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di Pasquo E, Giannubilo SR, Valentini B, Salvi S, Rullo R, Fruci S, Filippi E, Ornaghi S, Zullino S, Rossi F, Farsetti D, Di Martino DD, Vasapollo B, Locatelli A, De Santis M, Ciavattini A, Lanzone A, Mecacci F, Ferrazzi E, Valensise H, Ghi T. The "Preeclampsia and Hypertension Target Treatment" study: a multicenter prospective study to evaluate the effectiveness of the antihypertensive therapy based on maternal hemodynamic findings. Am J Obstet Gynecol MFM 2024; 6:101368. [PMID: 38574856 DOI: 10.1016/j.ajogmf.2024.101368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 03/20/2024] [Accepted: 04/01/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Despite major advances in the pharmacologic treatment of hypertension in the nonpregnant population, treatments for hypertension in pregnancy have remained largely unchanged over the years. There is recent evidence that a more adequate control of maternal blood pressure is achieved when the first given antihypertensive drug is able to correct the underlying hemodynamic disorder of the mother besides normalizing the blood pressure values. OBJECTIVE This study aimed to compare the blood pressure control in women receiving an appropriate or inappropriate antihypertensive therapy following the baseline hemodynamic findings. STUDY DESIGN This was a prospective multicenter study that included a population of women with de novo diagnosis of hypertensive disorders of pregnancy. A noninvasive assessment of the following maternal parameters was performed on hospital admission via Ultrasound Cardiac Output Monitor before any antihypertensive therapy was given: cardiac output, heart rate, systemic vascular resistance, and stroke volume. The clinician who prescribed the antihypertensive therapy was blinded to the hemodynamic evaluation and used as first-line treatment a vasodilator (nifedipine or alpha methyldopa) or a beta-blocker (labetalol) based on his preferences or on the local protocols. The first-line pharmacologic treatment was retrospectively considered hemodynamically appropriate in either of the following circumstances: (1) women with a hypodynamic profile (defined as low cardiac output [≤5 L/min] and/or high systemic vascular resistance [≥1300 dynes/second/cm2]) who were administered oral nifedipine or alpha methyldopa and (2) women with a hyperdynamic profile (defined as normal or high cardiac output [>5 L/min] and/or low systemic vascular resistances [<1300 dynes/second/cm2]) who were administered oral labetalol. The primary outcome of the study was to compare the occurrence of severe hypertension between women treated with a hemodynamically appropriate therapy and women treated with an inappropriate therapy. RESULTS A total of 152 women with hypertensive disorders of pregnancy were included in the final analysis. Most women displayed a hypodynamic profile (114 [75.0%]) and received a hemodynamically appropriate treatment (116 [76.3%]). The occurrence of severe hypertension before delivery was significantly lower in the group receiving an appropriate therapy than in the group receiving an inappropriately treated (6.0% vs 19.4%, respectively; P=.02). Moreover, the number of women who achieved target values of blood pressure within 48 to 72 hours from the treatment start was higher in the group who received an appropriate treatment than in the group who received an inappropriate treatment (70.7% vs 50.0%, respectively; P=.02). CONCLUSION In pregnant individuals with de novo hypertensive disorders of pregnancy, a lower occurrence of severe hypertension was observed when the first-line antihypertensive agent was tailored to the correct maternal hemodynamic profile.
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Affiliation(s)
- Elvira di Pasquo
- Department of Obstetrics and Gynecology, University Hospital of Parma, Parma, Italy (Drs di Pasquo, Valentini, and Ghi)
| | - Stefano Raffaele Giannubilo
- Department of Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy (Drs Giannubilo and Ciavattini)
| | - Beatrice Valentini
- Department of Obstetrics and Gynecology, University Hospital of Parma, Parma, Italy (Drs di Pasquo, Valentini, and Ghi)
| | - Silvia Salvi
- High-Risk Pregnancy Unit, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Largo Agostino Gemelli, Rome, Italy (Drs Salvi, Rullo, Fruci, and Lanzone)
| | - Roberta Rullo
- High-Risk Pregnancy Unit, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Largo Agostino Gemelli, Rome, Italy (Drs Salvi, Rullo, Fruci, and Lanzone)
| | - Stefano Fruci
- High-Risk Pregnancy Unit, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Largo Agostino Gemelli, Rome, Italy (Drs Salvi, Rullo, Fruci, and Lanzone)
| | - Elisa Filippi
- Department of Obstetrics and Gynecology, Ospedale Ca Foncello, Treviso, Italy (Drs Filippi and Santis)
| | - Sara Ornaghi
- Department of Obstetrics, University of Milan-Bicocca, Foundation Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Milan, Italy (Drs Ornaghi, Rossi, and Locatelli)
| | - Sara Zullino
- High-Risk Pregnancy Unit, Department of Women's and Children's Health, Azienda Ospedaliera Careggi, Florence, Italy (Drs Zullino and Dr Mecacci)
| | - Francesca Rossi
- Department of Obstetrics, University of Milan-Bicocca, Foundation Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Milan, Italy (Drs Ornaghi, Rossi, and Locatelli)
| | - Daniele Farsetti
- Division of Obstetrics and Gynecology, Department of Surgical Sciences, Policlinico Casilino, Tor Vergata University of Rome, Rome, Italy (Drs Farsetti, Vasapollo, and Valensise)
| | - Daniela Denis Di Martino
- Unit of Obstetrics, Division of Obstetrics and Gynecology, Department of Woman, Child, and Newborn, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy (Drs Di Martino and Ferrazzi)
| | - Barbara Vasapollo
- Division of Obstetrics and Gynecology, Department of Surgical Sciences, Policlinico Casilino, Tor Vergata University of Rome, Rome, Italy (Drs Farsetti, Vasapollo, and Valensise)
| | - Anna Locatelli
- Department of Obstetrics, University of Milan-Bicocca, Foundation Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Milan, Italy (Drs Ornaghi, Rossi, and Locatelli)
| | - Michela De Santis
- Department of Obstetrics and Gynecology, Ospedale Ca Foncello, Treviso, Italy (Drs Filippi and Santis)
| | - Andrea Ciavattini
- Department of Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy (Drs Giannubilo and Ciavattini)
| | - Antonio Lanzone
- High-Risk Pregnancy Unit, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Largo Agostino Gemelli, Rome, Italy (Drs Salvi, Rullo, Fruci, and Lanzone)
| | - Federico Mecacci
- High-Risk Pregnancy Unit, Department of Women's and Children's Health, Azienda Ospedaliera Careggi, Florence, Italy (Drs Zullino and Dr Mecacci)
| | - Enrico Ferrazzi
- Unit of Obstetrics, Division of Obstetrics and Gynecology, Department of Woman, Child, and Newborn, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy (Drs Di Martino and Ferrazzi)
| | - Hebert Valensise
- Division of Obstetrics and Gynecology, Department of Surgical Sciences, Policlinico Casilino, Tor Vergata University of Rome, Rome, Italy (Drs Farsetti, Vasapollo, and Valensise)
| | - Tullio Ghi
- Department of Obstetrics and Gynecology, University Hospital of Parma, Parma, Italy (Drs di Pasquo, Valentini, and Ghi); Obstetrics and Gynaecology Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy (Dr Ghi).
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Dall'Asta A, Minopoli M, Ramirez Zegarra R, Di Pasquo E, Ghi T. An update on maternal cardiac hemodynamics in fetal growth restriction and pre-eclampsia. JOURNAL OF CLINICAL ULTRASOUND : JCU 2023; 51:265-272. [PMID: 36377677 DOI: 10.1002/jcu.23392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 10/03/2022] [Accepted: 10/28/2022] [Indexed: 06/16/2023]
Abstract
Pre-eclampsia and fetal growth restriction (FGR) have been long related to primary placental dysfunction, caused by abnormal trophoblast invasion. Nevertheless, emerging evidence has led to a new hypothesis for the origin of pre-eclampsia and FGR. Suboptimal maternal cardiovascular adaptation has been shown to result in uteroplacental hypoperfusion, ultimately leading to placental hypoxic damage with secondary dysfunction. In this review, we summarize current evidence on maternal cardiac hemodynamics in FGR and pre-eclampsia. We also discuss the different approaches for antihypertensive treatment according to the hemodynamic phenotype observed in pre-eclampsia and FGR.
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Affiliation(s)
- Andrea Dall'Asta
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - Monica Minopoli
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - Ruben Ramirez Zegarra
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - Elvira Di Pasquo
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - Tullio Ghi
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
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Abstract
Hypertensive disorders of pregnancy, including gestational hypertension, preeclampsia, and eclampsia, are a worldwide health problem. Hypertensive disorders of pregnancy affect more than 10% of pregnancies and are associated with increased mortality and morbidity for both mother and fetus. Although patients' outcomes and family's experience will always be the primary concern regarding hypertensive complications during pregnancy, the economic aspect of this disease is also worth noting. Compared with normotensive pregnancies, those related with hypertension resulted in an excess increase in hospitalization and healthcare cost. Hence, the focus of this review is to analyze hypertensive disorders of pregnancy and to present practical tips with clear instructions for the clinical management of hypertensive disorders of pregnancy. This overview offers a detailed approach from the diagnosis to treatment and follow-up of a pregnant women with hypertension, evidence based, to support these instructions.
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Ayati A, Sarraf S, Asl Fallah S, Bagheri J, Ahmadi Tafti H, Same K, Hosseini K. Aortic dissection in the first trimester; is it a dead end? A narrative review of recent articles. J Card Surg 2022; 37:1705-1711. [PMID: 35352396 DOI: 10.1111/jocs.16451] [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] [Received: 12/29/2021] [Revised: 02/13/2022] [Accepted: 02/17/2022] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Acute-type aortic dissection (AD) during pregnancy is considered a rare and potentially fatal complication for both mother and fetus. Although the definite treatment for an acute-type AD is considered to be open-heart surgery, the decision to perform such a surgery during pregnancy requires a multidisciplinary approach and carries significant risks. METHODS In the present review of the literature, we have discussed various challenges in the management of acute-type AD during pregnancy, including therapeutic approaches, choosing the preferred imaging modalities, surgical techniques, and medication challenges. We have also reported an 8-week pregnant woman with Marfan syndrome who presented with chest pain and was diagnosed with acute AD. RESULTS The patient underwent a Bentall operation and was discharged in good condition with her fetus alive. The medical team's various decisions during preoperative, operative, and postoperative treatments were discussed. CONCLUSIONS Type A AD is considered infrequent in the second and third trimester of pregnancy and rare in the first trimester. Performing a CMR study without contrast in stable patients can help evaluate the extension of the flap. Urgent surgery in the hands of a skilled surgeon may prove lifesaving for the mother while maximizing the likelihood of preserving the fetus.
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Affiliation(s)
- Aryan Ayati
- Tehran Heart Center, Tehran Heart Center Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Syna Sarraf
- Tehran Heart Center, Tehran Heart Center Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Sahar Asl Fallah
- Rajaie Cardiovascular Medical And Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Jamshid Bagheri
- Tehran Heart Center, Tehran Heart Center Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Ahmadi Tafti
- Tehran Heart Center, Tehran Heart Center Research Institute, Tehran University of Medical Sciences, Tehran, Iran.,Research Center for Advanced Technologies in Cardiovascular Medicine, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Kaveh Same
- Tehran Heart Center, Tehran Heart Center Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Kaveh Hosseini
- Tehran Heart Center, Tehran Heart Center Research Institute, Tehran University of Medical Sciences, Tehran, Iran
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Johnson KM, Zash R, Modest AM, Luckett R, Diseko M, Mmalane M, Makhema J, Ramogola-Masire D, Wylie BJ, Shapiro R. Anti-hypertensive use for non-severe gestational hypertension in Botswana: A case-control study. Int J Gynaecol Obstet 2022; 156:481-487. [PMID: 34196980 PMCID: PMC8855659 DOI: 10.1002/ijgo.13809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 06/07/2021] [Accepted: 06/30/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The fetal risks and benefits of antihypertensives to treat gestational hypertension in pregnancy are understudied, particularly in low- and middle-income countries. METHODS We performed a nested case-control study within a retrospective cohort of obstetrical patients in Botswana from 2014 to 2019. We included women carrying singletons who developed new onset non-severe hypertension (140-159 mm Hg systolic or 90-109 mm Hg diastolic blood pressure) after 20 weeks of pregnancy. Cases were defined as women with either small-for-gestational-age (SGA) infants or stillbirth, analyzed separately; controls were otherwise similar women without the adverse outcome in each analysis. RESULTS We identified 1932 cases of SGA (7925 controls) and 316 cases of stillbirth (9619 controls). Cases with SGA were more likely to have used an anti-hypertensive than controls (33% vs 29%, adjusted odds ratio [aOR] 1.28, 95% confidence interval [CI] 1.15-1.43). Cases with stillbirth were more likely to have used an anti-hypertensive than controls (42% versus 29%, aOR 1.45, 95% CI 1.14-1.83). CONCLUSION Anti-hypertensive use for new-onset gestational hypertension was associated with an increased risk of having an SGA infant or a stillbirth among women who never developed severe hypertension. These data support conduct of a randomized clinical trial to determine the appropriate use of anti-hypertensives in non-severe gestational hypertension.
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Affiliation(s)
- Katherine M Johnson
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA, USA
| | - Rebecca Zash
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Botswana-Harvard Partnership, Gaborone, Botswana
| | - Anna M Modest
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA, USA
| | - Rebecca Luckett
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA, USA
| | | | | | | | - Doreen Ramogola-Masire
- Botswana-Harvard Partnership, Gaborone, Botswana
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Botswana
| | - Blair J Wylie
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA, USA
| | - Roger Shapiro
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Botswana-Harvard Partnership, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Mulrenin IR, Garcia JE, Fashe MM, Loop MS, Daubert MA, Urrutia RP, Lee CR. The impact of pregnancy on antihypertensive drug metabolism and pharmacokinetics: current status and future directions. Expert Opin Drug Metab Toxicol 2021; 17:1261-1279. [PMID: 34739303 DOI: 10.1080/17425255.2021.2002845] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Hypertensive disorders of pregnancy (HDP) are rising in prevalence, and increase risk of adverse maternal and fetal outcomes. Physiologic changes occur during pregnancy that alter drug pharmacokinetics. However, antihypertensive drugs lack pregnancy-specific dosing recommendations due to critical knowledge gaps surrounding the extent of gestational changes in antihypertensive drug pharmacokinetics and underlying mechanisms. AREAS COVERED This review (1) summarizes currently recommended medications and dosing strategies for non-emergent HDP treatment, (2) reviews and synthesizes existing literature identified via a comprehensive Pubmed search evaluating gestational changes in the maternal pharmacokinetics of commonly prescribed HDP drugs (notably labetalol and nifedipine), and (3) offers insight into the metabolism and clearance mechanisms underlying altered HDP drug pharmacokinetics during pregnancy. Remaining knowledge gaps and future research directions are summarized. EXPERT OPINION A series of small pharmacokinetic studies illustrate higher oral clearance of labetalol and nifedipine during pregnancy. Pharmacokinetic modeling and preclinical studies suggest these effects are likely due to pregnancy-associated increases in hepatic UGT1A1- and CYP3A4-mediated first-pass metabolism and lower bioavailability. Accordingly, higher and/or more frequent doses may be needed to lower blood pressure during pregnancy. Future research is needed to address various evidence gaps and inform the development of more precise antihypertensive drug dosing strategies.
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Affiliation(s)
- Ian R Mulrenin
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Julian E Garcia
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Muluneh M Fashe
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Matthew Shane Loop
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Melissa A Daubert
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC
| | - Rachel Peragallo Urrutia
- Division of General Obstetrics and Gynecology, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Craig R Lee
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
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von Dadelszen P, Vidler M, Tsigas E, Magee LA. Management of Preeclampsia in Low- and Middle-Income Countries: Lessons to Date, and Questions Arising, from the PRE-EMPT and Related Initiatives. MATERNAL-FETAL MEDICINE 2021. [DOI: 10.1097/fm9.0000000000000096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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8
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Magee LA, Rey E, Asztalos E, Hutton E, Singer J, Helewa M, Lee T, Logan AG, Ganzevoort W, Welch R, Thornton JG, von Dadelszen P. Management of non-severe pregnancy hypertension – A summary of the CHIPS Trial (Control of Hypertension in Pregnancy Study) research publications. Pregnancy Hypertens 2019; 18:156-162. [DOI: 10.1016/j.preghy.2019.08.166] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 08/12/2019] [Accepted: 08/24/2019] [Indexed: 10/25/2022]
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Cox AG, Marshall SA, Palmer KR, Wallace EM. Current and emerging pharmacotherapy for emergency management of preeclampsia. Expert Opin Pharmacother 2019; 20:701-712. [PMID: 30707633 DOI: 10.1080/14656566.2019.1570134] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Preeclampsia is a disease specific to pregnancy characterised by new onset hypertension with maternal organ dysfunction and/or fetal growth restriction. It remains a major cause of maternal and perinatal morbidity and mortality. For fifty years, antihypertensives have been the mainstay of treating preeclampsia, reducing maternal morbidity and mortality. With increased knowledge of the mechanisms underlying the disease has come opportunities for novel therapies that complement antihypertensives by protecting the maternal vasculature. Areas covered: In this review, the authors consider, in detail, the antihypertensives commonly used today in the emergency care of women with severe preeclampsia. They also review less common anti-hypertensive agents and discuss the role of magnesium sulphate in the management of preeclampsia and the prevention of eclampsia. Finally, they explore novel therapeutics for the acute management of preeclampsia. Expert opinion: The rapid control of maternal hypertension will, and must, remain the mainstay of emergency treatment for women with severe preeclampsia. The role of magnesium sulphate as a primary prevention for eclampsia is context dependant and should not displace a focus on correcting blood pressure safely. The exploration of novel adjuvant therapies will likely allow us to prolong pregnancy longer and improve perinatal outcomes safely for the mother.
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Affiliation(s)
- Annie G Cox
- a Ritchie Centre, Department of Obstetrics and GynaecologySchool of Clinical Sciences , Monash University , Clayton , Australia.,b The Ritchie Centre , Hudson Institute of Medical Research , Clayton , Australia
| | - Sarah A Marshall
- a Ritchie Centre, Department of Obstetrics and GynaecologySchool of Clinical Sciences , Monash University , Clayton , Australia.,b The Ritchie Centre , Hudson Institute of Medical Research , Clayton , Australia
| | - Kirsten R Palmer
- a Ritchie Centre, Department of Obstetrics and GynaecologySchool of Clinical Sciences , Monash University , Clayton , Australia
| | - Euan M Wallace
- a Ritchie Centre, Department of Obstetrics and GynaecologySchool of Clinical Sciences , Monash University , Clayton , Australia.,b The Ritchie Centre , Hudson Institute of Medical Research , Clayton , Australia
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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: 39] [Impact Index Per Article: 6.5] [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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Bortolotto MR, Francisco RPV, Zugaib M. Resistant Hypertension in Pregnancy: How to Manage? Curr Hypertens Rep 2018; 20:63. [PMID: 29892919 DOI: 10.1007/s11906-018-0865-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
PURPOSE OF REVIEW The concept of resistant hypertension may be changed during pregnancy by the physiological hemodynamic changes and the particularities of therapy choices in this period. This review discusses the management of pregnant patients with preexisting resistant hypertension and also of those who develop severe hypertension in gestation and puerperium. RECENT FINDINGS The main cause of severe hypertension in pregnancy is preeclampsia, and differential diagnosis must be done with secondary or primary hypertension. Women with preexisting resistant hypertension may need pharmacological therapy adjustment. Several drugs can be used to treat severe hypertension, with exception of angiotensin-converting enzyme inhibitors and angiotensin II receptor antagonists. The most used drugs are methyldopa, beta-blockers, and calcium channel antagonists. There is a general agreement that severe hypertension must be treated, but there are still debates over the goals of the treatment. Delivery is indicated in viable pregnancies in which blood pressure control is not achieved with three drugs in full doses. Resistant hypertension may arise in postpartum. The management of resistant hypertension in pregnancy must regard the possible etiology, the fetal well-being, and the mother's risk. Good care is mandatory to reduce maternal mortality risk.
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Affiliation(s)
- Maria Rita Bortolotto
- Divisao de Clinica Obstetrica, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil.
| | - Rossana Pulcineli Vieira Francisco
- Disciplina de Obstetricia, Departamento de Obstetricia e Ginecologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Marcelo Zugaib
- Disciplina de Obstetricia, Departamento de Obstetricia e Ginecologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
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Butalia S, Audibert F, Côté AM, Firoz T, Logan AG, Magee LA, Mundle W, Rey E, Rabi DM, Daskalopoulou SS, Nerenberg KA. Hypertension Canada's 2018 Guidelines for the Management of Hypertension in Pregnancy. Can J Cardiol 2018; 34:526-531. [PMID: 29731014 DOI: 10.1016/j.cjca.2018.02.021] [Citation(s) in RCA: 130] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 02/20/2018] [Accepted: 02/20/2018] [Indexed: 11/18/2022] Open
Abstract
We present Hypertension Canada's inaugural evidence-based Canadian recommendations for the management of hypertension in pregnancy. Hypertension in pregnancy is common, affecting approximately 7% of pregnancies in Canada, and requires effective management to reduce maternal, fetal, and newborn complications. Because of this importance, these guidelines were developed in partnership with the Society of Obstetricians and Gynaecologists of Canada with the main common objective of improving the management of women with hypertension in pregnancy. Guidelines for the diagnosis, assessment, prevention, and treatment of hypertension in adults and children are published separately. In this first Hypertension Canada guidelines for hypertension in pregnancy, 7 recommendations for the management of nonsevere and severe hypertension in pregnancy are presented. For nonsevere hypertension in pregnancy (systolic blood pressure 140-159 mm Hg and/or diastolic blood pressure 80-109 mm Hg), we provide guidance for the threshold for initiation of antihypertensive therapy, blood pressure targets, as well as first- and second-line antihypertensive medications. Severe hypertension (systolic blood pressure ≥ 160 mm Hg and/or diastolic blood pressure ≥ 110 mm Hg) requires urgent antihypertensive therapy to reduce maternal, fetal, and newborn adverse outcomes. The specific evidence and rationale underlying each of these guidelines are discussed.
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Affiliation(s)
- Sonia Butalia
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada.
| | - Francois Audibert
- Department of Obstetrics and Gynecology, CHU Sainte Justine, Université de Montréal, Montréal, Québec, Canada
| | | | - Tabassum Firoz
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | | | - Laura A Magee
- Department of Women and Children's Health, St Thomas' Hospital, London, United Kingdom; School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - William Mundle
- Maternal Fetal Medicine Clinic, Windsor Regional Hospital, Windsor, Ontario, Canada
| | - Evelyne Rey
- Division of Obstetric Medicine, Department of Obstetrics and Gynecology, CHU Sainte Justine, Montréal, Québec, Canada
| | - Doreen M Rabi
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Stella S Daskalopoulou
- Division of General Internal Medicine, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Kara A Nerenberg
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada; Departments of Medicine, Obstetrics and Gynecology, and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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Abstract
Blood pressure is a way of describing the end result of changes in cardiac output, intravascular volume and peripheral resistance. It has certain advantages in that it is a reproducible and easily measured parameter, but in itself, it offers only a limited understanding of the underlying haemodynamics. In pregnancy, profound haemodynamic changes occur and in hypertensive diseases of pregnancy defining a condition by blood pressure alone risks missing the underlying cause. Partly, this has been a problem of ascribing the cause of hypertensive syndromes to the placenta which has inhibited rigorous research into other possible causes of haemodynamic dysfunction. It is becoming increasingly evident that hypertension in pregnancy may be associated with primarily high cardiac output or high peripheral resistance. A knowledge of the underlying type of hypertension may allow more rational treatment of these conditions in pregnancy rather than therapeutic attempts at controlling blood pressure by any means possible as an end in itself.
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Affiliation(s)
- Christoph Lees
- Imperial College London, London, UK.
- Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, Imperial Healthcare NHS Trust, Du Cane Road, London, W12 0HS, UK.
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy.
| | - Enrico Ferrazzi
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
- Department of Woman, Mother and Neonate, Buzzi Children Hospital, University of Milan, Milan, Italy
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Podymow T, August P. New Evidence in the Management of Chronic Hypertension in Pregnancy. Semin Nephrol 2017; 37:398-403. [DOI: 10.1016/j.semnephrol.2017.05.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Tskhay VB, Kovtun NM, Schindler AE. Successful prevention of preeclampsia in a high-risk pregnancy using progestogen dydrogesterone: a clinical case. Horm Mol Biol Clin Investig 2016; 27:85-8. [PMID: 27383893 DOI: 10.1515/hmbci-2016-0019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 05/08/2016] [Indexed: 11/15/2022]
Abstract
The presented clinical example convincingly demonstrates the efficacy of dydrogesterone (30 mg) in the prevention of severe preeclampsia in a high-risk patient (early development of preeclampsia and preterm Cesarean section in her first pregnancy, arterial hypertension). This case suggests using dydrogesterone as an option to prevent preeclampsia, as previously shown in a prospective randomized study.
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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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