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Pels A, Ganzevoort W, Kenny LC, Baker PN, von Dadelszen P, Gluud C, Kariya CT, Leemhuis AG, Groom KM, Sharp AN, Magee LA, Jakobsen JC, Mol BWJ, Papageorghiou AT. Interventions affecting the nitric oxide pathway versus placebo or no therapy for fetal growth restriction in pregnancy. Cochrane Database Syst Rev 2023; 7:CD014498. [PMID: 37428872 PMCID: PMC10332237 DOI: 10.1002/14651858.cd014498] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/12/2023]
Abstract
BACKGROUND Fetal growth restriction (FGR) is a condition of poor growth of the fetus in utero. One of the causes of FGR is placental insufficiency. Severe early-onset FGR at < 32 weeks of gestation occurs in an estimated 0.4% of pregnancies. This extreme phenotype is associated with a high risk of fetal death, neonatal mortality, and neonatal morbidity. Currently, there is no causal treatment, and management is focused on indicated preterm birth to prevent fetal death. Interest has risen in interventions that aim to improve placental function by administration of pharmacological agents affecting the nitric oxide pathway causing vasodilatation. OBJECTIVES The objective of this systematic review and aggregate data meta-analysis is to assess the beneficial and harmful effects of interventions affecting the nitric oxide pathway compared with placebo, no therapy, or different drugs affecting this pathway against each other, in pregnant women with severe early-onset FGR. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (16 July 2022), and reference lists of retrieved studies. SELECTION CRITERIA We considered all randomised controlled comparisons of interventions affecting the nitric oxide pathway compared with placebo, no therapy, or another drug affecting this pathway in pregnant women with severe early-onset FGR of placental origin, for inclusion in this review. DATA COLLECTION AND ANALYSIS We used standard Cochrane Pregnancy and Childbirth methods for data collection and analysis. MAIN RESULTS We included a total of eight studies (679 women) in this review, all of which contributed to the data and analysis. The identified studies report on five different comparisons: sildenafil compared with placebo or no therapy, tadalafil compared with placebo or no therapy, L-arginine compared with placebo or no therapy, nitroglycerin compared with placebo or no therapy and sildenafil compared with nitroglycerin. The risk of bias of included studies was judged as low or unclear. In two studies the intervention was not blinded. The certainty of evidence for our primary outcomes was judged as moderate for the intervention sildenafil and low for tadalafil and nitroglycerine (due to low number of participants and low number of events). For the intervention L-arginine, our primary outcomes were not reported. Sildenafil citrate compared to placebo or no therapy (5 studies, 516 women) Five studies (Canada, Australia and New Zealand, the Netherlands, the UK and Brazil) involving 516 pregnant women with FGR were included. We assessed the certainty of the evidence as moderate. Compared with placebo or no therapy, sildenafil probably has little or no effect on all-cause mortality (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.80 to 1.27, 5 studies, 516 women); may reduce fetal mortality (RR 0.82, 95% CI 0.60 to 1.12, 5 studies, 516 women), and increase neonatal mortality (RR 1.45, 95% CI 0.90 to 2.33, 5 studies, 397 women), although the results are uncertain for fetal and neonatal mortality as 95% confidence intervals are wide crossing the line of no effect. Tadalafil compared with placebo or no therapy (1 study, 87 women) One study (Japan) involving 87 pregnant women with FGR was included. We assessed the certainty of the evidence as low. Compared with placebo or no therapy, tadalafil may have little or no effect on all-cause mortality (risk ratio 0.20, 95% CI 0.02 to 1.60, one study, 87 women); fetal mortality (RR 0.11, 95% CI 0.01 to 1.96, one study, 87 women); and neonatal mortality (RR 0.89, 95% CI 0.06 to 13.70, one study, 83 women). L-Arginine compared with placebo or no therapy (1 study, 43 women) One study (France) involving 43 pregnant women with FGR was included. This study did not assess our primary outcomes. Nitroglycerin compared to placebo or no therapy (1 studies, 23 women) One study (Brazil) involving 23 pregnant women with FGR was included. We assessed the certainty of the evidence as low. The effect on the primary outcomes is not estimable due to no events in women participating in both groups. Sildenafil citrate compared to nitroglycerin (1 study, 23 women) One study (Brazil) involving 23 pregnant women with FGR was included. We assessed the certainty of the evidence as low. The effect on the primary outcomes is not estimable due to no events in women participating in both groups. AUTHORS' CONCLUSIONS Interventions affecting the nitric oxide pathway probably do not seem to influence all-cause (fetal and neonatal) mortality in pregnant women carrying a baby with FGR, although more evidence is needed. The certainty of this evidence is moderate for sildenafil and low for tadalafil and nitroglycerin. For sildenafil a fair amount of data are available from randomised clinical trials, but with low numbers of participants. Therefore, the certainty of evidence is moderate. For the other interventions investigated in this review there are insufficient data, meaning we do not know whether these interventions improve perinatal and maternal outcomes in pregnant women with FGR.
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Affiliation(s)
- Anouk Pels
- Department of Obstetrics and Gynecology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Wessel Ganzevoort
- Department of Obstetrics and Gynecology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Louise C Kenny
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Philip N Baker
- College of Life Sciences, University of Leicester, Leicester, UK
| | | | - Christian Gluud
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, Capital Region, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Chirag T Kariya
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, Canada
| | - Aleid G Leemhuis
- Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Amsterdam, Netherlands
| | - Katie M Groom
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
| | - Andrew N Sharp
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - Laura A Magee
- Department of Obstetrics and Gynaecology, King's College London, London, UK
| | - Janus C Jakobsen
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ben Willem J Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Australia
- Aberdeen Centre for Women's Health Research, Institute of Applied Health Sciences, School of Medicine, Medial Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
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Chauhan M, Betancourt A, Balakrishnan M, Mishra A, Espinosa J, Shamshirsaz AA, Fox K, Belfort M, Yallampalli C. Calcitonin Gene Related Peptide, Adrenomedullin, and Adrenomedullin 2 Function in Uterine Artery During Human Pregnancy. Endocrinology 2022; 163:6374898. [PMID: 34558598 PMCID: PMC8574633 DOI: 10.1210/endocr/bqab204] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Indexed: 12/26/2022]
Abstract
RATIONALE Calcitonin gene-related peptide (CGRP) and its family members adrenomedullin (ADM) and adrenomedullin 2 (ADM2; also known as intermedin) support vascular adaptions in rat pregnancy. OBJECTIVE This study aimed to assess the relaxation response of uterine artery (UA) for CGRP, ADM, and ADM2 in nonpregnant and pregnant women and identify the involved mechanisms. FINDINGS (1) Segments of UA from nonpregnant women that were precontracted with U46619 (1μM) in vitro are insensitive to the hypotensive effects of CGRP, ADM, and ADM2; (2) CGRP, ADM, and ADM2 (0.1-100nM) dose dependently relax UA segments from pregnant women with efficacy for CGRP > ADM = ADM2; (3) the relaxation responses to CGRP, ADM, and ADM2 are differentially affected by the inhibitors of nitric oxide (NO) synthase (L-NAME), adenylyl cyclase (SQ22536), apamin, and charybdotoxin; (4) UA smooth muscle cells (UASMC) express mRNA for calcitonin receptor-like receptor (CRLR) and receptor activity modifying protein (RAMP)1 and RAMP2 but not RAMP3; (5) receptor heterodimer comprising CRLR/RAMP1 and CRLR/RAMP2 but not CRLR/RAMP3 is present in UA; (6) soluble fms-like tyrosine kinase (sFLT-1) and TNF-α treatment decrease the expression of RAMP1 mRNA (P < 0.05) in UASMC; and (7) sFLT-1 treatment impairs the association of CRLR with all 3 peptides while TNF-α inhibits the interaction of CGRP but not ADM or ADM2 with CRLR in UASMC (P < 0.05). CONCLUSIONS Relaxation sensitivity of UA for CGRP, ADM, and ADM2 is increased during pregnancy via peptide-specific involvement of NO system and endothelium-derived hyperpolarizing factors; vascular disruptors such as sFLT-1 and TNFα adversely impact their receptor system in UASMC.
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Affiliation(s)
- Madhu Chauhan
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX 77030, USA
- Correspondence: Madhu Chauhan, PhD, Department of Obstetrics and Gynecology, Baylor College of Medicine, 1102 bates Avenue, Houston, TX 77030, USA.
| | - Ancizar Betancourt
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Meena Balakrishnan
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Akansha Mishra
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Jimmy Espinosa
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Karin Fox
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Michael Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Chandra Yallampalli
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX 77030, USA
- Correspondence: Chandra Yallampalli, DMV, PhD, Department of Obstetrics and Gynecology, Baylor College of Medicine, 1102 bates Avenue, Houston, TX 77030, USA.
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Mecacci F, Avagliano L, Lisi F, Clemenza S, Serena C, Vannuccini S, Rambaldi MP, Simeone S, Ottanelli S, Petraglia F. Fetal Growth Restriction: Does an Integrated Maternal Hemodynamic-Placental Model Fit Better? Reprod Sci 2021; 28:2422-2435. [PMID: 33211274 PMCID: PMC8346440 DOI: 10.1007/s43032-020-00393-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 11/09/2020] [Indexed: 11/25/2022]
Abstract
In recent years, a growing interest has arisen regarding the possible relationship between adverse pregnancy outcomes (APOs) and inadequate maternal hemodynamic adaptations to the pregnancy. A possible association between "placental syndromes," such as preeclampsia (PE) and fetal growth restriction (FGR), and subsequent maternal cardiovascular diseases (CVD) later in life has been reported. The two subtypes of FGR show different pathogenetic and clinical features. Defective placentation, due to a poor trophoblastic invasion of the maternal spiral arteries, is believed to play a central role in the pathogenesis of early-onset PE and FGR. Since placental functioning is dependent on the maternal cardiovascular system, a pre-existent or subsequent cardiovascular impairment may play a key role in the pathogenesis of early-onset FGR. Late FGR does not seem to be determined by a primary abnormal placentation in the first trimester. The pathological pathway of late-onset FGR may be due to a primary maternal cardiovascular maladaptation: CV system shows a flat profile and remains similar to those of non-pregnant women. Since the second trimester, when the placenta is already developed and increases its functional request, a hypovolemic state could lead to placental hypoperfusion and to an altered maturation of the placental villous tree and therefore to an altered fetal growth. Thus, this review focalizes on the possible relationship between maternal cardiac function and placentation in the development of both early and late-onset FGR. A better understanding of maternal hemodynamics in pregnancies complicated by FGR could bring various benefits in clinical practice, improving screening and therapeutic tools.
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Affiliation(s)
- F Mecacci
- Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and Gynecology, University of Florence, Viale Morgagni 44, 50134, Florence, Italy
| | - L Avagliano
- Department of Health Sciences, San Paolo Hospital Medical School, University of Milano, Milan, Italy
| | - F Lisi
- Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and Gynecology, University of Florence, Viale Morgagni 44, 50134, Florence, Italy
| | - S Clemenza
- Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and Gynecology, University of Florence, Viale Morgagni 44, 50134, Florence, Italy
| | - Caterina Serena
- Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and Gynecology, University of Florence, Viale Morgagni 44, 50134, Florence, Italy.
| | - S Vannuccini
- Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and Gynecology, University of Florence, Viale Morgagni 44, 50134, Florence, Italy
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - M P Rambaldi
- Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and Gynecology, University of Florence, Viale Morgagni 44, 50134, Florence, Italy
| | - S Simeone
- Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and Gynecology, University of Florence, Viale Morgagni 44, 50134, Florence, Italy
| | - S Ottanelli
- Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and Gynecology, University of Florence, Viale Morgagni 44, 50134, Florence, Italy
| | - F Petraglia
- Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and Gynecology, University of Florence, Viale Morgagni 44, 50134, Florence, Italy
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Hussain QA, McKay IJ, Gonzales-Marin C, Allaker RP. Detection of adrenomedullin and nitric oxide in different forms of periodontal disease. J Periodontal Res 2015; 51:16-25. [DOI: 10.1111/jre.12273] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Q. A. Hussain
- Institute of Dentistry; Barts and The London School of Medicine & Dentistry; Queen Mary University of London; London UK
| | - I. J. McKay
- Institute of Dentistry; Barts and The London School of Medicine & Dentistry; Queen Mary University of London; London UK
| | - C. Gonzales-Marin
- Institute of Dentistry; Barts and The London School of Medicine & Dentistry; Queen Mary University of London; London UK
| | - R. P. Allaker
- Institute of Dentistry; Barts and The London School of Medicine & Dentistry; Queen Mary University of London; London UK
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Serpero LD, Bellissima V, Colivicchi M, Sabatini M, Frigiola A, Ricotti A, Ghiglione V, Strozzi MC, Li Volti G, Galvano F, Gazzolo D. Next generation biomarkers for brain injury. J Matern Fetal Neonatal Med 2013; 26 Suppl 2:44-9. [PMID: 24059552 DOI: 10.3109/14767058.2013.829688] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Valensise H, Vasapollo B, Novelli GP, Giorgi G, Verallo P, Galante A, Arduini D. Maternal and fetal hemodynamic effects induced by nitric oxide donors and plasma volume expansion in pregnancies with gestational hypertension complicated by intrauterine growth restriction with absent end-diastolic flow in the umbilical artery. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2008; 31:55-64. [PMID: 18098350 DOI: 10.1002/uog.5234] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
OBJECTIVE To evaluate the effect of plasma volume expansion (PVE) and nitric oxide (NO) donors, in addition to antihypertensive therapy for gestational hypertensive pregnancies complicated by intrauterine growth restriction (IUGR) with absent end-diastolic flow (AEDF) in the umbilical artery (UA). METHODS This was a case-control study into which 32 gestational hypertensive pregnancies with IUGR and AEDF were enrolled. Sixteen of these were treated with antihypertensive drugs, NO donors and PVE (Group A), and 16, matched for maternal age, gestational age and fetal conditions, were treated with antihypertensive drugs only (Group B). All patients underwent fetal and uteroplacental assessment and maternal echocardiography to evaluate total vascular resistance (TVR) and cardiac output before and 5-14 days after initiation of treatment. RESULTS After 5-14 days of treatment, the maternal TVR in Group A fell from 2170 +/- 248 to 1377 +/- 110 dynes.s.cm(-5) (P < 0.01), and that in Group B fell from 2090 +/- 260 to 1824 +/- 126 dynes.s.cm(-5) (P < 0.01), with the reduction being greater in Group A than in Group B (P < 0.01). There was a significant increase in cardiac output in Group A after 5-14 days of treatment vs. baseline (6.19 +/- 0.77 vs. 4.32 +/- 0.66, P < 0.001), and, after treatment, cardiac output was significantly greater in Group A than it was in Group B (6.19 +/- 0.77 vs. 4.70 +/- 0.44, P < 0.001). Reappearance of end-diastolic flow in the UA occurred in 14/16 patients in Group A but in no patients in Group B (87.5% vs. 0%, P < 0.05). The interval between detection of UA-AEDF and delivery was 28 +/- 16 days in Group A and 11 +/- 6 days in Group B (P < 0.05). CONCLUSION Administration of NO donors and PVE in gestational hypertensive pregnancies affected by IUGR and UA-AEDF appears to improve both maternal and fetal hemodynamics, inducing prolongation of gestation.
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Affiliation(s)
- H Valensise
- Department of Obstetrics and Gynecology, Perinatal Medicine, Frascati (Rome), Rome, Italy.
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Abstract
BACKGROUND Pre-eclampsia, a multisystem disorder of pregnancy characterised by high blood pressure and protein in the urine, is associated with endothelial dysfunction. Nitric oxide mediates many functions of the endothelium, including vasodilatation and inhibition of platelet aggregation. Pre-eclampsia may be associated with nitric oxide deficiency, but the evidence to support this suggestion is contradictory. Nevertheless, it has been hypothesised that agents which increase nitric oxide may prevent pre-eclampsia. OBJECTIVES To assess the effectiveness and safety of nitric oxide donors and precursors for preventing pre-eclampsia and its complications. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (November 2006), CENTRAL (The Cochrane Library 2006, Issue 3), and EMBASE (2002 to December 2004). SELECTION CRITERIA Studies were included if they were randomised trials evaluating nitric oxide donors or precursors for preventing pre-eclampsia and its complications. DATA COLLECTION AND ANALYSIS Both review authors independently assessed studies for inclusion. Data were extracted and double checked for accuracy. MAIN RESULTS Six trials (310 women) were included. Four were of good quality and two were of uncertain quality. Four trials (170 women) compared nitric oxide donors (glyceryl trinitrate) or precursors (L-arginine) with either placebo or no intervention. There are insufficient data for reliable conclusions about the effects on pre-eclampsia (four trials, 170 women; relative risk (RR) 0.83, 95% confidence interval (CI) 0.49 to 1.41) or its complications. One trial (36 women) compared a nitric oxide donor with nifedipine, and another (76 women) compared it with antiplatelet agents. Both were too small for reliable conclusions about possible differential effects. Glyceryl trinitrate was associated with an increased risk of headache (two trials, 56 women; RR 6.85, 95% CI 1.42 to 33.04), and of stopping treatment (two trials, 56 women; RR 4.02, 95% CI 1.15 to 14.09) compared to placebo. However, the increase for both outcomes was due to an extreme result in one small trial (7/7 versus 0/9 for both outcomes). AUTHORS' CONCLUSIONS There is insufficient evidence to draw reliable conclusions about whether nitric oxide donors and precursors prevent pre-eclampsia or its complications.
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Affiliation(s)
- S Meher
- University of Liverpool, Division of Perinatal and Reproductive Medicine, First Floor, Liverpool Women's NHS Foundation Trust, Crown Street, Liverpool, UK, L8 7SS.
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Harman CR, Baschat AA. Comprehensive assessment of fetal wellbeing: which Doppler tests should be performed? Curr Opin Obstet Gynecol 2003; 15:147-57. [PMID: 12634607 DOI: 10.1097/00001703-200304000-00010] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Doppler applications in pregnancy are expanding exponentially. Flow velocity waveforms provide important information 12 weeks to term, from maternal vessels, placental circulation and fetal systemic vessels, with implications for both mother and fetus. As applications proliferate, awareness of the complexity of fetal and placental circulations, in normal pregnancy and in sequential responses to compromise, has also grown. The necessary data are now available to establish core values in Doppler evaluation for at-risk pregnancies. RECENT FINDINGS Uterine arteries depict maternal vascular effects of the invading placenta, predicting the frequency and severity of pre-eclampsia and intrauterine growth restriction. New evidence suggests early treatment based on this principle, significantly reduces these impacts. Umbilical artery Doppler reflects downstream placental vascular resistance, strongly correlated with intrauterine growth restriction and the multisystem effects of placental deficiency. Abnormalities are progressive, with reduction, loss, and finally a reversal of diastolic flow. When umbilical arteries become abnormal, the differentiation of fetal status requires Doppler information from systemic vessels. Middle cerebral artery changes begin when the redistribution of cardiac output reflects rising placental resistance, demonstrating 'brain sparing' when cerebrovascular dilation occurs. In the compromised intrauterine growth retarded fetus, precordial veins illustrate fetal cardiac function, changing as the respiratory status declines. This Doppler information is combined with biophysical profile scoring to determine the need for and timing of intervention. SUMMARY Doppler evaluation of at-risk pregnancies provides crucial prognostic and diagnostic detail about placentation and fetal adaptation. What has been research detail is now becoming the standard of care, in comprehensive fetal-maternal assessment.
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Affiliation(s)
- Chris R Harman
- Center for Advanced Fetal Care, Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland School of Medicine, Baltimore, Maryland, USA.
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