Medications during pregnancy: antihypertensives and immunosuppressives

Ginger extract attenuates labetalol induced apoptosis, DNA damage, histological and ultrastructural changes in the heart of rat fetuses

Labetalol is a medication used to treat maternal hypertension during pregnancy. However, it is often associated with many side effects. Recently, several studies have been focused on the protective effect of medicinal plant extracts, such as ginger, against drugs inducing toxicity. Therefore, it has been hypothesized that ginger aqueous extraction can ameliorate labetalol-induced histological, ultrastructural changes, DNA damage, and apoptosis in fetal heart tissue. To achieve the aim of this study, sixty pregnant female albino rats were divided into 4 groups (15 each). Group I (Control). Group II received ginger (200 mg/kg). Group III received labetalol (300 mg/kg). Group IV received labetalol first followed by ginger. All groups were orally injected daily during the organogenesis phase of gestation i.e., from the 6th to the 15th day, and sacrificed at the 20th day of gestation. Results showed that labetalol-induced marked histological and ultrastructural alterations. Also, there was severe DNA damage and an increase in the apoptotic rates determined by Annexin-V/PI dual staining assay. Injection of the ginger aqueous extract caused evident improvement in cardiac tissue, DNA damage, and apoptotic rates. In conclusion, the results suggest that ginger extract could be a potential candidate agent for reducing labetalol-induced cardiotoxicity in the fetal heart of albino rats.

Pregnancy management of women with kidney transplantation

Women with renal disease, besides many dysfunctions, face increasing infertility and high-risk pregnancy due to uremia and changes of the hormonal functions. After renal transplantation, sexual dysfunction improves, providing the possibility of successful pregnancy for women of childbearing age. However, kidney transplanted patients are high-risk pregnant patients with increased maternal and fetal risks, and the graft also may be compromised during pregnancy; most studies report on several successive deliveries due to multidisciplinary team management. In clinical practice, the graft is rarely affected during the period of gestation. Fetal development disorders are also rare although preterm delivery and intrauterine growth retardation are common. For now, several studies and clinical investigations proved that, under multidisciplinary control, kidney transplanted female patients are also possible to have safe pregnancy and successful delivery. There are conflicting data in the literature about the prevention of complications and the timing of pregnancy. Herein, we would like to present some experience of our centre. A total of 847 kidney transplantations have been performed between June 1993 and December 2013 with 163 childbearing aged females (18-45 years) in our center. We report on three kidney transplanted patients who have given birth to healthy newborns. In our practice, severe complications have not been observed.

Pregnancy in renal transplantation: Recipient and donor aspects in the Arab world

OBJECTIVE

There are many kidney transplant recipients and living donors of reproductive age, and the prevalence of pregnancies in kidney transplant recipients can reach 55% in the Middle Eastern countries. Living kidney donation is predominant in this region. As the risks and outcomes of pregnancy should be a part of counselling for both recipients and donors, we reviewed available reports on maternal and foetal outcomes in these particular populations.

METHODS

Information was obtained from retrospective analyses of a large database, and from single-centre reports indexed in PubMed on pregnancy in donors and kidney transplant recipients. The keywords used for the search included 'fertility', 'kidney disease', 'pregnancy', 'maternal/foetal outcomes', 'kidney transplant recipient', 'immunosuppression side-effects', 'living donor' and 'Arab countries'.

RESULTS

Pregnancies in kidney transplant recipients are most successful in those with adequate kidney function and controlled comorbidities. Similarly to other regions, pregnant recipients in the Middle East had a higher risk of pre-eclampsia (26%) and gestational diabetes (7%) than in the general population. Caesarean section was quite common, with an incidence rate of 61%, and the incidence of pre-term birth reached 46%.

CONCLUSIONS

Most living donors can have successful pregnancies and should not be routinely discouraged. Women who had pregnancies before and after donation were more likely to have adverse maternal outcomes (gestational diabetes, hypertension, proteinuria, and pre-eclampsia) in the latter, but no adverse foetal outcomes were found after donation. The evaluation before donation should include a gestational history and counselling about the potential risks.

What about the renal function during childhood of children born from dialysed mothers?

INTRODUCTION

Pregnancy during dialysis is a high-risk condition which is becoming more and more common. The renal outcome of children born from such pregnancies needs to be investigated since renal development may be affected (i.e. exposure to uraemic toxins, therapies, intermittent haemodynamic changes during sessions, prematurity, growth retardation).

METHODS

We performed a single-centre prospective global and renal evaluation (inulin clearance or 2009 Schwartz formula in children <4 years) in 10 children from 7 mothers who underwent haemodialysis during pregnancy.

RESULTS

The median (range) age of mothers at the beginning of pregnancy was 30 (22-33) years, with maximal weekly haemodialysis duration of 18 (12-30) h. Systemic arterial hypertension was reported in 4 of 10 pregnancies, polyhydramnios in 3 and oligohydramnios in 1. The median (range) gestational age was 32 (29-39) weeks of gestation (WG). Seven children were born before 36 WG. The median (range) birth weight (BW) was 1735 (930-3430)g, and eight children had a BW <2500 g. One child had a PAX2 mutation requiring early renal transplantation and was thus excluded from further analysis. Even though glomerular filtration rate and blood pressure were normal in all other children, a significant urine albumin-to-creatinine ratio was found in three children and an increased urine beta-2-microglobulin concentration in an additional one, questioning the presence of an underlying silent reduction in nephron number.

CONCLUSIONS

Despite the small number of patients, this pilot study highlights the potential risk of renal impairment in children born from dialysed mothers. Further studies are required but until then, careful monitoring of these children is important.

Pregnancy following liver transplantation during childhood and adolescence

More than 80% of pediatric transplant recipients will survive to reach adulthood, and many will consider having children. We report on outcomes and management of five pregnancies in four women undergoing orthotopic liver transplantation during childhood or adolescence and followed up at our Transplant Center. A retrospective clinical folder audit was performed. Mean age at transplantation was 13.3 ± 3.4 yr (range, 10-18 yr). Mean interval between transplantation and pregnancy was 15.4 ± 4.9 yr (range, 10-22 yr). Mean maternal age at conception was 28 ± 3.5 yr (range, 23-32 yr). Mean gestational age was 36.6 ± 1.7 wk. Mean birth weight was 2672 ± 249 g. Immunosuppression was cyclosporin based in three women and tacrolimus based in one woman. Pregnancy complications necessitating the induction of labor included fetal distress and rising maternal liver enzymes in two women, cholestasis of pregnancy and impaired renal graft function in one woman, fetal distress and preeclampsia in one woman. Modes of delivery were normal vaginal delivery in three women and cesarean section in one woman. No maternal or fetal deaths and no congenital malformations occurred. No episodes of rejection occurred during pregnancy. Two women experienced acute cellular rejection requiring an increase in baseline immunosuppression in the first year, following delivery. No graft losses occurred during a mean follow-up of 44 ± 17.9 months post-delivery. With careful management, pregnancy post-liver transplantation can have a successful outcome.

Antihypertensive drugs in pregnancy

Blood pressure targets and medications that are safe differ in pregnant women compared with nonpregnant individuals. The principles of treatment for mild, moderate, and severe hypertension in pregnancy, chronic versus gestational versus preeclampsia, and women hypertensive at term versus remote from term are reviewed. The choice of antihypertensive drugs also is discussed; methyldopa, labetalol, and nifedipine, among others, appear safe for use in pregnancy, whereas angiotensin converting enzyme inhibitors and angiotensin receptor blockers should be avoided. The management of increased blood pressure in the postpartum period, and agents to use in lactation, are also discussed.

Pregnancy after kidney transplantation

Reproductive success is a common, expected outcome for male and female recipients of solid-organ transplants. Men can father children, and women can become pregnant and carry the fetus to delivery. There are, however, important maternal and fetal complications that need to be considered to provide optimal care to the mother and her infant. Although pregnancy is common after the transplantation of all solid organs, guidelines for optimal counseling and clinical management are limited. This review discusses information to help the physician counsel the kidney transplant recipient about risks of pregnancy for the mother and the fetus and provides information to help guide treatment of the pregnant transplant recipient.

Hypertension in pregnancy

Hypertensive disorders of pregnancy are the most common medical disorders of pregnancy and are associated with increased maternal and perinatal risks. The pathophysiology, diagnosis, and treatment are herein reviewed for chronic hypertension, preeclampsia, gestational hypertension, and severe hypertension. The benefits and risks of treating mild, moderate, and severe hypertension are discussed. A variety of oral and parenteral therapies are approved for the treatment of hypertension in pregnancy; methyldopa, labetalol, and nifedipine have been used safely in pregnancy, as has hydrochlorothiazide in those already taking this medication before conception. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are contraindicated in pregnancy because of adverse fetal effects, and atenolol should be avoided due to concerns with fetal growth. Severe hypertension >160/110 mmHg may require parenteral therapy, and treatment with intravenous labetalol now supplants the use of hydralazine. Women may remain hypertensive for a period postpartum and require treatment for a short interval. Early or severe preeclampsia warrants workup postpartum for secondary causes. Pregnancy induced hypertension or preeclampsia are emerging as risk factors for future cardiovascular risk.

Obstetric considerations in the management of pregnancy in kidney transplant recipients

Kidney transplant improves reproductive function; planning for pregnancy is crucial. Prenatal management must address potential fetal complications: preterm delivery, intrauterine growth restriction, low birth weight; as well as maternal: hypertension, preeclampsia, gestational diabetes, acute rejection or graft loss. The latter depends upon timing after transplant, prepregnancy kidney function, and continuation of immunosuppressive agents at appropriate levels. Graft function is not adversely affected if preconception kidney function was normal. Acute rejection, 9%-14%, must be immediately addressed, with kidney biopsy if necessary. Blood pressure should be meticulously managed; serious morbidity results from poor control. Blood pressures >130/80 mmHg require acceptable antihypertensives: beta-blockers, alpha-methyldopa, hydralazine, and calcium channel blockers. Preeclampsia requires seizure prophylaxis with magnesium sulfate, with expeditious delivery. Screening for urinary tract infections with aggressive treatment and for opportunistic infections that may affect the fetus is essential. Surveillance for fetal anomalies, growth, and antenatal testing is important. Steroids for fetal lung maturity are indicated for preterm delivery. Vaginal birth is preferred, reserving cesarean for obstetrical indications, with pain management similar to normal laboring patients. Surveillance for infection postpartum is warranted. Conflicting information exists regarding safety of breastfeeding with immunosuppressive drugs; immunosuppressive medication must be adjusted to prepregnancy levels and contraception counseling addressed.