, calcium channel blockers, and mixed/multi-drug therapy) versus placebo/no therapy reduced the risk of severe hypertension by 30% to 70%. Labetalol decreased proteinuria/preeclampsia (odds ratio, 0.73 [95% credible interval, 0.54-0.99]) and fetal/newborn death (odds ratio, 0.54 [0.30-0.98]) compared with placebo/no therapy, and proteinuria/preeclampsia compared with methyldopa (odds ratio, 0.66 [0.44-0.99]) and calcium channel blockers (odds ratio, 0.63 [0.41-0.96]). No other differences were identified, but credible intervals were wide. Trial sequential analysis indicated that 2500 to 10 000 women/arm (severe hypertension or safety outcomes) to >15 000/arm (fetal/newborn death) would be required to provide definitive evidence. CONCLUSIONS In summary, all commonly prescribed antihypertensives in pregnancy reduce the risk of severe hypertension, but labetalol may also decrease proteinuria/preeclampsia and fetal/newborn death. Evidence is lacking for many other safety outcomes. Prohibitive sample sizes are required for definitive evidence. Real-world data are needed to individualize care.
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Affiliation(s)
- Jeffrey N. Bone
- Department of Obstetrics and Gynaecology, University of British Columbia (UBC), Canada (J.N.B., A.S., S.P., S.O., M.V.)
| | - Akshdeep Sandhu
- Department of Obstetrics and Gynaecology, University of British Columbia (UBC), Canada (J.N.B., A.S., S.P., S.O., M.V.)
| | - Edgardo D. Abalos
- Centro Rosarino de Estudios Perinatales, Rosario, Argentina (E.D.A.)
| | - Asma Khalil
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George’s University Hospitals, NHS Foundation Trust, United Kingdom (A.K.).,Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George’s University of London, United Kingdom (A.K.)
| | - Joel Singer
- School of Population and Public Health, UBC, Canada (J.S.)
| | - Sarina Prasad
- Department of Obstetrics and Gynaecology, University of British Columbia (UBC), Canada (J.N.B., A.S., S.P., S.O., M.V.)
| | - Shazmeen Omar
- Department of Obstetrics and Gynaecology, University of British Columbia (UBC), Canada (J.N.B., A.S., S.P., S.O., M.V.)
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, University of British Columbia (UBC), Canada (J.N.B., A.S., S.P., S.O., M.V.)
| | - Peter von Dadelszen
- Department of Women and Children’s Health, King’s College London, United Kingdom (P.v.D., L.A.M.)
| | - Laura A. Magee
- Department of Women and Children’s Health, King’s College London, United Kingdom (P.v.D., L.A.M.)
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Abe M, Arima H, Yoshida Y, Fukami A, Sakima A, Metoki H, Tada K, Mito A, Morimoto S, Shibata H, Mukoyama M. Optimal blood pressure target to prevent severe hypertension in pregnancy: A systematic review and meta-analysis. Hypertens Res 2022; 45:887-899. [PMID: 35136186 DOI: 10.1038/s41440-022-00853-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 12/25/2021] [Accepted: 12/31/2021] [Indexed: 12/25/2022]
Abstract
Severe hypertension in pregnancy is a hypertensive crisis that requires urgent and intensive care due to its high maternal and fetal mortality. However, there is still a conflict of opinion on the recommendations of antihypertensive therapy. This study aimed to identify the optimal blood pressure (BP) levels to prevent severe hypertension in pregnant women with nonsevere hypertension. Ovid MEDLINE and the Cochrane Library were searched, and only randomized controlled trials (RCTs) were included if they compared the effects of antihypertensive drugs and placebo/no treatment or more intensive and less intensive BP-lowering treatments in nonsevere hypertensive pregnant patients. A random effects model meta-analysis was performed to estimate the pooled risk ratio (RR) for the outcomes. Forty RCTs with 6355 patients were included in the study. BP-lowering treatment significantly prevented severe hypertension (RR, 0.46; 95% CI, 0.37-0.56), preeclampsia (RR, 0.82; 95% CI, 0.69-0.98), severe preeclampsia (RR, 0.38; 95% CI, 0.17-0.84), placental abruption (RR, 0.52; 95% CI, 0.32-0.86), and preterm birth (< 37 weeks; RR, 0.81; 95% CI, 0.71-0.93), while the risk of small for gestational age infants was increased (RR, 1.25; 95% CI, 1.02-1.54). An achieved systolic blood pressure (SBP) of < 130 mmHg reduced the risk of severe hypertension to nearly one-third compared with an SBP of ≥ 140 mmHg, with a significant interaction of the BP levels achieved with BP-lowering therapy. There was no significant interaction between the subtypes of hypertensive disorders of pregnancy and BP-lowering treatment, except for placental abruption. BP-lowering treatment aimed at an SBP < 130 mmHg and accompanied by the careful monitoring of fetal growth might be recommended to prevent severe hypertension.
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Affiliation(s)
- Makiko Abe
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Hisatomi Arima
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan.
| | - Yuichi Yoshida
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University, Oita, Japan
| | - Ako Fukami
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine, Fukuoka, Japan
| | - Atsushi Sakima
- Health Administration Center, University of the Ryukyus, Okinawa, Japan
| | - Hirohito Metoki
- Division of Public Health, Hygiene and Epidemiology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Kazuhiro Tada
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Asako Mito
- Division of Maternal Medicine, Center for Maternal-Fetal-Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Satoshi Morimoto
- Department of Endocrinology and Hypertension, Tokyo Women's Medical University, Tokyo, Japan
| | - Hirotaka Shibata
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University, Oita, Japan
| | - Masashi Mukoyama
- Department of Nephrology, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
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Bej P, Das S. Effect of labetalol for treating patients with pregnancy-induced hypertension: A systematic review. JOURNAL OF THE PRACTICE OF CARDIOVASCULAR SCIENCES 2022. [DOI: 10.4103/jpcs.jpcs_69_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
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9
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Ma S, Wu L, Yu Q, Chen D, Geng C, Peng H, Yu L, Zhang M. Associations Between Trajectory of Different Blood Pressure Components in Pregnancy and Risk of Adverse Birth Outcomes - A Real World Study. Risk Manag Healthc Policy 2021; 14:3255-3263. [PMID: 34393532 PMCID: PMC8360358 DOI: 10.2147/rmhp.s318956] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 07/22/2021] [Indexed: 11/23/2022] Open
Abstract
Background High blood pressure during pregnancy has been suggested to be associated with adverse birth outcomes (ABO), but it is unclear how different blood pressure changes and the extent of the effect. Therefore, we aimed to investigate the association between blood pressure trajectories (systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), pulse pressure (PP)) of pregnant women and ABO in a real-world study. Material and Methods Leveraging 28,679 pregnant women and their fetuses from a register-based cohort from January 1, 2010, to December 31, 2019. Blood pressure trajectories were estimated by package “traj” in R software using real-world blood pressure data of routine antenatal care examinations. Logistic regression models were applied to examine the association between trajectories of different blood pressure components (SBP, DBP, MAP, and PP) during pregnancy and the risk of ABO. Results Trajectories of all blood pressure components were identically labeled as low-stable, moderate-increasing, moderate-decreasing and high-stable. After adjusting for confounding factors, compared with pregnant women with the low-stable pattern, pregnant women with a high-stable or moderate-increasing pattern had a significantly increased risk of developing adverse birth outcomes. Pregnant women with a moderate-decreasing pattern had no significant increased risk of ABO but had a lower risk of adverse birth outcomes than those with a moderate-increasing pattern. The trajectories crossed at 17–20 weeks of gestation for all blood pressure components. Conclusion Our study results indicated that reduction and maintenance of blood pressure to a low level of less than 110 mmHg for SBP and 65 mmHg for DBP after 20 weeks of gestation would benefit prevention of adverse birth outcomes, regardless of the level of blood pressure at early pregnancy.
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Affiliation(s)
- Shengqi Ma
- Department of Epidemiology, School of Public Health, Medical College of Soochow University, Suzhou, Jiangsu, People's Republic of China
| | - Lei Wu
- Department of Maternal and Child Health, Suzhou Industrial Park Centers for Disease Control and Prevention, Suzhou, Jiangsu, People's Republic of China
| | - Qing Yu
- Department of Gynecology and Obstetrics, Suzhou Kowloon Hospital, Suzhou, Jiangsu, People's Republic of China
| | - Donghui Chen
- Department of Maternal and Child Health, Suzhou Industrial Park Centers for Disease Control and Prevention, Suzhou, Jiangsu, People's Republic of China
| | - Chunsong Geng
- Department of Gynecology and Obstetrics, Suzhou Kowloon Hospital, Suzhou, Jiangsu, People's Republic of China
| | - Hao Peng
- Department of Epidemiology, School of Public Health, Medical College of Soochow University, Suzhou, Jiangsu, People's Republic of China
| | - Lugang Yu
- Department of Maternal and Child Health, Suzhou Industrial Park Centers for Disease Control and Prevention, Suzhou, Jiangsu, People's Republic of China
| | - Mingzhi Zhang
- Department of Epidemiology, School of Public Health, Medical College of Soochow University, Suzhou, Jiangsu, People's Republic of China
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Makhija A, Khatik N, Raghunandan C. A randomized control trial to study the effect of integrated yoga on pregnancy outcome in hypertensive disorder of pregnancy. Complement Ther Clin Pract 2021; 43:101366. [PMID: 33765549 DOI: 10.1016/j.ctcp.2021.101366] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 01/01/2021] [Accepted: 03/13/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The study aimed to evaluate the effects of integrated yoga on blood pressure and pregnancy outcome in hypertensive disorder of pregnancy. METHODS Seventy-nine patients were randomized into study and control groups. The study group received the intervention in the form of integrated yoga for 4 weeks. Final analysis was done on 30 patients each of study and control group. RESULTS The mean systolic BP declined by 7.43 ± 5.86 mmHg in the study group as compared to 2.50 ± 5.21 mm Hg in the control group (p value 0.002). The mean diastolic BP prior to delivery was 88.00 ± 3.71 mmHg in the study group and 92.20 ± 5.02 mmHg in the control group (p = 0.001). The maternal comfort in labor was significantly higher and the duration of labor significantly reduced in the study group. CONCLUSION Integrated yoga effectively reduced systolic and diastolic blood pressures and increased maternal comfort during labor in hypertensive disorder of pregnancy.
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Affiliation(s)
- Amrita Makhija
- Department of Obstetrics and Gynecology, Lady Hardinge Medical College, New Delhi, India.
| | - Neha Khatik
- Department of Obstetrics and Gynecology, Lady Hardinge Medical College, New Delhi, India
| | - Chitra Raghunandan
- Department of Obstetrics and Gynecology, Lady Hardinge Medical College, New Delhi, India
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11
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Florio KL, DeZorzi C, Williams E, Swearingen K, Magalski A. Cardiovascular Medications in Pregnancy: A Primer. Cardiol Clin 2020; 39:33-54. [PMID: 33222813 DOI: 10.1016/j.ccl.2020.09.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Cardiovascular disease and cardiovascular disease-related disorders remain among the most common causes of maternal morbidity and mortality in the United States. Due to increased rates of obesity, delayed childbearing, and improvements in medical technology, greater numbers of women are entering pregnancy with preexisting medical comorbidities. Use of cardiovascular medications in pregnancy continues to increase, and medical management of cardiovascular conditions in pregnancy will become increasingly common. Obstetricians and cardiologists must familiarize themselves with the pharmacokinetics of the most commonly used cardiovascular medications in pregnancy and how these medications respond to the physiologic changes related to pregnancy, embryogenesis, and lactation.
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Affiliation(s)
- Karen L Florio
- Heart Disease in Pregnancy Program, Saint Luke's Hospital of Kansas City, 4401 Wornall Road PEET Center, Kansas City, MO 64111, USA; University of Missouri-Kansas City School of Medicine, 4401 Wornall Road PEET Center, Kansas City, MO 64111, USA.
| | - Christopher DeZorzi
- University of Missouri-Kansas City School of Medicine, 4401 Wornall Road PEET Center, Kansas City, MO 64111, USA; Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | - Emily Williams
- University of Missouri-Kansas City School of Medicine, 4401 Wornall Road PEET Center, Kansas City, MO 64111, USA
| | - Kathleen Swearingen
- Heart Disease in Pregnancy Program, Saint Luke's Hospital of Kansas City, 4401 Wornall Road PEET Center, Kansas City, MO 64111, USA
| | - Anthony Magalski
- University of Missouri-Kansas City School of Medicine, 4401 Wornall Road PEET Center, Kansas City, MO 64111, USA; Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
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12
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Rezk M, Emarh M, Masood A, Dawood R, El-Shamy E, Gamal A, Badr H. Methyldopa versus labetalol or no medication for treatment of mild and moderate chronic hypertension during pregnancy: a randomized clinical trial. Hypertens Pregnancy 2020; 39:393-398. [PMID: 32697618 DOI: 10.1080/10641955.2020.1791902] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 06/30/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE to assess the maternal and fetal outcome in women with mild to moderate chronic hypertension on antihypertensive drug (methyldopa or labetalol) therapy compared to no medication. METHODS This multicenter randomized clinical study was conducted at Menoufia University hospital, Shibin El-kom Teaching hospital at Menoufia governorate, Egypt.486 pregnant women with mild to moderate chronic hypertension were randomized into three groups; methyldopa group (n = 164), labetalol group (n = 160), and control or no medication group (n = 162) who were followed from the beginning of pregnancy till the end of puerperium to record maternal and fetal outcome. RESULTS There was a highly significant difference between treatment groups (methyldopa and labetalol) and control group regarding the development of maternal severe hypertension, development of preeclampsia, renal impairment, presence of ECG changes, placental abruption, and repeated admission to hospital for blood pressure control (p < 0.001) with higher occurrence in the control (no treatment) group. Neonates in the labetalol group were more prone for the development of small for gestational age (SGA), neonatal hypotension, neonatal hyperbilirubinemia, and admission to NICU than their counterparts in the methyldopa and control groups (p < 0.001). The rate of prematurity was significantly higher in the control group than the treatment groups (p < 0.05). CONCLUSION Treatment of mild to moderate chronic hypertension during pregnancy is beneficial in decreasing both maternal and fetal morbidity. The use of labetalol was associated with higher rates of SGA, neonatal hypotension, and neonatal hyperbilirubinemia compared to methyldopa or no medication.
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Affiliation(s)
- Mohamed Rezk
- Department of Obstetrics and Gynecology, Menoufia University , Shibin Al Kawm, Egypt
| | - Mohamed Emarh
- Department of Obstetrics and Gynecology, Menoufia University , Shibin Al Kawm, Egypt
| | - Alaa Masood
- Department of Obstetrics and Gynecology, Menoufia University , Shibin Al Kawm, Egypt
| | - Ragab Dawood
- Department of Obstetrics and Gynecology, Menoufia University , Shibin Al Kawm, Egypt
| | - Elsayed El-Shamy
- Department of Obstetrics and Gynecology, Menoufia University , Shibin Al Kawm, Egypt
| | - Awni Gamal
- Department of Cardiology, Menoufia University , Shibin Al Kawm, Egypt
| | - Hassan Badr
- Department of Pediatrics, Menoufia University , Shibin Al Kawm, Egypt
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Wang Y, Bao J, Peng M. Effect of magnesium sulfate combined with labetalol on serum sFlt-1/PlGF ratio in patients with early-onset severe pre-eclampsia. Exp Ther Med 2020; 20:276. [PMID: 33200001 PMCID: PMC7664615 DOI: 10.3892/etm.2020.9406] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 04/24/2020] [Indexed: 11/06/2022] Open
Abstract
The aim of the present study was to investigate the therapeutic effect of magnesium sulfate combined with labetalol on the early-onset severe pre-eclampsia (ES-PE) and explore the role of soluble fms-like tyrosine kinase-1 (sFlT-1), placental growth factor (PlGF), and sFlt-1/PlGF ratio in the treatment. A total of 164 ES-PE patients admitted to the Maternity and Child Health Care Hospital of Hubei (Wuhan, China) were assigned to this observational study. Among them, 83 patients were enrolled in group A and treated with magnesium sulfate combined with labetalol hydrochloride, and 81 patients were enrolled in group B and treated with magnesium sulfate. The therapeutic effect, adverse reactions and pregnancy outcomes in the two groups were analyzed. Serum sFlt-1 and PlGF concentrations, before and after treatment, were measured by enzyme-linked immunosorbent assay (ELISA). Receiver operating characteristic (ROC) curve analysis was performed to assess the predictive value of pre-treatment serum sFlt-1/PlGF ratio for the clinical outcome. The effective rate was significantly higher in group A than that in group B. Group A presented superior pregnancy outcomes over group B. The serum sFlt-1 concentration and sFlt-1/PlGF ratio after treatment were significantly lower than those before treatment in groups A and B, whereas PlGF concentration was significantly higher after treatment in both groups. After treatment, group A had markedly lower serum sFlt-1 concentration and sFlt-1/PlGF ratio than group B, and markedly higher PlGF concentration than group B. The area under curve (AUC) of serum sFlt-1/PlGF ratio before treatment for the prediction of the clinical efficacy was 0.737. In conclusion, magnesium sulfate combined with labetalol could be effectively used for the treatment of ES-PE. The results of ELISA revealed that the balance of sFlT-1 and PlGF was improved after treatment and the sFlT-1/PlGF ratio was decreased. The assessment of sFlt-1/PlGF ratio before treatment was shown to have a certain predictive value for the efficacy of ES-PE treatment.
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Affiliation(s)
- Ying Wang
- Department of Obstetrics, Maternity and Child Health Care Hospital of Hubei, Wuhan, Hubei 430000, P.R. China
| | - Jing Bao
- Department of Obstetrics, Maternity and Child Health Care Hospital of Hubei, Wuhan, Hubei 430000, P.R. China
| | - Min Peng
- Department of Obstetrics, Maternity and Child Health Care Hospital of Hubei, Wuhan, Hubei 430000, P.R. China
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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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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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Reddy S, Jim B. Hypertension and Pregnancy: Management and Future Risks. Adv Chronic Kidney Dis 2019; 26:137-145. [PMID: 31023448 DOI: 10.1053/j.ackd.2019.03.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 03/08/2019] [Accepted: 03/08/2019] [Indexed: 02/08/2023]
Abstract
Pregnancy-induced hypertension is a major cause of maternal and fetal morbidity and mortality. The overall strategies of defining and managing these conditions are aimed at preventing cardiovascular and cerebrovascular complications in the mother without jeopardizing fetal well-being. Our understanding of the origin of these disorders is evolving. Women with chronic hypertension should undergo a prepregnancy evaluation and close monitoring during and after pregnancy to ensure medication safety and to prevent end-organ damage. Based on available data, the current recommendation is that antihypertensive therapy should be initiated only in women with severe hypertension (defined as systolic blood pressure ≥160 mm Hg and/or diastolic blood pressure ≥105 mm Hg). It is now becoming more and more clear that hypertensive complications during pregnancy are potentially linked to cardiovascular, kidney, and metabolic diseases later in life. This review discusses the spectrum of hypertensive disorders of pregnancy, general management principles, and the need to monitor for long-term cardiovascular sequelae for decades afterward.
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Antihypertensive drug therapy for women with non-severe hypertensive disorders of pregnancy: a systematic review and meta-analysis. Hypertens Res 2019; 42:699-707. [PMID: 30626932 DOI: 10.1038/s41440-018-0188-0] [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: 08/15/2018] [Revised: 09/26/2018] [Accepted: 10/15/2018] [Indexed: 11/08/2022]
Abstract
Hypertensive disorders of pregnancy (HDP) represent a frequent disorder among pregnancies. Women with severe hypertension in pregnancy are at increased risk of maternal complications and require antihypertensive drug therapy. This study aimed to systematically review randomized control trials of antihypertensive drug(s) treating non-severe hypertension during pregnancy to estimate the effectiveness and safety of this intervention. On May 8, 2018, we searched PubMed, Cochrane Library, and Ichu-Shi with no restriction on publication year. We selected randomized control trials that involved women with HDP being treated with antihypertensive drug(s) as intervention. Fourteen trials (1804 women) were identified for meta-analysis. There were no significant differences in the risk of maternal death (373 women; risk ratio (RR) 0.70; 95% confidence interval (CI) 0.04 to 11.45), proteinuria (1214 women; RR 1.00; 95% CI 0.67 to 1.49), side effects (360 women; RR 2.69; 95% CI 0.32 to 22.64), cesarean section (1239 women; RR 0.97; 95% CI 0.82 to 1.15), neonatal and birth death (1548 women; RR 0.80; 95% CI 0.43 to 1.49), preterm birth (904 women; RR 0.86; 95% CI 0.53 to 1.39), or small for gestational age infants (1082 women; RR 1.04; 95% CI 0.66 to 1.63) with antihypertensive drug therapy versus placebo or no treatment. The current review suggests that antihypertensive drug therapy does not reduce or increase the risk of maternal or perinatal outcomes. Further studies are needed to build reliable estimates of the effectiveness and safety of antihypertensive drug therapy for women with HDP.
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Kaye AB, Bhakta A, Moseley AD, Rao AK, Arif S, Lichtenstein SJ, Aggarwal NT, Volgman AS, Sanghani RM. Review of Cardiovascular Drugs in Pregnancy. J Womens Health (Larchmt) 2018; 28:686-697. [PMID: 30407107 DOI: 10.1089/jwh.2018.7145] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Cardiovascular disease is now the leading cause of pregnancy-related deaths in the United States. Increasing maternal mortality in the United States underscores the importance of proper cardiovascular management. Significant physiological changes during pregnancy affect the heart's ability to respond to pathological processes such as hypertension and heart failure. These physiological changes further affect the pharmacokinetic and pharmacodynamic properties of cardiac medications. During pregnancy, these changes can significantly alter medication efficacy and metabolism. This article systematically reviews the literature on safety, efficacy, pharmacokinetics, and pharmacodynamics of cardiovascular drugs used for hypertension and heart failure during pregnancy and lactation. The 2017 American College of Cardiology/American Heart Association hypertension guidelines recommend transitioning pregnant patients to methyldopa, nifedipine, or labetalol. Heart failure medications, including beta-blockers, furosemide, and digoxin, are relatively safe and can be used effectively. Medications that block the renin angiotensin-aldosterone system have been shown to be beneficial in the general population; however, they are teratogenic and, therefore, contraindicated in pregnancy. Cardiovascular medications can also enter breast milk and, therefore, care must be taken when selecting drugs during the lactation period. A summary of the safety of drugs during pregnancy and lactation from an online resource, LactMed by the National Library of Medicine's TOXNET database, is included. High-risk pregnant patients with cardiovascular disease require a multispecialty team of doctors, including health care providers from obstetrics and gynecology, maternal fetal medicine, internal medicine, cardiovascular disease specialists, and specialized pharmacology expertise.
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Affiliation(s)
- Aaron B Kaye
- 1 Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Amar Bhakta
- 1 Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Alex D Moseley
- 2 Division of Cardiovascular Health and Disease, College of Medicine, Cincinnati, Ohio
| | - Anupama K Rao
- 3 University Cardiologists, Rush University Medical Center, Chicago, Illinois
| | - Sally Arif
- 4 Department of Pharmacy Practice, Midwestern University, Chicago College of Pharmacy, Downers Grove, Illinois
| | - Seth J Lichtenstein
- 1 Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Neelum T Aggarwal
- 5 Rush Alzheimer's Disease Center, Rush Heart Center for Women, Chicago, Illinois
| | | | - Rupa M Sanghani
- 3 University Cardiologists, Rush University Medical Center, Chicago, Illinois
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Abalos E, Duley L, Steyn DW, Gialdini C. Antihypertensive drug therapy for mild to moderate hypertension during pregnancy. Cochrane Database Syst Rev 2018; 10:CD002252. [PMID: 30277556 PMCID: PMC6517078 DOI: 10.1002/14651858.cd002252.pub4] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Antihypertensive drugs are often used in the belief that lowering blood pressure will prevent progression to more severe disease, and thereby improve pregnancy outcome. This Cochrane Review is an updated review, first published in 2001 and subsequently updated in 2007 and 2014. OBJECTIVES To assess the effects of antihypertensive drug treatments for women with mild to moderate hypertension during pregnancy. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (13 September 2017), and reference lists of retrieved studies. SELECTION CRITERIA All randomised trials evaluating any antihypertensive drug treatment for mild to moderate hypertension during pregnancy, defined as systolic blood pressure 140 to 169 mmHg and/or diastolic blood pressure 90 to 109 mmHg. Comparisons were of one or more antihypertensive drug(s) with placebo, with no antihypertensive drug, or with another antihypertensive drug, and where treatment was planned to continue for at least seven days. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. MAIN RESULTS For this update, we included 63 trials (data from 58 trials, 5909 women), with moderate to high risk of bias overall.We carried out GRADE assessments for the main 'antihypertensive drug versus placebo/no antihypertensive drug' comparison only. Evidence was graded from very low to moderate certainty, with downgrading mainly due to design limitations and imprecision.For many outcomes, trials contributing data evaluated different hypertensive drugs; while we did not downgrade for this indirectness, results should be interpreted with caution.Antihypertensive drug versus placebo/no antihypertensive drug (31 trials, 3485 women)Primary outcomes: moderate-certainty evidence suggests that use of antihypertensive drug(s) probably halves the risk of developing severe hypertension (risk ratio (RR) 0.49; 95% confidence interval (CI) 0.40 to 0.60; 20 trials, 2558 women), but may have little or no effect on the risk of proteinuria/pre-eclampsia (average risk ratio (aRR) 0.92; 95% CI 0.75 to 1.14; 23 trials, 2851 women; low-certainty evidence). Moderate-certainty evidence also shows that antihypertensive drug(s) probably have little or no effect in the risk of total reported fetal or neonatal death (including miscarriage) (aRR 0.72; 95% CI 0.50 to 1.04; 29 trials, 3365 women), small-for-gestational-age babies (aRR 0.96; 95% CI 0.78 to 1.18; 21 trials, 2686 babies) or preterm birth less than 37 weeks (aRR 0.96; 95% CI 0.83 to 1.12; 15 trials, 2141 women). SECONDARY OUTCOMES we are uncertain of the effect of antihypertensive drug(s) on the risk of maternal death, severe pre-eclampsia, or eclampsia, orimpaired long-term growth and development of the baby in infancy and childhood, because the certainty of this evidence is very low. There may be little or no effect on the risk of changed/stopped drugs due to maternal side-effects, or admission to neonatal or intensive care nursery (low-certainty evidence). There is probably little or no difference in the risk of elective delivery (moderate-certainty evidence).Antihypertensive drug versus another antihypertensive drug (29 trials, 2774 women)Primary outcomes: beta blockers and calcium channel blockers together in the meta-analysis appear to be more effective than methyldopa in avoiding an episode of severe hypertension (RR 0.70; 95% CI 0.56 to 0.88; 11 trials, 638 women). There was also an increase in this risk when other antihypertensive drugs were compared with calcium channel blockers (RR 1.86; 95% CI 1.09 to 3.15; 5 trials, 223 women), but no evidence of a difference when methyldopa and calcium channel blockers together were compared with beta blockers (RR1.18, 95% CI 0.95 to 1.48; 10 trials, 692 women). No evidence of a difference in the risk of proteinuria/pre-eclampsia was found when alternative drugs were compared with methyldopa (aRR 0.78; 95% CI 0.58 to 1.06; 11 trials, 997 women), with calcium channel blockers (aRR: 1.24, 95% CI 0.70 to 2.19; 5 trials, 375 women), or with beta blockers (aRR 1.21, 95% CI 0.88 to 1.67; 12 trials, 1107 women).For the babies, we found no evidence of a difference in the risk oftotal reported fetal or neonatal death (including miscarriage) when comparing other antihypertensive drugs with methyldopa (aRR 0.77, 95% CI 0.52 to 1.14; 22 trials, 1791 babies), with calcium channel blockers (aRR 0.90, 95% CI 0.52 to 1.57; nine trials, 700 babies), or with beta blockers (aRR: 1.23, 95% CI 0.81 to 1.88; 19 trials, 1652 babies); nor in the risk for small-for-gestational age in the comparison with methyldopa (aRR 0.79, 95% CI 0.52 to 1.20; seven trials, 597 babies), with calcium channel blockers (aRR 1.05, 95% CI 0.64 to 1.73; four trials, 200 babies), or with beta blockers (average RR 1.13, 95% CI 0.80 to 1.60; 7 trials, 680 babies). No evidence of an overall difference among groups in the risk of preterm birth (less than 37 weeks) was found in the comparison with methyldopa (aRR: 0.91; 95% CI 0.68 to 1.22; 11 trials, 835 women), with calcium channel blockers (aRR 0.85, 95% CI 0.59 to 1.23; six trials, 330 women), or with beta blockers (aRR 1.22, 95% CI 0.90 to 1.66; 9 trials, 806 women). SECONDARY OUTCOMES There were no cases of maternal death andeclampsia. There is no evidence of a difference in the risk of severe pre-eclampsia, changed/stopped drug due to maternal side-effects, elective delivery, admission to neonatal or intensive care nursery when other antihypertensive drugs are compared with methyldopa, calcium channel blockers or beta blockers. Impaired long-term growth and development in infancy and childhood was not reported for these comparisons. AUTHORS' CONCLUSIONS Antihypertensive drug therapy for mild to moderate hypertension during pregnancy reduces the risk of severe hypertension. The effect on other clinically important outcomes remains unclear. If antihypertensive drugs are used, beta blockers and calcium channel blockers appear to be more effective than the alternatives for preventing severe hypertension. High-quality large sample-sized randomised controlled trials are required in order to provide reliable estimates of the benefits and adverse effects of antihypertensive treatment for mild to moderate hypertension for both mother and baby, as well as costs to the health services, women and their families.
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Affiliation(s)
- Edgardo Abalos
- Centro Rosarino de Estudios Perinatales (CREP)Moreno 878, 6th floorRosarioSanta FeArgentinaS2000DKR
| | - Lelia Duley
- Nottingham Health Science PartnersNottingham Clinical Trials UnitC Floor, South BlockQueen's Medical CentreNottinghamUKNG7 2UH
| | - D Wilhelm Steyn
- University of StellenboschObstetrics & GynaecologyDepartment of Obstetrics & GynaecologyPO Box 19063TygerbergStellenboschSouth Africa7505
| | - Celina Gialdini
- Centro Rosarino de Estudios Perinatales (CREP)Department of Obstetrics, Hospital Provincial de RosarioMoreno 878, 6th floorRosarioArgentinaS2000DKR
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Antza C, Cifkova R, Kotsis V. Hypertensive complications of pregnancy: A clinical overview. Metabolism 2018; 86:102-111. [PMID: 29169855 DOI: 10.1016/j.metabol.2017.11.011] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 11/14/2017] [Accepted: 11/15/2017] [Indexed: 12/22/2022]
Abstract
Hypertensive disorders in pregnancy are a worldwide health problem for women and their infants complicating up to 10% of pregnancies and associated with increased maternal and neonatal morbidity and mortality. In Europe, 2.3-3% of pregnancies are complicated by preeclampsia. Gestational diabetes, obesity, no previous or multiple births, maternal age less than 20 or greater than 35years old and thrombophilia can be some of the possible factors related to increased risk for hypertension in pregnancy. Complications of hypertension during pregnancy affect both mothers and their infants. Ambulatory blood pressure monitoring helps to distinguish true hypertension from the white coat as pregnant women with office abnormal values may have normal out of office blood pressure. Imbalance between proangiogenic and antiangiogenic factors in placenta may lead to endothelial dysfunction, vasoconstriction, activation of the coagulation system, and hemolysis. Carotid intima-media thickness, pulse wave velocity, augmentation index, and arterial wall tension were found to be significantly increased in women with preeclampsia compared to normotensive pregnant women. Uterine artery Doppler and serum biomarkers can be used to evaluate the probability of hypertension and complications during pregnancy, but further research in the field is needed. Lately, micro ribonucleic acids have also been the focus of research as potential biomarkers.
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Affiliation(s)
- C Antza
- Hypertension Center, 3rd Department of Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Greece
| | - R Cifkova
- Charles University in Prague, Center for Cardiovascular Prevention, First Faculty of Medicine and Thomayer Hospital, Prague, Czech Republic
| | - V Kotsis
- Hypertension Center, 3rd Department of Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Greece.
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Adam K. Pregnancy in Women with Cardiovascular Diseases. Methodist Debakey Cardiovasc J 2018; 13:209-215. [PMID: 29744013 DOI: 10.14797/mdcj-13-4-209] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Patients with cardiovascular disease represent a significant cohort at risk for complications during pregnancy. The normal physiologic changes of pregnancy could further compromise the hemodynamics of various cardiovascular conditions, resulting in clinical deterioration and even death. The fetus of a gravida with cardiovascular disease also has an increased risk of morbidity, including an increased risk of inherited cardiac genetic disorders, fetal growth restriction, and premature delivery. These complications also increase the risk for antenatal and perinatal mortality. Ideally, the management of a patient with cardiac disease who is considering pregnancy should start with pre-conception counseling that outlines the maternal and fetal complications associated with her particular cardiac disorder. The pregnancy is best managed by a dedicated team of specialists in maternal-fetal medicine, cardiology, cardiovascular surgery, anesthesiology, and neonatology, preferably in a tertiary care center.
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Cabiddu G, Spotti D, Gernone G, Santoro D, Moroni G, Gregorini G, Giacchino F, Attini R, Limardo M, Gammaro L, Todros T, Piccoli GB. A best-practice position statement on pregnancy after kidney transplantation: focusing on the unsolved questions. The Kidney and Pregnancy Study Group of the Italian Society of Nephrology. J Nephrol 2018; 31:665-681. [PMID: 29949013 PMCID: PMC6182355 DOI: 10.1007/s40620-018-0499-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 04/30/2018] [Indexed: 12/15/2022]
Abstract
Kidney transplantation (KT) is often considered to be the method best able to restore fertility in a woman with chronic kidney disease (CKD). However, pregnancies in KT are not devoid of risks (in particular prematurity, small for gestational age babies, and the hypertensive disorders of pregnancy). An ideal profile of the potential KT mother includes “normal” or “good” kidney function (usually defined as glomerular filtration rate, GFR ≥ 60 ml/min), scant or no proteinuria (usually defined as below 500 mg/dl), normal or well controlled blood pressure (one drug only and no sign of end-organ damage), no recent acute rejection, good compliance and low-dose immunosuppression, without the use of potentially teratogen drugs (mycophenolic acid and m-Tor inhibitors) and an interval of at least 1–2 years after transplantation. In this setting, there is little if any risk of worsening of the kidney function. Less is known about how to manage “non-ideal” situations, such as a pregnancy a short time after KT, or one in the context of hypertension or a failing kidney. The aim of this position statement by the Kidney and Pregnancy Group of the Italian Society of Nephrology is to review the literature and discuss what is known about the clinical management of CKD after KT, with particular attention to women who start a pregnancy in non-ideal conditions. While the experience in such cases is limited, the risks of worsening the renal function are probably higher in cases with markedly reduced kidney function, and in the presence of proteinuria. Well-controlled hypertension alone seems less relevant for outcomes, even if its effect is probably multiplicative if combined with low GFR and proteinuria. As in other settings of kidney disease, superimposed preeclampsia (PE) is differently defined and this impairs calculating its real incidence. No specific difference between non-teratogen immunosuppressive drugs has been shown, but calcineurin inhibitors have been associated with foetal growth restriction and low birth weight. The clinical choices in cases at high risk for malformations or kidney function impairment (pregnancies under mycophenolic acid or with severe kidney-function impairment) require merging clinical and ethical approaches in which, beside the mother and child dyad, the grafted kidney is a crucial “third element”.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Monica Limardo
- Azienda Ospedaliera della Provincia di Lecco, Lecco, Italy
| | | | - Tullia Todros
- Department of Surgery, Università di Torino, Turin, Italy
| | - Giorgina Barbara Piccoli
- Department of Clinical and Biological Sciences, Università di Torino, Turin, Italy. .,Centre Hospitalier Le Mans, Le Mans, France.
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Odigboegwu O, Pan LJ, Chatterjee P. Use of Antihypertensive Drugs During Preeclampsia. Front Cardiovasc Med 2018; 5:50. [PMID: 29896480 PMCID: PMC5987086 DOI: 10.3389/fcvm.2018.00050] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 05/04/2018] [Indexed: 01/13/2023] Open
Abstract
Treatment of pregnancy-related hypertensive disorders, such as preeclampsia (PE), remain a challenging problem in obstetrics. Typically, aggressive antihypertensive drug treatment options are avoided to prevent pharmacological-induced hypotension. Another major concern of administering antihypertensive drugs during pregnancy is possible adverse fetal outcome. In addition, management of hypertension during pregnancy in chronic hypertensive patients or in patients with prior kidney problems are carefully considered. Recent studies suggest that PE patients are at increased cardiovascular risk postpartum. Therefore, these patients need to be monitored postpartum for the subsequent development of other cardiovascular diseases. In this review article, we review the antihypertensive drugs currently being used to treat patients with PE and the advantages or disadvantages of using these drugs during pregnancy.
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Affiliation(s)
- Obinnaya Odigboegwu
- Department of Internal Medicine, Scott and White Medical Center-Temple, Texas A&M Health Science Center, Temple, TX, United States
| | - Lu J Pan
- Department of Internal Medicine, Scott and White Medical Center-Temple, Texas A&M Health Science Center, Temple, TX, United States
| | - Piyali Chatterjee
- Department of Internal Medicine, Scott and White Medical Center-Temple, Texas A&M Health Science Center, Temple, TX, United States
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Cabiddu G, Castellino S, Gernone G, Santoro D, Moroni G, Giannattasio M, Gregorini G, Giacchino F, Attini R, Loi V, Limardo M, Gammaro L, Todros T, Piccoli GB. A best practice position statement on pregnancy in chronic kidney disease: the Italian Study Group on Kidney and Pregnancy. J Nephrol 2016; 29:277-303. [PMID: 26988973 PMCID: PMC5487839 DOI: 10.1007/s40620-016-0285-6] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 02/08/2016] [Indexed: 01/09/2023]
Abstract
Pregnancy is increasingly undertaken in patients with chronic kidney disease (CKD) and, conversely, CKD is increasingly diagnosed in pregnancy: up to 3 % of pregnancies are estimated to be complicated by CKD. The heterogeneity of CKD (accounting for stage, hypertension and proteinuria) and the rarity of several kidney diseases make risk assessment difficult and therapeutic strategies are often based upon scattered experiences and small series. In this setting, the aim of this position statement of the Kidney and Pregnancy Study Group of the Italian Society of Nephrology is to review the literature, and discuss the experience in the clinical management of CKD in pregnancy. CKD is associated with an increased risk for adverse pregnancy-related outcomes since its early stage, also in the absence of hypertension and proteinuria, thus supporting the need for a multidisciplinary follow-up in all CKD patients. CKD stage, hypertension and proteinuria are interrelated, but they are also independent risk factors for adverse pregnancy-related outcomes. Among the different kidney diseases, patients with glomerulonephritis and immunologic diseases are at higher risk of developing or increasing proteinuria and hypertension, a picture often difficult to differentiate from preeclampsia. The risk is higher in active immunologic diseases, and in those cases that are detected or flare up during pregnancy. Referral to tertiary care centres for multidisciplinary follow-up and tailored approaches are warranted. The risk of maternal death is, almost exclusively, reported in systemic lupus erythematosus and vasculitis, which share with diabetic nephropathy an increased risk for perinatal death of the babies. Conversely, patients with kidney malformation, autosomal-dominant polycystic kidney disease, stone disease, and previous upper urinary tract infections are at higher risk for urinary tract infections, in turn associated with prematurity. No risk for malformations other than those related to familiar urinary tract malformations is reported in CKD patients, with the possible exception of diabetic nephropathy. Risks of worsening of the renal function are differently reported, but are higher in advanced CKD. Strict follow-up is needed, also to identify the best balance between maternal and foetal risks. The need for further multicentre studies is underlined.
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Affiliation(s)
| | | | | | | | - Gabriella Moroni
- Nephrology, Fondazione Ca' Granda Ospedale Maggiore, Milano, Italy
| | | | | | | | - Rossella Attini
- Obstetrics, Department of Surgery, University of Torino, Torino, Italy
| | - Valentina Loi
- Nephrology, Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Monica Limardo
- Nephrology, Azienda Ospedaliera della Provincia di Lecco, Lecco, Italy
| | - Linda Gammaro
- Nephrology, Ospedale Fracastoro, San Bonifacio, Italy
| | - Tullia Todros
- Obstetrics, Department of Surgery, University of Torino, Torino, Italy
| | - Giorgina Barbara Piccoli
- Nephrology, ASOU San Luigi, Department of Clinical and Biological Sciences, University of Torino, Torino, Italy.
- Nephrologie, Centre Hospitalier du Mans, Le Mans, France.
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Harvey RE, Coffman KE, Miller VM. Women-specific factors to consider in risk, diagnosis and treatment of cardiovascular disease. ACTA ACUST UNITED AC 2015; 11:239-257. [PMID: 25776297 DOI: 10.2217/whe.14.64] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In the era of individualized medicine, gaps in knowledge remain about sex-specific risk factors, diagnostic and treatment options that might reduce mortality from cardiovascular disease (CVD) and improve outcomes for both women and men. In this review, contributions of biological mechanisms involving the sex chromosomes and the sex hormones on the cardiovascular system will be discussed in relationship to the female-specific risk factors for CVD: hypertensive disorders of pregnancy, menopause and use of hormonal therapies for contraception and menopausal symptoms. Additionally, sex-specific factors to consider in the differential diagnosis and treatment of four prevalent CVDs (hypertension, stroke, coronary artery disease and congestive heart failure) will be reviewed with emphasis on areas where additional research is needed.
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Affiliation(s)
- Ronée E Harvey
- Department of Physiology & Biomedical, Engineering, Medical Sciences 4-20, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Kirsten E Coffman
- Department of Physiology & Biomedical, Engineering, Medical Sciences 4-20, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Virginia M Miller
- Department of Physiology & Biomedical, Engineering, Medical Sciences 4-20, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA.,Department of Surgery, Medical Sciences, 4-20, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
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27
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Clark SM, Dunn HE, Hankins GDV. A review of oral labetalol and nifedipine in mild to moderate hypertension in pregnancy. Semin Perinatol 2015; 39:548-55. [PMID: 26344738 DOI: 10.1053/j.semperi.2015.08.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Hypertension is the most commonly encountered medical condition in pregnancy, contributing significantly to maternal and perinatal morbidity and mortality. Mild to moderate hypertension in pregnancy is defined as systolic blood pressure of 140-159 mmHg or diastolic blood pressure of 90-109 mmHg (7-9% of pregnancies). When treating hypertension in pregnancy, not only do physiologic changes of pregnancy have an effect on the pharmacokinetics and pharmacodynamics of the drugs used, but the pathophysiology of hypertensive disorders of pregnancy also have an effect. To date, evidence is lacking on the pharmacokinetics and pharmacodynamics of commonly used antihypertensive drugs, which often times leads to suboptimal treatment of hypertensive pregnant women. When considering which agents to use for treatment of mild to moderate hypertension, specifically in gestational and chronic hypertension, oral labetalol and nifedipine are valid options. An overview of the profile for use, safety, and current pharmacokinetic data for each agent is presented here.
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Affiliation(s)
- Shannon M Clark
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, The University of Texas Medical Branch-Galveston, 301 University Blvd., Route 0587, Galveston, TX 77550.
| | - Holly E Dunn
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, The University of Texas Medical Branch-Galveston, 301 University Blvd., Route 0587, Galveston, TX 77550
| | - Gary D V Hankins
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, The University of Texas Medical Branch-Galveston, 301 University Blvd., Route 0587, Galveston, TX 77550
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29
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Magee LA, Namouz-Haddad S, Cao V, Koren G, von Dadelszen P. Labetalol for hypertension in pregnancy. Expert Opin Drug Saf 2015; 14:453-61. [PMID: 25692529 DOI: 10.1517/14740338.2015.998197] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Labetalol is one of the most commonly used antihypertensive medications for the treatment of hypertension during pregnancy, an increasingly common and leading cause of maternal mortality and morbidity worldwide. AREAS COVERED The literature reviewed included the 2014 Canadian national pregnancy hypertension guideline and its references. The additional published literature was retrieved through searches of Medline, CINAHL, and The Cochrane Library using appropriate controlled vocabulary (e.g., pregnancy, hypertension, pre-eclampsia, pregnancy toxemias) and key words (e.g., diagnosis, evaluation, classification, prediction, prevention, prognosis, treatment, and postpartum follow-up).Results were restricted to systematic reviews, randomized controlled trials, controlled clinical trials, and observational studies published in French or English, Jan-Mar/14. The unpublished literature was identified by searching websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. We evaluated the impact of interventions on substantive clinical outcomes for mothers and babies. EXPERT OPINION Labetalol is a reasonable choice for treatment of severe or non-severe hypertension in pregnancy. However, we should continue our search for other therapeutic options.
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Affiliation(s)
- Laura A Magee
- University of British Columbia, BC Women's Hospital and Health Centre , 4500 Oak Street, Room 1U59, Vancouver, BC V6H 3N1 , Canada +1 604 875 3054; +1 604 875 2424; Ext: 6012 ; +1 604 875 3212 ;
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30
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Magee LA, von Dadelszen P, Singer J, Lee T, Rey E, Ross S, Asztalos E, Murphy KE, Menzies J, Sanchez J, Gafni A, Gruslin A, Helewa M, Hutton E, Koren G, Lee SK, Logan AG, Ganzevoort JW, Welch R, Thornton JG, Moutquin JM. Do labetalol and methyldopa have different effects on pregnancy outcome? Analysis of data from the Control of Hypertension In Pregnancy Study (CHIPS) trial. BJOG 2015; 123:1143-51. [PMID: 26265372 DOI: 10.1111/1471-0528.13569] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To compare pregnancy outcomes, accounting for allocated group, between methyldopa-treated and labetalol-treated women in the CHIPS Trial (ISRCTN 71416914) of 'less tight' versus 'tight' control of pregnancy hypertension. DESIGN Secondary analysis of CHIPS Trial cohort. SETTING International randomised controlled trial (94 sites, 15 countries). POPULATION OR SAMPLE Of 987 CHIPS recruits, 481/566 (85.0%) women treated with antihypertensive therapy at randomisation. Of 981 (99.4%) women followed to delivery, 656/745 (88.1%) treated postrandomisation. METHODS Logistic regression to compare outcomes among women who took methyldopa or labetalol, adjusted for the influence of baseline factors. MAIN OUTCOME MEASURES CHIPS primary (perinatal loss or high level neonatal care for >48 hours) and secondary (serious maternal complications) outcomes, birthweight <10th centile, severe maternal hypertension, pre-eclampsia and delivery at <34 or <37 weeks. RESULTS Methyldopa and labetalol were used commonly at randomisation (243/987, 24.6% and 238/987, 24.6%, respectively) and post-randomisation (224/981, 22.8% and 433/981, 44.1%, respectively). Following adjusted analyses, methyldopa (versus labetalol) at randomisation was associated with fewer babies with birthweight <10th centile [adjusted odds ratio (aOR) 0.48; 95% CI 0.20-0.87]. Methyldopa (versus labetalol) postrandomisation was associated with fewer CHIPS primary outcomes (aOR 0.64; 95% CI 0.40-1.00), birthweight <10th centile (aOR 0.54; 95% CI 0.32-0.92), severe hypertension (aOR 0.51; 95% CI 0.31-0.83), pre-eclampsia (aOR 0.55; 95% CI 0.36-0.85), and delivery at <34 weeks (aOR 0.53; 95% CI 0.29-0.96) or <37 weeks (aOR 0.55; 95% CI 0.35-0.85). CONCLUSION These nonrandomised comparisons are subject to residual confounding, but women treated with methyldopa (versus labetalol), particularly those with pre-existing hypertension, may have had better outcomes. TWEETABLE ABSTRACT There was no evidence that women treated with methyldopa versus labetalol had worse outcomes.
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Affiliation(s)
- L A Magee
- Medicine, University of British Columbia, Vancouver, BC, Canada.,Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | | | - P von Dadelszen
- Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - J Singer
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.,Centre for Health Evaluation and Outcome Sciences (CHÉOS), Providence Health Care Research Institute, UBC, Vancouver, BC, Canada
| | - T Lee
- Centre for Health Evaluation and Outcome Sciences (CHÉOS), Providence Health Care Research Institute, UBC, Vancouver, BC, Canada
| | - E Rey
- Medicine and Obstetrics and Gynaecology, University of Montreal, Montreal, QC, Canada
| | - S Ross
- Obstetrics and Gynaecology, University of Alberta, Edmonton, AB, Canada
| | - E Asztalos
- Paediatrics, University of Toronto, Toronto, ON, Canada.,Obstetrics and Gynaecology, University of Toronto, Toronto, ON, Canada.,The Centre for Mother, Infant and Child Research, Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada
| | - K E Murphy
- Obstetrics and Gynaecology, University of Toronto, Toronto, ON, Canada.,The Centre for Mother, Infant and Child Research, Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada
| | - J Menzies
- Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - J Sanchez
- The Centre for Mother, Infant and Child Research, Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada
| | - A Gafni
- Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - A Gruslin
- Obstetrics and Gynaecology, University of Ottawa, Ottawa, ON, Canada
| | - M Helewa
- Obstetrics and Gynaecology, University of Manitoba, Winnipeg, MB, Canada
| | - E Hutton
- Obstetrics and Gynaecology, McMaster University, Hamilton, ON, Canada
| | - G Koren
- Paediatrics, University of Toronto, Toronto, ON, Canada
| | - S K Lee
- Paediatrics, University of Toronto, Toronto, ON, Canada
| | - A G Logan
- Medicine, University of Toronto, Toronto, ON, Canada
| | - J W Ganzevoort
- Obstetrics and Gynaecology, University of Amsterdam, Amsterdam, the Netherlands
| | - R Welch
- Obstetrics and Gynaecology, Derriford Hospital, Devon, UK
| | - J G Thornton
- Obstetrics and Gynaecology, University of Nottingham, Nottingham, UK
| | - J-M Moutquin
- Obstetrics and Gynaecology, Universite de Sherbrooke, Sherbrooke, QC, Canada
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Pregnancy in Chronic Kidney Disease: questions and answers in a changing panorama. Best Pract Res Clin Obstet Gynaecol 2015; 29:625-42. [DOI: 10.1016/j.bpobgyn.2015.02.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 02/18/2015] [Accepted: 02/23/2015] [Indexed: 01/10/2023]
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32
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McComb MN, Chao JY, Ng TMH. Direct Vasodilators and Sympatholytic Agents. J Cardiovasc Pharmacol Ther 2015; 21:3-19. [PMID: 26033778 DOI: 10.1177/1074248415587969] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 03/31/2015] [Indexed: 11/16/2022]
Abstract
Direct vasodilators and sympatholytic agents were some of the first antihypertensive medications discovered and utilized in the past century. However, side effect profiles and the advent of newer antihypertensive drug classes have reduced the use of these agents in recent decades. Outcome data and large randomized trials supporting the efficacy of these medications are limited; however, in general the blood pressure-lowering effect of these agents has repeatedly been shown to be comparable to other more contemporary drug classes. Nevertheless, a landmark hypertension trial found a negative outcome with a doxazosin-based regimen compared to a chlorthalidone-based regimen, leading to the removal of α-1 adrenergic receptor blockers as first-line monotherapy from the hypertension guidelines. In contemporary practice, direct vasodilators and sympatholytic agents, particularly hydralazine and clonidine, are often utilized in refractory hypertension. Hydralazine and minoxidil may also be useful alternatives for patients with renal dysfunction, and both hydralazine and methyldopa are considered first line for the treatment of hypertension in pregnancy. Hydralazine has also found widespread use for the treatment of systolic heart failure in combination with isosorbide dinitrate (ISDN). The data to support use of this combination in African Americans with heart failure are particularly robust. Hydralazine with ISDN may also serve as an alternative for patients with an intolerance to angiotensin antagonists. Given these niche indications, vasodilators and sympatholytics are still useful in clinical practice; therefore, it is prudent to understand the existing data regarding efficacy and the safe use of these medications.
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Affiliation(s)
- Meghan N McComb
- University of Southern California School of Pharmacy, Los Angeles, CA, USA
| | - James Y Chao
- University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Tien M H Ng
- University of Southern California School of Pharmacy, Los Angeles, CA, USA University of Southern California Keck School of Medicine, Los Angeles, CA, USA
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Hussain A, Karovitch A, Carson MP. Blood pressure goals and treatment in pregnant patients with chronic kidney disease. Adv Chronic Kidney Dis 2015; 22:165-9. [PMID: 25704354 DOI: 10.1053/j.ackd.2014.08.002] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 07/31/2014] [Accepted: 08/05/2014] [Indexed: 12/24/2022]
Abstract
As the age of pregnant women and prevalence of obesity and diabetes are increasing, so is the prevalence of medical disorders during pregnancy, particularly hypertension and the associated CKD. Pregnancy can worsen kidney function in women with severe disease, and hypertension puts them at risk for pre-eclampsia and the associated complications. There are no specific guidelines for hypertension management in this population, and tight control will not prevent pre-eclampsia. Women with end-stage kidney disease should be placed on intense dialysis regimens to improve obstetric outcomes, and angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are best avoided. This article will review the rationale for a management plan that includes a multidisciplinary team to discuss risks and develop a plan before conception, antepartum monitoring for maternal and fetal morbidity, individualization of medical management using medications with established records during pregnancy, and balancing the level of blood pressure control proved to protect kidney function against the potential effects that aggressive blood pressure control could have on the fetal-placental unit.
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Ruys TP, Maggioni A, Johnson MR, Sliwa K, Tavazzi L, Schwerzmann M, Nihoyannopoulos P, Kozelj M, Marelli A, Elkayam U, Hall R, Roos-Hesselink JW. Cardiac medication during pregnancy, data from the ROPAC. Int J Cardiol 2014; 177:124-8. [DOI: 10.1016/j.ijcard.2014.09.013] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Revised: 09/08/2014] [Accepted: 09/15/2014] [Indexed: 10/24/2022]
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35
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Association between labetalol use for hypertension in pregnancy and adverse infant outcomes. Eur J Obstet Gynecol Reprod Biol 2014; 175:124-8. [DOI: 10.1016/j.ejogrb.2014.01.019] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 01/07/2014] [Accepted: 01/12/2014] [Indexed: 11/20/2022]
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Xie RH, Guo Y, Krewski D, Mattison D, Walker MC, Nerenberg K, Wen SW. Beta-Blockers increase the risk of being born small for gestational age or of being institutionalised during infancy. BJOG 2014; 121:1090-6. [DOI: 10.1111/1471-0528.12678] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2013] [Indexed: 11/29/2022]
Affiliation(s)
- R-h Xie
- Department of Obstetrics and Gynaecology; Nanfang Hospital; Southern Medical University; Guangzhou China
- OMNI Research Group; Department of Obstetrics and Gynaecology; University of Ottawa Faculty of Medicine; Ottawa ON Canada
- Clinical Epidemiology Program; Ottawa Hospital Research Institute; Ottawa ON Canada
| | - Y Guo
- OMNI Research Group; Department of Obstetrics and Gynaecology; University of Ottawa Faculty of Medicine; Ottawa ON Canada
- Clinical Epidemiology Program; Ottawa Hospital Research Institute; Ottawa ON Canada
| | - D Krewski
- McLaughlin Centre for Population Health Risk Assessment; Institute of Population Health; University of Ottawa; Ottawa ON Canada
- Risk Sciences International; Ottawa ON Canada
- Department of Epidemiology and Community Medicine; University of Ottawa; Ottawa ON Canada
| | - D Mattison
- McLaughlin Centre for Population Health Risk Assessment; Institute of Population Health; University of Ottawa; Ottawa ON Canada
- Risk Sciences International; Ottawa ON Canada
| | - MC Walker
- OMNI Research Group; Department of Obstetrics and Gynaecology; University of Ottawa Faculty of Medicine; Ottawa ON Canada
- Clinical Epidemiology Program; Ottawa Hospital Research Institute; Ottawa ON Canada
- Department of Epidemiology and Community Medicine; University of Ottawa; Ottawa ON Canada
| | - K Nerenberg
- Department of Medicine; Faculty of Medicine; University of Ottawa; Ottawa ON Canada
| | - SW Wen
- OMNI Research Group; Department of Obstetrics and Gynaecology; University of Ottawa Faculty of Medicine; Ottawa ON Canada
- Clinical Epidemiology Program; Ottawa Hospital Research Institute; Ottawa ON Canada
- Department of Epidemiology and Community Medicine; University of Ottawa; Ottawa ON Canada
- School of Public Health; Central South University; Changsha China
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37
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Abalos E, Duley L, Steyn DW. Antihypertensive drug therapy for mild to moderate hypertension during pregnancy. Cochrane Database Syst Rev 2014:CD002252. [PMID: 24504933 DOI: 10.1002/14651858.cd002252.pub3] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Mild to moderate hypertension during pregnancy is common. Antihypertensive drugs are often used in the belief that lowering blood pressure will prevent progression to more severe disease, and thereby improve the outcome. OBJECTIVES To assess the effects of antihypertensive drug treatments for women with mild to moderate hypertension during pregnancy. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2013) and reference lists of retrieved studies. SELECTION CRITERIA All randomised trials evaluating any antihypertensive drug treatment for mild to moderate hypertension during pregnancy defined, whenever possible, as systolic blood pressure 140 to 169 mmHg and diastolic blood pressure 90 to 109 mmHg. Comparisons were of one or more antihypertensive drug(s) with placebo, with no antihypertensive drug, or with another antihypertensive drug, and where treatment was planned to continue for at least seven days. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data. MAIN RESULTS Forty-nine trials (4723 women) were included. Twenty-nine trials compared an antihypertensive drug with placebo/no antihypertensive drug (3350 women). There is a halving in the risk of developing severe hypertension associated with the use of antihypertensive drug(s) (20 trials, 2558 women; risk ratio (RR) 0.49; 95% confidence interval (CI) 0.40 to 0.60; risk difference (RD) -0.10 (-0.13 to -0.07); number needed to treat to harm (NNTH) 10 (8 to 13)) but little evidence of a difference in the risk of pre-eclampsia (23 trials, 2851 women; RR 0.93; 95% CI 0.80 to 1.08). Similarly, there is no clear effect on the risk of the baby dying (27 trials, 3230 women; RR 0.71; 95% CI 0.49 to 1.02), preterm birth (15 trials, 2141 women; RR 0.96; 95% CI 0.85 to 1.10), or small-for-gestational-age babies (20 trials, 2586 women; RR 0.97; 95% CI 0.80 to 1.17). There were no clear differences in any other outcomes.Twenty-two trials (1723 women) compared one antihypertensive drug with another. Alternative drugs seem better than methyldopa for reducing the risk of severe hypertension (11 trials, 638 women; RR (random-effects) 0.54; 95% CI 0.30 to 0.95; RD -0.11 (-0.20 to -0.02); NNTH 7 (5 to 69)). There is also a reduction in the overall risk of developing proteinuria/pre-eclampsia when beta blockers and calcium channel blockers considered together are compared with methyldopa (11 trials, 997 women; RR 0.73; 95% CI 0.54 to 0.99). However, the effect on both severe hypertension and proteinuria is not seen in the individual drugs. Other outcomes were only reported by a small proportion of studies, and there were no clear differences. AUTHORS' CONCLUSIONS It remains unclear whether antihypertensive drug therapy for mild to moderate hypertension during pregnancy is worthwhile.
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Affiliation(s)
- Edgardo Abalos
- Centro Rosarino de Estudios Perinatales (CREP), Moreno 878, 6th floor, Rosario, Santa Fe, Argentina, S2000DKR
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