Propranolol for the treatment of hypertension in pregnancy

Pregnancy Arrhythmias: Management in the Emergency Department and Critical Care

Pregnancy is closely associated with an elevated risk of arrhythmias, constituting the predominant cardiovascular complication during this period. Pregnancy may induce the exacerbation of previously controlled arrhythmias and, in some instances, arrhythmias may present for the first time in pregnancy. The most important proarrhythmic mechanisms during pregnancy are the atrial and ventricular stretching, coupled with increased sympathetic activity. Notably, arrhythmias, particularly those originating in the ventricles, heighten the likelihood of syncope, increasing the potential for sudden cardiac death. The effective management of arrhythmias during the peripartum period requires a comprehensive, multidisciplinary approach from the prepartum to the postpartum period. The administration of antiarrhythmic drugs during pregnancy necessitates meticulous attention to potential alterations in pharmacokinetics attributable to maternal physiological changes, as well as the potential for fetal adverse effects. Electric cardioversion is a safe and effective intervention during pregnancy and should be performed immediately in patients with hemodynamic instability. This review discusses the pathophysiology of arrythmias in pregnancy and their management.

The Risk for Neonatal Hypoglycemia and Bradycardia after Beta-Blocker Use during Pregnancy or Lactation: A Systematic Review and Meta-Analysis

Beta-blockers are often used during pregnancy to treat cardiovascular diseases. The described neonatal side effects of maternal beta-blocker use are hypoglycemia and bradycardia, but the evidence base for these is yet to be evaluated comprehensively. Hence, this systematic review and meta-analysis was performed to evaluate the potential increased risk for hypoglycemia and bradycardia in neonates exposed to beta-blockers in utero or during lactation. A systematic search of English-language human studies was conducted until 21 April 2021. Both observational studies and randomized controlled trials investigating hypoglycemia and/or bradycardia in neonates following beta-blocker exposure during pregnancy and lactation were included. All articles were screened by two authors independently and eligible studies were included. Pair-wise and proportion-based meta-analysis was conducted and the certainty of evidence (CoE) was performed by standard methodologies. Of the 1.043 screened articles, 55 were included in this systematic review. Our meta-analysis showed a probable risk of hypoglycemia (CoE—Moderate) and possible risk of bradycardia (CoE—Low) in neonates upon fetal beta-blocker exposure. Therefore, we suggest the monitoring of glucose levels in exposed neonates until 24 h after birth. Due to the limited clinical implication, monitoring of the heart rate could be considered for 24 h. We call for future studies to substantiate our findings.

Arrhythmias in Pregnancy

Increasing maternal mortality and incidence of arrhythmias in pregnancy have been noted over the past 2 decades in the United States. Pregnancy is associated with a greater risk of arrhythmias, and patients with a history of arrhythmias are at significant risk of arrhythmia recurrence during pregnancy. The incidence of atrial fibrillation in pregnancy is rising. This review discusses the management of tachyarrhythmias and bradyarrhythmias in pregnancy, including management of cardiac arrest. Management of fetal arrhythmias are also reviewed. For patients without structural heart disease, β-blocker therapy, especially propranolol and metoprolol, and antiarrhythmic drugs, such as flecainide and sotalol, can be safely used to treat tachyarrhythmias. As a last resort, catheter ablation with minimal fluoroscopy can be performed. Device implantation can be safely performed with minimal fluoroscopy and under echocardiographic or ultrasound guidance in patients with clear indications for devices during pregnancy. Because of rising maternal mortality in the United States, which is partly driven by increasing maternal age and comorbidities, a multidisciplinary and/or integrative approach to arrhythmia management from the prepartum to the postpartum period is needed.

Perinatal anxiety: approach to diagnosis and management in the obstetric setting

Anxiety is common in women during the perinatal period, manifests with various symptoms and severity, and is associated with significant maternal morbidity and adverse obstetric and neonatal outcomes. Given the intimate relationship and frequency of contact, the obstetric provider is positioned optimally to create a therapeutic alliance and to treat perinatal anxiety. Time constraints, absence of randomized controlled trials, mixed quality of data, and concern for potential adverse reproductive outcomes all limit the clinician's ability to initiate informed risk-benefit discussions. Clear understanding of the role of the obstetric provider in the identification, stabilization, and initiation of medication and/or referral to psychotherapy for women with perinatal anxiety disorders is critical to maternal and neonatal wellbeing. Informed by our clinical practice as perinatal psychiatric providers, we have provided a concise summary of current research on the approach to the treatment of perinatal anxiety disorders in the obstetric setting that includes psychotherapy and supportive interventions, primary and adjuvant psychiatric medication, and general prescribing pearls. Medications that we examined include antidepressants, benzodiazepines, sedative-hypnotics, antihistamines, quetiapine, buspirone, propranolol, and melatonin. Further research into management of perinatal anxiety, particularly psychopharmacologic management, is warranted.

Labetalol, a combined alpha- and beta-blocker, in hypertension of pregnancy

Labetalol was given to women with hypertension of pregnancy in their last trimester to study its acute effect on circulation and metabolism. Seven women were given 50 mg labetalol i v. There was a significant decrease of blood pressure from a mean of 143/101 +/- 4/2 (SEM) to 127/88 +/- 5/2 mm Hg. Maternal heart rate fell significantly from 77 +/- 5 to 68 +/- 3 beats per min. These changes persisted during a three-hour observation period. The hypotensive response was accompanied by a significant increase in plasma noradrenaline from 1.54 +/- 0.16 to 2.37 +/- 0.41 nmol/l, suggesting sympathetic activation. Plasma cyclic AMP, which is increased by beta 2-adrenoceptor stimulation, was significantly elevated after labetalol. This supports the hypothesis of partial beta-agonist activity of labetalol. Lipid metabolism, as judged from measurements of plasma FFA, glycerol and 3-hydroxybuturic acid, showed little change. The acute effect of labetalol on uteroplacental blood flow was determined in eight women with pregnancy hypertension using a gammacamera on line with a computer. 0.5 mCi indium-113m was given i v before and 30 min after labetalol was administered i v in a dose of 1 mg per kg body weight. After the injections of indium-113m, serial scintigrams were recorded during 10 s periods for 240 s. By computerized summation of the scintigrams, an image was obtained in which the placenta could be outlined for time-activity analysis of the isotope accumulation curve. From this curve a uteroplacental blood flow index could be calculated. Labetalol induced a significant drop of mean arterial blood pressure from 114 +/- mm Hg to 100 +/- 3 mm Hg after 30 min in this group of women. However, the uteroplacental blood flow index did not change. As we have earlier shown with this technique that uteroplacental blood flow can be severely impaired in hypertension of pregnancy, the finding of substained uteroplacental blood flow simultaneously with a decrease in blood pressure should be of clinical importance. Taken together with other studies of clinical effects, these results indicate that labetalol is useful in the treatment of hypertension of pregnancy.

Cardiovascular pharmacotherapeutic considerations during pregnancy and lactation

Cardiovascular drugs are often used in pregnancy for the treatment of maternal and fetal conditions. Mothers could also require continued postpartum drug therapy. Most cardiovascular drugs taken by pregnant women can cross the placenta and therefore expose the developing embryo and fetus to their pharmacologic and teratogenic effects. These effects are influenced by the intrinsic pharmacokinetic properties of a given drug as well as by the complex physiological changes occurring during pregnancy. Many drugs are also transferred into human milk and therefore can potentially have adverse effects on the nursing infant. This 2-part article summarizes some of the available literature concerning the risks and benefits of using various cardiovascular drugs and drug classes during pregnancy and lactation. Included in the discussion are cardiac glycosides, antiarrhythmic drugs, drugs used to treat both acute and chronic hypertension, cholesterol-lowering agents, anticoagulants, thrombolytics, and antiplatelet drugs.

Influence of pregnancy on the risk for cardiac events in patients with hereditary long QT syndrome. LQTS Investigators

BACKGROUND

The effects of pregnancy on women with the hereditary long QT syndrome are currently unknown. The appropriate medical management of pregnant patients with the long QT syndrome has not been established.

METHODS AND RESULTS

The study was a retrospective analysis of the 422 women (111 probands affected with the long QT syndrome and 311 first-degree relatives) enrolled in the long QT syndrome registry who had one or more pregnancies. The first-degree relatives were classified as affected (QTc >0.47), borderline (QTc=0.45 to 0.47), and unaffected (QTc <0.45). Cardiac events were defined as the combined incidence of long QT syndrome-related death, aborted cardiac arrest, and syncope. The incidence of cardiac events was compared during equal prepregnancy, pregnancy, and postpartum intervals (40 weeks each). Multivariate logistic regression analysis was performed by use of a mixed-effects model to identify independent predictors of cardiac events among probands. The pregnancy and postpartum intervals were not associated with cardiac events among first-degree relatives. The postpartum interval was independently associated with cardiac events among probands (odds ratio [OR], 40.8; 95% confidence interval [CI], 3.1 to 540; P=.01); the pregnancy interval was not associated with cardiac events. Treatment with beta-adrenergic blockers was independently associated with a decrease in the risk for cardiac events among probands (OR, 0.023; 95% CI, 0.001 to 0.44; P=.01).

CONCLUSIONS

The postpartum interval is associated with a significant increase in risk for cardiac events among probands with the long QT syndrome but not among first-degree relatives. Prophylactic treatment with beta-adrenergic blockers should be continued during the pregnancy and postpartum intervals in probands with the long QT syndrome.

[Arrhythmias and pregnancy]

Although arrhythmias are one of the most frequent consultations during pregnancy, fortunately the majority are benign. Usually, they are well tolerated assuming they occur in patients with structurally normal hearts. However, pregnancy adds a new aspect to the so called "arrhythmia tolerance", because arrhythmia and therapy may jeopardize the fetus. For acute treatment of narrow and wide tachycardias, with few exceptions, antiarrhythmic medications appear to be safe. In addition to the relative security of drugs such as adenosine, digoxin, propranolol, procainamide and flecainide, we could use direct current countershock with no evidence of significant complications. Because no drug is absolutely safe, chronic pharmacologic therapy is best avoided during pregnancy. Finally, radiofrequency ablation could be recommended as an alternative in women with previous tachycardias who would like to become pregnant.

New-onset ventricular tachycardia during pregnancy

During evaluation for palpitations, presyncope, or syncope, seven pregnant women had documented ventricular tachycardia. Before pregnancy none had a history of significant cardiac disease or symptomatic arrhythmia. The tachycardia rate ranged from 117 to 250 beats/min and lasted up to 65 seconds. Arrhythmia evaluation in five of the patients suggested catecholamine-sensitive ventricular tachycardia. This diagnosis was supported by either a positive relation to exercise or isoproterenol infusion, suppression of arrhythmia by beta-blockade or sleep, and lack of induction of arrhythmia by programmed electrical stimulation of the heart. The arrhythmias resolved in one patient soon after evaluation and in one other patient after 2 months of controlling therapy. Five other patients continued to receive therapy throughout pregnancy. Delivery was accomplished in all patients without significant maternal or neonatal complications.

Behavioral and biochemical studies in rats following prenatal treatment with beta-adrenoceptor antagonists

Increased motor activity and poor performance in the active avoidance test were observed in the offspring of rats treated with dl-propranolol or sotalol during pregnancy, but not with atenolol and d-propranolol. All substances were administered in drinking water from days 8-22 of gestation. A significant increase in the density of muscarinic acetylcholine receptors in the hippocampus was found for dl-propranolol and sotalol, at 35 and 20 days of age, respectively. Twenty-day-old pups born to dl-propranolol-treated rats exhibited a non-significant decrease in the number of beta-adrenoceptors in the frontal cortex. Assuming that all the beta-adrenoceptor antagonists tested had access to the developing fetal brain, the effect of dl-propranolol and sotalol on behavior could stem from central beta 2-adrenoceptor blockade. In view of the lack of behavioral changes after atenolol, a beta 1-selective adrenoceptor antagonist, it is suggested that the clinical use of beta 1-selective adrenoceptor antagonists during pregnancy might be safer for the fetus than beta 2-adrenoceptor antagonists.

Transplacental and mammary passage of radioactivity in rats treated vaginally and orally with [14C]propranolol

The milk transfer, maternal-fetal distribution, and disposition of the antihypertensive/spermicidal agent propranolol were studied in pregnant and lactating rats. Single doses (10 mg/kg) of an aqueous solution of [14C]propranolol were administered either orally (po) or intravaginally (ivg) on gestational d 15, or on postpartum d 7-10. Upon ivg administration, [14C]propranolol was quickly transferred to systemic circulation and the mean blood [14C] concentrations were significantly greater during the first 0.25-2 h than in po dosed counterparts. About 98% of the ivg applied dose was absorbed after 6 h in gravid rats, and the combined 6-h excretions of radioactivity in the urine (ivg = 24.6%; po = 22.9%) and feces (ivg = 16.8%; po = 14.6%) were equivalent in both groups. At the end of 6 h, the levels of [14C] in the urinary bladder, adrenal, uterus, ovary, spleen, skeletal muscle, brain, heart, lung and fat were significantly higher in ivg treated rats than po dosed animals. Compared with the maternal plasma (ivg = 0.76; po = 0.88 microgram/ml), the mean concentrations of [14C] in the placentas were similar in both groups, while the amounts of [14C] were three to five times lower in the amniotic fluids and the fetuses of both po and ivg treated dams. In lactating rats, over 99% of the administered radioactivity was absorbed from the vagina within 6 h. The blood concentrations of [14C] were significantly elevated at 0.5 and 1 h in the per vaginam treated animals, and afterward the disappearance rate of [14C] followed a similar course in both groups. Following ivg application, the milk radioactivity peaked at 0.5 h and declined rapidly. However, the appearance of [14C] in milk was rather slow after oral dosing: the milk [14C] peaked between 2 and 3 h posttreatment and remained steady thereafter. The milk to blood (M/B) [14C] concentration ratios were markedly greater during 0.5 to 1 h in the ivg group than in their po dosed counterparts. At 6 h, the [14C] levels in the whole blood, plasma, milk, and mammary gland were virtually equivalent in the ivg and po treated females. Comparison of the areas under the milk [14C] concentration-time curves (AUCs) indicated that the milk availability of [14C] was about 31% more in dams dosed vaginally. These data suggest that route of administration alters the disposition and milk excretion of [14C]propranolol-derived radioactivity in pregnant and lactating rats.

Nifedipine as a second line antihypertensive drug in pregnancy

Slow-release nifedipine has been used in the treatment of severe hypertension in 23 pregnant women. In 22 this was in combination with other drugs, in 18 including atenolol. Good control of blood pressure was achieved in 20 women. The perinatal mortality of the group was 130/1000, with a high caesarean section rate (71% of live-births), a high rate of abnormal CTGs, a high rate of premature delivery, and a high rate of infants who were small-for-dates. Whether this is due to the disease process or the medication is uncertain. For the present time these combinations should only be used in severe hypertensives or in the context of a controlled trial.

Impact of beta 1 selectivity and intrinsic sympathomimetic activity on potential unwanted noncardiovascular effects of beta blockers

Beta-adrenoceptor-blocking drugs are widely used as effective antihypertensive and antianginal agents, but treatment with these agents may be contraindicated in hypertensive patients in whom receptor blockade would interfere with noncardiovascular activities dependent on sympathetic drive. beta blockade impairs pulmonary function in asthmatic patients through antagonism of beta 2 bronchodilation. However, patients with chest problems may be treated effectively with beta 1-selective drugs, including acebutolol, atenolol and metoprolol. The metabolic response to hypoglycemia, which is mediated by beta-receptor stimulation, involves insulin release, gluconeogenesis, tachycardia and increased systolic pressure. Beta 1-selective drugs are preferred in patients who need to increase blood glucose levels because they do not interfere with glycogenolysis. Hypertension induced by pregnancy may be treated with a beta blocker with no apparent adverse effects on the fetus or neonate. Those possessing intrinsic sympathomimetic activity may be preferable.

Treatment of hypertension in pregnancy with methyldopa: a randomized double blind study

Twenty-five patients whose pregnancies were complicated by chronic hypertension were entered in a double-blind study and randomly allocated to treatment with methyldopa (Aldomet) or placebo. Thirteen patients were in the treatment group and 12 in the placebo group. The two groups showed no significant difference in demographic and pretreatment laboratory profiles. Methyldopa-treated patients registering in the first trimester had a significant reduction in the mean arterial pressure (MAP) during the second and third trimesters (P less than 0.025). No significant differences in birth weight (BW), ponderal index (PI) were found when results were corrected for gestational age (GA), race, and sex. The mean GA was significantly prolonged in the methyldopa-treated group by 10.3 days (P less than 0.05). The frequency of superimposed pre-eclampsia was similar in both groups (33.3% vs. 38.4%). However, 75% of the superimposed pre-eclampsia occurred antepartum in the placebo group, while 80% of the methyldopa-treated group developed superimposed pre-eclampsia intrapartum. The results of this small study suggest that the treatment of hypertension in pregnancy may reduce MAP and possibly delay the occurrence of superimposed pre-eclampsia and thus afford a prolongation of the pregnancy.

Hemodynamic changes after chronic pindolol administration in pregnant renal hypertensive rats

The aim of the present study on pregnant renal hypertensive rats was to investigate the effects on central hemodynamics and uteroplacental blood flow after chronic administration of pindolol, a nonspecific beta-adrenergic receptor blocking agent with intrinsic beta-stimulatory effect. Renal hypertension was induced by partial clamping of both renal arteries four weeks before pregnancy. Pindolol was administered with the food during the entire pregnancy period. Two to four days before expected delivery mean arterial pressure, heart rate, cardiac output, (dye-dilution technique) and utero-placental blood supply (microsphere technique) were determined. The chronic pindolol treatment reduced heart rate by 25 per cent while both mean arterial pressure and cardiac output remained unchanged. However, blood flow to uterus and placentae was reduced by 43 and 64 per cent, respectively, after pindolol treatment. Clinical as well as experimental studies (15, 16) demonstrate a reduced utero-placental blood supply when pregnancies are complicated by hypertension. As pregnancies with severe hypertension are associated with an increased frequency of intrauterine growth retardation and intrauterine asphyxia the present results indicate that the combination of hypertension and long-term treatment with beta-blockers might reduce utero-placental blood flow enough as to seriously interfere with fetal oxygen supply thereby increasing the risk of intra- and extra-uterine asphyxia.

Effect of propranolol treatment in pregnant rats on motor activity and avoidance learning of the offspring

Rats born to mothers treated with propranolol, during days 8-22 of gestation, displayed hyperactivity in the open field which lasted up to 60 days of age and an impairment of avoidance in the shuttle box which was more marked in the male rats. Females exhibited hyperactivity in the open field but developed impaired avoidance learning only when exposed prenatally to both propranolol and hypoxia. Propranolol administration during the last term of pregnancy (days 18-22) affected mostly shuttle box performance. In contrast, hyperactivity could be induced by treatment during various stages of pregnancy, (days 8-22, 8-18, or 18-22) with the duration of hyperactivity being directly related to the length of treatment of the mothers. The possible mechanism of the disruptive effect of propranolol in the fetus and newborn is discussed.

Beta-adrenoceptor blocking drugs: adverse reactions and drug interactions

Beta adrenoceptor blocking drugs are relatively well tolerated and adverse reactions to them are not common. The ones that do occur are reviewed in this paper under the following headings: Short term adverse reactions, drug interactions, long term adverse reactions, risks in pregnancy and hazards of abrupt withdrawal. Predictable short term effects may be caused either by the actions of these drugs on the beta 1- or beta 2-receptors. The beta 1 adverse effects are hypotension, bradycardia and cardiac failure; these are best avoided by not giving beta-adrenoceptor blocking drugs to susceptible patients with cardiac disease. The beta 2 adverse effects on the bronchi, the peripheral arteries and various metabolic functions may be reduced to some extent by using a relatively cardioselective drug. Unpredictable short term effects such as fatigue, sexual dysfunction and gastrointestinal symptoms may occur but are not common problems with this group of drugs. Similarly, serious drug interactions are infrequent. Under the heading of long term adverse effects the practolol problem and the risk of causing malignant disorders have been considered. There is no evidence that any of the currently available drugs will cause either a practolol syndrome or malignant disease in man. However, the need for careful appraisal by drug regulatory bodies and continued vigilance by all prescribers of beta-adrenoceptor blocking drugs remains. The possible adverse effects of treatment during pregnancy are also considered. It now appears that beta-adrenoceptor drugs can be used safely in pregnancy but since neonatal bradycardia and hypoglycemia may occur, care should be taken to look for these complications. A serious deterioration may occur when beta-adrenoceptor drugs, given to patients with significant ischemic heart disease, are suddenly stopped. This is a rare occurrence but prescribers should be aware of it.

Pindolol: a review of its pharmacology, pharmacokinetics, clinical uses, and adverse effects

Pindolol is a new noncardioselective beta adrenergic blocking agent with intrinsic sympathomimetic activity. In the treatment of mild to moderate hypertension, pindolol provides effective control of blood pressure in a large majority of patients when administered alone or, more commonly, when combined with a thiazide diuretic. Pindolol is approximately as effective as propranolol in the therapy of hypertension, but in some crossover trials central nervous system side effects were more frequent with pindolol. A "ceiling effect" may be observed as dosages are titrated upward above approximately 20 to 30 mg per day, such that further blood pressure reductions may not be achievable. Some patients will exhibit a paradoxical increase in blood pressure with an increase in dosage. In patients who respond to modest doses of pindolol, twice or even once daily dosing is often adequate. This prolonged duration of hypotensive activity, while not suggested by the kinetics of this or similar drugs, is probably common to most beta blockers. Investigations in small numbers of patients with angina pectoris have reported variable but generally beneficial results with pindolol.

Atenolol in the treatment of pregnancy-induced hypertension

1 The pharmacological properties of atenolol suggest its possible usefulness in pregnancy-induced hypertension. The pharmacokinetics of atenolol in the pregnant woman, concentrations in cord blood, and its effects on maternal blood pressure and the foetus, are evaluated. 2 We studied 13 pregnant women with hypertension, most of them uncontrolled on methyldopa. Whole blood concentrations and urinary excretion of the drug were measured over 24 h following a 100 mg dose. Effects on maternal blood pressure, pulse rate and foetal heart rate and cardiotocograph were compared for the 4 days before treatment and the first 4 days of treatment. The birth weights and Apgar scores of the babies were recorded. 2 The pharmacokinetics of atenolol (plasma half-life of about 8 h) in pregnant women do not differ from the findings in the non-pregnant. The levels of atenolol in the cord blood were confirmed as approximately equal to those in the maternal blood. 4 In the ten women in whom blood pressure was assessed a small significant fall in blood pressure was observed. 5 A 5% mean fall in foetal heart rate resulted but in one case was a rate below 120 beats/min recorded. There was no evidence of depression of the stress response of the foetal heart. Apgar scores 5 min post partum were satisfactory. 6 Atenolol appears to be safe for use in hypertensive pregnancies. Its effectiveness as an antihypertensive agent in pregnancy requires further controlled evaluation.

Neonatal effects of maternal administration of acebutolol

Systolic blood pressure, heart rate, and blood glucose concentration were measured in the first three days of life in 10 infants born to mothers who had received acebutolol, a cardioselective beta-adrenergic-blocking agent, for hypertension in pregnancy and compared with values in 10 infants whose mothers had received methyldopa. The blood pressure was expressed as a percentage of the expected value. Blood pressure was significantly lower in the infants of the mothers given acebutolol (p less than 0.02, less than 0.01, and less than 0.01 respectively during the three days of observation). Heart rate was also lower, but the significance was only at the 0.05 level. Blood glucose was not significantly different between the two groups. These results suggest that care should be taken in prescribing beta-adrenergic-blocking drugs during pregnancy.

Circulatory and metabolic effects of a combined alpha- and beta-adrenoceptor blocker (labetalol) in hypertension of pregnancy

1 Seven women with hypertension of pregnancy were given the combined alpha- and beta-adrenoceptor blocking drug labetalol (50 mg i.v.) in their last trimester. Acute effects were studied for 3 h after administration. 2 Systolic and diastolic blood pressures were significantly reduced from 143 +/- 4 (s.e. mean) to 127 +/- 5 mmHg and from 101 +/- 2 to 88 +/- 2 mmHg, respectively. Maternal heart rate fell significantly from 77 +/- 5 to 68 +/- 3 beats/min. The changes remained during the 3 h of observation. Foetal heart rate was not affected. No side-effects were encountered. 3 Plasma noradrenaline increased significantly from 1.54 +/- 0.16 to a peak value of 2.37 +/- 0.41 nmol/l suggesting sympathetic activation following labetalol. Plasma adrenaline levels were essentially unchanged. Plasma glucose, insulin and C-peptide showed only minor changes. No major effects on lipid metabolism were seen except a significant fall of nonesterified fatty acids at 60 min. Plasma cyclic AMP increased significantly throughout the observation period, perhaps indicating beta-adrenoceptor agonist activity of labetalol. 4 The effectiveness of labetalol as an acute hypertensive agent together with apparent absence of metabolic disturbances and other side-effects makes it an interesting drug for the treatment of hypertension during pregnancy.

Anti-hypertensive therapy with propranolol during pregnancy and lactation

A hypertensive women was treated throughout pregnancy with propranolol 40 mg daily without complication. At delivery the umbilical cord plasma concentration was similar to that in the maternal venous plasma. Milk:plasma ratios were less than 1, although a higher ratio would be predicted. Estimated daily intake of propranolol in breast milk by the infant was about 3 micrograms. There appears to be no reason to advise women receiving propranolol to avoid breast feeding.

The treatment of hypertension in pregnancy

The drug treatment of hypertension occurring during pregnancy is described. Diagnostic problems and management are outlined, and the available literature regarding the use of standard hypotensive agents in pregnancy is reviewed by drug class. Based on currently published literature and opinion, the following drugs are recommended when needed during pregnancy (with proper monitoring) : methyldopa, hydralazine, and furosemide. Caution is recommended when the following drugs are used during pregnancy: propranolol, and thiazide diuretics. The following drugs are not recommended for use during pregnancy based on currently available information: reserpine, clonidine, chlorthalidone, prazosin, minoxidil, spironolactone, ethacrynic acid, metoprolol, nadolol, and guanethidine.

Successful pregnancy soon after oral contraceptive-associated malignant hypertension

A woman who developed malignant hypertension while taking a very low oestrogen oral contraceptive underwent an uncomplicated pregnancy conceived 3 months later. Her BP was well controlled with propranolol alone.

Propranolol and hydrallazine in the management of essential hypertension in pregnancy

A combination of propranolol and hydrallazine was administered to 13 patients with longstanding hypertension during 15 pregnancies. Hydrallazine was continued through labour and delivery in all patients, while in eight patients propranolol was discontinued 2 to 15 days before delivery. Blood pressure control was uniformly good and superimposed pre-eclampsia did not occur during combined therapy. There were 14 livebirths and one unexplained stillbirth. Except for two cases of milk hypoglycemia, there were no neonatal complications.

Comparison of the alpha and beta blocking drug, labetalol, and methyl dopa in the treatment of moderate and severe pregnancy-induced hypertension

Twentysix women with pregnancy-induced hypertension have been randomly treated with either labetalol or Aldomet. A more satisfactory control of blood pressure was obtained with labetalol with minimal side-effects. After two weeks of treatment with labetalol renal function had significantly improved with a markedly lower incidence of proteinuria. More patients went into spontaneous labour following labetalol than following Aldomet; the Bishop score was also higher in this group. No adverse effects attributable to labetalol were noted in the baby either ante- or post-natally.