Mechanisms of vasodilatation in pregnancy: studies of the role of prostaglandins and nitric-oxide in changes of vascular reactivity in the in situ blood perfused mesentery of pregnant rats

Protocol for management of pregnant patients requiring emergency minor oral surgical procedures: a prospective study in 52 patients

Objectives

Dental or maxillofacial emergencies are uncommon during pregnancy, but if they occur, they are challenging to treat due to potential risks. The mother should not be denied necessary medical or dental care because of pregnancy. The aim of the study is to observe outcomes of pregnancy in patients requiring emergency minor oral surgical procedures during gestation and to determine the safety of the pregnant woman undergoing the procedure and the fetus.

Materials and Methods

The study was conducted on 52 pregnant women requiring emergency oral surgical procedures. A standard treatment protocol for treatment of specific entities was followed. Close monitoring and observation were the primary goal of treatment. All patients were followed postoperatively until complete recovery from the surgical procedures and then until birth of the baby. A control group of 52 healthy pregnant patients who did not require oral surgical procedures was considered for statistical analysis. The measurements to calculate observation were fetal loss (spontaneous abortion), preterm birth, low-birth weight, or incidence of any congenital anomalies in the baby and its association with surgical procedures.

Results

No fetal loss occurred in any of the cases. However, four patients experienced preterm birth and seven neonates exhibited low birth weights. No congenital abnormalities were discovered. In one instance, a patient who underwent surgery for a mandibular symphysis fracture under general anesthesia in the 31st week of pregnancy experienced labor pain on the fourth postoperative day, requiring an emergency Caesarean section.

Conclusion

The results of our study demonstrate that, compared to the control group, minor emergency surgeries performed during pregnancy have no discernible negative effects on the fetus. These procedures can safely be performed by adhering to our described protocols.

Evidence of Nitric Oxide Impairment During Hypertensive Pregnancies

Hypertensive disorders of pregnancy complicate up to 10% of pregnancies worldwide, and they can be classified into (1) gestational hypertension, (2) preeclampsia, (3) chronic hypertension and (4) chronic hypertension with preeclampsia. Nitric oxide (NO) plays an essential role in the haemodynamic adaptations observed during pregnancy. It has been shown that the nitric oxide pathway's dysfunction during pregnancy is associated with placental- and vascular-related diseases such as hypertensive disorders of pregnancy. This review aims to present a brief definition of hypertensive disorders of pregnancy and physiological maternal cardiovascular adaptations during pregnancy. We also detail how NO signalling is altered in the (a) systemic vasculature, (b) uterine artery/spiral arteries, (c) implantation and (d) placenta of hypertensive disorders during pregnancy. We conclude by summarizing the anti-hypertensive therapy of hypertensive disorders of pregnancy as a specific management strategy.

Pathophysiology of Preeclampsia and L-Arginine/L-Citrulline Supplementation as a Potential Strategy to Improve Birth Outcomes

In preeclampsia, the shallow invasion of cytotrophoblast cells to uterine spiral arteries, leading to a reduction in placental blood flow, is associated with an imbalance of proangiogenic/antiangiogenic factors to impaired nitric oxide (NO) production. Proangiogenic factors, such as vascular endothelial growth factor (VEGF) and placental growth factor (PlGF), require NO to induce angiogenesis through antioxidant regulation mechanisms. At the same time, there are increases in antiangiogenic factors in preeclampsia, such as soluble fms-like tyrosine kinase type 1 receptor (sFIt1) and toll-like receptor 9 (TLR9), which are mechanism derivates in the reduction of NO bioavailability and oxidative stress in placenta.Different strategies have been proposed to prevent or alleviate the detrimental effects of preeclampsia. However, the only intervention to avoid the severe consequences of the disease is the interruption of pregnancy. In this scenario, different approaches have been analysed to treat preeclamptic pregnant women safely. The supplementation with amino acids is one of them, especially those associated with NO synthesis. In this review, we discuss emerging concepts in the pathogenesis of preeclampsia to highlight L-arginine and L-citrulline supplementation as potential strategies to improve birth outcomes. Clinical and experimental data concerning L-arginine and L-citrulline supplementation have shown benefits in improving NO availability in the placenta and uterine-placental circulation, prolonging pregnancy in patients with gestational hypertension and decreasing maternal blood pressure.

Caveolin-1/Endothelial Nitric Oxide Synthase Interaction Is Reduced in Arteries From Pregnant Spontaneously Hypertensive Rats

We have investigated the role caveolae/caveolin-1 (Cav-1) plays in endothelial nitric oxide synthase (eNOS) activation and how it impacts pregnancy-induced decreased vascular reactivity in normotensive (Wistar rats) and spontaneously hypertensive rats (SHR). Wistar rats and SHR were divided into non-pregnant (NP) and pregnant (P). Nitrite levels were assessed by the Griess method in the aorta and mesenteric vascular bed. In functional studies, arteries were incubated with methyl-β-cyclodextrin (dextrin, 10mmol/L), which disrupts caveolae by depleting cholesterol, and concentration-response curves to phenylephrine (PE) and acetylcholine (ACh) were constructed. Electronic microscopy was used to determine endothelial caveolae density in the aorta and resistance mesenteric artery in the presence of vehicle or dextrin (10mmol/L). Western blot was performed to evaluate Cav-1, p-Cav-1, calmodulin (CaM), and heat shock protein 90 (Hsp90) expression. Cav-1/eNOS interaction in the aorta and mesenteric vascular bed was assessed by co-immunoprecipitation. Nitric oxide (NO) generation was greater in arteries from P groups compared to NP groups. Dextrin did not change vascular responses in the aorta from P groups or the number of caveolae in P groups compared to NP groups. Compared to NP Wistar rats, NP SHR showed smaller number of caveolae and reduced Cav-1 expression. Pregnancy did not alter Cav-1, CaM, or Hsp90 expression in the aorta or mesenteric vascular bed from Wistar rats or SHR. These results suggest that pregnancy does not alter expression of the main eNOS regulatory proteins, but it decreases Cav-1/eNOS interaction. Reduced Cav-1/eNOS interaction in the aorta and mesenteric vascular bed seems to be an important mechanism to increase eNOS activity and nitric oxide production in pregnant normotensive and hypertensive rats.

Minimally Invasive Hemodynamic Assessment during Obstetric Hysterectomy for Invasive Placentation with Epidural Anesthesia

Background

The present study aimed to describe the evolution of hemodynamic parameters over time of patients with invasive placentation during their third trimester who were delivered via cesarean section and subsequently underwent obstetric hysterectomy under epidural anesthesia.

Methods

A prospective, descriptive, longitudinal, 11-month cohort study of 43 patients aged between 18 and 37 years who presented with invasive placentation. Minimal invasive monitoring was placed before the administration of epidural anesthesia for hemodynamic parameter tracking during the cesarean section. After delivery, the patients underwent an obstetric hysterectomy. Blood loss, hemodynamic parameters, and coagulation were managed via goal-directed therapy. Parameters were compared via repeated measures ANOVA and effect size estimation (Cohen's d).

Results

The mean age of the patients was 29.2 ± 3.4 years and was moderately overweight. They had minor cardiac index variance (P=NS, no significance), vascular systemic resistance index (NS), heart rate (P=NS), and median arterial pressure (P=NS). Differences were observed in the stroke volume index (P=0.015) due to moderately higher values (d = 0.3, P=0.016) in the middle of the surgery. Patients had lower cardiac index (d = -0.36, NS) and cardiac workload requirements (d = -0.29, P=0.034) toward the completion of surgery.

Conclusion

Patients who are in their third trimester and who subsequently underwent obstetric hysterectomy under epidural anesthesia had modest surgical hemodynamic variance and reduced cardiac workload requirements toward the end of the surgery.

Hemodynamic and Electrocardiographic Aspects of Uncomplicated Singleton Pregnancy

Pregnancy is associated with significant changes in maternal hemodynamics, which are triggered by profound systemic vasodilation and mediated through the autonomic nervous system as well as the renin-angiotensin-aldosterone system. Vascular function changes to help accommodate an increase in intravascular volume due to blood volume expansion associated with pregnancy while maintaining the efficiency of ventricular-arterial coupling and diastolic perfusion pressure. The heart undergoes physiological (eccentric) hypertrophy due to increased volume load and cardiac stroke work, whereas the functional change of the left ventricle remains controversial. There are changes in cardiac electrical activity during pregnancy which can be detected in the electrocardiogram that are not related to disease. Sympathetic activation is a common phenomenon during uncomplicated pregnancy and may be a compensatory mechanism induced by profound systemic vasodilation and a decrease in mean arterial pressure. Despite marked sympathetic activation, vasoconstrictor responsiveness is blunted during uncomplicated pregnancy. There are race and ethnic differences in maternal hemodynamic adaptations to uncomplicated pregnancy, which may be attributed to differences in socioeconomic status or in prevalence rates of cardiovascular risk factors.

Loss of Anticontractile Effect of Perivascular Adipose Tissue on Pregnant Rats: A Potential Role of Tumor Necrosis Factor-α

The present investigation examined the effect of pregnancy on the anticontractile effect of perivascular adipose tissue (PVAT) on the rat. Ring segments of the aorta, with and without PVAT, were set up in organ baths for isometric tension recording. In both groups, concentration-response curves to 5-hydroxytryptamine (5-HT) were displaced to the right with a reduction of the maximum response in aorta segments with PVAT. The anticontractile effect of PVAT was attenuated on segments from pregnant rats. 4-Aminopyridine (4-AP), an inhibitor of voltage-gated potassium (Kv) channels, enhanced 5-HT-induced contractions of aorta segments from pregnant and nonpregnant rats only when PVAT was attached. There was no difference in the effect of 4-aminopyridine on 5-HT-induced contractions of aorta segments with PVAT from pregnant and nonpregnant rats. There was also no significant difference in the expression of Kv7.4 channels in aorta segments (with PVAT) between pregnant and nonpregnant rats. Tumor necrosis factor-α (TNF-α) was detected in PVAT from pregnant and nonpregnant rats. The level of TNF-α was significantly greater in PVAT from pregnant rats. Treatment of pregnant rats with pentoxyphyline significantly reduced the level of TNF-α in the PVAT and restored the anticontractile effect of PVAT on aorta segments from pregnant rats. Finally, TNF-α (10 ng/mL) potentiated 5-HT-induced contractions of PVAT-containing pregnant rat aorta. These results would suggest that the loss of anticontractile effect of PVAT in pregnant rat aorta could be due to enhanced production of TNF-α in the PVAT in these rats.

Perivascular adipose tissue, vascular reactivity and hypertension

Most blood vessels are surrounded by a variable amount of adventitial adipose tissue, perivascular adipose tissue (PVAT), which was originally thought to provide mechanical support for the vessel. It is now known that PVAT secretes a number of bioactive substances including vascular endothelial growth factor, tumor necrosis factor-alpha (TNF-α), leptin, adiponectin, insulin-like growth factor, interleukin-6, plasminogen activator substance, resistin and angiotensinogen. Several studies have shown that PVAT significantly modulated vascular smooth muscle contractions induced by a variety of agonists and electrical stimulation by releasing adipocyte-derived relaxing (ADRF) and contracting factors. The identity of ADRF is not yet known. However, several vasodilators have been suggested including adiponectin, angiotensin 1-7, hydrogen sulfide and methyl palmitate. The anticontractile effect of PVAT is mediated through the activation of potassium channels since it is abrogated by inhibiting potassium channels. Hypertension is characterized by a reduction in the size and amount of PVAT and this is associated with the attenuated anticontractile effect of PVAT in hypertension. However, since a reduction in size and amount of PVAT and the attenuated anticontractile effect of PVAT were already evident in prehypertensive rats with no evidence of impaired release of ADRF, there is the possibility that the anticontractile effect of PVAT was not directly related to an altered function of the adipocytes per se. Hypertension is characterized by low-grade inflammation and infiltration of macrophages. One of the adipokines secreted by macrophages is TNF-α. It has been shown that exogenously administered TNF-α enhanced agonist-induced contraction of a variety of vascular smooth muscle preparations and reduced endothelium-dependent relaxation. Other procontractile factors released by the PVAT include angiotensin II and superoxide. It is therefore possible that the loss could be due to an increased amount of these proinflammatory and procontractile factors. More studies are definitely required to confirm this.

The PI3K-Akt-eNOS pathway is involved in aortic hyporeactivity to Phenylephrine associated with late pregnancy in spontaneously hypertensive rats

AIM

This study aimed to evaluate the effects of Wortmannin, an inhibitor of phosphatidylinositol 3-kinase (PI3K)/protein kinase B (Akt), on aortic hyporeactivity to Phenylephrine (Phe) and nitric oxide bioavailability associated with pregnancy in hypertensive rats.

MAIN METHODS

The intact aortic rings of pregnant and non-pregnant Wistar or spontaneously hypertensive rats (SHRs) were stimulated with Phe (1nmol/L to 10mmol/L) before and after incubation with Wortmannin (10nmol/L, 30min). Western blot experiments analyzed the expression of phosphorylated PI3K [p85-PI3K], Akt [p-Akt (Ser 473)] and eNOS [p-eNOS (Ser 1177)] in aorta homogenates of pregnant and non-pregnant Wistar rats or SHRs. The effect of Wortmannin (10nmol/L) on the cytosolic concentrations of nitric oxide (NO; measured using 4,5-diaminofluorescein diacetate [DAF-2DA], 10mmol/L), Ca(2+) (using Fluo 3-AM, 5μmol/L) and reactive oxygen species (ROS; using dihydroethidium [DHE], 2.5mmol/L) were measured fluorimetrically in freshly isolated endothelial cells.

KEY FINDINGS

Wortmannin increases the reactivity of the aorta to Phe and decreases NO concentrations in the aortic endothelial cells of pregnant Wistar rats and SHR.

SIGNIFICANCE

The PI3/AKT/endothelial nitric oxide synthase (eNOS) pathway contributes to aortic hyporeactivity to Phenylephrine associated with pregnancy in normo- and hypertensive rats.

Endothelium-dependent relaxation and angiotensin II sensitivity in experimental preeclampsia

Objective

We investigated endothelial dysfunction and the role of angiotensin (Ang)-II type I (AT1-R) and type II (AT2-R) receptor in the changes in the Ang-II sensitivity in experimental preeclampsia in the rat.

Methods

Aortic rings were isolated from low dose lipopolysaccharide (LPS) infused pregnant rats (experimental preeclampsia; n=9), saline-infused pregnant rats (n=8), and saline (n=8) and LPS (n=8) infused non-pregnant rats. Endothelium-dependent acetylcholine--mediated relaxation was studied in phenylephrine-preconstricted aortic rings in the presence of vehicle, N^G-nitro-L-arginine methyl ester and/or indomethacin. To evaluate the role for AT1-R and AT2-R in Ang-II sensitivity, full concentration response curves were obtained for Ang-II in the presence of losartan or PD123319. mRNA expression of the AT1-R and AT2-R, eNOS and iNOS, COX1 and COX2 in aorta were evaluated using real-time RT-PCR.

Results

The role of vasodilator prostaglandins in the aorta was increased and the role of endothelium-derived hyperpolarizing factor and response of the AT1-R and AT2-R to Ang-II was decreased in pregnant saline infused rats as compared with non-pregnant rats. These changes were not observed during preeclampsia.

Conclusion

Pregnancy induced adaptations in endothelial function, which were not observed in the rat model for preeclampsia. This role of lack of pregnancy induced endothelial adaptation in the pathophysiology of experimental preeclampsia needs further investigation.

Arterial endothelium-derived hyperpolarization: potential role in pregnancy adaptations and complications

Pregnancy encompasses substantial changes in vascular function to accommodate dramatic increases in blood volume and uteroplacental blood flow to the growing fetus. Despite increased hemodynamics, decreased peripheral resistance results in a reduction in mean arterial blood pressure. Vascular tone, and hence peripheral resistance, is determined by a delicate balance of constrictor and dilator capacities. In the normal physiological response to pregnancy, endothelial-derived hyperpolarization (EDH) has been shown to be a major contributor; both EDH and nitric oxide (NO) are predominantly involved in providing an increased vascular capacity for vasodilation. The ability of EDH and NO to adequately accommodate increased blood volume is tested in pathological states such as placental insufficiency or diabetes and both EDH and NO-dependent mechanisms seem to be impacted in these situations. Pregnancy complications also have an impact on the cardiovascular health of the offspring. In adult offspring born from complicated pregnancies, the data suggest that EDH mechanisms are largely maintained, whereas NO is commonly reduced. A diversity of EDH mechanisms may be useful in providing many targets for potential therapeutic avenues for compromised pregnancies; however, further research delineating the mechanisms of EDH and the interactions of NO and EDH, in normal and pathological pregnancies is required.

Management of pregnant patient in dentistry

The purpose of this article is to update general dentists and maxillofacial surgeons in the perioperative management of the pregnant patient. Pregnancy results in physiologic changes in almost all organ systems in the body mediated mainly by hormones; which influences the treatment schedule. Understanding these normal changes is essential for providing quality care for pregnant women. The general principles that apply in this situation are discussed, followed by the relevant physiologic changes and their treatment implications, the risks of various medications to the mother and fetus, the management of concomitant medical problems in the pregnant patient, appropriate timing of oral and maxillofacial surgery during pregnancy, and management of emergencies during pregnancy. Information about the compatibility, complications, and excretion of the common drugs during pregnancy is provided. Guidelines for the management of a pregnant patient in the dental office are summarized. How to cite this article: Kurien S, Kattimani V S, Sriram R, Sriram S K, Prabhakar Rao V K, Bhupathi A, Bodduru R, Patil N N. Management of Pregnant Patient in Dentistry. J Int Oral Health 2013; 5(1):88-97.

Management of severe odontogenic infections in pregnancy

BACKGROUND

The objective of this study was to review the management of patients presenting with severe odontogenic infections and who are also pregnant.

METHODS

A retrospective clinical audit was conducted of all female patients admitted to the Royal Adelaide Hospital by the Oral and Maxillofacial Surgery Unit from 1999 to 2009 with severe odontogenic infections. Pregnant patients were identified and their age, medical history, previous obstetric and gynaecological history, stage of current pregnancy, presenting infection, diagnosis and management were recorded, as well as the outcome of the pregnancy.

RESULTS

A total of 346 female patients were admitted to the Royal Adelaide Hospital under the care of the Oral and Maxillofacial Surgery Unit with an admission diagnosis of severe odontogenic infection and five were pregnant. Besides surgical and anaesthetic assessment, mother and foetus were assessed by the Obstetric and Gynaecology Unit. In all, five with severe infection were successfully resolved and four proceeded to a normal delivery with a healthy child. The remaining patient had an already planned therapeutic abortion.

CONCLUSIONS

Pregnant patients with severe odontogenic infections require urgent referral to a tertiary hospital with full surgical, anaesthetic and obstetric services. This allows appropriate management of the complex requirements of mother and foetus.

Adaptive changes of mesenteric arteries in pregnancy: a meta-analysis

The vascular response to pregnancy has been frequently studied in mesenteric artery models by investigating endothelial cell (EC)- and smooth muscle cell (SMC)-dependent responses to mechanical (flow-mediated vasodilation, myogenic reactivity, and vascular compliance) and pharmacological stimuli (G protein-coupled receptor responses: Gq(EC), Gs(SMC), Gq(SMC)). It is unclear to what extent these pathways contribute to normal pregnancy-induced vasodilation across species, strains, and/or gestational age and at which receptor level pregnancy affects the pathways. We performed a meta-analysis on responses to mechanical and pharmacological stimuli associated with pregnancy-induced vasodilation of mesenteric arteries and included 55 (188 responses) out of 398 studies. Most included studies (84%) were performed in Wistar and Sprague-Dawley rats (SDRs) and compared late gestation versus nonpregnant controls (80%). Pregnancy promotes flow-mediated vasodilation in all investigated species. Only in SDRs, pregnancy additionally stimulates both vasodilator Gq(EC) sensitivity (EC(50) reduced by -0.76 [-0.92, -0.60] log[M]) and Gs(SMC) sensitivity (EC(50) reduced by -0.51 [-0.82, -0.20] log[M]), depresses vasopressor Gq(SMC) sensitivity (EC(50) increase in SDRs by 0.23 [0.16, 0.31] log[M]), and enhances arterial compliance. We conclude that 1) pregnancy facilitates flow-mediated vasodilation at term among all investigated species, and the contribution of additional vascular responses is species and strain specific, and 2) late pregnancy mediates vasodilation through changes at the receptor level for the substances tested. The initial steps of vasodilation in early pregnancy remain to be elucidated.

Influence of hyperglycemia during and after pregnancy on postpartum vascular function

Endothelial dysfunction is commonly observed in women with a previous diagnosis of gestational diabetes mellitus (GDM). Whether arterial stiffness is also related to pregnancy and/or postpartum glucose intolerance has not been determined. We examined the influence of GDM during pregnancy and hyperglycemia in the postpartum period on arterial function. Thirty postpartum women were stratified into one of three groups: 1) normoglycemic pregnancy, normoglycemic postpartum (NORM), 2) GDM during pregnancy, normoglycemic postpartum (GDM-N); and 3) GDM during pregnancy, hyperglycemic postpartum (GDM-H). Ten never-pregnant controls were also recruited (Control). All measures were made at 2 mo postpartum or in the early follicular phase in Control women. Arterial stiffness was assessed by pulse wave velocity (PWV) and brachial and carotid artery distensibility. Endothelial function was determined by flow-mediated dilation (FMD). PWV was not different between the four groups. Distensibility of the brachial and carotid arteries was lower in GDM-N women (brachial: 1.1 × 10(-3) mmHg(-1) ± 3.6 × 10(-4); carotid: 2.0 × 10(-3) ± 3.3 × 10(-4)) and GDM-H (brachial: 1.4 × 10(-3) mmHg(-1) ± 4.1 × 10(-4); carotid: 1.8 × 10(-3) mmHg(-1) ± 5.0 × 10(-4)) compared with NORM women (brachial: 3.4 × 10(-3) mmHg(-1) ± 7.0 × 10(-4); carotid: 3.9 × 10(-3) ± 7.4 × 10(-4)). However, only brachial artery distensibility returned to Control levels by 2 mo postpartum in the NORM women. FMD was lower in previously GDM women (GDM-N: 4.1% ± 2.3; GDM-H: 4.4% ± 0.9) compared with NORM women (10.8% ± 1.3; P < 0.01). These findings suggest that the vascular function of women in the early postpartum period is influenced by GDM during pregnancy and the persistence of clinical and/or subclinical hyperglycemia after delivery.

Autonomic circulatory control during pregnancy in humans

Pregnancy is associated with dramatic alterations in maternal hemodynamics, which begin as early as 4 to 5 weeks of gestation. It has been proposed that these changes occur through autonomic control mechanisms, but the actual role of the autonomic nervous system in pregnancy is poorly understood. Here, we review what is known about the hemodynamic adaptation, changes in vascular endothelial function, sympathetic neural control and vascular responsiveness in pregnancy, and baroreflex function during pregnancy in humans. However, whether and how the sympathetic nervous system plays a role in hemodynamic homeostasis during EARLY human pregnancy remains completely unknown. Understanding the pathophysiology underlying autonomic control of maternal hemodynamics may be particularly important for prevention of cardiovascular complications during pregnancy and may improve risk stratification and prevention of cardiovascular disease for women well beyond the postpartum period.

The role of nitric oxide in female reproduction

The cardiovascular system undergoes profound changes during pregnancy. Maternal intravascular volume begins to increase in the first trimester rising an average of 45% by term.1Cardiac output increases similarly2and is redistributed to organs whose functions are crucial for a successful pregnancy. In the guinea pig, uterine artery (UA) blood flow increases 3500%, while mesenteric and renal artery blood flows increase only 90% and 10% respectively.3Blood flow to the trunk actually diminishes. The mechanism underlying this redistribution is unknown. Coupled with the rise in cardiac output is a decrease in the systemic pressor response to angiotensin II (AII), norepinephrine(NE), and epinephrine.4–8There is also a decrease in the contraction response among some but not all vascular beds. For example, contraction of UA to NE and thromboxane is characteristically reduced by pregnancy, whereas the response of the carotid artery is unaltered8–10Since pregnancy does not alter neuroeffector mechanisms of NE such as release, receptor sensitivity, and accumulation11, changes in sympathetic control during pregnancy must be dependent on alterations at sites other than the neuroeffector junction. We have hypothesized that the mechanisms which alter vascular reactivity during pregnancy also mediate the redistribution of maternal cardiac output.9We have further hypothesized that many of these mechanisms involve endothelium-dependent factors which are modulated by sex hormones.

Differential [Ca2+]i signaling of vasoconstriction in mesenteric microvessels of normal and reduced uterine perfusion pregnant rats

Vascular resistance and blood pressure (BP) are reduced during late normal pregnancy (Norm-Preg). In contrast, studies in human preeclampsia and in animal models of hypertension in pregnancy (HTN-Preg) have suggested that localized reduction in uterine perfusion pressure (RUPP) in late pregnancy is associated with increased systemic vascular resistance and BP; however, the vascular mechanisms involved are unclear. Because Ca2+ is a major determinant of vascular contraction, we hypothesized that the intracellular free calcium concentration ([Ca2+]i) signaling of vasoconstriction is differentially regulated in systemic microvessels during normal and RUPP in late pregnancy. Pressurized mesenteric microvessels from Norm-Preg and RUPP rats were loaded with fura 2 in preparation for simultaneous measurement of diameter and [Ca2+]i (presented as fura 2 340/380 ratio). Basal [Ca2+]i was lower in RUPP (0.73 +/- 0.03) compared with Norm-Preg rats (0.82 +/- 0.03). Membrane depolarization by 96 mM KCl, phenylephrine (Phe, 10(-5) M), angiotensin II (ANG II, 10(-7) M), or endothelin-1 (ET-1, 10(-7) M) caused an initial peak followed by maintained vasoconstriction and [Ca2+]i. KCl caused similar peak vasoconstriction and [Ca2+]i in Norm-Preg (45.5 +/- 3.3 and 0.89 +/- 0.02%) and RUPP rats (46.3 +/- 2.1 and 0.87 +/- 0.01%). Maximum vasoconstriction to Phe, ANG II, and ET-1 was not significantly different between Norm-Preg (28.6 +/- 4.8, 32.5 +/- 6.3, and 40 +/- 4.6%, respectively) and RUPP rats (27.8 +/- 5.9, 34.4 +/- 4.3, and 38.8 +/- 4.1%, respectively). In contrast, the initial Phe-, ANG II-, and ET-1-induced 340/380 ratio ([Ca2+]i) was reduced in RUPP (0.83 +/- 0.02, 0.82 +/- 0.02, and 0.83 +/- 0.03, respectively) compared with Norm-Preg rats (0.95 +/- 0.04, 0.93 +/- 0.01, and 0.92 +/- 0.02, respectively). Also, the [Ca2+]i-vasoconstriction relationship was similar in KCl-treated but shifted to the left in Phe-, ANG II-, and ET-1-treated microvessels of RUPP compared with Norm-Preg rats. The lower agonist-induced [Ca2+]i signal of vasoconstriction and the leftward shift in the [Ca2+]i-vasoconstriction relationship in microvessels of RUPP compared with Norm-Preg rats suggest activation of [Ca2+]i sensitization pathway(s). The similarity in vasoconstriction in RUPP and Norm-Preg rats suggests that such a [Ca2+]i sensitization pathway(s) may also provide a feedback effect on Ca2+ mobilization/homeostatic mechanisms to protect against excessive vasoconstriction in systemic microvessels during RUPP in late pregnancy.

Oral and maxillofacial surgery for the pregnant patient

This article describes clinical approaches for the perioperative management of the pregnant oral and maxillofacial surgical patient. The following topics are discussed: ethical principles of treatment during pregnancy, physiologic changes and their treatment considerations, fetal and maternal risks of various medications, medical problems occurring during pregnancy, and common minimally invasive approaches that the surgeon can apply to minimize the risk to the mother and unborn child. The strategies discussed provide successful treatment outcomes during this important time in the female surgical patient's life.

Pregnancy-induced modulation of calcium mobilization and down-regulation of Rho-kinase expression contribute to attenuated vasopressin-induced contraction of the rat aorta

Normal pregnancy is characterized by attenuated vascular reactivity to a variety of contractile agonists and this, in part, has been attributed to increased circulating vasodilators and/or impaired Ca(2+)-influx through L-type Ca(2+)-channels. Our hypothesis in this study was that reduced Ca(2+)-dependent (influx) and Ca(2+)-independent (involving the RhoA/Rho-kinase pathway) mechanisms contributed to attenuated vasopressin-induced contraction of the pregnant rat aorta. AVP (10(-10) -3 x 10(-7) M) induced concentration-dependent contraction of aortic ring segments from nonpregnant and pregnant rats with no significant change in pD(2) values (8.53+/-0.11 and 8.33+/-0.18 in nonpregnant and pregnant rats, respectively). The maximum response was however significantly reduced in aorta segments from pregnant rats. Nifedipine (10(-6) M) significantly inhibited AVP-induced contraction in artery segments from nonpregnant but not pregnant rats indicating a reduced role for Ca(2+)-influx through L-type Ca(2+)-channels in AVP-induced contractions of the pregnant rat aorta. Western blot analysis revealed the expression of ROCK-1 and ROCK-II isoforms in aorta segments from both groups. There was a significant reduction in the expression of ROCK-1 and ROCK-II isoforms in aortic tissues from pregnant rats. This is consistent with the reduced potency of Y-27632 in inhibiting AVP (10(-7) M) induced contraction in aorta segments from pregnant rats. It was concluded that pregnancy-induced attenuated vascular response to AVP was due to decreased Ca(2+)-influx through L-type Ca(2+)-channels and decreased sensitization of the contractile myofilaments to Ca(2+).

Increased expression and activity of heme oxygenase-2 in pregnant rat aorta is not involved in attenuated vasopressin-induced contraction

Pregnancy is associated with attenuated vascular reactivity to a variety of contractile agonists. Heme oxygenases are expressed in the placenta, and it has been suggested that the heme oxygenase/carbon monoxide (HO/CO) pathway plays a significant role in regulating blood flow through the feto-placental unit. In this study we investigated the possible involvement of heme oxygenases in the reduced vascular reactivity associated with pregnancy. Arginine vasopressin (AVP) (10(-10)-3x10(-7) M) induced concentration-dependent contraction of aortic ring segments from non-pregnant and pregnant (16-19 days) rats. Pregnancy did not alter the sensitivity to AVP (pD2=8.5+/-0.1 and pD2=8.4+/-0.2 in non-pregnant and pregnant rats, respectively) but significantly reduced the maximum response (107.9+/-12.7% and 38.6+/-7.4%, respectively, relative to noradrenaline-induced contraction). Western blot analysis revealed the expression of HO-2 but not HO-1 isoform in both groups. There was a significant increase in the expression and activity of HO-2 protein in aortic tissues from pregnant rats compared with those from age-matched non-pregnant rats. In the presence of L-NAME to inhibit nitric oxide (NO) synthesis, tin protoporphyrin IX (SnPP-IX, 10(-5) M), an inhibitor of heme oxygenase, did not significantly affect AVP-induced contraction in aorta segments from pregnant and non-pregnant rats. It was concluded that, though pregnancy increased the expression and activity of HO-2 in the aorta, HO-2 was not involved in the attenuated response to AVP.

Effect of pregnancy on the roles of nitric oxide and prostaglandins in 5-hydroxytryptamine-induced contractions in rat isolated thoracic and abdominal aorta

1. Vascular resistance and sensitivity to circulating pressor and vasoconstrictor substances are blunted during pregnancy. This has been attributed mainly to an increased production of endothelium-derived mediators. The aim of the present study was to determine whether pregnancy changes the relative participation of nitric oxide (NO) and prostaglandins (PG) in the modulation of the contractile response to 5-hydroxytryptamine (5-HT) in two anatomically distint segments of the rat aorta. 2. Full concentration-response curves to 5-HT were obtained in isolated rings from the thoracic and abdominal portion of the aorta from pregnant and non-pregnant rats in the presence and absence of the NO synthase (NOS) inhibitor N(G)-nitro-l-arginine methyl ester (L-NAME; 10 micromol/L) or the PG synthesis inhibitor indomethacin (10 micromol/L). Cyclo-oxygenase (COX)-1, COX-2 and endothelial (e) NOS protein expression were determined in the same tissues by immunoblot. 3. The effects of pregnancy were accentuated in the abdominal compared with the thoracic aorta. In addition, the relative participation of the NO and PG pathways seems to be changed during pregnancy. Although NO seems to be the mediator mainly responsible for the effect of pregnancy in the thoracic aorta, our results suggest a complex interaction between NO and PG in the abdominal aorta. Indomethacin significantly reduced the contractile response of both segments of the aorta, whereas expression of COX-1, COX-2 and eNOS were increased only in the abdominal segment of pregnant animals. 4. These results show that the effect of pregnancy is not homogeneous along the aorta. There seems to be a mutual interaction between PG and NO in the abdominal, but not in the thoracic, aorta from pregnant rats: the role of NO becomes evident in the absence of vasodilatory PG, whereas the participation of the latter increases in the absence of NO working as a compensatory mechanism.

Circadian variations of plasma renin activity (PRA), aldosterone and electrolyte concentrations in plasma in pregnant and non-pregnant goats

The aim of this study was to estimate and analyse circadian variations of the renin-angiotensin-aldosterone system (RAA) activity in blood of goats and the influence of late pregnancy on the circadian variations of RAA system. The study was carried out on a group of 17 non-pregnant and 9 pregnant goats. The animals were kept in uniform environmental conditions, (9 h light/15 h darkness). Blood samples were collected seven times over a period of 24 h, every 4 h. Plasma renin activity (PRA), plasma aldosterone (PA), sodium, potassium and chloride concentrations were determined. PRA and PA of both groups changed during 24 h, with the highest values in the dark phase and with higher RAA system activity (especially during the night) in the pregnant goats. In the non-pregnant goats, no circadian changes in PRA and PA were observed. The circadian changes in PRA and PA found in pregnant goats had acrophases at 06:27 h and 01:13 h, respectively. Plasma electrolyte concentrations in both groups of goats also changed during 24 h. These results suggest that circadian changes of potassium concentration in plasma of goats during late pregnancy may be one of the main factors affecting the RAA system.

Pregnancy-associated increase in rat systemic arteries endothelial nitric oxide production diminishes vasoconstrictor but does not enhance vasodilator responses

Late pregnancy in rats is characterized by a decrease in arterial pressure and in isolated arterial vessels response to vasoconstrictors. In uterine arteries the pregnancy-associated attenuation of the response to vasoconstrictors has been attributed to an increase in basal and agonist-induced endothelial NO production. However, the role of NO in pregnancy-associated changes of systemic arteries reactivity to vasoactive agents remains to be fully elucidated. We examined whether pregnancy influences the reactivity of systemic arteries to vasodilator or vasoconstrictor agents through NO-dependent mechanisms. Thoracic aortic rings and mesenteric arterial bed of late pregnant rats showed refractoriness to phenylephrine-induced vasoconstriction that was abolished by NO synthase inhibition. The potency of L-NNA to enhance tension of aortic rings preconstricted with phenylephrine (10-20% of their maximal response) was significantly lower in preparations from pregnant animals. In phenylephrine-contracted aortas and mesenteric bed, the effects of the endothelium-dependent vasodilators acetylcholine, A23187 and bradykinin, were not influenced by pregnancy. Similarly, pregnancy did not affect the vasodilator responses of adenosine, isoproterenol, capsaicin, nitroprusside, forskolin, and Hoe234 in the mesenteric bed. NO synthase activity measured by determining the conversion of L-[(3)H]-arginine to L-[(3)H]-citrulline in aorta and mesenteric arteries homogenates was not altered by pregnancy. These findings show that endothelial-dependent and -independent vasodilators action as well as NO synthase activity in systemic arteries is uninfluenced by pregnancy, whereas pregnancy-associated hyporeactivity of systemic arteries to vasoconstrictors is related to an enhanced endothelial NO production either spontaneous or elicited directly or indirectly by vasoconstrictor agents. This interpretation implies that the enhanced NO production observed in systemic arteries during late pregnancy involves cellular pathways other than the ones involved in the response to endothelium-dependent vasodilators such as acetylcholine.

Nitric oxide in mesenteric vascular reactivity: a comparison between rats with normotension and hypertension

1. Nitric oxide (NO) plays an important role in various physiological functions. The continuous formation of endogenous NO from endothelial cells maintains a vasodilator tone and regulates blood flow and pressure. However, the role of NO in hypertension remains controversial. 2. In the present study, we used an in situ mesenteric perfusion system. The primary objectives of the study were to examine whether or not mesenteric vasoreactivity is changed by alterations in perfusion pressure and to assess the role of NO in changes of vascular reactivity in hypertension. 3. Spontaneously hypertensive rats (SHR; 12-15 weeks of age) and age-matched normotensive Wistar-Kyoto (WKY) rats were used as the experimental and control groups, respectively. Endothelium-dependent and -independent vasodilation was detected by acetylcholine (ACh) or NO donors (sodium nitroprusside (SNP) and S-nitroso-N-acetylpenicillamine (SNAP)). Dose-dependent reactivity to these agents (10(-6) to 10(-4) mol/L) was detected by bolus intra-arterial injections of 10 microL of the test agents at 5 min intervals. Dose-dependent responses to vasoconstrictor drugs, such as noradrenaline (NA) and phenylephrine (PE; 10(-6) to 10(-4) mol/L) were also observed. The NO synthase inhibitor NG-nitro-L-arginine methyl ester (L-NAME; 10 mg/kg) was given to examine the contribution of NO to the vasoreactivity of the mesenteric bed. 4. Acetylcholine, SNP and SNAP produced dose-dependent vasodilation in both WKY rats and SHR. The magnitude of the vasodilation was significantly greater in SHR than in WKY rats. It was also greater at high than low flow rates in SHR. The increase in mesenteric perfusion pressure following L-NAME was significantly higher in SHR than in WKY rats. However, there were no differences in responses to L-NAME between low and high flow rates in SHR. Endothelium-independent vasoconstriction (NA and PE) was dose dependent in both SHR and WKY rats. The magnitude of the endothelium-independent vasoconstriction was greater in SHR than in WKY rats. 5. The results suggest that endothelium-dependent or -independent mesenteric vasoconstriction and vasodilation is enhanced in SHR compared with WKY rats, supporting the concept of enhancement of NO function in the hypertensive state. Flow-induced shear stress is also a key factor in the regulation of peripheral resistance depending on NO formation in hypertension.

Does nitric oxide contribute to the basal vasodilation of pregnancy in conscious rabbits?

Pregnancy produces marked systemic vasodilation, but the mechanism is unknown. Experiments were performed in conscious rabbits to test the hypotheses that increased nitric oxide (NO) production contributes to the increased vascular conductance, but that the contribution varies among vascular beds. Rabbits were instrumented with aortic and vena caval catheters and ultrasonic flow probes implanted around the ascending aorta, superior mesenteric artery, terminal aorta, and/or a femoral artery. Hemodynamic responses to intravenous injection of N(omega)-nitro-L-arginine (L-NA; 20 mg/kg or increasing doses of 2, 5, 10, 15, and 20 mg/kg) were determined in rabbits first before pregnancy (NP) and then at the end of gestation (P). L-NA produced similar increases in arterial pressure between groups, but the following responses were larger (P < 0.05) when the rabbits were pregnant: 1) decreases in total peripheral conductance [-3.7 +/- 0.3 (NP), -5.0 +/- 0.5 (P) ml x min(-1) x mmHg(-1)], 2) decreases in mesenteric conductance [-0.47 +/- 0.05 (NP), -0.63 +/- 0.07 (P) ml x min(-1) x mmHg(-1)], 3) decreases in terminal aortic conductance [-0.43 +/- 0.05 (NP), -0.95 +/- 0.19 ml x min(-1) x mmHg(-1) (P)], and 4) decreases in heart rate [-41 +/- 4 (NP), -62 +/- 5 beats/min (P)]. Nevertheless, total peripheral and terminal aortic conductances remained elevated in the pregnant rabbits (P < 0.05) after L-NA. Furthermore, decreases in cardiac output and femoral conductance were not different between the reproductive states. We conclude that the contribution of NO to vascular tone increases during pregnancy, but only in some vascular beds. Moreover, the data support a role for NO in the pregnancy-induced increase in basal heart rate. Finally, unknown factors in addition to NO must also underlie the basal vasodilation observed during pregnancy.

Prostanoids, but not nitric oxide, counterregulate angiotensin II mediated vasoconstriction in vivo

To evaluate the modulating effects of nitric oxide and prostanoids during angiotensin II-mediated vasoconstriction, male Wistar rats (n=25) were infused with increasing doses of angiotensin II following pretreatment with the cyclooxygenase inhibitor indomethacin, the nitric oxide-synthase inhibitor NG-nitro-L-arginine methyl ester (L-NAME) plus sodium nitroprusside to restore mean arterial blood pressure, or saline. Hemodynamics were studied with the radioactive microsphere method. Indomethacin did not alter systemic or regional hemodynamics. L-NAME+sodium nitroprusside reduced cardiac output, as well as systemic and renal vascular conductance. Angiotensin II increased mean arterial blood pressure and heart rate, and decreased systemic vascular conductance as well as vascular conductance in gastrointestinal tract, kidney, skeletal muscle, skin, mesentery+pancreas, spleen and adrenal. Indomethacin enhanced the angiotensin II-mediated effects in all vascular beds, whereas L-NAME+sodium nitroprusside enhanced its effect in mesentery+pancreas only. In conclusion, vasodilator prostanoids, but not nitric oxide, counterregulate angiotensin II-mediated vasoconstriction in vivo.

The effect of pregnancy on the response to blood loss in a rat model

STUDY OBJECTIVES

A commonly held belief is that the blunted hemodynamic response to hemorrhage observed in pregnant women is secondary to expanded blood volume. In addition to increased blood volume, pregnancy is also a vasodilated state. Vasodilatation may have deleterious effects on the response to hemorrhage by inhibiting central blood shunting after blood loss. How these conflicting variables of increased blood volume and vasodilatation integrate into a whole body model of maternal hemorrhagic shock has yet to be studied in a controlled experiment. We tested the null hypothesis that there would be no difference in the hemodynamic and metabolic responses to hemorrhage between pregnant (PRG) and non-pregnant (NPRG) rats.

METHODS

Twenty-four adult female Sprague-Dawley rats (12 PRG and 12 NPRG) were anesthetized with Althesin via the intraperitoneal route. Femoral arteries were cannulated by cut-down. Twelve (six PRG and six NPRG) rats underwent controlled catheter hemorrhage of 25% of their total blood volume. Twelve rats (six PRG and six NPRG) served as non-hemorrhage controls. Mean arterial pressure (MAP) and base excess (BE) were measured pre-hemorrhage and then every 15 min post-hemorrhage for the next 90 min. Data were reported as mean+/-standard error of the mean (S.E.M.) over the 90-min post-hemorrhage observation period. Group comparisons were analyzed by ANOVA with repeated values post-hoc by Bonferroni. Statistical significance was defined by an alpha=0.05.

RESULTS

PRG and NPRG rats were evenly matched for MAP (P=0.788) and BE (P=0.146) pre-hemorrhage. Post-hemorrhage there were no mortalities in either group. Post-hemorrhage both the PRG and NPRG groups experienced significant (P=0.011) drops in systolic and diastolic blood pressures as compared to their non-hemorrhage controls. Post-hemorrhage there was no significant (P=0.43) difference in MAP between the PRG (89+/-2 mmHg) and NPRG (80+/-2 mmHg) rats. BE also dropped significantly within both PRG (P=0.004) and NPRG (P=0.001) groups post-hemorrhage. No significant (P=0.672) difference was noted in BE between PRG and NPRG groups post-hemorrhage -6.1+/-0.3 mEq/l and -6.9+/-0.4 mEq/l, respectively.

CONCLUSION

After a controlled hemorrhage of 25% of total blood volume we found no significant differences in MAP and BE between pregnant and non-pregnant rats. Pregnancy does not affect the response to hemorrhage.

Baroreceptor afferent discharge in the pregnant rat

Pregnancy is associated with blunted reflex responses to cardiac and arterial baroreceptor stimulation. We tested the hypothesis that arterial baroreceptor afferent discharge is attenuated in response to a pressure stimulus in pregnant rats. Multifiber aortic depressor nerve activity (ADNA), mean arterial pressure (MAP), and heart rate were measured in anesthetized (pentobarbital sodium, 35 mg/kg ip) late-pregnant and virgin rats in response to increases ¿phenylephrine (PE), 1.5-24 microg. kg(-1). min(-1) and 1-16 microg/kg and decreases ¿sodium nitroprusside (SNP), 5-80 microg. kg(-1). min(-1) and 0.05-16 microg/kg in MAP. Resting MAP was lower in pregnant rats, but changes in MAP were similar to those in virgin rats during both PE and SNP administration. ADNA was significantly attenuated in pregnant animals during both PE and SNP infusions (P < 0.05) due to a more rapid adaptation to the pressure stimulus. Bolus drug administration evoked similar changes in MAP and ADNA in both groups; however, the maximum decrease in ADNA was achieved at the lowest dose of SNP in pregnant rats. Thus baroreceptor afferent discharge is attenuated in pregnant rats, and this involves a more rapid adaptation to a pressure stimulus.

Endothelium and aortic contraction to endothelin-1 in the pregnant rat

Endothelium-derived factors modulate tone and may be involved in hyporeactivity to vasoconstrictors, such as norepinephrine or angiotensin II, as has been previously described during gestation. The endothelium produces endothelin-1, a major vasoconstrictor peptide, therefore aortic contractions to endothelin-1 (10-10 to 3 ×10-7 M) were used to assess the role of the endothelium in pregnant Wistar rats (at 20 days of gestation). Late pregnancy is characterized by a significantly diminished systolic blood pressure in conscious rats (-17 mmHg, P < 0.001, n = 14). In pregnant and in age-matched nonpregnant female rats, endothelin-1 induced aortic contraction was greater when endothelium was present (at least P < 0.01). Indomethacin significantly reduced this contraction in aortic rings with intact endothelium in all groups. In aortic rings that had endothelium physically removed, contraction to endothelin-1 was greater in pregnant rats than in nonpregnant ones. Indomethacin decreased contraction of aortic rings in pregnant rats only. These results suggest an enhanced synthesis of vasoconstrictors by cyclooxygenases in vascular smooth muscle during pregnancy. In vessels with intact endothelium, we did not find hyporeactivity to endothelin-1 during late pregnancy. Contraction to endothelin-1 involved ETA receptors because it was decreased by BQ-123, an ETA receptor antagonist, whereas there was no significant change when using BQ-788, an ETB receptor antagonist.

Key words: endothelin-1, endothelium, contraction, aorta, gestation.

The effect of chronic nitric oxide inhibition on vascular reactivity and blood pressure in pregnant rats

CONTEXT

The exact mechanism involved in changes in blood pressure and peripheral vascular resistance during pregnancy is unknown.

OBJECTIVE

To evaluate the importance of endothelium-derived relaxing factor (EDRF) and its main component, nitric oxide, in blood pressure and vascular reactivity in pregnant rats.

DESIGN

Clinical trial in experimentation animals.

SETTING

University laboratory of Pharmacology.

SAMPLE

Female Wistar rats with normal blood pressure, weight (152 to 227 grams) and age (90 to 116 days).

INTERVENTION

The rats were divided in to four groups: pregnant rats treated with L-NAME (13 rats); pregnant control rats (8 rats); virgin rats treated with L-NAME (10 rats); virgin control rats (12 rats). The vascular preparations and caudal blood pressure were obtained at the end of pregnancy, or after the administration of L-NAME in virgin rats.

MAIN MEASUREMENTS

The caudal blood pressure and the vascular response to acetylcholine in pre-contracted aortic rings, both with and without endothelium, and the effect of nitric oxide inhibition, Nw-L-nitro-arginine methyl-ester (L-NAME), in pregnant and virgin rats. The L-NAME was administered in the drinking water over a 10-day period.

RESULTS

The blood pressure decreased in pregnancy. Aortic rings of pregnant rats were more sensitive to acetylcholine than those of virgin rats. After L-NAME treatment, the blood pressure increased and relaxation was blocked in both groups. The fetal-placental unit weight of the L-NAME group was lower than that of the control group.

CONCLUSION

Acetylcholine-induced vasorelaxation sensitivity was greater in pregnant rats and that blood pressure increased after L-NAME administration while the acetylcholine-induced vasorelaxation response was blocked.

Endothelin-1 and relaxation of the rat aorta during pregnancy in nitroarginine-induced hypertension

In pregnant rats during hypertension induced by NO synthase inhibition, endothelin (ET) plasma levels are increased as in some preeclamptic women. Previously, the enhanced vasodepressor effect of endothelin-1 (ET-1) has been observed in this model, thus we decided to study the relaxation induced by ET-1 on the aorta. Non-pregnant or pregnant Wistar rats (n = 7 by group) were fed for 7 days (day 13-day 20) on a nitroarginine-enriched diet (L-NNA, 0.063% i.e. 30 mg/kg/day) or a control diet. Systolic blood pressure, measured by the tail cuff method on conscious rats at day 20 of gestation, was raised by the chronic L-NNA treatment (mean +/- s.e.m., mmHg, p < 0.001: pregnant L-NNA treated, 145 +/- 1.84 vs. pregnant control, 101 +/- 2.00 and non-pregnant L-NNA treated, 148 +/- 3.11 vs. non-pregnant control, 119 +/- 1.80). On day 20 ex vivo aortic ring relaxation was produced by ET-1 in vessels previously precontracted with norepinephrine only when endothelium was present. In control rats, ET-1 (10(-8) to 5 x 10(-8) M) produced a short but significant relaxation (mean value between 4 to 19%) followed by a long-lasting contracting phase, and a higher ET-1 concentration (10(-7) M) only produced contraction. Chronic L-NNA treatment decreased the level of relaxation (at least p < 0.05, in non-pregnant and pregnant rats) and with a 30 min L-NAME (10(-4) M) preincubation, relaxation was completely inhibited in non-pregnant and pregnant rats. BQ-123, an ETA receptor antagonist, did not produce any effect on ET-1 induced relaxation. BQ-788, an ETB receptor antagonist, significantly decreased it. In conclusion, in female rats, as in male rats, ET-1 induces a transient relaxation in the preconstricted aorta which involves endothelial ETB receptors. Despite a decrease in the systemic vascular reactivity during late gestation, the vasodilating and vasoconstricting properties of ET-1 on the aorta are not changed.

Vascular reactivity in preeclampsia

It has long been known that vascular reactivity is altered in preeclamptic patients compared with normal pregnant women. This change even occurs weeks earlier than any clinical manifestation of the disease. Many investigators believe that the conditions for the development of preeclampsia are set as early as the first trimester. These changes in vascular reactivity appear to be independent of the blood pressure because they also occur in chronic hypertensive women destined to have preeclampsia. This review focuses on these changes in vascular reactivity reported in preeclampsia. Increased reactivity of the blood vessels in preeclampsia has been described in most, but not all, studies. The cause for the differences in reactivity between vessels from preeclamptic and normal pregnant women is not known. However, it cannot be attributed solely and with certainty to abnormalities in endothelium-dependent relaxation or the nitric oxide system because the study results published to date remain contradictory. In addition to functional differences, vessels from normal pregnant and preeclamptic women show distinct mechanical properties.

Effects of pregnancy and chronic hypoxia on contractile responsiveness to alpha1-adrenergic stimulation

Decreased contractile response to vasoconstrictors in uterine and nonuterine vessels contributes to increased blood flow to the uterine circulation during normal pregnancy. Pregnancies complicated by preeclampsia and/or chronic hypoxia show a reversal or diminution of these pregnancy-associated changes. We sought to determine whether chronic hypoxia opposes the reduction in contractile response in uterine and nonuterine vessels during normal pregnancy and, if so, whether decreased basal nitric oxide (NO) activity was involved. We examined the contractile response to phenylephrine (PE) in guinea pig uterine artery (UA), mesenteric artery (MA), and thoracic aorta (TA) rings isolated from nonpregnant or pregnant guinea pigs that had been exposed throughout gestation to either low (1,600 m, n = 47) or high (3,962 m, n = 43) altitude. In the UA, pregnancy reduced contractile sensitivity to PE and did so similarly at low and high altitude (EC50: 4.0 x 10(-8) nonpregnant, 9.3 x 10(-8) pregnant at low altitude; 4.8 x 10(-8) nonpregnant, 1.0 x10(-8) pregnant at high altitude; both P < 0.05). Addition of the NO synthase inhibitor nitro-L-arginine (NLA; 200 mM) to the vessel bath increased contractile sensitivity in the pregnant UA (P < 0.05) and eliminated the effect of pregnancy at both altitutes. NLA also raised contractile sensitivity in the nonpregnant high-altitude UA, but contractile response without NLA did not differ in the high- and low-altitude animals. In the MA, pregnancy decreased contractile sensitivity to PE at high altitude only, and this shift was reversed by NO inhibition. In the TA, neither pregnancy nor altitude affected contractile response, but NO inhibition raised contractile response in nonpregnant and pregnant TA at both altitudes. We concluded that pregnancy diminished contractile response to PE in the UA, likely as a result of increased NO activity, and that these changes were similar at low and high altitude. Counter to our hypothesis, chronic hypoxia did not diminish the pregnancy-associated reduction in contractile sensitivity to PE or inhibit basal NO activity in the UA; rather it enhanced, not diminished, basal NO activity in the nonpregnant UA and the pregnant MA.

Neuropeptide Y and mesenteric sympathetic vasoconstriction in pregnant and non-pregnant Wistar-Kyoto rats

1. We have investigated the role of neuropeptide Y (NPY) in sympathetic vasoconstriction and its possible contribution to decreased mesenteric vasoconstrictor responses to electrical field stimulation (EFS) in pregnancy in vivo using an in situ bloodperfused mesenteric preparation in 18-20 day pregnant and age-matched non-pregnant Wistar-Kyoto (WKY) rats. 2. Mean blood pressure (BP) was decreased in pregnant compared with non-pregnant rats. Mesenteric basal perfusion pressure (PP) was not significantly reduced in pregnancy. BIBP 3226, a specific NPY Y1 receptor antagonist, did not affect mean BP or mesenteric basal PP in pregnant or non-pregnant animals. 3. Mesenteric vasoconstrictor responses to EFS were blunted in pregnant compared with non-pregnant controls. BIBP 3226 significantly suppressed mesenteric vasoconstrictor responses to EFS in both pregnant and non-pregnant animals. Decreased mesenteric responses to EFS in pregnancy were still evident following NPY Y1 receptor blockade. 4. These results suggest that endogenous NPY plays a role in rat mesenteric sympathetic vasoconstriction in vivo. However, NPY is unlikely to be responsible for the impairment of EFS-induced mesenteric vasoconstriction in pregnant WKY rats.

The role of nitric oxide in angiotensin II-induced renal vasoconstriction in renovascular hypertension

OBJECTIVE

To evaluate the contribution of nitric oxide to the regulation of angiotensin II-induced renal vasoconstriction in normotensive rats and in rats with aortic coarctation-induced hypertension.

METHODS

We evaluated the renal vascular reactivity of nonischemic kidney to angiotensin II with and without nitric oxide synthesis inhibitor (NG-nitro-L-arginine methyl ester) in the isolated perfused kidney. The nitrite concentration in renal perfusate of nonischemic kidney was measured as an index of nitric oxide released and the activity of nitric oxide synthase in renal tissue was determined by production of [3H]-L-citrulline.

RESULTS

The perfusion of NG-nitro-L-arginine methyl ester potentiated angiotensin II-induced renal vasoconstriction in normotensive rats but had no effect on hypertensive rats. The release of nitrites in kidneys from hypertensive rats was lower than that in kidneys from normotensive rats. The activity of renal nitric oxide synthase was less in the hypertensive rats than it was in the normotensive rats.

CONCLUSIONS

Nitric oxide counteracts the vasoconstrictor effect of angiotensin II in normotensive rats, whereas this protective mechanism is impaired in hypertensive rats. This impairment potentiates effect of angiotensin II on vascular resistance, thereby contributing to the development of high blood pressure.

Role of nitric oxide on the central hemodynamic response to acute volume expansion in the pregnant rat

OBJECTIVES

Our hypothesis was that during pregnancy nitric oxide acts as mediator in the hemodynamic response to volume expansion.

STUDY DESIGN

The study was performed on 12 rats on days 19 to 20 of pregnancy. Six rats were injected intravenously with hexamethonium bromide plus the inhibitor of nitric oxide synthase L-nitro-arginine methyl ester. For a control group, six rats were injected with hexamethonium bromide plus the L-nitro-arginine methyl ester vehicle. A volume expansion (1.2% body weight) was performed in both groups by intravenous infusion of bovine albumin (6%) solution.

RESULTS

In the control group volume expansion induced a hyperdynamic circulation characterized by increased cardiac output, decreased total vascular resistance, and no change in arterial pressure; however, in the study group volume expansion induced a pressor response without hyperdynamic circulation.

CONCLUSION

During pregnancy volume expansion induces a hyperdynamic circulatory state possibly mediated by nitric oxide release. A defect in the release of nitric oxide may be responsible for an inadequate hemodynamic response to volume expansion.

Systemic hemodynamics and regional blood flow during chronic nitric oxide synthesis inhibition in pregnant rats

Pregnancy-induced hypertension in women is associated with severe vasoconstriction and reductions in organ blood flow and cardiac output. Recent studies have indicated that nitric oxide (NO) synthesis inhibition during mid to late gestation in pregnant rats results in severe hypertension and proteinuria. The purpose of this study was to determine the systemic hemodynamic and regional blood flow alterations associated with chronic NO synthesis inhibition in the pregnant rat. The study was conducted in four groups of rats: virgin rats (n=6), pregnant rats (n=10), virgin rats treated with L-NAME (n=6), and pregnant rats treated with L-NAME (n=11). Rats were treated with L-NAME in drinking water at a dose of 1 mg/d for a week starting from day 13 of gestation in pregnant rats or an equivalent time for virgins. Mean arterial pressure (MAP), cardiac output, total peripheral resistance (TPR), and regional flows were measured by tracing radiolabeled microspheres in conscious rats. Pregnant rats that were given L-NAME showed significantly higher MAP (137+/-6 versus 96+/-2 mm Hg), higher TPR (5.08+/-0.58 versus 2.90+/-0.44 mm Hg/mL/min/100 g), and lower cardiac output (87.4+/-8.4 versus 113.3+/-11.1 mL/min) than pregnant controls. Chronic NO synthesis inhibition decreased the renal blood flow in pregnant rats at a significantly greater magnitude than in virgin rats. Significant reductions in regional blood flow to the heart, lungs, liver, diaphragm, and skeletal muscles were also observed in pregnant rats treated with L-NAME. The results of this study indicate that NO may play a role in mediating the alterations in systemic hemodynamics and regional blood flow in late pregnant rats.

A longitudinal study of maternal bloodflow in normal pregnancy and the puerperium: analysis of Doppler waveforms using Laplace transform techniques

OBJECTIVE

To describe changes in the maternal cerebral circulation and the external iliac arteries throughout pregnancy and the puerperium using the Laplace transform analysis of Doppler waveforms.

DESIGN

A prospective longitudinal study.

SETTING

Department of Obstetrics and Gynaecology, Nottingham University Hospital.

SAMPLE

A cohort of 17 healthy women studied every four weeks from early pregnancy until term and up to three months postpartum. Pre-conception data were available for 10 subjects.

METHODS

Doppler signals were recorded from the internal carotid, middle cerebral and external iliac arteries. The waveforms were analysed using two different techniques: standard indices (systolic:diastolic ratio, pulsatility and resistance indices) and Laplace transform analysis, an alternative method of waveform shape analysis which may provide additional haemodynamic information.

RESULTS

Vessel wall tone decreased at an early stage in pregnancy in the cerebral circulation and in the external iliac artery, but this rose again following delivery. The Laplace transform analysis techniques suggest dramatic eight-fold increases in downstream resistance within the external iliac artery in the second half of pregnancy. An increase in downstream resistance to flow also occurred in the internal carotid artery whereas more stable conditions were noted in the middle cerebral artery.

CONCLUSIONS

Having a preliminary idea of the normal ranges for the Laplace transform analysis variables during pregnancy in a variety of maternal vessels, haemodynamic changes in pregnancies complicated by conditions, such as pre-eclampsia, can now be studied.

ACTH responses to hypotension and feedback inhibition of ACTH increased by chronic progesterone treatment

During pregnancy, arterial pressure, baroreceptor sensitivity, and adrenocorticotropic hormone (ACTH) responses to hypotension are decreased. Basal ACTH and cortisol are increased in pregnancy, suggesting a reduction in cortisol feedback inhibition of ACTH. Acute treatment with progesterone decreases arterial pressure, baroreflex-mediated responses, and corticosteroid feedback effects on ACTH. These experiments test the hypothesis that chronic increases in progesterone produce changes in arterial pressure, ACTH responses to stress, and feedback inhibition of ACTH similar to pregnancy. Ewes were treated with progesterone for 60-80 days. This increase in plasma progesterone (to 7.6 +/- 0.4 ng/ml) did not alter basal ACTH, cortisol, arterial pressure, or heart rate. However, ACTH and AVP responses to hypotension were augmented in progesterone-treated ewes compared with untreated ewes. Chronic progesterone treatment resulted in greater inhibition of ACTH by cortisol. Because chronic progesterone treatment did not decrease the ACTH response to hypotension or attenuate the feedback control of ACTH secretion, these results suggest that the changes in pituitary-adrenal control during pregnancy do not reflect a simple effect of progesterone alone.

Pregnancy-induced hypertension: genesis of and response to endothelial injury and the role of endothelin 1

This paper discusses the spectrum of pregnancy-induced hypertension and presents a theory for its etiology. Endothelial injury is the purported precursor to pregnancy-induced hypertensive disorders, and this discussion expands on a possible mechanism by which injury could occur as a result of incomplete trophoblastic invasion. We review endothelin physiology and compare and contrast the evidence surrounding endothelin 1 as a putative mediator of PIH. An approach to treatment utilizing antagonists to the endothelin 1 receptor is introduced.

Nitric oxide and pregnancy

We have hypothesized that an alteration in the production of endothelium-dependent factors by sex hormones is a potential unifying mechanism for both the decreased arterial contractility and the redistribution of cardiac output characteristic of normal pregnancy. Thus, the effect of pregnancy/ estradiol on any one vascular bed will reflect the number and distribution of estrogen receptors. In this article, we review what is known about the effects of pregnancy and estrogen on nitric oxide synthase. Pregnancy increases Ca(2+)-dependent NOS activity early in gestation. The timing of the increase parallels the increase in plasma estradiol concentration. The increase in maternal brain NOS during pregnancy is blocked by tamoxifen. cGMP content increases along a similar time course in most but not all tissues. The changes in cGMP more closely approximate the changes in blood flow during pregnancy. This suggests that multiple elements of the NO:cGMP pathway are altered by pregnancy. It also shows that cGMP content cannot always be used as a surrogate for NOS activity. Estradiol, but not progesterone or testosterone, increases CA(2+)-dependent NOS activity. NO accounts for some, but not all of the pregnancy-associated changes in maternal arterial contractile response. It is not involved in uterine quiescence. Nitric oxide synthase is developmentally regulated in the fetus and is likely important in regulating the distribution of fetal blood flow.

Possible involvement of endothelium-derived hyperpolarizing factor in vascular responses of abdominal aorta from pregnant rats

Increased relaxant response to acetylcholine during pregnancy is proposed to be due to an estrogen-mediated increase in nitric oxide release. We studied acetylcholine-induced pathways of relaxation in the thoracic and abdominal aortic rings from pregnant and nonpregnant Wistar-Kyoto rats and measured basal and stimulated release of nitrites in these vessels. Endothelium-dependent relaxation was significantly greater in pregnant than in nonpregnant rats. Acetylcholine provoked a concentration-dependent relaxation on thoracic and abdominal aortic rings from nonpregnant and pregnant rats. After N118-nitro-L-arginine methyl ester pretreatment, the relaxation was significantly inhibited in the two preparations of nonpregnant and pregnant rodents. The relaxation was not inhibited by indomethacin in any of the aortic segments from pregnant and nonpregnant rats. After cytochrome P450 arachidonic acid metabolism inhibitor clotrimazole, a nonsignificant decrease in the Emax to acetylcholine-induced relaxation was observed in the thoracic segments of pregnant and nonpregnant rats. On the other hand, in abdominal aorta, clotrimazole decreased maximal relaxation in rings from pregnant rats (P<.05) but did not change the acetylcholine-induced relaxation from nonpregnant rats. Our results show an increase in the acetylcholine-stimulated release of nitrites in thoracic aortic rings from pregnant rats compared with rings from nonpregnant rats, which cannot be evidenced in abdominal aortic rings. These results suggest that acetylcholine-induced vasodilation in the abdominal segment from pregnant rats is mediated only in part by nitric oxide, the remainder apparently due to an endothelium-derived vasodilator, cytochrome P450-dependent, which may be endothelium-derived hyperpolarizing factor/epoxyeicosatrienoic acid.

Nitric oxide blunts sympathetic response of pregnant normotensive and hypertensive rat arteries

Rat pregnancy is associated with a blunted response to vasocontrictors both in vivo and in vitro as well as a decrease in arterial pressure. We examined the influence of pregnancy on neurally induced vasoconstrictor and vasodilator responses of the isolated mesenteric arterial bed from normotensive Wistar and spontaneously hypertensive nonpregnant and 20-day pregnant rats and determined the possible role of nitric oxide (NO) in modulating these responses. MAP (mm Hg) in pregnant normotensive (98+/-1, n=13) and hypertensive (136+/-5, n=13) rats was lower (P<.05) than in nonpregnant controls (114+/-2, n=14, and 174+/-3, n=12, respectively). In isolated mesenteric arterial beds, electrical field stimulation (EFS; 34 V, 3 ms, 10-64 Hz) of perivascular nerves at basal tone induced a frequency-dependent increase in perfusion pressure that was significantly (P<.001) greater in preparations from hypertensive compared with normotensive rats. Pregnancy was associated with a significant decrease in the maximal vasoconstrictor response elicited by EFS in both normotensive and hypertensive groups compared with their nonpregnant controls. In phenylephrine-preconstricted mesenteric beds, EFS (60 V, 1 ms, 1-8 Hz) elicited a similar frequency-dependent decrease in perfusion pressure in normotensive and hypertensive groups, but pregnancy did not influence these responses. In the presence of the NO synthase inhibitor N(omega)-nitro-L-arginine (200 micromol/L), the maximal vasoconstrictor response induced by EFS was significantly (P<.001) augmented in both normotensive and hypertensive groups, and the differences observed between pregnant and nonpregnant groups were abolished. Responses to sodium nitroprusside were not affected by pregnancy, although they were greater in preparations from hypertensive rats. These results indicate that NO contributes to pregnancy-associated diminished vasoconstrictor response to sympathetic stimulation in the mesenteric arterial bed of both normotensive and hypertensive rats.

Demonstration of the existence of nitric oxide-independent as well as nitric oxide-dependent vasodilator mechanisms in the in situ renal circulation in near term pregnant rats

1. We have investigated the role of endogenous nitric oxide on renal vascular reactivity in late pregnancy in in situ blood perfused kidneys of alpha-chloralose anaesthetized Wistar-Kyoto rats. Nitric oxide synthesis inhibition was achieved by intravenous administration of NG-nitro-L-arginine or NG-nitro-L-arginine methyl ester. 2. Intra-arterial mean blood pressure was lower in pregnancy compared with nonpregnant controls. Following nitric oxide synthesis inhibition mean blood pressure increased in both pregnant and nonpregnant groups, but remained lower in pregnant animals. 3. Basal renal perfusion pressure was similar in pregnant and nonpregnant groups. Intravenous administration of Ng-nitro-L-arginine resulted in dose-dependent increases in renal perfusion pressure but responses were substantially depressed in pregnancy. 4. Renal vasoconstrictor responses to regional angiotensin II (AII) were decreased in pregnancy, whereas those to noradrenaline (NA) did not differ from nonpregnant controls. NG-nitro-L-arginine (5 mg kg-1) potentiated renal responses to regional AII and NA in both groups, but AII responses remained lower in pregnancy. Blunted renal AII responses in pregnancy were still evident following large doses of NG-nitro-L-arginine methyl ester (100 mg kg-1). 5. The results demonstrate that nitric oxide synthesis inhibition increases renal perfusion pressure to a lesser extent in pregnant compared with nonpregnant rats, and that reduced renal pressor responses to AII are still evident in pregnancy after nitric oxide synthesis inhibition. 6. These results suggest that although endogenous nitric oxide synthesis modulates renal vasoconstrictor responses in both pregnant and nonpregnant animals, this mechanism does not fully account for the blunted renal vasconstrictor responses to regional AII or nitric oxide inhibitors in near term pregnant rats. The nature of this important physiological vasodilator mechanism in pregnancy remains to be elucidated.