1
|
Cleary EM, Racchi NW, Patton KG, Kudrimoti M, Costantine MM, Rood KM. Trial of Intrapartum Extended-Release Nifedipine to Prevent Severe Hypertension Among Pregnant Individuals With Preeclampsia With Severe Features. Hypertension 2023; 80:335-342. [PMID: 36189646 DOI: 10.1161/hypertensionaha.122.19751] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Preeclampsia is associated with maternal and perinatal morbidity. Besides acute therapy for severe hypertension, best practices are lacking for intrapartum hypertension management. Our objective was to test the hypothesis that intrapartum initiation of extended-release nifedipine in individuals with preeclampsia with severe features prevents severe hypertension. METHODS Randomized, triple-blind, placebo-controlled trial of individuals with preeclampsia with severe features undergoing labor induction between 220/7 and 416/7 weeks gestation. Participants were randomized to oral extended-release nifedipine 30 mg or identical placebo every 24 hours. Primary outcome is defined as receipt of ≥1 dose of acute hypertension therapy for severe blood pressure (≥160/110 mm Hg) sustained ≥10 minutes. Secondary outcomes included route of delivery, neonatal intensive care unit admission, and a composite of adverse neonatal outcomes. RESULTS Of 365 individuals screened, 55 were randomized to nifedipine and 55 to placebo. Primary outcome was observed in 34.0% of individuals in nifedipine group versus 55.1% in placebo group (relative risk [RR] 0.62 [95% CI, 0.39-0.97]); number needed to treat to prevent receipt of acute treatment was 4.7 (95% CI, 2.5-44.3). Fewer individuals in nifedipine group required cesarean delivery compared with placebo group (20.8% versus 34.7%, RR, 0.60 [95% CI, 0.31-1.15]). Neonatal intensive care unit admission rate was lower in nifedipine group compared with placebo (29.1% versus 47.1%; RR 0.62 [95% CI, 0.37-1.02]). Neonatal composite was similar between groups (35.8% versus 41.2%, RR, 0.83 [95% CI, 0.51-1.37]). CONCLUSIONS Initiation of extended-release nifedipine is effective in reducing intrapartum acute hypertensive therapy among individuals with preeclampsia with severe features. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT04392375.
Collapse
Affiliation(s)
- Erin M Cleary
- Departments of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, The Ohio State University College of Medicine, Columbus, OH (E.M.C., K.G.P., M.M.C., K.M.R.)
| | - Nicholas W Racchi
- Ohio University Heritage College of Osteopathic Medicine, Athens, OH (N.W.R)
| | - K Grace Patton
- Departments of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, The Ohio State University College of Medicine, Columbus, OH (E.M.C., K.G.P., M.M.C., K.M.R.)
| | | | - Maged M Costantine
- Departments of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, The Ohio State University College of Medicine, Columbus, OH (E.M.C., K.G.P., M.M.C., K.M.R.)
| | - Kara M Rood
- Departments of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, The Ohio State University College of Medicine, Columbus, OH (E.M.C., K.G.P., M.M.C., K.M.R.)
| |
Collapse
|
2
|
Bailey-Hytholt CM, Shen TL, Nie B, Tripathi A, Shukla A. Placental Trophoblast-Inspired Lipid Bilayers for Cell-Free Investigation of Molecular Interactions. ACS APPLIED MATERIALS & INTERFACES 2020; 12:31099-31111. [PMID: 32558532 DOI: 10.1021/acsami.0c06197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The placenta plays a key role in regulating the maternal-fetal transport but it is a difficult organ to study due to a lack of existing in vitro models. Lipid bilayers inspired by the placenta can provide a facile new in vitro tool with promise for screening molecular transport across this important organ. Here we developed lipid bilayers that mimic the composition of human placental trophoblast cells at different times during the course of pregnancy. Mass spectrometry identified five major lipid classes (phosphatidylcholine, phosphatidylethanolamine, phosphatidylinositol, phosphatidylserine, and sphingomyelin) present at varying concentrations in trophoblasts representative of the first and third trimesters and full-term placenta. We successfully developed supported and suspended lipid bilayers mimicking these trophoblast lipid compositions and then demonstrated the utility of these synthetic placenta models for investigating molecular interactions. Specifically, we investigated the interactions with di(2-ethylhexyl) phthalate (DEHP), a common plasticizer and environmental toxicant, and amphotericin B, a common yet toxic, antifungal therapeutic. Overall, we observed that DEHP adsorbs and potentially embeds itself within all placental lipid bilayers, with varying levels of interaction. For both amphotericin B and a liposomal formulation of amphotericin B, AmBisome, we noted lower levels of permeation in transport studies with bilayers and trophoblast cells compared with DEHP, likely driven by differences in size. AmBisome interacted less with both the supported and suspended placental lipid bilayers in comparison to amphotericin B, suggesting that drug delivery carriers can vary the impact of a pharmaceutical agent on these lipid structures. We found that the apparent permeability observed in suspended bilayers was approximately an order of magnitude less than those observed for trophoblast monolayers, which is typical of lipid bilayers. Ultimately, these placenta mimetic lipid bilayers can serve as a platform for the rapid initial screening of molecular interactions with the maternal-fetal interface to better inform future testing.
Collapse
Affiliation(s)
- Christina M Bailey-Hytholt
- School of Engineering, Center for Biomedical Engineering, Brown University, Providence, Rhode Island 02912, United States
| | - Tun-Li Shen
- Department of Chemistry, Brown University, Providence, Rhode Island 02912, United States
| | - Bonnee Nie
- Department of Biochemistry and Molecular Biology, Brown University, Providence, Rhode Island 02912, United States
| | - Anubhav Tripathi
- School of Engineering, Center for Biomedical Engineering, Brown University, Providence, Rhode Island 02912, United States
| | - Anita Shukla
- School of Engineering, Center for Biomedical Engineering, Brown University, Providence, Rhode Island 02912, United States
| |
Collapse
|
3
|
Brussé IA, Kluivers ACM, Zambrano MD, Shetler K, Miller EC. Neuro-obstetrics: A multidisciplinary approach to care of women with neurologic disease. HANDBOOK OF CLINICAL NEUROLOGY 2020; 171:143-160. [PMID: 32736747 DOI: 10.1016/b978-0-444-64239-4.00007-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The term "neuro-obstetrics" refers to a multidisciplinary approach to the care of pregnant women with neurologic comorbidities, both preconceptionally and throughout pregnancy. General preconception care should be offered to all women, including women with neurologic disease. Women with neurologic comorbidities should also be offered specialist preconception care by an obstetrician who consults with a neurologist, anesthesiologist, and if indicated clinical geneticist and/or other specialists. In women with neurologic comorbidities, neurologic sequelae may influence the course of the pregnancy and delivery. Also, pregnancy may influence the severity of the neurologic condition, depending on the type of disease. Physiologic adaptations during pregnancy and altered pharmacokinetics may cause altered blood serum levels of drugs, leading to decreased or increased drug effects. When administering drugs to a woman who wishes to conceive, it is important to consider possible teratogenic effects and possible secretion in breast milk. Tailoring medication regimens should be considered, preferably preconceptionally. In this chapter, we review general principles of neuro-obstetric care, as well as some specific considerations for neurologists, obstetricians, and anesthesiologists caring for pregnant women with common neurologic conditions.
Collapse
Affiliation(s)
- Ingrid A Brussé
- Department of Obstetrics and Gynecology, Division of Obstetrics and Fetal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - Anna C M Kluivers
- Department of Obstetrics and Gynecology, Division of Obstetrics and Fetal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Maria D Zambrano
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States
| | - Kara Shetler
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States
| | - Eliza C Miller
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States; NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, United States
| |
Collapse
|
4
|
Yoo K, Kang D, Jeong H, Jeong C, Choi Y, Lee J. A dose–response study of remifentanil for attenuation of the hypertensive response to laryngoscopy and tracheal intubation in severely preeclamptic women undergoing caesarean delivery under general anaesthesia. Int J Obstet Anesth 2013. [DOI: 10.1016/j.ijoa.2012.09.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
5
|
Gaballa HA, El-Shahawy EED, Atta DS, Gerbash EF. Clinical and serological risk factors of systemic lupus erythematosus outcomes during pregnancy. EGYPTIAN RHEUMATOLOGIST 2012. [DOI: 10.1016/j.ejr.2012.04.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
6
|
Chen Q, Guo F, Liu S, Xiao J, Wang C, Snowise S, Stone PR, Chamley LW. Calcium channel blockers prevent endothelial cell activation in response to necrotic trophoblast debris: possible relevance to pre-eclampsia. Cardiovasc Res 2012; 96:484-93. [PMID: 22933321 DOI: 10.1093/cvr/cvs279] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS Pre-eclampsia is characterized by endothelial activation, which is triggered by placental factor(s). One such factor may be trophoblastic debris that is shed into the maternal blood to become trapped against the maternal pulmonary endothelium. Phagocytosis of necrotic trophoblastic debris (NTD) induces endothelial cell activation with increased secretion of interleukin-6 (IL-6) and transforming growth factor β1 (TGFβ1), which may induce systemic endothelial cell activation. In addition to its effects on vascular smooth muscle, evidence suggests that nifedipine may also affect the endothelium, contributing to the therapeutic benefits of the drug. We investigated whether nifedipine could reverse the endothelial cell activation induced by NTD. METHODS AND RESULTS Trophoblastic debris was collected from placental explants and exposed to endothelial cells with or without nifedipine, verapamil, or a nitric oxide (NO) donor for 24 h. Endothelial cell activation was measured by cell-surface intracellular adhesion molecule-1 and E-selectin, as well as monocyte adhesion. The activation of endothelial cells exposed to NTD or sera from pre-eclamptic women was significantly reduced by nifedipine or verapamil. In addition, the increases in the levels of IL-6 or TGFβ1 in conditioned media from endothelial cells following phagocytosis of NTD were significantly reduced by nifedipine. These actions of nifedipine were reversed by the NO synthetase inhibitor l-NAME and mimicked by a NO donor. CONCLUSION Our results suggest that calcium channel blockers may have a direct effect upon endothelial cells, reducing the endothelial cell activation that is a key pathogenic feature of pre-eclampsia. This action may be mediated, in part, by NO.
Collapse
Affiliation(s)
- Qi Chen
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences, The University of Auckland, 85 Park Road, Grafton 1011, New Zealand.
| | | | | | | | | | | | | | | |
Collapse
|
7
|
|
8
|
Abstract
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.
Collapse
Affiliation(s)
- Tiina Podymow
- Division of Nephrology, McGill University Health Center, Royal Victoria Hospital, 687 Pine Avenue West, Montreal, Quebec, Canada.
| | | |
Collapse
|
9
|
Abstract
Hypertensive disorders of pregnancies remain a central public health concern throughout the world, and are a major cause of maternal mortality in the developing world. Although treatment options have not significantly changed in recent years, insight on the pathogenesis of preeclampsia/eclampsia has been remarkable. With improved animal models of preeclampsia and large-scale human trials, we have embarked upon a new era where angiogenic biomarkers based on mechanism of disease can be designed to assist in early diagnosis and treatment. There is also a growing recognition of how elusive the diagnosis of eclampsia can be, especially in the postpartum period. Proper treatment of these patients depends heavily on the correct diagnosis, especially by the emergency physician. Finally, large epidemiologic studies have revealed that preeclampsia, once thought to be a self-limited entity, now appears to portend real damage to the cardiovascular and other organ systems in the long term. This review will present the latest update on our understanding of the various hypertensive disorders of pregnancies and their treatment options.
Collapse
|
10
|
Abstract
Pre-eclampsia is a significant, multifactorial, multiorgan disease affecting 5%-8% of all pregnancies in the US where it is the third leading cause of maternal mortality. Despite improvements in the diagnosis and management of pre-eclampsia, severe complications can occur in both the mother and the fetus, and there is no effective method of prevention. Early detection and identification of pregnant women most at risk of developing the disease have proven challenging, but recent efforts combining biochemical and biophysical markers are promising. Efforts at prevention of pre-eclampsia with aspirin and calcium have had limited success, but research on modifiable risk factors, such as obesity surgery, are encouraging. Obstetric management of severe pre-eclampsia focuses on medical management of blood pressure and prevention of seizures using magnesium sulfate, but the ultimate cure remains delivery of the fetus and placenta. Timing of delivery depends on several factors, including gestational age, fetal lung maturity, and most importantly, disease severity. Anesthetic management includes regional anesthesia with careful evaluation of the patient's airway, volume status, and coagulation status to reduce morbidity and mortality. The potential complications of general anesthesia, including intracranial hemorrhage, in these patients make regional anesthesia the preferred choice in many cases. Nevertheless, it is important to be aware of the contraindications to neuraxial anesthesia and to prepare always for the possibility of encountering a difficult airway.
Collapse
Affiliation(s)
- Judi A Turner
- Department of Anesthesiology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.
| |
Collapse
|
11
|
Sandrim VC, Palei ACT, Luizon MR, Izidoro-Toledo TC, Cavalli RC, Tanus-Santos JE. eNOS haplotypes affect the responsiveness to antihypertensive therapy in preeclampsia but not in gestational hypertension. THE PHARMACOGENOMICS JOURNAL 2009; 10:40-5. [PMID: 19704415 DOI: 10.1038/tpj.2009.38] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Variations of the endothelial nitric oxide synthase (eNOS) gene have been associated with hypertensive disorders of pregnancy. We examined whether eNOS polymorphisms affect the therapeutic responses of women with gestational hypertension (GH) or preeclampsia (PE). We studied 304 hypertensive pregnant women (152 GH and 152 PE), who were stratified according to clinical and laboratorial parameters of therapeutic responsiveness. We compared the frequencies of three eNOS genetic polymorphisms (T-786C, Glu298Asp and b/a intron 4) in responsive and nonresponsive PE and GH patients. We found no significant differences in genotype or allele distributions when responsive and nonresponsive groups were compared (both PE or GH; all P>0.05). However, the eNOS haplotype distribution differed in PE (but not in GH)-responsive and -nonresponsive groups (P=0.0003). The 'C-Glu-a' and 'T-Asp-a' hapotypes were associated with responsiveness and nonresponsiveness to therapy, respectively (both P<0.001), thus suggesting that eNOS haplotypes affect the responsiveness to antihypertensive therapy in PE.
Collapse
Affiliation(s)
- V C Sandrim
- Santa Casa de Belo Horizonte, Av. Francisco Sales 1111, Belo Horizonte, MG, Brazil
| | | | | | | | | | | |
Collapse
|
12
|
Affiliation(s)
- Tiina Podymow
- Division of Nephrology, McGill University Health Center, Royal Victoria Hospital, 687 Pine Ave West, Ross 2.38, Montreal, Quebec, Canada H3A 1A1.
| | | |
Collapse
|
13
|
Dyer RA, Piercy JL, Reed AR. The role of the anaesthetist in the management of the pre-eclamptic patient. Curr Opin Anaesthesiol 2007; 20:168-74. [PMID: 17479015 DOI: 10.1097/aco.0b013e328136c1ac] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Recent literature on the anaesthetist's role in the management of the patient with severe pre-eclampsia is reviewed, with particular emphasis on the role of regional anaesthesia. RECENT FINDINGS Laboratory findings in pre-eclamptic women include increased levels of markers of oxidative stress and circulating tyrosine kinase 1, and inflammatory activation of leucocytes. Magnesium sulphate is the most effective agent for seizure prophylaxis. The optimal pharmacological agents for acute control of blood pressure remain controversial. The benefits of epidural analgesia in labour are well established. Single-shot spinal anaesthesia for caesarean section is safe in the absence of contraindications. Successful use of combined spinal-epidural anaesthesia has been described. Most studies on maternal haemodynamics have employed heart rate and blood pressure data as surrogate measures of cardiac output. Noninvasive cardiac output studies provide further insight into the haemodynamic response during neuraxial techniques for caesarean section. SUMMARY The value of regional anaesthesia cannot be over-emphasized. Recent research into spinal anaesthesia for caesarean section suggests a lower susceptibility to hypotension and probably less impairment of cardiac output than in healthy parturients. Noninvasive cardiac output measurement may also have advantages in critical care management.
Collapse
Affiliation(s)
- Robert A Dyer
- Department of Anaesthesia, University of Cape Town and New Groote Schuur Hospital, Cape Town, South Africa.
| | | | | |
Collapse
|
14
|
Bibliography. Current world literature. Women's health. Curr Opin Obstet Gynecol 2006; 18:666-74. [PMID: 17099340 DOI: 10.1097/gco.0b013e328011ef42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|