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Deng NJ, Xian-Yu CY, Han RZ, Huang CY, Ma YT, Li HJ, Gao TY, Liu X, Zhang C. Pharmaceutical administration for severe hypertension during pregnancy: Network meta-analysis. Front Pharmacol 2023; 13:1092501. [PMID: 36699058 PMCID: PMC9869161 DOI: 10.3389/fphar.2022.1092501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 12/27/2022] [Indexed: 01/11/2023] Open
Abstract
Aims: To evaluate the efficacy of different pharmacologic treatment for severe hypertension during pregnancy. Methods: Two reviewers searched Ovid MEDLINE, Ovid EMbase, and the Cochrane Library for randomized clinical trials from the establishment of the database to 15 July 2021 that were eligible for inclusion and analyzed the pharmaceuticals used for severe hypertension in pregnancy. Results: 29 relevant trials with 2,521 participants were involved. Compared with diazoxide in rate of achieving target blood pressure, other pharmaceuticals, including epoprostenol (RR:1.58, 95%CI:1.01-2.47), hydralazine\dihydralazine (RR:1.57, 95%CI:1.07-2.31), ketanserin (RR:1.67, 95%CI:1.09-2.55), labetalol (RR:1.54, 95%CI:1.04-2.28), nifedipine (RR:1.54, 95%CI:1.04-2.29), and urapidil (RR:1.57, 95%CI:1.00-2.47), were statistically significant in the rate of achieving target blood pressure. According to the SUCRA, diazoxide showed the best therapeutic effect, followed by nicardipine, nifedipine, labetalol, and nitroglycerine. The three pharmaceuticals with the worst therapeutic effect were ketanserin, hydralazine, and urapidil. It is worth noting that the high ranking of the top two pharmaceuticals, including diazoxide and nicardipine, comes from extremely low sample sizes. Other outcomes were reported in the main text. Conclusion: This comprehensive network meta-analysis demonstrated that the nifedipine should be recommended as a strategy for blood pressure management in pregnant women with severe hypertension. Moreover, the conventional pharmaceuticals, including labetalol and hydralazine, showed limited efficacy. However, it was important to note that the instability of hydralazine reducing blood pressure and the high benefit of labetalol with high dosages intakes should also be of concern to clinicians.
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Affiliation(s)
- Nian-Jia Deng
- Center for Evidence-Based Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Chen-Yang Xian-Yu
- Center for Evidence-Based Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Rui-Zheng Han
- Department of Ultrasound, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Cheng-Yang Huang
- Center for Evidence-Based Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Yu-Tong Ma
- Center for Evidence-Based Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Hui-Jun Li
- Center for Evidence-Based Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Teng-Yu Gao
- Center for Evidence-Based Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Xin Liu
- Center for Evidence-Based Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Chao Zhang
- Center for Evidence-Based Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China,*Correspondence: Chao Zhang,
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2
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Ali RM, Salah D. Nitroglycerin versus labetalol to control the blood pressure in acute severe pre-eclampsia. EGYPTIAN JOURNAL OF ANAESTHESIA 2022. [DOI: 10.1080/11101849.2022.2110434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Affiliation(s)
- Rania M Ali
- Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Dina Salah
- Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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3
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Comparative efficacy and safety of oral nifedipine with other antihypertensive medications in the management of hypertensive disorders of pregnancy: a systematic review and meta-analysis of randomized controlled trials. J Hypertens 2022; 40:1876-1886. [PMID: 35969195 DOI: 10.1097/hjh.0000000000003233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hypertensive disorders of pregnancy are the most frequently occurring medical condition during pregnancy, resulting in fetal and/or maternal morbidity and mortality. This meta-analysis compared the efficacy and safety of nifedipine with other antihypertensive medications used in hypertensive disorders of pregnancy. METHODOLOGY A comprehensive search was performed using PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar. The meta-analysis was carried out using Review Manager Software, and the pooled effect estimate was generated as standardized mean difference and odds ratio with 95% confidence interval and two-sided P -value. RESULTS The meta-analysis was comprised of 22 randomized control trials with 2595 participants. It was found that meantime and number of doses required to achieve target blood pressure were lower in the nifedipine group ( P < 0.05). Even though it is statistically insignificant, fetal APGAR (Appearance, Pulse, Grimace, Activity, and Respiration) scores less than seven favors nifedipine intervention. Furthermore, none of the fetal or maternal secondary outcomes were found significant. CONCLUSION Nifedipine was found to be more effective than other antihypertensive medications to reduce blood pressure, particularly in patients with severe hypertension. However, future clinical studies, including real-world data are necessary to establish the safety profile of nifedipine concerning the fetal outcomes in hypertensive pregnant women.
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4
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Hitzerd E, Broekhuizen M, Neuman RI, Colafella KMM, Merkus D, Schoenmakers S, Simons SHP, Reiss IKM, Danser AHJ. Human Placental Vascular Reactivity in Health and Disease: Implications for the Treatment of Pre-eclampsia. Curr Pharm Des 2020; 25:505-527. [PMID: 30950346 DOI: 10.2174/1381612825666190405145228] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 03/29/2019] [Indexed: 12/17/2022]
Abstract
Adequate development of the placenta is essential for optimal pregnancy outcome. Pre-eclampsia (PE) is increasingly recognized to be a consequence of placental dysfunction and can cause serious maternal and fetal complications during pregnancy. Furthermore, PE increases the risk of neonatal problems and has been shown to be a risk factor for cardiovascular disease of the mother later in life. Currently, there is no adequate treatment for PE, mainly because its multifactorial pathophysiology remains incompletely understood. It originates in early pregnancy with abnormal placentation and involves a cascade of dysregulated systems in the placental vasculature. To investigate therapeutic strategies it is essential to understand the regulation of vascular reactivity and remodeling of blood vessels in the placenta. Techniques using human tissue such as the ex vivo placental perfusion model provide insight in the vasoactive profile of the placenta, and are essential to study the effects of drugs on the fetal vasculature. This approach highlights the different pathways that are involved in the vascular regulation of the human placenta, changes that occur during PE and the importance of focusing on restoring these dysfunctional systems when studying treatment strategies for PE.
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Affiliation(s)
- Emilie Hitzerd
- Department of Pediatrics, Division of Neonatology, Erasmus MC University Medical Center, Rotterdam, Netherlands.,Department of Internal Medicine; Division of Pharmacology and Vascular Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Michelle Broekhuizen
- Department of Pediatrics, Division of Neonatology, Erasmus MC University Medical Center, Rotterdam, Netherlands.,Department of Internal Medicine; Division of Pharmacology and Vascular Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands.,Department of Cardiology; Division of Experimental Cardiology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Rugina I Neuman
- Department of Internal Medicine; Division of Pharmacology and Vascular Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands.,Department of Gynecology and Obstetrics, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Katrina M Mirabito Colafella
- Department of Internal Medicine; Division of Pharmacology and Vascular Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands.,Cardiovascular Program, Monash Biomedicine Discovery Institute, Monash University, Melbourne, Australia.,Department of Physiology, Monash University, Melbourne, Australia
| | - Daphne Merkus
- Department of Cardiology; Division of Experimental Cardiology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Sam Schoenmakers
- Department of Gynecology and Obstetrics, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Sinno H P Simons
- Department of Pediatrics, Division of Neonatology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Irwin K M Reiss
- Department of Pediatrics, Division of Neonatology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - A H Jan Danser
- Department of Internal Medicine; Division of Pharmacology and Vascular Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands
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5
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Braunthal S, Brateanu A. Hypertension in pregnancy: Pathophysiology and treatment. SAGE Open Med 2019; 7:2050312119843700. [PMID: 31007914 PMCID: PMC6458675 DOI: 10.1177/2050312119843700] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 03/22/2019] [Indexed: 12/14/2022] Open
Abstract
Hypertensive disorders of pregnancy, an umbrella term that includes preexisting and gestational hypertension, preeclampsia, and eclampsia, complicate up to 10% of pregnancies and represent a significant cause of maternal and perinatal morbidity and mortality. Despite the differences in guidelines, there appears to be consensus that severe hypertension and non-severe hypertension with evidence of end-organ damage need to be controlled; yet the ideal target ranges below 160/110 mmHg remain a source of debate. This review outlines the definition, pathophysiology, goals of therapy, and treatment agents used in hypertensive disorders of pregnancy.
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Affiliation(s)
| | - Andrei Brateanu
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
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6
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Tamargo J, Caballero R, Delpón E. Pharmacotherapy for hypertension in pregnant patients: special considerations. Expert Opin Pharmacother 2019; 20:963-982. [PMID: 30943045 DOI: 10.1080/14656566.2019.1594773] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Hypertensive disorders of pregnancy (HDP) represent a major cause of maternal, fetal and neonatal morbidity and mortality and identifies women at risk for cardiovascular and other chronic diseases later in life. When antihypertensive drugs are used during pregnancy, their benefit and harm to both mother and fetus should be evaluated. AREAS COVERED This review summarizes the pharmacological characteristics of the recommended antihypertensive drugs and their impact on mother and fetus when administered during pregnancy and/or post-partum. Drugs were identified using MEDLINE and the main international Guidelines for the management of HDP. EXPERT OPINION Although there is a consensus that severe hypertension should be treated, treatment of mild hypertension without end-organ damage (140-159/90-109 mmHg) remains controversial and there is no agreement on when to initiate therapy, blood pressure targets or recommended drugs in the absence of robust evidence for the superiority of one drug over others. Furthermore, the long-term outcomes of in-utero antihypertensive exposure remain uncertain. Therefore, evidence-based data regarding the treatment of HDP is lacking and well designed randomized clinical trials are needed to resolve all these controversial issues related to the management of HDP.
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Affiliation(s)
- Juan Tamargo
- a Department of Pharmacology and Toxicology, School of Medicine , Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, CIBERCV , Madrid , Spain
| | - Ricardo Caballero
- a Department of Pharmacology and Toxicology, School of Medicine , Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, CIBERCV , Madrid , Spain
| | - Eva Delpón
- a Department of Pharmacology and Toxicology, School of Medicine , Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, CIBERCV , Madrid , Spain
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7
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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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8
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Marshall SA, Cox AG, Parry LJ, Wallace EM. Targeting the vascular dysfunction: Potential treatments for preeclampsia. Microcirculation 2018; 26:e12522. [PMID: 30556222 DOI: 10.1111/micc.12522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 11/22/2018] [Accepted: 12/10/2018] [Indexed: 12/18/2022]
Abstract
Preeclampsia is a pregnancy-specific disorder, primarily characterized by new-onset hypertension in combination with a variety of other maternal or fetal signs. The pathophysiological mechanisms underlying the disease are still not entirely clear. Systemic maternal vascular dysfunction underlies the clinical features of preeclampsia. It is a result of oxidative stress and the actions of excessive anti-angiogenic factors, such as soluble fms-like tyrosine kinase, soluble endoglin, and activin A, released by a dysfunctional placenta. The vascular dysfunction then leads to impaired regulation and secretion of relaxation factors and an increase in sensitivity/production of constrictors. This results in a more constricted vasculature rather than the relaxed vasodilated state associated with normal pregnancy. Currently, the only effective "treatment" for preeclampsia is delivery of the placenta and therefore the baby. Often, this means a preterm delivery to save the life of the mother, with all the attendant risks and burdens associated with fetal prematurity. To lessen this burden, there is a pressing need for more effective treatments that target the maternal vascular dysfunction that underlies the hypertension. This review details the vascular effects of key drugs undergoing clinical assessment as potential treatments for women with preeclampsia.
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Affiliation(s)
- Sarah A Marshall
- Departments of Obstetrics and Gynaecology and Medicine, School of Clinical Sciences, The Ritchie Centre, Monash University, Clayton, Victoria, Australia
| | - Annie G Cox
- Departments of Obstetrics and Gynaecology and Medicine, School of Clinical Sciences, The Ritchie Centre, Monash University, Clayton, Victoria, Australia
| | - Laura J Parry
- School of BioSciences, The University of Melbourne, Parkville, Victoria, Australia
| | - Euan M Wallace
- Departments of Obstetrics and Gynaecology and Medicine, School of Clinical Sciences, The Ritchie Centre, Monash University, Clayton, Victoria, Australia
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Ishikawa T, Obara T, Nishigori H, Miyakoda K, Ishikuro M, Metoki H, Ohkubo T, Sugawara J, Yaegashi N, Akazawa M, Kuriyama S, Mano N. Antihypertensives prescribed for pregnant women in Japan: Prevalence and timing determined from a database of health insurance claims. Pharmacoepidemiol Drug Saf 2018; 27:1325-1334. [DOI: 10.1002/pds.4654] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Revised: 08/16/2018] [Accepted: 08/19/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Tomofumi Ishikawa
- Laboratory of Clinical Pharmacy; Tohoku University Graduate School of Pharmaceutical Sciences; 1-1 Seiryo-machi, Aoba-ku Sendai Miyagi 980-8574 Japan
| | - Taku Obara
- Department of Pharmaceutical Sciences; Tohoku University Hospital; 1-1, Seiryo-machi, Aoba-ku Sendai Miyagi 980-8574 Japan
- Environment and Genome Research Center; Tohoku University Graduate School of Medicine; 2-1, Seiryo-machi, Aoba-ku Sendai Miyagi 980-8573 Japan
- Tohoku Medical Megabank Organization; Tohoku University; 2-1, Seiryo-machi, Aoba-ku Sendai Miyagi 980-8573 Japan
| | - Hidekazu Nishigori
- Environment and Genome Research Center; Tohoku University Graduate School of Medicine; 2-1, Seiryo-machi, Aoba-ku Sendai Miyagi 980-8573 Japan
- Department of Gynecology and Obstetrics; Tohoku University Graduate School of Medicine; 1-1, Seiryo-machi, Aoba-ku Sendai Miyagi 980-8574 Japan
| | - Keiko Miyakoda
- Tohoku Medical Megabank Organization; Tohoku University; 2-1, Seiryo-machi, Aoba-ku Sendai Miyagi 980-8573 Japan
| | - Mami Ishikuro
- Environment and Genome Research Center; Tohoku University Graduate School of Medicine; 2-1, Seiryo-machi, Aoba-ku Sendai Miyagi 980-8573 Japan
- Tohoku Medical Megabank Organization; Tohoku University; 2-1, Seiryo-machi, Aoba-ku Sendai Miyagi 980-8573 Japan
| | - Hirohito Metoki
- Tohoku Medical Megabank Organization; Tohoku University; 2-1, Seiryo-machi, Aoba-ku Sendai Miyagi 980-8573 Japan
- Division of Public Health, Hygiene and Epidemiology, Faculty of Medicine; Tohoku Medical and Pharmaceutical University; 4-4 Komatsushima, Aoba-ku Sendai Miyagi 981-8558 Japan
| | - Takayoshi Ohkubo
- Department of Hygiene and Public Health; Teikyo University School of Medicine; 2-11-1 Kaga, Itabashi-ku Tokyo 173-8605 Japan
| | - Junichi Sugawara
- Tohoku Medical Megabank Organization; Tohoku University; 2-1, Seiryo-machi, Aoba-ku Sendai Miyagi 980-8573 Japan
- Department of Gynecology and Obstetrics; Tohoku University Graduate School of Medicine; 1-1, Seiryo-machi, Aoba-ku Sendai Miyagi 980-8574 Japan
| | - Nobuo Yaegashi
- Environment and Genome Research Center; Tohoku University Graduate School of Medicine; 2-1, Seiryo-machi, Aoba-ku Sendai Miyagi 980-8573 Japan
- Tohoku Medical Megabank Organization; Tohoku University; 2-1, Seiryo-machi, Aoba-ku Sendai Miyagi 980-8573 Japan
- Department of Gynecology and Obstetrics; Tohoku University Graduate School of Medicine; 1-1, Seiryo-machi, Aoba-ku Sendai Miyagi 980-8574 Japan
| | - Manabu Akazawa
- Department of Public Health and Epidemiology; Meiji Pharmaceutical University; 2-522-1, Noshio, Kiyose Tokyo 204-8588 Japan
| | - Shinichi Kuriyama
- Environment and Genome Research Center; Tohoku University Graduate School of Medicine; 2-1, Seiryo-machi, Aoba-ku Sendai Miyagi 980-8573 Japan
- Tohoku Medical Megabank Organization; Tohoku University; 2-1, Seiryo-machi, Aoba-ku Sendai Miyagi 980-8573 Japan
- Tohoku University International Research Institute for Disaster Science; 2-1, Seiryo-machi, Aoba-ku Sendai Miyagi 980-8573 Japan
| | - Nariyasu Mano
- Laboratory of Clinical Pharmacy; Tohoku University Graduate School of Pharmaceutical Sciences; 1-1 Seiryo-machi, Aoba-ku Sendai Miyagi 980-8574 Japan
- Department of Pharmaceutical Sciences; Tohoku University Hospital; 1-1, Seiryo-machi, Aoba-ku Sendai Miyagi 980-8574 Japan
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10
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Sridharan K, Sequeira RP. Drugs for treating severe hypertension in pregnancy: a network meta-analysis and trial sequential analysis of randomized clinical trials. Br J Clin Pharmacol 2018; 84:1906-1916. [PMID: 29974489 PMCID: PMC6089822 DOI: 10.1111/bcp.13649] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 05/16/2018] [Accepted: 05/17/2018] [Indexed: 12/29/2022] Open
Abstract
AIMS Several antihypertensive drugs are used in the treatment of severe hypertension in pregnancy. The present study is a network meta-analysis comparing the efficacy and safety of these drugs. METHODS Electronic databases were searched for randomized clinical trials comparing drugs used in the treatment of severe hypertension in pregnancy. The number of women achieving the target blood pressure (BP) was the primary outcome. Doses required and time taken for achieving the target BP, failure rate, and incidences of maternal tachycardia, palpitation, hypotension, headache, and neonatal death and stillbirth were the secondary outcomes. Mixed treatment comparison pooled estimates were generated using a random-effects model. Odds ratios for the categorical and mean difference for the numerical outcomes were the effect estimates. RESULTS Fifty-one studies were included in the systematic review and 46 in the meta-analysis. No significant differences in the number of patients achieving target BP was observed between any of the drugs. Diazoxide [-15 (-20.6, -9.4)], nicardipine [-11.8 (-22.3, -1.2)], nifedipine/celastrol [-19.3 (-27.4, -11.1)], nifedipine/vitamin D [-17.1 (-25.7, -9.7)], nifedipine/resveratrol [-13.9 (-22.6, -5.2)] and glyceryl trinitrate [-33.8 (-36.7, -31)] were observed to achieve the target BP (in minutes) more rapidly than hydralazine. Nifedipine required fewer doses than hydralazine for achieving the target BP. Glyceryl trinitrate and labetalol were associated with fewer incidences of tachycardia and palpitation respectively than hydralazine. Trial sequential analysis concluded adequate evidence for hydralazine and nifedipine compared with labetalol. Moderate quality of evidence was observed for direct comparison estimate between labetalol and hydralazine but was either low or very low for other comparisons. CONCLUSION The present evidence suggests similar efficacy between nifedipine, hydralazine and labetalol in the treatment of severe hypertension in pregnancy. Subtle differences may exist in their safety profile. The evidence is inadequate for other drugs.
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Affiliation(s)
- Kannan Sridharan
- Department of Pharmacology and Therapeutics, College of Medicine and Medical SciencesArabian Gulf UniversityManamaBahrain
| | - Reginald P. Sequeira
- Department of Pharmacology and Therapeutics, College of Medicine and Medical SciencesArabian Gulf UniversityManamaBahrain
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11
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Pretorius T, van Rensburg G, Dyer RA, Biccard BM. The influence of fluid management on outcomes in preeclampsia: a systematic review and meta-analysis. Int J Obstet Anesth 2017; 34:85-95. [PMID: 29398426 DOI: 10.1016/j.ijoa.2017.12.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 12/11/2017] [Accepted: 12/18/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND The optimal fluid management strategy to ensure best outcomes in preeclamptic patients remains a controversial issue, with little evidence to support any one approach. OBJECTIVE The aim of this systematic review was to investigate the effect of various fluid management strategies on clinical outcomes, haemodynamic indices and biochemical markers in preeclamptic women and their babies. Primary outcome measures were the occurrence of pulmonary oedema and/or the development of renal impairment. METHODS A systematic review of randomised fluid management strategies was conducted. Five electronic databases were searched using the expanded search terms: 'intravenous fluid', 'plasma substitutes', 'intravenous fluid management', 'intravenous fluid therapy', plasma volume expansion', 'fluid restriction', 'oncotic therapy', 'crystalloids', 'colloids', 'preeclampsia', 'toxemia of pregnancy', 'pregnancy-induced hypertension', 'eclampsia' and 'gestational proteinuric hypertension'. RESULTS Six randomised controlled trials (RCTs), from nine publications, were included in the final analysis. There were no differences between groups with respect to the incidence of pulmonary oedema, perinatal mortality, preterm delivery and caesarean section. Colloid volume expansion was associated with a significantly lower systolic and diastolic blood pressure, but had no effect on heart rate or cardiac index. Data on systemic vascular resistance (SVR), serum atrial natriuretic peptide (ANP) and urine volume could not be aggregated. CONCLUSION Data on the ideal fluid strategy in women with preeclampsia is limited, and insufficient to make any strong recommendations. Further randomised controlled studies are needed to provide more evidence for which fluid management strategies are best suited to this heterogeneous patient group.
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Affiliation(s)
- T Pretorius
- Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.
| | - G van Rensburg
- Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - R A Dyer
- Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - B M Biccard
- Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
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12
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Duffy J, Hirsch M, Pealing L, Showell M, Khan KS, Ziebland S, McManus RJ. Inadequate safety reporting in pre-eclampsia trials: a systematic evaluation. BJOG 2017; 125:795-803. [PMID: 29030992 DOI: 10.1111/1471-0528.14969] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Randomised trials and their syntheses in meta-analyses offer a unique opportunity to assess the frequency and severity of adverse reactions. OBJECTIVE To assess safety reporting in pre-eclampsia trials. SEARCH STRATEGY Systematic search using bibliographic databases, including Cochrane Central Register of Controlled Trials, Embase, and MEDLINE, from inception to August 2017. SELECTION CRITERIA Randomised trials evaluating anticonvulsant or antihypertensive medication for pre-eclampsia. DATA COLLECTION AND ANALYSIS Descriptive statistics appraising the adequacy of adverse reaction and toxicity reporting. MAIN RESULTS We included 60 randomised trials. Six trials (10%) were registered with the International Clinical Trials Registry Platform, two registry records referred to adverse reactions, stating 'safety and toleration' and 'possible side effects' would be collected. Twenty-six trials (43%) stated the frequency of withdrawals within each study arm, and five trials (8%) adequately reported these withdrawals. Adverse reactions were inconsistently reported across eligible trials: 24 (40%) reported no serious adverse reactions and 36 (60%) reported no mild adverse reactions. The methods of definition or measurement of adverse reactions were infrequently reported within published trial reports. CONCLUSIONS Pre-eclampsia trials regularly omit critical information related to safety. Despite the paucity of reporting, randomised trials collect an enormous amount of safety data. Developing and implementing a minimum data set could help to improve safety reporting, permitting a more balanced assessment of interventions by considering the trade-off between the benefits and harms. FUNDING National Institute for Health Research (DRF-2014-07-051), UK; Maternity Forum, Royal Society of Medicine, UK. TWEETABLE ABSTRACT Developing @coreoutcomes could help to improve safety reporting in #preeclampsia trials. @NIHR_DC.
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Affiliation(s)
- Jmn Duffy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.,Balliol College, University of Oxford, Oxford, UK
| | - M Hirsch
- Women's Health Research Unit, The Blizard Institute, Barts and the London School of Medicine and Dentistry, London, UK.,Royal Free London NHS Trust, London, UK
| | - L Pealing
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - M Showell
- Cochrane Gynaecology and Fertility Group, University of Auckland, Auckland, New Zealand
| | - K S Khan
- Women's Health Research Unit, The Blizard Institute, Barts and the London School of Medicine and Dentistry, London, UK
| | - S Ziebland
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - R J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Duffy JMN, Hirsch M, Kawsar A, Gale C, Pealing L, Plana MN, Showell M, Williamson PR, Khan KS, Ziebland S, McManus RJ. Outcome reporting across randomised controlled trials evaluating therapeutic interventions for pre-eclampsia. BJOG 2017; 124:1829-1839. [DOI: 10.1111/1471-0528.14702] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2017] [Indexed: 02/05/2023]
Affiliation(s)
- JMN Duffy
- Nuffield Department of Primary Care Health Sciences; University of Oxford; Oxford UK
| | - M Hirsch
- Women's Health Research Unit; Barts and the London School of Medicine and Dentistry; London UK
- Royal Free London NHS Trust; London UK
| | - A Kawsar
- Royal Free London NHS Trust; London UK
| | - C Gale
- Neonatal Medicine; Faculty of Medicine; Imperial College London; London UK
| | - L Pealing
- Nuffield Department of Primary Care Health Sciences; University of Oxford; Oxford UK
| | - MN Plana
- Clinical Biostatistics Unit; Ramon y Cajal Institute of Research and Centro de Investigación Biomédica en Red Epidemiology and Public Health; Madrid Spain
| | - M Showell
- Cochrane Gynaecology and Fertility Group; University of Auckland; Auckland New Zealand
| | - PR Williamson
- MRC North West Hub for Trials Methodology Research; Institute of Translational Medicine; University of Liverpool; Liverpool UK
| | - KS Khan
- Women's Health Research Unit; Barts and the London School of Medicine and Dentistry; London UK
| | - S Ziebland
- Nuffield Department of Primary Care Health Sciences; University of Oxford; Oxford UK
| | - RJ McManus
- Nuffield Department of Primary Care Health Sciences; University of Oxford; Oxford UK
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14
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15
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Foo L, Tay J, Lees CC, McEniery CM, Wilkinson IB. Hypertension in Pregnancy: Natural History and Treatment Options. Curr Hypertens Rep 2015; 17:36. [DOI: 10.1007/s11906-015-0545-1] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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16
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Johal T, Lees CC, Everett TR, Wilkinson IB. The nitric oxide pathway and possible therapeutic options in pre-eclampsia. Br J Clin Pharmacol 2015; 78:244-57. [PMID: 24313856 DOI: 10.1111/bcp.12301] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2013] [Accepted: 11/01/2013] [Indexed: 01/06/2023] Open
Abstract
Pre-eclampsia is a serious multisystem disorder with diverse clinical manifestations. Although not causal, endothelial dysfunction and reduced nitric oxide bioavailability are likely to play an important role in the maternal and fetal pathophysiology of this condition. Lack of treatment modalities that can target the underlying pathophysiological changes and reverse the endothelial dysfunction frequently leads to iatrogenic preterm delivery of the fetus, causing neonatal morbidity and mortality, and the condition itself is associated with short- and longer term maternal morbidity and mortality. Drugs that target various components of the nitric oxide-soluble guanylyl cyclase pathway can help to increase NO bioavailability. The purpose of this review is to outline the current status of clinical research involving these therapeutic modalities in the context of pre-eclampsia, with the focus being on the following: nitric oxide donors, including organic nitrates and S-nitrosothiols; l-arginine, the endogenous precursor of NO; inhibitors of cyclic guanosine 3',5'-monophosphate breakdown, including sildenafil; and other novel inhibitors of NO donor metabolism. The advantages and limitations of each modality are outlined, and scope for development into established therapeutic options for pre-eclampsia is explored.
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Affiliation(s)
- Tamanrit Johal
- Fetal Medicine Department, Rosie Hospital, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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17
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18
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Ornaghi S, Paidas MJ. Upcoming drugs for the treatment of preeclampsia in pregnant women. Expert Rev Clin Pharmacol 2014; 7:599-603. [DOI: 10.1586/17512433.2014.944501] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Spencer RN, Carr DJ, David AL. Treatment of poor placentation and the prevention of associated adverse outcomes--what does the future hold? Prenat Diagn 2014; 34:677-84. [PMID: 24799349 PMCID: PMC4265258 DOI: 10.1002/pd.4401] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 04/29/2014] [Accepted: 04/29/2014] [Indexed: 12/14/2022]
Abstract
Poor placentation, which manifests as pre-eclampsia and fetal growth restriction, is a major pregnancy complication. The underlying cause is a deficiency in normal trophoblast invasion of the spiral arteries, associated with placental inflammation, oxidative stress, and an antiangiogenic state. Peripartum therapies, such as prenatal maternal corticosteroids and magnesium sulphate, can prevent some of the adverse neonatal outcomes, but there is currently no treatment for poor placentation itself. Instead, management relies on identifying the consequences of poor placentation in the mother and fetus, with iatrogenic preterm delivery to minimise mortality and morbidity. Several promising therapies are currently under development to treat poor placentation, to improve fetal growth, and to prevent adverse neonatal outcomes. Interventions such as maternal nitric oxide donors, sildenafil citrate, vascular endothelial growth factor gene therapy, hydrogen sulphide donors, and statins address the underlying pathology, while maternal melatonin administration may provide fetal neuroprotection. In the future, these may provide a range of synergistic therapies for pre-eclampsia and fetal growth restriction, depending on the severity and gestation of onset.
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Affiliation(s)
- RN Spencer
- Institute for Women's Health, University College LondonLondon, UK
| | - DJ Carr
- Institute for Women's Health, University College LondonLondon, UK
| | - AL David
- Institute for Women's Health, University College LondonLondon, UK
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20
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Magee LA, Pels A, Helewa M, Rey E, von Dadelszen P. Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy. Pregnancy Hypertens 2014; 4:105-45. [PMID: 26104418 DOI: 10.1016/j.preghy.2014.01.003] [Citation(s) in RCA: 245] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 01/17/2014] [Indexed: 02/05/2023]
Abstract
OBJECTIVE This guideline summarizes the quality of the evidence to date and provides a reasonable approach to the diagnosis, evaluation and treatment of the hypertensive disorders of pregnancy (HDP). EVIDENCE The literature reviewed included the previous Society of Obstetricians and Gynaecologists of Canada (SOGC) HDP guidelines from 2008 and their reference lists, and an update from 2006. Medline, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Registry of Controlled Trials (CCRCT) and Database of Abstracts and Reviews of Effects (DARE) were searched for literature published between January 2006 and March 2012. Articles were restricted to those published in French or English. Recommendations were evaluated using the criteria of the Canadian Task Force on Preventive Health Care and GRADE.
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Affiliation(s)
| | - Anouk Pels
- Academic Medical Centre, Amsterdam, The Netherlands
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22
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Abstract
BACKGROUND Very high blood pressure during pregnancy poses a serious threat to women and their babies. The aim of antihypertensive therapy is to lower blood pressure quickly but safety, to avoid complications. Antihypertensive drugs lower blood pressure but their comparative effectiveness and safety, and impact on other substantive outcomes is uncertain. OBJECTIVES To compare different antihypertensive drugs for very high blood pressure during pregnancy. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group Trials Register (9 January 2013). SELECTION CRITERIA Studies were randomised trials. Participants were women with severe hypertension during pregnancy. Interventions were comparisons of one antihypertensive drug with another. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and assessed trial quality. Two review authors extracted data and checked them for accuracy. MAIN RESULTS Thirty-five trials (3573 women) with 15 comparisons were included. Women allocated calcium channel blockers were less likely to have persistent high blood pressure compared to those allocated hydralazine (six trials, 313 women; 8% versus 22%; risk ratio (RR) 0.37, 95% confidence interval (CI) 0.21 to 0.66). Ketanserin was associated with more persistent high blood pressure than hydralazine (three trials, 180 women; 27% versus 6%; RR 4.79, 95% CI 1.95 to 11.73), but fewer side-effects (three trials, 120 women; RR 0.32, 95% CI 0.19 to 0.53) and a lower risk of HELLP (haemolysis, elevated liver enzymes and lowered platelets) syndrome (one trial, 44 women; RR 0.20, 95% CI 0.05 to 0.81).Labetalol was associated with a lower risk of hypotension compared to diazoxide (one trial 90 women; RR 0.06, 95% CI 0.00 to 0.99) and a lower risk of caesarean section (RR 0.43, 95% CI 0.18 to 1.02), although both were borderline for statistical significance.Both nimodipine and magnesium sulphate were associated with a high incidence of persistent high blood pressure, but this risk was lower for nimodipine compared to magnesium sulphate (one trial, 1650 women; 47% versus 65%; RR 0.84, 95% CI 0.76 to 0.93). Nimodipine was associated with a lower risk of respiratory difficulties (RR 0.28, 95% CI 0.08 to 0.99), fewer side-effects (RR 0.68, 95% CI 0.55 to 0.85) and less postpartum haemorrhage (RR 0.41, 95% CI 0.18 to 0.92) than magnesium sulphate. Stillbirths and neonatal deaths were not reported.There are insufficient data for reliable conclusions about the comparative effects of any other drugs. AUTHORS' CONCLUSIONS Until better evidence is available the choice of antihypertensive should depend on the clinician's experience and familiarity with a particular drug; on what is known about adverse effects; and on women's preferences. Exceptions are nimodipine, magnesium sulphate (although this is indicated for women who require an anticonvulsant for prevention or treatment of eclampsia), diazoxide and ketanserin, which are probably best avoided.
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Affiliation(s)
- Lelia Duley
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, Nottingham, UK.
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Spezielle Arzneimitteltherapie in der Schwangerschaft. ARZNEIMITTEL IN SCHWANGERSCHAFT UND STILLZEIT 2012. [PMCID: PMC7271212 DOI: 10.1016/b978-3-437-21203-1.10002-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Trapani A, Gonçalves LF, Pires MMDS. Transdermal nitroglycerin in patients with severe pre-eclampsia with placental insufficiency: effect on uterine, umbilical and fetal middle cerebral artery resistance indices. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2011; 38:389-394. [PMID: 21374750 DOI: 10.1002/uog.8983] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
OBJECTIVES To evaluate the effect of transdermal nitroglycerin on Doppler velocity waveforms of the uterine, umbilical and fetal middle cerebral arteries in patients with severe pre-eclampsia. METHODS This was a prospective study of 30 singleton pregnancies (gestational age range: 24-31 weeks) with severe pre-eclampsia and abnormal uterine and umbilical artery Doppler waveforms. We compared maternal blood pressure as well as the resistance index (RI) and the pulsatility index (PI) of the uterine, umbilical and fetal middle cerebral arteries before and after application of a transdermal nitroglycerin patch (average dose 0.4 mg/h) for a period of 3 days. Intra-day comparisons before and after administration of nitroglycerin and a comparison between days 0 (no patch) and 3 after administration of the first dose of nitroglycerin were performed using ANOVA for paired samples. RESULTS A significant decrease in the PI and RI of the uterine (25.3 ± 4.9% and 21.2 ± 6.2%, respectively, P < 0.001) and umbilical (23.1 ± 6.9% and 19.7 ± 6.1%, respectively, P < 0.001) arteries was noted when comparing the first day without medication against the third day with the patch. No significant change in the PI and RI of the middle cerebral artery was observed. The mean arterial blood pressure decreased from 119.5 ± 4.5 mmHg to 114.8 ± 4.4 mmHg (P < 0.05). CONCLUSION The use of transdermal nitroglycerin in patients with severe pre-eclampsia is associated with a significant reduction in the RI and PI of the uterine and umbilical arteries, as well as of maternal blood pressure. Transdermal nitroglycerin does not affect the RI and PI of the fetal middle cerebral artery.
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Affiliation(s)
- A Trapani
- Hospital of Federal University of Santa Catarina, Florianópolis, SC, Brazil.
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25
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Magee LA, Abalos E, von Dadelszen P, Sibai B, Easterling T, Walkinshaw S. How to manage hypertension in pregnancy effectively. Br J Clin Pharmacol 2011; 72:394-401. [PMID: 21545480 PMCID: PMC3175509 DOI: 10.1111/j.1365-2125.2011.04002.x] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Accepted: 04/07/2011] [Indexed: 11/29/2022] Open
Abstract
The hypertensive disorders of pregnancy (HDP) are a leading cause of maternal mortality and morbidity in both well and under-resourced settings. Maternal, fetal, and neonatal complications of the HDP are concentrated among, but not limited to, women with pre-eclampsia. Pre-eclampsia is a systemic disorder of endothelial cell dysfunction and as such, blood pressure (BP) treatment is but one aspect of its management. The most appropriate BP threshold and goal of antihypertensive treatment are controversial. Variation between international guidelines has more to do with differences in opinion rather than differences in published data. For women with severe hypertension [defined as a sustained systolic BP (sBP) of ≥160 mmHg and/or a diastolic BP (dBP) of ≥110 mmHg], there is consensus that antihypertensive therapy should be given to lower the maternal risk of central nervous system complications. The bulk of the evidence relates to parenteral hydralazine and labetalol, or to oral calcium channel blockers such as nifedipine capsules. There is, however, no consensus regarding management of non-severe hypertension (defined as a sBP of 140-159 mmHg or a dBP of 90-109 mmHg), because the relevant randomized trials have been underpowered to define the maternal and perinatal benefits and risks. Although antihypertensive therapy may decrease the occurrence of BP values of 160-170/100-110 mmHg, therapy may also impair fetal growth. The potential benefits and risks do not seem to be associated with any particular drug or drug class. Oral labetalol and methyldopa are used most commonly, but many different β-adrenoceptor blockers and calcium channel blockers have been studied in clinical trials.
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Affiliation(s)
- Laura A Magee
- BC Women's Hospital and Heath Centre and University of British Columbia, 4500 Oak Street, Room D213, Vancouver, BC V6H 3N1, Canada.
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26
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Abstract
BACKGROUND Very high blood pressure during pregnancy poses a serious threat to women and their babies. Antihypertensive drugs lower blood pressure. Their comparative effects on other substantive outcomes, however, is uncertain. OBJECTIVES To compare different antihypertensive drugs for very high blood pressure during pregnancy. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group Trials Register (28 February 2006) and CENTRAL (The Cochrane Library 2006, Issue 2). SELECTION CRITERIA Studies were randomised trials. Participants were women with severe hypertension during pregnancy. Interventions were comparisons of one antihypertensive drug with another. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data. MAIN RESULTS Twenty-four trials (2949 women) with 12 comparisons were included. Women allocated calcium channel blockers rather than hydralazine were less likely to have persistent high blood (five trials, 263 women; 6% versus 18%; relative risk (RR) 0.33, 95% confidence interval (CI) 0.15 to 0.70). Ketanserin was associated with more persistent high blood pressure than hydralazine (four trials, 200 women; 27% versus 6%; RR 4.79, 95% CI 1.95 to 11.73), but fewer side-effects (three trials, 120 women; RR 0.32, 95% CI 0.19 to 0.53) and a lower risk of HELLP (Haemolysis, Elevated Liver enzymes and Lowered Platelets) syndrome (one trial, 44 women, RR 0.20, 95% CI 0.05 to 0.81). Labetalol was associated with a higher risk of hypotension (one trial 90 women; RR 0.06, 95% CI 0.00 to 0.99) and caesarean section (RR 0.43, 95% CI 0.18 to 1.02) than diazoxide. Data were insufficient for reliable conclusions about other outcomes. The risk of persistent high blood pressure was greater for nimodipine compared to magnesium sulphate (two trials 1683 women; 47% versus 65%; RR 0.84, 95% CI 0.76 to 0.93). Nimodipine was also associated with a higher risk of eclampsia (RR 2.24, 95% CI 1.06 to 4.73) and respiratory difficulties (RR 0.28, 95% CI 0.08 to 0.99), but fewer side-effects (RR 0.68, 95% CI 0.54 to 0.86) and less postpartum haemorrhage (RR 0.41, 95% CI 0.18 to 0.92) than magnesium sulphate. Stillbirths and neonatal deaths were not reported. There are insufficient data for reliable conclusions about the comparative effects of any other drugs. AUTHORS' CONCLUSIONS Until better evidence is available, the choice of antihypertensive should depend on the clinician's experience and familiarity with a particular drug, and on what is known about adverse effects. Exceptions are diazoxide, ketanserin, nimodipine and magnesium sulphate, which are probably best avoided.
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Affiliation(s)
- L Duley
- University of Oxford, Nuffield Department of Medicine, Room 5609, Level 5, John Radcliffe Hospital, Headington, Oxford, UK OX3 9DU.
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