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Bratton S, Taylor MK, Cortez P, Schiattarella A, Fochesato C, Sisti G. Does atenolol use during pregnancy cause small for gestational age neonates? A meta-analysis. J Perinat Med 2024; 52:858-862. [PMID: 39115600 DOI: 10.1515/jpm-2024-0114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 07/22/2024] [Indexed: 10/08/2024]
Abstract
OBJECTIVES Atenolol is a commonly used beta bloscker in non-pregnant women. Many providers are hesitant in prescribing atenolol in pregnancy because of a possible association with poor fetal growth. We aimed to assess the association between atenolol and the occurrence of small for gestational age neonates compared to other beta blockers, as described in the existing literature. METHODS We used the meta-analytic method to generate a forest plot for risk ratios (RR) of small for gestational age in patients who used atenolol vs. other beta blockers. Statistical heterogeneity was assessed with the I2 statistic. RESULTS Two studies were included, with a resultant RR of 1.94 [95 % confidence interval (CI) 1.60; 2.35]. A study by Duan et al. in 2018 noted the following rate of small for gestational age for each beta blocker use: 112/638 atenolol, 590/3,357 labetalol, 35/324 metoprolol, and 50/489 propranolol. A study by Tanaka et al. in 2016 noted the following rate of small for gestational age: 8/22 for propranolol, 2/12 for metoprolol, 2/6 for atenolol, 0/5 for bisoprolol. Heterogeneity (I2) was 0 %. CONCLUSIONS Our results suggested an elevated risk of small for gestational age associated with atenolol use in comparison to other beta blockers, specifically labetalol, propranolol, bisoprolol, and metoprolol.
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Affiliation(s)
- Shauna Bratton
- College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Megan K Taylor
- College of Medicine, University of Arizona, Tucson, AZ, USA
| | | | - Antonio Schiattarella
- Department of Woman, Child and General and Specialized Surgery, Luigi Vanvitelli University of Campania, Naples, Italy
| | - Cecilia Fochesato
- Department of Obstetrics and Gynecology, Multimedica Ospedale S. Giuseppe, University of Milan, Milan, Italy
| | - Giovanni Sisti
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, College of Medicine - Tucson, University of Arizona, Tucson, AZ, USA
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2
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Conti-Ramsden F, de Marvao A, Chappell LC. Pharmacotherapeutic options for the treatment of hypertension in pregnancy. Expert Opin Pharmacother 2024; 25:1739-1758. [PMID: 39225514 DOI: 10.1080/14656566.2024.2398602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 08/21/2024] [Accepted: 08/27/2024] [Indexed: 09/04/2024]
Abstract
INTRODUCTION Hypertensive disorders of pregnancy affect approximately one in 10 pregnancies and are associated with increased risk of adverse fetal, neonatal and maternal outcomes. There is strong evidence that effective treatment of hypertension (blood pressure ≥ 140/90 mmHg), and enhanced monitoring throughout pregnancy reduces these risks. AREAS COVERED This article provides a contemporaneous review of treatment of hypertension in pregnancy with antihypertensive agents. We completed a systematic search and review of all meta-analyses and systematic reviews of studies comparing antihypertensives for treatment of pregnancy hypertension in the last five years. We provide a clinically focused summary of when to treat hypertension in pregnancy and which antihypertensive agents can be offered. Special scenarios reviewed include treatment-resistant hypertension and pre-pregnancy antihypertensive optimization. EXPERT OPINION Several antihypertensives are considered safe and are known to be effective for treatment of hypertension in pregnancy. Given the current uncertainty as to which antihypertensive(s) are superior for treatment of hypertension in pregnancy, women should be counselled and offered a range of antihypertensive options in keeping with evidence on clinical effectiveness, local context and availability of antihypertensive(s), potential side effect profile, and women's preference. Further research is required to help guide clinical decision making, and move toward personalized treatment.
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Affiliation(s)
- Frances Conti-Ramsden
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Antonio de Marvao
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
- British Heart Foundation Centre of Research Excellence, School of Cardiovascular and Metabolic Medicine and Sciences, King's College London, London, UK
- Medical Research Council Laboratory of Medical Sciences, Imperial College London, London, UK
| | - Lucy C Chappell
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
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3
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Wegner LS, Steinhard J, Frank T, Laser KT, Kubiak K. Fetal Long QT Syndrome - Challenges in Perinatal Management: A Review and Case Report. Induction of Labor and Vaginal Birth Under Continuous Magnesium Therapy. Z Geburtshilfe Neonatol 2024; 228:328-339. [PMID: 38387612 DOI: 10.1055/a-2231-9348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
Congenital LQTS is an often undetected inherited cardiac channel dysfunction and can be a reason for intrauterine fetal demise. It can present in utero as CTG and ultrasound abnormalities, i. e., bradycardia, ventricular tachycardia, or fetal hydrops. Diagnosis is made by CTG, echocardiography, or fMCG. Intrauterine therapy with a ß blocker and i. v. magnesium should be started. Our objective was to examine the current knowledge about diagnosis and treatment of LQTS and in particular to highlight the opportunity of vaginal birth under continuous intravenous magnesium therapy. Therefore, a thorough MEDLINE and Google Scholar search was conducted. Randomized controlled trials, meta-analyses, prospective and retrospective cohort trials, and case reports were considered. We showed the possibility of vaginal delivery under continuous magnesium therapy in a case of suspected fetal LQTS. A stepwise concept for diagnosis, monitoring, and peripartum management in low, intermediate, and high risk cases of fetal LQTS is presented. If risk is low or intermediate, a vaginal delivery under continuous monitoring is reasonable. Induction of labor at term should be evaluated.
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Affiliation(s)
- Linda Sarah Wegner
- Obstetrics and Gynecology, St. Franziskus-Hospital Münster GmbH, Münster, Germany
| | - Johannes Steinhard
- Department of Fetal Cardiology, Heart and Diabetes Center, Bad Oeynhausen Hospital, Bad Oeynhausen, Germany
| | - Thomas Frank
- Department of Neonatology and Pediatric Intensive Care, St. Franziskus-Hospital Münster GmbH, Münster, Germany
| | - Kai Thorsten Laser
- Department of Fetal Cardiology, Heart and Diabetes Center, Bad Oeynhausen Hospital, Bad Oeynhausen, Germany
| | - Karol Kubiak
- Obstetrics and Gynecology, St. Franziskus-Hospital Münster GmbH, Münster, Germany
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4
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Herzig MS, McIlvaine S, Feinberg L, Spiel MH, Carroll BJ. Outcomes of Bicuspid Aortic Valve in Pregnancy. Am J Cardiol 2024; 221:74-76. [PMID: 38697454 DOI: 10.1016/j.amjcard.2024.04.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 04/08/2024] [Accepted: 04/19/2024] [Indexed: 05/05/2024]
Affiliation(s)
- Matthew S Herzig
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
| | - Susan McIlvaine
- Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Loryn Feinberg
- Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Melissa H Spiel
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts
| | - Brett J Carroll
- Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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5
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Tamirisa KP, Oliveros E, Paulraj S, Mares AC, Volgman AS. An Overview of Arrhythmias in Pregnancy. Methodist Debakey Cardiovasc J 2024; 20:36-50. [PMID: 38495654 PMCID: PMC10941715 DOI: 10.14797/mdcvj.1325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 12/27/2023] [Indexed: 03/19/2024] Open
Abstract
Cardiovascular disease significantly jeopardizes pregnancies in the United States, impacting 1% to 4% of pregnancies annually. Among complications, cardiac arrhythmias are prevalent, posing concerns for maternal and fetal health. The incidence of arrhythmias during pregnancy is rising, partly due to advances in congenital heart surgery and a growing population of women with structural heart disease. While most arrhythmias are benign, the increasing prevalence of more serious arrhythmias warrants a proactive approach. Guidance and reassurance suffice in many cases, but persistent symptoms require cautious use of antiarrhythmic drugs or other therapies for a safe outcome. Managing more serious arrhythmias requires a comprehensive, multidisciplinary approach involving specialists, including maternal-fetal medicine physicians, cardiologists, electrophysiologists, and anesthesiologists.
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Louchet M, Tisseyre M, Kaguelidou F, Treluyer JM, Préta LH, Chouchana L. Drug-induced fetal and offspring disorders, beyond birth defects. Therapie 2024; 79:205-219. [PMID: 38008599 DOI: 10.1016/j.therap.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 11/09/2023] [Indexed: 11/28/2023]
Abstract
Studies on drug utilization in western countries disclosed that about nine over ten women use at least one or more drugs during pregnancy. Determining whether a drug is safe or not in pregnant women is a challenge of all times. As a developing organism, the fetus is particularly vulnerable to effects of drugs used by the mother. Historically, research has predominantly focused on birth defects, which represent the most studied adverse pregnancy outcomes. However, drugs can also alter the ongoing process of pregnancy and impede the general growth of the fetus. Finally, adverse drug reactions can theoretically damage all developing systems, organs or tissues, such as the central nervous system or the immune system. This extensive review focuses on different aspects of drug-induced damages affecting the fetus or the newborn/infant, beyond birth defects, which are not addressed here.
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Affiliation(s)
- Margaux Louchet
- URP 7323 "Pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte", Université Paris Cité, 75000 Paris, France; Service de gynécologie-obstétrique, Fédération hospitalo-universitaire PREMA, hôpital Louis-Mourier, AP-HP Nord - Université Paris Cité, 75000 Paris, France
| | - Mylène Tisseyre
- URP 7323 "Pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte", Université Paris Cité, 75000 Paris, France; Centre régional de pharmacovigilance, service de pharmacologie périnatale, pédiatrique et adulte, hôpitaux Cochin-Necker, AP-HP Centre - Université Paris Cité, 75000 Paris, France
| | - Florentia Kaguelidou
- URP 7323 "Pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte", Université Paris Cité, 75000 Paris, France; Centre d'investigation clinique pédiatrique, Inserm CIC 1426, hôpital Robert-Debré, AP-HP Nord - Université Paris Cité, 75000 Paris, France
| | - Jean-Marc Treluyer
- URP 7323 "Pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte", Université Paris Cité, 75000 Paris, France; Centre régional de pharmacovigilance, service de pharmacologie périnatale, pédiatrique et adulte, hôpitaux Cochin-Necker, AP-HP Centre - Université Paris Cité, 75000 Paris, France
| | - Laure-Hélène Préta
- URP 7323 "Pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte", Université Paris Cité, 75000 Paris, France
| | - Laurent Chouchana
- URP 7323 "Pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte", Université Paris Cité, 75000 Paris, France; Centre régional de pharmacovigilance, service de pharmacologie périnatale, pédiatrique et adulte, hôpitaux Cochin-Necker, AP-HP Centre - Université Paris Cité, 75000 Paris, France.
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7
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Kaizer AM, Winbo A, Clur SAB, Etheridge SP, Ackerman MJ, Horigome H, Herberg U, Dagradi F, Spazzolini C, Killen SAS, Wacker-Gussmann A, Wilde AAM, Sinkovskaya E, Abuhamad A, Torchio M, Ng CA, Rydberg A, Schwartz PJ, Cuneo BF. Effects of cohort, genotype, variant, and maternal β-blocker treatment on foetal heart rate predictors of inherited long QT syndrome. Europace 2023; 25:euad319. [PMID: 37975542 PMCID: PMC10655062 DOI: 10.1093/europace/euad319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/16/2023] [Indexed: 11/19/2023] Open
Abstract
AIMS In long QT syndrome (LQTS), primary prevention improves outcome; thus, early identification is key. The most common LQTS phenotype is a foetal heart rate (FHR) < 3rd percentile for gestational age (GA) but the effects of cohort, genotype, variant, and maternal β-blocker therapy on FHR are unknown. We assessed the influence of these factors on FHR in pregnancies with familial LQTS and developed a FHR/GA threshold for LQTS. METHODS AND RESULTS In an international cohort of pregnancies in which one parent had LQTS, LQTS genotype, familial variant, and maternal β-blocker effects on FHR were assessed. We developed a testing algorithm for LQTS using FHR and GA as continuous predictors. Data included 1966 FHRs at 7-42 weeks' GA from 267 pregnancies/164 LQTS families [220 LQTS type 1 (LQT1), 35 LQTS type 2 (LQT2), and 12 LQTS type 3 (LQT3)]. The FHRs were significantly lower in LQT1 and LQT2 but not LQT3 or LQTS negative. The LQT1 variants with non-nonsense and severe function loss (current density or β-adrenergic response) had lower FHR. Maternal β-blockers potentiated bradycardia in LQT1 and LQT2 but did not affect FHR in LQTS negative. A FHR/GA threshold predicted LQT1 and LQT2 with 74.9% accuracy, 71% sensitivity, and 81% specificity. CONCLUSION Genotype, LQT1 variant, and maternal β-blocker therapy affect FHR. A predictive threshold of FHR/GA significantly improves the accuracy, sensitivity, and specificity for LQT1 and LQT2, above the infant's a priori 50% probability. We speculate this model may be useful in screening for LQTS in perinatal subjects without a known LQTS family history.
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Affiliation(s)
- Alexander M Kaizer
- Biostatistics and Informatics, Colorado School of Public Health, University of Colorado-Anschutz Medical Campus, Aurora, CO, USA
| | - Annika Winbo
- Department of Clinical Sciences, Pediatrics, Umeå University, Umea, Sweden
- Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Sally-Ann B Clur
- Department of Pediatric Cardiology, Emma Children’s Hospital, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- Department of Cardiology, University Medical Center, Amsterdam, The Netherlands
| | - Susan P Etheridge
- Department of Pediatrics, Division of Cardiology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Michael J Ackerman
- Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Mayo Clinic, Rochester, MN, USA
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, MN, USA
- Department of Molecular Pharmacology & Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA
- Windland Smith Rice Genetic Heart Rhythm Clinic and Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, MN, USA
| | - Hitoshi Horigome
- Department of Pediatrics, Section of Cardiology, Tsukuba University, Tsukuba, Japan
| | - Ulrike Herberg
- Department of Pediatric Cardiology, RWTH University Hospital Aachen, Aachen, Germany
- Department of Pediatric Cardiology, University Hospital Bonn, Bonn, Germany
| | - Federica Dagradi
- Center for Cardiac Arrhythmias of Genetic Origin and Laboratory of Cardiovascular Genetics, IRCCS Istituto Auxologico Italiano, Via Pier Lombardo 22, 2015 Milan, Italy
| | - Carla Spazzolini
- Center for Cardiac Arrhythmias of Genetic Origin and Laboratory of Cardiovascular Genetics, IRCCS Istituto Auxologico Italiano, Via Pier Lombardo 22, 2015 Milan, Italy
| | - Stacy A S Killen
- Department of Pediatrics, Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Annette Wacker-Gussmann
- Department of Congenital Heart Disease and Paediatric Cardiology, German Heart Center, Munich, Germany
| | - Arthur A M Wilde
- Department of Cardiology, University Medical Center, Amsterdam, The Netherlands
- Department of Cardiology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Department of Cardiology, Amseterdam University Medical Center, Amsterdam, The Netherlands
| | - Elena Sinkovskaya
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Alfred Abuhamad
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Margherita Torchio
- Center for Cardiac Arrhythmias of Genetic Origin and Laboratory of Cardiovascular Genetics, IRCCS Istituto Auxologico Italiano, Via Pier Lombardo 22, 2015 Milan, Italy
| | - Chai-Ann Ng
- Mark Cowley Lidwill Research Program in Cardiac Electrophysiology, Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
- The School of Clinical Medicine, UNSW Sydney, Darlinghurst, New South Wales, Australia
| | - Annika Rydberg
- Department of Clinical Sciences, Pediatrics, Umeå University, Umea, Sweden
- Department of Cardiology, University Medical Center, Amsterdam, The Netherlands
| | - Peter J Schwartz
- Center for Cardiac Arrhythmias of Genetic Origin and Laboratory of Cardiovascular Genetics, IRCCS Istituto Auxologico Italiano, Via Pier Lombardo 22, 2015 Milan, Italy
| | - Bettina F Cuneo
- Department of Pediatrics, Section of Cardiology, University of Denver School of Medicine, 13123 16th Ave, Box 100, Aurora, CO 80045, USA
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8
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Tropea T, Mavichak W, Evangelinos A, Brennan-Richardson C, Cottrell EC, Myers JE, Johnstone ED, Brownbill P. Fetoplacental vascular effects of maternal adrenergic antihypertensive and cardioprotective medications in pregnancy. J Hypertens 2023; 41:1675-1687. [PMID: 37694528 PMCID: PMC10552840 DOI: 10.1097/hjh.0000000000003532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 06/07/2023] [Accepted: 07/24/2023] [Indexed: 09/12/2023]
Abstract
Maternal cardiovascular diseases, including hypertension and cardiac conditions, are associated with poor fetal outcomes. A range of adrenergic antihypertensive and cardioprotective medications are often prescribed to pregnant women to reduce major maternal complications during pregnancy. Although these treatments are not considered teratogenic, they may have detrimental effects on fetal growth and development, as they cross the fetoplacental barrier, and may contribute to placental vascular dysregulation. Medication risk assessment sheets do not include specific advice to clinicians and women regarding the safety of these therapies for use in pregnancy and the potential off-target effects of adrenergic medications on fetal growth have not been rigorously conducted. Little is known of their effects on the fetoplacental vasculature. There is also a dearth of knowledge on adrenergic receptor activation and signalling within the endothelium and vascular smooth muscle cells of the human placenta, a vital organ in the maintenance of adequate blood flow to satisfy fetal growth and development. The fetoplacental circulation, absent of sympathetic innervation, and unique in its reliance on endocrine, paracrine and autocrine influence in the regulation of vascular tone, appears vulnerable to dysregulation by adrenergic antihypertensive and cardioprotective medications compared with the adult peripheral circulation. This semi-systematic review focuses on fetoplacental vascular expression of adrenergic receptors, associated cell signalling mechanisms and predictive consequences of receptor activation/deactivation by antihypertensive and cardioprotective medications.
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Affiliation(s)
- Teresa Tropea
- Maternal & Fetal Health Research Centre, Division of Developmental Biology & Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester
- St Mary's Hospital, Manchester University Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Weerawaroon Mavichak
- Maternal & Fetal Health Research Centre, Division of Developmental Biology & Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester
- St Mary's Hospital, Manchester University Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Angelos Evangelinos
- Maternal & Fetal Health Research Centre, Division of Developmental Biology & Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester
- St Mary's Hospital, Manchester University Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Charlotte Brennan-Richardson
- Maternal & Fetal Health Research Centre, Division of Developmental Biology & Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester
- St Mary's Hospital, Manchester University Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Elizabeth C. Cottrell
- Maternal & Fetal Health Research Centre, Division of Developmental Biology & Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester
- St Mary's Hospital, Manchester University Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Jenny E. Myers
- Maternal & Fetal Health Research Centre, Division of Developmental Biology & Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester
- St Mary's Hospital, Manchester University Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Edward D. Johnstone
- Maternal & Fetal Health Research Centre, Division of Developmental Biology & Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester
- St Mary's Hospital, Manchester University Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Paul Brownbill
- Maternal & Fetal Health Research Centre, Division of Developmental Biology & Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester
- St Mary's Hospital, Manchester University Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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9
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Rodriguez CP, Economy KE, Duarte VE, Mehta N, Duncan ME, Chandler S, Gauvreau K, Easter SR, Wu F, Lachtrupp C, Tedrow U, Valente AM, Tadros T. Mobile Cardiac Telemetry Use to Predict Adverse Pregnancy Outcomes in Patients With Congenital Heart Disease. JACC. ADVANCES 2023; 2:100593. [PMID: 38938332 PMCID: PMC11198184 DOI: 10.1016/j.jacadv.2023.100593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 06/07/2023] [Accepted: 06/16/2023] [Indexed: 06/29/2024]
Abstract
Background Patients with congenital heart disease (CHD) have a higher incidence of arrhythmias during pregnancy, yet the utility of mobile cardiac telemetry (MCT) to predict adverse outcomes is unknown. Objectives The purpose of this study is to determine whether arrhythmias on screening MCT correlate with adverse pregnancy outcomes. Methods Patients with CHD prospectively enrolled in the Standardized Outcomes in Reproductive Cardiovascular Care initiative underwent 24-hour MCT (within 18 months prior to pregnancy). Positive findings on MCT were defined as episodes of bradyarrhythmia, symptomatic atrioventricular block, ectopic atrial or ventricular activity, and supraventricular or ventricular tachycardia. Clinically significant arrhythmia events (CSAEs) were those requiring medical or device intervention or an emergency room visit. Clinical events during the antepartum, intrapartum, and postpartum periods were compared using Fisher's exact test. Analyses were performed using Stata version 16. Results In 141 pregnancies in 118 patients with CHD, MCT detected positive findings in 17%. Adverse cardiac outcomes occurred in 11% of pregnancies, of which CSAE occurred in 3.5%. Positive MCT was significantly associated with subsequent CSAE (21% vs 0%, P < 0.001) and cumulative adverse maternal cardiac outcomes (33% vs 7%, P = 0.001) but did not correlate with obstetric (46% vs 41%, P = 0.660) or neonatal outcomes (33% vs 31%, P = 0.810). Of the patients with CSAE, 75% had ≥moderate CHD complexity. Conclusions Patients with CHD had a high rate of positive MCT findings. This was associated with CSAE and adverse maternal cardiac outcomes. Patients with ≥moderate CHD complexity may benefit from screening MCT to improve preconceptual counseling and planning.
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Affiliation(s)
- Carla P. Rodriguez
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiology, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Katherine E. Economy
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Valeria E. Duarte
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiology, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nishaki Mehta
- Division of Cardiology, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Madeline E. Duncan
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Stephanie Chandler
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Sarah Rae Easter
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Fred Wu
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiology, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Cara Lachtrupp
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Usha Tedrow
- Division of Cardiology, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anne Marie Valente
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiology, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas Tadros
- Division of Cardiology, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
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10
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Joglar JA, Kapa S, Saarel EV, Dubin AM, Gorenek B, Hameed AB, Lara de Melo S, Leal MA, Mondésert B, Pacheco LD, Robinson MR, Sarkozy A, Silversides CK, Spears D, Srinivas SK, Strasburger JF, Tedrow UB, Wright JM, Zelop CM, Zentner D. 2023 HRS expert consensus statement on the management of arrhythmias during pregnancy. Heart Rhythm 2023; 20:e175-e264. [PMID: 37211147 DOI: 10.1016/j.hrthm.2023.05.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 05/12/2023] [Indexed: 05/23/2023]
Abstract
This international multidisciplinary expert consensus statement is intended to provide comprehensive guidance that can be referenced at the point of care to cardiac electrophysiologists, cardiologists, and other health care professionals, on the management of cardiac arrhythmias in pregnant patients and in fetuses. This document covers general concepts related to arrhythmias, including both brady- and tachyarrhythmias, in both the patient and the fetus during pregnancy. Recommendations are provided for optimal approaches to diagnosis and evaluation of arrhythmias; selection of invasive and noninvasive options for treatment of arrhythmias; and disease- and patient-specific considerations when risk stratifying, diagnosing, and treating arrhythmias in pregnant patients and fetuses. Gaps in knowledge and new directions for future research are also identified.
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Affiliation(s)
- José A Joglar
- The University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Elizabeth V Saarel
- St. Luke's Health System, Boise, Idaho, and Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio
| | | | | | | | | | | | | | - Luis D Pacheco
- The University of Texas Medical Branch at Galveston, Galveston, Texas
| | | | - Andrea Sarkozy
- University Hospital of Antwerp, University of Antwerp, Antwerp, Belgium
| | | | - Danna Spears
- University Health Network, Toronto, Ontario, Canada
| | - Sindhu K Srinivas
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | | | | | - Carolyn M Zelop
- The Valley Health System, Ridgewood, New Jersey; New York University Grossman School of Medicine, New York, New York
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11
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DeFilippis EM, Bhagra C, Casale J, Ging P, Macera F, Punnoose L, Rasmusson K, Sharma G, Sliwa K, Thorne S, Walsh MN, Kittleson MM. Cardio-Obstetrics and Heart Failure: JACC: Heart Failure State-of-the-Art Review. JACC. HEART FAILURE 2023; 11:1165-1180. [PMID: 37678960 DOI: 10.1016/j.jchf.2023.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 05/26/2023] [Accepted: 07/05/2023] [Indexed: 09/09/2023]
Abstract
Heart failure and cardiomyopathy are significant contributors to pregnancy-related deaths, as maternal morbidity and mortality have been increasing over time. In this setting, the role of the multidisciplinary cardio-obstetrics team is crucial to optimizing maternal, obstetrical and fetal outcomes. Although peripartum cardiomyopathy is the most common cardiomyopathy experienced by pregnant individuals, the hemodynamic changes of pregnancy may unmask a pre-existing cardiomyopathy leading to clinical decompensation. Additionally, there are unique management considerations for women with pre-existing cardiomyopathy as well as for those women with advanced heart failure who may be on left ventricular assist device support or have undergone heart transplantation. The purpose of this review is to discuss: 1) preconception counseling; 2) risk stratification and management strategies for pregnant women extending to the postpartum "fourth trimester" with pre-existing heart failure or "pre-heart failure;" 3) the safety of heart failure medications during pregnancy and lactation; and 4) management of pregnancy for women on left ventricular assist device support or after heart transplantation.
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Affiliation(s)
- Ersilia M DeFilippis
- Division of Cardiology, NewYork-Presbyterian Columbia University Irving Medical Center, New York, New York, USA
| | - Catriona Bhagra
- Department of Cardiology, Cambridge University and Royal Papworth NHS Foundation Trusts, Cambridge, United Kingdom
| | - Jillian Casale
- Department of Pharmacy Services, Cooperman Barnabas Medical Center, Livingston, New Jersey, USA
| | - Patricia Ging
- Department of Pharmacy, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Francesca Macera
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy; Department of Cardiology, Cliniques Universitaires de Bruxelles - Hôpital Erasme, Brussels, Belgium
| | - Lynn Punnoose
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kismet Rasmusson
- Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, Utah, USA
| | - Garima Sharma
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Karen Sliwa
- Cape Heart Institute, Department of Medicine, Division of Cardiology, Faculty of Health Sciences, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Sara Thorne
- Division of Cardiology, Pregnancy & Heart Disease Program, Mount Sinai Hospital & University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA.
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12
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Martinez A, Lakkimsetti M, Maharjan S, Aslam MA, Basnyat A, Kafley S, Reddy SS, Ahmed SS, Razzaq W, Adusumilli S, Khawaja UA. Beta-Blockers and Their Current Role in Maternal and Neonatal Health: A Narrative Review of the Literature. Cureus 2023; 15:e44043. [PMID: 37746367 PMCID: PMC10517705 DOI: 10.7759/cureus.44043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 08/24/2023] [Indexed: 09/26/2023] Open
Abstract
Beta-blockers are a class of medications that act on beta-adrenergic receptors and are categorized as cardio-selective and non-selective. They are principally used to treat cardiovascular conditions such as hypertension and arrhythmias. Beta-blockers have also been used to treat non-cardiogenic indications in non-pregnant individuals and the pediatric population. In pregnancy, labetalol is the mainstay treatment for hypertension and other cardiovascular indications. However, contraindications to certain sub-types of beta-blockers include bradycardia, heart failure, obstructive lung diseases, and hemodynamic instability. There is conflicting evidence of the adverse effects on fetal and neonatal health due to a scarce safety and efficacy profile, and further studies are necessary to understand the pharmacokinetics of the different classes of beta-blockers in pregnancy and fetal health. Understanding the hemodynamic changes during the stages of pregnancy is important to target a more beneficial therapy for both mother and fetus as well as better neonatal outcomes. Beta-blocker use in the pediatric population is less documented in studies but does have the potential to treat various cardiogenic and non-cardiogenic conditions. Future comprehensive studies would further benefit the direction of beta-blocker treatment during pregnancy in neonates and pediatrics.
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Affiliation(s)
- Andrea Martinez
- Medical School, Universidad Autonoma de Guadalajara, Zapopan, MEX
| | | | - Sameep Maharjan
- General Practice, Patan Academy of Health Sciences, Kathmandu, NPL
| | - Muhammad Ammar Aslam
- Medical School, Sargodha Medical College, University of Health Sciences, Sargodha, PAK
| | - Anouksha Basnyat
- General Practice, Hospital for Advanced Medicine & Surgery (HAMS), Kathmandu, NPL
| | - Shashwat Kafley
- Medical School, Enam Medical College and Hospital, Dhaka, BGD
| | | | - Saima S Ahmed
- Vascular Surgery, Dow International Medical College, Karachi, PAK
| | - Waleed Razzaq
- Internal Medicine, Services Hospital Lahore, Lahore, PAK
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13
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Lailler G, Grave C, Gabet A, Regnault N, Deneux-Tharaux C, Kretz S, Mounier-Vehier C, Tsatsaris V, Plu-Bureau G, Blacher J, Olié V. Adverse Maternal and Infant Outcomes in Women With Chronic Hypertension in France (2010-2018): The Nationwide CONCEPTION Study. J Am Heart Assoc 2023; 12:e027266. [PMID: 36847049 PMCID: PMC10111462 DOI: 10.1161/jaha.122.027266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
Background It has been suggested that chronic hypertension is a risk factor for negative maternal and fetal outcomes during pregnancy and postpartum. We aimed to estimate the association of chronic hypertension on adverse maternal and infant outcomes and assess the impact of antihypertensive treatment and these outcomes. Methods and Results Using data from the French national health data system, we identified and included in the CONCEPTION cohort all women in France who delivered their first child between 2010 and 2018. Chronic hypertension before pregnancy was identified through antihypertensive medication purchases and by diagnosis during hospitalization. We assessed the incidence risk ratios (IRRs) of maternofetal outcomes using Poisson models. A total of 2 822 616 women were included, and 42 349 (1.5%) had chronic hypertension and 22 816 were treated during pregnancy. In Poisson models, the adjusted IRR (95% CI) of maternofetal outcomes for women with hypertension were as follows: 1.76 (1.54-2.01) for infant death, 1.73 (1.60-1.87) for small gestational age, 2.14 (1.89-2.43) for preterm birth, 4.58 (4.41-4.75) for preeclampsia, 1.33 (1.27-1.39) for cesarean delivery, 1.84 (1.47-2.31) for venous thromboembolism, 2.62 (1.71-4.01) for stroke or acute coronary syndrome, and 3.54 (2.11-5.93) for maternal death postpartum. In women with chronic hypertension, being treated with an antihypertensive drug during pregnancy was associated with a significantly lower risk of obstetric hemorrhage, stroke, and acute coronary syndrome during pregnancy and postpartum. Conclusions Chronic hypertension is a major risk factor of infant and maternal negative outcomes. In women with chronic hypertension, the risk of pregnancy and postpartum cardiovascular events may be decreased by antihypertensive treatment during pregnancy.
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Affiliation(s)
- Grégory Lailler
- Santé publique France Saint-Maurice France.,Department of Medicine Université Paris Est Créteil France
| | | | | | | | - Catherine Deneux-Tharaux
- Obstetrical Perinatal and Pediatric Epidemiology Research Team (EPOPé), Centre for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), French National Institute for Health and Medical Research (INSERM) Paris France.,Department of Medicine Université Paris Cité Paris France
| | - Sandrine Kretz
- Centre de diagnostic et de thérapeutique, Assistance Publique Hôpitaux de Paris (AP-HP), Hôtel Dieu de Paris Paris France
| | | | - Vassilis Tsatsaris
- Department of Medicine Université Paris Cité Paris France.,Maternité Port-Royal, Assistance Publique Hôpitaux de Paris (AP-HP), Hôpital Cochin Paris France
| | - Geneviève Plu-Bureau
- Obstetrical Perinatal and Pediatric Epidemiology Research Team (EPOPé), Centre for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), French National Institute for Health and Medical Research (INSERM) Paris France.,Department of Medicine Université Paris Cité Paris France.,Unité de gynécologie médicale, Assistance Publique Hôpitaux de Paris (AP-HP), Hôpital Port-Royal Cochin Paris France
| | - Jacques Blacher
- Department of Medicine Université Paris Cité Paris France.,Centre de diagnostic et de thérapeutique, Assistance Publique Hôpitaux de Paris (AP-HP), Hôtel Dieu de Paris Paris France
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14
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Antihypertensives in Pregnancy. Obstet Gynecol Clin North Am 2023; 50:39-78. [PMID: 36822710 DOI: 10.1016/j.ogc.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
Hypertensive disorders of pregnancy (HDP) can result in significant maternal morbidity and even mortality. Available data suggest that many antihypertensives can be safely used in pregnant patients, albeit with close supervision of parameters like fetal growth and amniotic fluid volume. This article summarizes current guidelines on the diagnosis and treatment of hypertension in pregnancy and provides an in-depth guide to the available safety and efficacy data for antihypertensives during pregnancy and postpartum.
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15
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Teelucksingh S, Murali Govind R, Dobson R, Nelson-Piercy C, Ovadia C. Treating Vestibular Migraine When Pregnant and Postpartum: Progress, Challenges and Innovations. Int J Womens Health 2023; 15:321-338. [PMID: 36814528 PMCID: PMC9940493 DOI: 10.2147/ijwh.s371491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 01/18/2023] [Indexed: 02/18/2023] Open
Abstract
Vestibular migraine is a leading cause of vertigo in pregnancy and, although not a distinct migraine subtype, is an episodic syndrome associated with migraine. Vestibular migraine is associated with diverse symptoms such as vertigo, aura, allodynia, osmophobia, nausea, vomiting and tinnitus, many of which may be exacerbated by, masked or even dismissed in pregnancy. Vestibular migraine is likely an underdiagnosed and undertreated condition in pregnancy. The aetiology of vestibular migraine remains incompletely understood, although various theories have been proposed, including genetic predisposition, neurochemical dysregulation and pro-inflammatory mechanisms, all of which are derived from the pathophysiology of classical migraine. Physiologic changes to the endocrine, haematologic and vascular systems in pregnancy may affect pathophysiological processes in vestibular migraine, and can alter the course of symptoms experienced in pregnancy. These changes also predispose to secondary headache disorders, which may have similar presentations. There has been considerable progress in therapeutic advances in vestibular migraine prophylaxis and treatment outside of pregnancy. There is currently no significant evidence base for acute treatment or prophylaxis for pregnant patients, with treatment recommendations extrapolated from studies on classical migraine, and offered on a benefit versus risk basis. Challenges commonly encountered include difficulty establishing a diagnosis, in addition to recognising and treating neuropsychiatric and gestational co-morbidities. Anxiety, depression, hypertensive disorders and cardiovascular disease are closely associated with migraine, and important contributors to morbidity and mortality during pregnancy. Identifying and treating vestibular migraine during pregnancy offers a unique opportunity to impact future patient health through screening and early treatment of associated co-morbidities. There have been innovations in classical migraine therapy that may confer benefit in vestibular migraine in pregnancy, with emphasis on lifestyle modification, effective prophylaxis, abortive therapies, cognitive behaviour therapy and management of vestibular migraine-related comorbidities.
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Affiliation(s)
- Siara Teelucksingh
- Department of Obstetric Medicine, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK
| | - Renuka Murali Govind
- Department of Obstetric Medicine, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK
| | - Ruth Dobson
- Preventive Neurology Unit, Queen Mary University of London, London, UK
- Department of Neurology, Royal London Hospital, London, UK
| | - Catherine Nelson-Piercy
- Department of Obstetric Medicine, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK
- Department of Women and Children’s Health, King’s College London, London, UK
| | - Caroline Ovadia
- Department of Women and Children’s Health, King’s College London, London, UK
- Department of Obstetrics and Gynaecology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
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16
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To the Editor – Maternal inappropriate sinus tachycardia during pregnancy. Heart Rhythm O2 2023. [DOI: 10.1016/j.hroo.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
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17
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Katsi V, Papakonstantinou IP, Papazachou O, Makris T, Tsioufis K. Beta-Blockers in Pregnancy: Clinical Update. Curr Hypertens Rep 2023; 25:13-24. [PMID: 36735202 DOI: 10.1007/s11906-023-01234-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2023] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW The aim of this review was to determine the anticipated benefits and adverse effects of beta-blockers in pregnant women with hypertension. The other issue was to assess the possible adverse effects of beta-blockers for their babies and provide current consensus recommendations for appropriate selection and individualized antihypertensive treatment with beta-blockers in pregnancy-associated hypertension. RECENT FINDINGS Hypertensive disorders of pregnancy are a major cause of maternal and fetal morbidity, with consequences later in life. Certain beta-blockers are useful for ameliorating hypertension in pregnancy and may have a protective role in endothelial dysfunction. However, some aspects of beta-blocker use in pregnancy are contentious among providers. Evidence on their safety, although well documented, is variable, and recent research reveals areas of controversy. Besides intrauterine growth restriction, other neonatal and obstetric complications remain a concern and should be explored thoroughly. Attention is necessary when treating pregnancy-associated hypertensive disorders with beta-blockers. Specific beta-blockers are considered safe in pregnancy, although the associated effects in the fetus are not clearly known and evidence is lacking for many safety outcomes, other than intrauterine growth restriction. Nevertheless, beta-blockers with specific indications in pregnancy under individualized selection and monitoring may confer substantial improvements in pregnant women with hypertension.
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Affiliation(s)
- Vasiliki Katsi
- Department of Cardiology, School of Medicine, Hippokration General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Ourania Papazachou
- Departmentof Cardiology, General and Maternal Hospital of Athens Elena Venizelou, Athens, Greece
| | - Thomas Makris
- Departmentof Cardiology, General and Maternal Hospital of Athens Elena Venizelou, Athens, Greece
| | - Konstantinos Tsioufis
- Department of Cardiology, School of Medicine, Hippokration General Hospital, National and Kapodistrian University of Athens, Athens, Greece
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18
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Ormesher L, Vause S, Higson S, Roberts A, Clarke B, Curtis S, Ordonez V, Ansari F, Everett TR, Hordern C, Mackillop L, Stern V, Bonnett T, Reid A, Wallace S, Oyekan E, Douglas H, Cauldwell M, Reddy M, Palmer K, Simpson M, Brennand J, Minns L, Freeman L, Murray S, Mary N, Castleman J, Morris KR, Haslett E, Cassidy C, Johnstone ED, Myers JE. Prevalence of pre-eclampsia and adverse pregnancy outcomes in women with pre-existing cardiomyopathy: a multi-centre retrospective cohort study. Sci Rep 2023; 13:153. [PMID: 36599871 DOI: 10.1038/s41598-022-26606-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 12/16/2022] [Indexed: 01/05/2023] Open
Abstract
Pre-eclampsia is associated with postnatal cardiac dysfunction; however, the nature of this relationship remains uncertain. This multicentre retrospective cohort study aimed to determine the prevalence of pre-eclampsia in women with pre-existing cardiac dysfunction (left ventricular ejection fraction < 55%) and explore the relationship between pregnancy outcome and pre-pregnancy cardiac phenotype. In this cohort of 282 pregnancies, pre-eclampsia prevalence was not significantly increased (4.6% [95% C.I 2.2-7.0%] vs. population prevalence of 4.6% [95% C.I. 2.7-8.2], p = 0.99); 12/13 women had concurrent obstetric/medical risk factors for pre-eclampsia. The prevalence of preterm pre-eclampsia (< 37 weeks) and fetal growth restriction (FGR) was increased (1.8% vs. 0.7%, p = 0.03; 15.2% vs. 5.5%, p < 0.001, respectively). Neither systolic nor diastolic function correlated with pregnancy outcome. Antenatal ß blockers (n = 116) were associated with lower birthweight Z score (adjusted difference - 0.31 [95% C.I. - 0.61 to - 0.01], p = 0.04). To conclude, this study demonstrated a modest increase in preterm pre-eclampsia and significant increase in FGR in women with pre-existing cardiac dysfunction. Our results do not necessarily support a causal relationship between cardiac dysfunction and pre-eclampsia, especially given the population's background risk status. The mechanism underpinning the relationship between cardiac dysfunction and FGR merits further research but could be influenced by concomitant ß blocker use.
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Affiliation(s)
- Laura Ormesher
- Maternal & Fetal Health Research Centre, Division of Developmental Biology and Medicine, University of Manchester, Manchester, UK. .,Saint Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK.
| | - Sarah Vause
- Saint Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Suzanne Higson
- Manchester Heart Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Anna Roberts
- Saint Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Bernard Clarke
- Manchester Heart Centre, Manchester University NHS Foundation Trust, Manchester, UK.,Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | | | | | | | | | - Claire Hordern
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Lucy Mackillop
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Victoria Stern
- Academic Unit of Developmental and Reproductive Medicine, University of Sheffield, Sheffield, UK
| | - Tessa Bonnett
- Academic Unit of Developmental and Reproductive Medicine, University of Sheffield, Sheffield, UK
| | - Alice Reid
- Department of Obstetrics, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Suzanne Wallace
- Department of Obstetrics, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Ebruba Oyekan
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | | | - Maya Reddy
- Monash Women's, Monash Health, Monash University, Melbourne, Australia
| | - Kirsten Palmer
- Monash Women's, Monash Health, Monash University, Melbourne, Australia
| | - Maggie Simpson
- Scottish Adult Congenital Cardiac Service, Golden Jubilee National Hospital, Glasgow, UK
| | - Janet Brennand
- Scottish Adult Congenital Cardiac Service, Golden Jubilee National Hospital, Glasgow, UK.,Queen Elizabeth University Hospital, NHS Greater Glasgow & Clyde, Glasgow, UK
| | - Laura Minns
- Department of Cardiology, Norfolk& Norwich University Hospital Foundation Trust, Norwich, UK
| | - Leisa Freeman
- Department of Cardiology, Norfolk& Norwich University Hospital Foundation Trust, Norwich, UK
| | - Sarah Murray
- Royal Infirmary of Edinburgh, NHS Lothian University Hospitals Division, Edinburgh, UK
| | - Nirmala Mary
- Royal Infirmary of Edinburgh, NHS Lothian University Hospitals Division, Edinburgh, UK
| | - James Castleman
- Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Katie R Morris
- Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK.,Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | | | - Edward D Johnstone
- Maternal & Fetal Health Research Centre, Division of Developmental Biology and Medicine, University of Manchester, Manchester, UK.,Saint Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Jenny E Myers
- Maternal & Fetal Health Research Centre, Division of Developmental Biology and Medicine, University of Manchester, Manchester, UK.,Saint Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
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19
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Ardissino M, Slob EAW, Rajasundaram S, Reddy RK, Woolf B, Girling J, Johnson MR, Ng FS, Gill D. Safety of beta-blocker and calcium channel blocker antihypertensive drugs in pregnancy: a Mendelian randomization study. BMC Med 2022; 20:288. [PMID: 36064525 PMCID: PMC9446737 DOI: 10.1186/s12916-022-02483-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 07/14/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Beta-blocker (BB) and calcium channel blocker (CCB) antihypertensive drugs are commonly used in pregnancy. However, data on their relative impact on maternal and foetal outcomes are limited. We leveraged genetic variants mimicking BB and CCB antihypertensive drugs to investigate their effects on risk of pre-eclampsia, gestational diabetes and birthweight using the Mendelian randomization paradigm. METHODS Genetic association estimates for systolic blood pressure (SBP) were extracted from summary data of a genome-wide association study (GWAS) on 757,601 participants. Uncorrelated single-nucleotide polymorphisms (SNPs) associated with SBP (p < 5 × 10-8) in BB and CCB drug target gene regions were selected as proxies for drug target perturbation. Genetic association estimates for the outcomes were extracted from GWASs on 4743 cases and 136,325 controls (women without a hypertensive disorder in pregnancy) for pre-eclampsia or eclampsia, 7676 cases and 130,424 controls (women without any pregnancy-related morbidity) for gestational diabetes, and 155,202 women (who have given birth at least once) for birthweight of the first child. All studies were in European ancestry populations. Mendelian randomization estimates were generated using the two-sample inverse-variance weighted model. RESULTS Although not reaching the conventional threshold for statistical significance, genetically-proxied BB was associated with reduced risk of pre-eclampsia (OR per 10 mmHg SBP reduction 0.27, 95%CI 0.06-1.19, p = 0.08) and increased risk of gestational diabetes (OR per 10 mmHg SBP reduction 2.01, 95%CI 0.91-4.42, p = 0.08), and significantly associated with lower birthweight of first child (beta per 10 mmHg SBP reduction - 0.27, 95%CI - 0.39 to - 0.15, p = 1.90 × 10-5). Genetically-proxied CCB was associated with reduced risk of pre-eclampsia and eclampsia (OR 0.62, 95%CI 0.43-0.89, p = 9.33 × 10-3), and was not associated with gestational diabetes (OR 1.05, 95% CI 0.76-1.45, p = 0.76) or changes in birthweight of first child (beta per 10 mmHg SBP reduction 0.02, 95%CI - 0.04-0.07, p = 0.54). CONCLUSIONS While BB and CCB antihypertensive drugs may both be efficacious for lowering blood pressure in pregnancy, this genetic evidence suggests that BB use may lower birthweight. Conversely, CCB use may reduce risk of pre-eclampsia and eclampsia without impacting gestational diabetes risk or birthweight. These data support further study on the effects of BBs on birthweight.
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Affiliation(s)
- Maddalena Ardissino
- National Heart and Lung Institute, Imperial College London, London, UK
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Eric A W Slob
- Medical Research Council Biostatistics Unit, University of Cambridge, Cambridge, UK
- Department of Applied Economics, Erasmus School of Economics, Erasmus University Rotterdam, Rotterdam, the Netherlands
- Erasmus University Rotterdam Institute for Behavior and Biology, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Skanda Rajasundaram
- Centre for Evidence-Based Medicine, University of Oxford, Oxford, UK
- Faculty of Medicine, Imperial College London, London, UK
| | - Rohin K Reddy
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Benjamin Woolf
- School of Psychological Science, University of Bristol, Bristol, UK
- Medical Research Council Integrative Epidemiology Unit, University of Bristol, Bristol, UK
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Joanna Girling
- Chelsea and Westminster Hospital NHS Foundation Trust, West Middlesex Hospital, London, UK
| | - Mark R Johnson
- Division of Reproductive and Developmental Biology, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Fu Siong Ng
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Dipender Gill
- Medical Research Council Biostatistics Unit, University of Cambridge, Cambridge, UK.
- Department of Epidemiology and Biostatistics, School of Public Health, Medical School Building, St Mary's Hospital, Imperial College London, W2 1PG, London, UK.
- Chief Scientific Office, Research and Early Development, Novo Nordisk, Copenhagen, Denmark.
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20
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Gédéon T, Akl E, D'Souza R, Altit G, Rowe H, Flannery A, Siriki P, Bhatia K, Thorne S, Malhamé I. Acute Myocardial Infarction in Pregnancy. Curr Probl Cardiol 2022; 47:101327. [PMID: 35901856 DOI: 10.1016/j.cpcardiol.2022.101327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 07/17/2022] [Indexed: 11/03/2022]
Abstract
Cardiovascular disease, and particularly ischemic heart disease, is a leading cause of maternal morbidity and mortality in high-income countries. The incidence of acute myocardial infarction (AMI) has been rising over the past two decades due to increasing maternal age and a higher prevalence of cardiovascular risk factors in the pregnant population. Causes of AMI in pregnancy are diverse and may require specific considerations for their diagnosis and management. In this narrative review, we provide an overview of physiologic changes, risk factors, and etiologies leading to AMI in pregnancy, as well as diagnostic tools, reperfusion strategies, and pharmacological treatments for this complex population. In addition, we outline considerations for labor and delivery planning and long-term follow-up of patients with AMI in pregnancy.
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Affiliation(s)
- Tara Gédéon
- Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - Elie Akl
- Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - Rohan D'Souza
- Department of Obstetrics and Gynaecology, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Gabriel Altit
- Department of Paediatrics, McGill University Health Centre, Montreal, Canada
| | - Hilary Rowe
- Department of Pharmacy, Nanaimo Regional General Hospital, Island Health, Nanaimo, Canada; Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada
| | - Alexandria Flannery
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Canada
| | | | - Kailash Bhatia
- Department of Anaesthesia, Manchester University Hospitals and St Mary's Hospital, University of Manchester, Manchester, United Kingdom
| | - Sara Thorne
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Isabelle Malhamé
- Department of Medicine, McGill University Health Centre, Montreal, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Canada.
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21
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Klein AZ, O'Connor K, Levine LD, Gonzalez-Hernandez G. Using Twitter Data for Cohort Studies of Drug Safety in Pregnancy: Proof-of-concept With β-Blockers. JMIR Form Res 2022; 6:e36771. [PMID: 35771614 PMCID: PMC9284350 DOI: 10.2196/36771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 04/27/2022] [Accepted: 06/06/2022] [Indexed: 01/26/2023] Open
Abstract
Background Despite the fact that medication is taken during more than 90% of pregnancies, the fetal risk for most medications is unknown, and the majority of medications have no data regarding safety in pregnancy. Objective Using β-blockers as a proof-of-concept, the primary objective of this study was to assess the utility of Twitter data for a cohort study design—in particular, whether we could identify (1) Twitter users who have posted tweets reporting that they took medication during pregnancy and (2) their associated pregnancy outcomes. Methods We searched for mentions of β-blockers in 2.75 billion tweets posted by 415,690 users who announced their pregnancy on Twitter. We manually reviewed the matching tweets to first determine if the user actually took the β-blocker mentioned in the tweet. Then, to help determine if the β-blocker was taken during pregnancy, we used the time stamp of the tweet reporting intake and drew upon an automated natural language processing (NLP) tool that estimates the date of the user’s prenatal time period. For users who posted tweets indicating that they took or may have taken the β-blocker during pregnancy, we drew upon additional NLP tools to help identify tweets that report their pregnancy outcomes. Adverse pregnancy outcomes included miscarriage, stillbirth, birth defects, preterm birth (<37 weeks gestation), low birth weight (<5 pounds and 8 ounces at delivery), and neonatal intensive care unit (NICU) admission. Normal pregnancy outcomes included gestational age ≥37 weeks and birth weight ≥5 pounds and 8 ounces. Results We retrieved 5114 tweets, posted by 2339 users, that mention a β-blocker, and manually identified 2332 (45.6%) tweets, posted by 1195 (51.1%) of the users, that self-report taking the β-blocker. We were able to estimate the date of the prenatal time period for 356 pregnancies among 334 (27.9%) of these 1195 users. Among these 356 pregnancies, we identified 257 (72.2%) during which the β-blocker was or may have been taken. We manually verified an adverse pregnancy outcome—preterm birth, NICU admission, low birth weight, birth defects, or miscarriage—for 38 (14.8%) of these 257 pregnancies. We manually verified a gestational age ≥37 weeks for 198 (90.4%) and a birth weight ≥5 pounds and 8 ounces for 50 (22.8%) of the 219 pregnancies for which we did not identify an adverse pregnancy outcome. Conclusions Our ability to detect pregnancy outcomes for Twitter users who posted tweets reporting that they took or may have taken a β-blocker during pregnancy suggests that Twitter can be a complementary resource for cohort studies of drug safety in pregnancy.
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Affiliation(s)
- Ari Z Klein
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Karen O'Connor
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Lisa D Levine
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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22
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Gyselaers W, Lees C. Maternal Low Volume Circulation Relates to Normotensive and Preeclamptic Fetal Growth Restriction. Front Med (Lausanne) 2022; 9:902634. [PMID: 35755049 PMCID: PMC9218216 DOI: 10.3389/fmed.2022.902634] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 05/04/2022] [Indexed: 11/13/2022] Open
Abstract
This narrative review summarizes current evidence on the association between maternal low volume circulation and poor fetal growth. Though much work has been devoted to the study of cardiac output and peripheral vascular resistance, a low intravascular volume may explain why high vascular resistance causes hypertension in women with preeclampsia (PE) that is associated with fetal growth restriction (FGR) and, at the same time, presents with normotension in FGR itself. Normotensive women with small for gestational age babies show normal gestational blood volume expansion superimposed upon a constitutionally low intravascular volume. Early onset preeclampsia (EPE; occurring before 32 weeks) is commonly associated with FGR, and poor plasma volume expandability may already be present before conception, thus preceding gestational volume expansion. Experimentally induced low plasma volume in rodents predisposes to poor fetal growth and interventions that enhance plasma volume expansion in FGR have shown beneficial effects on intrauterine fetal condition, prolongation of gestation and birth weight. This review makes the case for elevating the maternal intravascular volume with physical exercise with or without Nitric Oxide Donors in FGR and EPE, and evaluating its role as a potential target for prevention and/or management of these conditions.
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Affiliation(s)
- Wilfried Gyselaers
- Department of Obstetrics, Ziekenhuis Oost Limburg, Genk, Belgium.,Department of Physiology, Hasselt University, Hasselt, Belgium
| | - Christoph Lees
- Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom.,Department of Metabolism, Digestion and Reproduction, Institute for Reproductive and Developmental Biology, Imperial College London, London, United Kingdom.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, London, United Kingdom
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23
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McLaughlin K, Snelgrove JW, Sienas LE, Easterling TR, Kingdom JC, Albright CM. Phenotype-Directed Management of Hypertension in Pregnancy. J Am Heart Assoc 2022; 11:e023694. [PMID: 35285667 PMCID: PMC9075436 DOI: 10.1161/jaha.121.023694] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Hypertensive disorders of pregnancy are among the most serious conditions that pregnancy care providers face; however, little attention has been paid to the concept of tailoring clinical care to reduce associated adverse maternal and perinatal outcomes based on the underlying disease pathogenesis. This narrative review discusses the integration of phenotype-based clinical strategies in the management of high-risk pregnant patients that are currently not common clinical practice: real-time placental growth factor testing at Mount Sinai Hospital, Toronto and noninvasive hemodynamic monitoring to guide antihypertensive therapy at the University of Washington Medical Center, Seattle. Future work should focus on promoting more widespread integration of these novel strategies into obstetric care to improve outcomes of pregnancies at high risk of adverse maternal-fetal outcomes from these complications of pregnancy.
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Affiliation(s)
- Kelsey McLaughlin
- Department of Obstetrics and GynecologyDivision of Maternal‐Fetal MedicineSinai Health SystemUniversity of TorontoTorontoCanada
| | - John W. Snelgrove
- Department of Obstetrics and GynecologyDivision of Maternal‐Fetal MedicineSinai Health SystemUniversity of TorontoTorontoCanada
| | - Laura E. Sienas
- Department of Obstetrics and GynecologyDivision of Maternal‐Fetal MedicineUniversity of Washington Medical CenterSeattleWA
| | - Thomas R. Easterling
- Department of Obstetrics and GynecologyDivision of Maternal‐Fetal MedicineUniversity of Washington Medical CenterSeattleWA
| | - John C. Kingdom
- Department of Obstetrics and GynecologyDivision of Maternal‐Fetal MedicineSinai Health SystemUniversity of TorontoTorontoCanada
| | - Catherine M. Albright
- Department of Obstetrics and GynecologyDivision of Maternal‐Fetal MedicineUniversity of Washington Medical CenterSeattleWA
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24
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Ashworth D, Battersby C, Green M, Hardy P, McManus RJ, Cluver C, Chappell LC. Which antihypertensive treatment is better for mild to moderate hypertension in pregnancy? BMJ 2022; 376:e066333. [PMID: 35042721 DOI: 10.1136/bmj-2021-066333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
| | | | - Marcus Green
- Action on Pre-eclampsia (APEC), Evesham WR11 4EU, UK
| | - Pollyanna Hardy
- National Perinatal Epidemiology Unit Clinical Trials Unit, University of Oxford, UK
| | | | - Catherine Cluver
- Department of Obstetrics and Gynaecology, Stellenbosch University, Cape Town, South Africa
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25
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Inter-Specialty Controversies on the Treatment of Cardiovascular Diseases during Pregnancy: A Questionnaire Study. Medicina (B Aires) 2022; 58:medicina58010138. [PMID: 35056446 PMCID: PMC8780357 DOI: 10.3390/medicina58010138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/09/2022] [Accepted: 01/12/2022] [Indexed: 11/17/2022] Open
Abstract
Background and Objectives: Management of cardiovascular disease (CVD) during pregnancy is challenging and usually requires eminence-based decisions due to limited strong-evidence data in this field. The purpose of our study was to compare the attitudes of anaesthesiologists, cardiologists, and gynaecologists towards the diagnosis and treatment of potentially life-threatening CVDs during pregnancy. Materials and Methods: A cross-sectional, questionnaire-based study was performed among 111 doctors (55 anaesthesiologists, 36 cardiologists, 20 gynaecologists). Personal opinions on the recommendations (n = 19) regarding rare, potentially life-threatening CVDs during pregnancy were recorded using a five-item Likert scale. Results: Opinions regarding eight statements (42%) varied substantially between specialties (p < 0.05). The most distinctive differences between physicians concerned the following recommendations: “thrombolysis should only be used in pulmonary embolism with cardiogenic shock” (agree: 52.7% of anaesthesiologists, 80.4% of cardiologists, 25.0% of gynaecologists; p < 0.001); “women with the antiphospholipid syndrome should restart treatment with vitamin K antagonists from the second trimester of pregnancy” (agree: 12.7% of anaesthesiologists, 69.4% of cardiologists, 20.0% of gynaecologists; p < 0.001); “women with symptomatic pulmonary hypertension should have a Swan–Ganz catheter inserted for labour” (agree: 20.0% of anaesthesiologists, 11.1% of cardiologists, 55.0% of gynaecologists; p = 0.001). Conclusions: Physicians’ opinions regarding diagnostics and treatment of CVDs in pregnancy remain controversial. A multidisciplinary approach is recommended to ensure the safety and effectiveness of management in these unique medical conditions.
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26
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MUSCALU O, TUDORACHE D, MIHAI BM, VLADAREANU IT, BOHILTEA RE. Pregnancy and Delivery in a 27-Year-Old ICD Carrier. MAEDICA 2021; 16:729-733. [PMID: 35261679 PMCID: PMC8897792 DOI: 10.26574/maedica.2020.16.4.729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Implantable cardiac devices represent the first line treatment option used not only for secondary prevention of sudden cardiac death but also for primary prevention in patients with cardiac pathologies considered at risk of sudden cardiac death caused by ventricular tachycardia or ventricular fibrillation. The number of women with implantable cardiac devices reaching child bearing age is expected to increase more and more in the next years. Despite this tendency, there are only a few reported cases of pregnancies in implantable cardiac defibrillator carriers, leading to insufficient evidence and clear guideline recommendations on how to manage and monitor pregnancy in patients with this type of cardiac pathology. Closely monitoring within a multidisciplinary team consisting of an obstretician, electrophysiologist and anesthesiologist is required for this group of pregnant patients in order to achieve the best maternal and neonatal results. The present study describes the case of succesful outcome in a 27-year-old implantable cardiac defibrillator carrier implanted after an aborted cardiac arrest and reccurent polymorphic ventricular tachycardia due to myocarditis eight years prior to pregnancy, with an aim to emphasize the monitoring particularities and management during pregnancy.
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Affiliation(s)
- Oana MUSCALU
- Department of Cardiology, Colentina Clinical Hostpital, Bucharest, Romania
| | - Dragos TUDORACHE
- Department of Obstetrics and Gynecology, Elias University Emergency Hospital, Bucharest, Romania
| | - Bianca-Margareta MIHAI
- Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, Bucharest, Romania
| | | | - Roxana Elena BOHILTEA
- “Carol Davila” University of Medicine and Pharmacy, Department of Obstetrics and Gynecology, Bucharest, Romania
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27
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Abstract
Globally, headache disorders are an important cause of disability in adults. As many types of headache (eg, migraine, tension-type and medication-overuse) are more common in women and have peak incidence in reproductive years, chronic headache disorders are highly prevalent in pregnant women. Some women with a history of migraine may find that it improves during pregnancy while others may find that their migraines become more unpredictable. Ideally, women with migraine and problematic headache disorder should be offered preconception counselling to address pregnancy-related concerns and advice on the use of medicines, which should be supported by high-quality information. For women with history of headache, the use of effective non-pharmacological options should be maximised, and the smallest number of the safest medicines at the lowest effective doses should be used while preparing for pregnancy and during pregnancy. This article forms part of the series of prescribing for pregnancy and discusses the impact of headache and migraine on pregnancy, the impact of pregnancy on headache and migraine and options for prophylaxis and treatment.
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Affiliation(s)
- Caroline Ovadia
- Department of Women and Children's Health, King's College London, London, UK
- Obstetrics and Gynaecology, Guy's and St Thomas' NHS Foundation Trust, London, UK
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28
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Jacob SE, Shankar R, John A, Eapen CE, Yadav B, Rathore S. Maternal and neonatal outcomes in extra hepatic portal vein obstruction: Our experience. J Family Med Prim Care 2021; 10:2608-2613. [PMID: 34568143 PMCID: PMC8415649 DOI: 10.4103/jfmpc.jfmpc_1486_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 09/27/2020] [Accepted: 10/28/2020] [Indexed: 11/06/2022] Open
Abstract
Background: Women with Extra hepatic portal vein obstruction (EHPVO) are mostly young and belong to Asian countries. In the Indian subcontinent, 20–30% variceal bleeds are caused by EHPVO. Hence pregnancy is a concern in such patients. The objective of this study is to observe the maternal and neonatal outcomes in women with EHPVO. Materials and Method: Extra hepatic portal vein obstruction was studied retrospectively in 28 pregnancies in 20 women from Jan 2011 to July 2018 at a tertiary hospital in South India and the pregnancy outcomes were observed during this period. Institutional Review Board approval obtained. Results: The mean age of the women was 24.3 years and the mean age of diagnosis was 18.5 years. Splenomegaly, thrombocytopenia and anaemia were seen in 22 (78.5%), 17 (60.7%) and 8 (28.5%) of pregnancies, respectively. Rate of abortions and preterm deliveries were 2 (7.1%, n =28) and 10 (35.7%, n =28). There was one stillbirth (3.6%) in the study group. EHPVO was diagnosed in 25 (89.3%) women prenatally in our series. During pregnancy only one woman had variceal bleed, which was managed conservatively. Blood and blood product transfusion was required in 7(25%) of women and there was no maternal mortality. Conclusion: Pregnancies in EHPVO have good maternal and neonatal outcomes, provided they are taken care of by a multidisciplinary approach in a tertiary care centre.
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Affiliation(s)
- Smitha Elizabeth Jacob
- Department of Obstetrics and Gynaecology, Christian Medical College & Hospital, Vellore, Tamil Nadu, India
| | - Ravi Shankar
- Department of Cardiac Thoracic Surgery, Christian Medical College & Hospital, Vellore, Tamil Nadu, India
| | - Anoop John
- Department of Gastroenterology, Christian Medical College & Hospital, Vellore, Tamil Nadu, India
| | - C E Eapen
- Department of Gastroenterology, Christian Medical College & Hospital, Vellore, Tamil Nadu, India
| | - Bijesh Yadav
- Department of Biostatistics, Christian Medical College & Hospital, Vellore, Tamil Nadu, India
| | - Swati Rathore
- Department of Obstetrics and Gynaecology, Christian Medical College & Hospital, Vellore, Tamil Nadu, India
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Brugada J, Katritsis DG, Arbelo E, Arribas F, Bax JJ, Blomström-Lundqvist C, Calkins H, Corrado D, Deftereos SG, Diller GP, Gomez-Doblas JJ, Gorenek B, Grace A, Ho SY, Kaski JC, Kuck KH, Lambiase PD, Sacher F, Sarquella-Brugada G, Suwalski P, Zaza A. 2019 ESC Guidelines for the management of patients with supraventricular tachycardiaThe Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC). Eur Heart J 2021; 41:655-720. [PMID: 31504425 DOI: 10.1093/eurheartj/ehz467] [Citation(s) in RCA: 522] [Impact Index Per Article: 174.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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30
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DeFilippis EM, Haythe JH, Walsh MN, Kittleson MM. Intersection of Heart Failure and Pregnancy: Beyond Peripartum Cardiomyopathy. Circ Heart Fail 2021; 14:e008223. [PMID: 33980039 DOI: 10.1161/circheartfailure.120.008223] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Heart failure (HF) is a leading cause of morbidity and mortality in pregnant women in the United States. Although peripartum cardiomyopathy is the most common diagnosis for pregnant women with HF, women with preexisting cardiomyopathies and systolic dysfunction are also at risk as the hemodynamic demands of pregnancy can lead to decompensation, arrhythmia, and rarely death. The differential diagnosis of HF in pregnancy is broad and includes Takotsubo or stress cardiomyopathy, exacerbation of a preexisting cardiomyopathy, such as familial cardiomyopathy, hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, or left ventricular noncompaction. This review will explore the implications of pregnancy in women with preexisting cardiomyopathies and de novo HF, risk assessment and preconception planning, decisions about contraception, the safety of HF medications and implantable cardioverter-defibrillators during pregnancy, pregnancy in women with left ventricular assist devices and following heart transplantation.
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Affiliation(s)
- Ersilia M DeFilippis
- Division of Cardiology, New York Presbyterian-Columbia University Irving Medical Center (E.M.D., J.H.H.)
| | - Jennifer H Haythe
- Division of Cardiology, New York Presbyterian-Columbia University Irving Medical Center (E.M.D., J.H.H.)
| | | | - Michelle M Kittleson
- Division of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (M.M.K.)
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31
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Topf A, Bacher N, Kopp K, Mirna M, Larbig R, Brandt MC, Kraus J, Hoppe UC, Motloch LJ, Lichtenauer M. Management of Implantable Cardioverter-Defibrillators during Pregnancy-A Systematic Review. J Clin Med 2021; 10:jcm10081675. [PMID: 33919684 PMCID: PMC8069958 DOI: 10.3390/jcm10081675] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/28/2021] [Accepted: 03/29/2021] [Indexed: 12/28/2022] Open
Abstract
Background: With the advent of implantable cardioverter-defibrillator (ICD) technology in recent decades, patients with inherited or congenital cardiomyopathy have a greater chance of survival into adulthood. Women with ICDs in this group are now more likely to reach reproductive age. However, pregnancy represents a challenge for clinicians, as no guidelines for the treatment of pregnant women with an ICD are currently available. Methods: To analyze this issue, we performed a systematic screening of the literature using the keywords: pregnancy with ICD, lead fracture in pregnancy, lead thrombi in pregnancy, ventricular tachycardia in pregnancy, inappropriate shocks in pregnancy, ICD discharge in pregnancy and ICD shock in pregnancy. Of 1101 publications found, 27 publications were eligible for further analysis (four retrospective trials and 23 case reports). Results: According to physiological changes in pregnancy, resulting in an increase in heart rate and cardiac output, a vulnerability for malignant arrhythmias and device-related complications in ICD carriers might be suspected. While the literature is limited on this issue, maternal complications including arrhythmia burden with following ICD therapies, thromboembolic events and lead complications as well as inappropriate shock therapy have been reported. According to the limited available studies, associated risk seems not to be more frequent than in the general population and depends on the underlying cardiac pathology. Furthermore, worsening of heart failure and related cardiovascular disease have been reported with associated risk of preterm delivery. These observations are exaggerated by restricted applications of diagnostics and treatment due to the risk of fetal harm in this population. Conclusions: Due to limited data on management of ICDs during pregnancy, further scientific investigations are required. Consequently, careful risk assessment with individual risk evaluation and close follow ups with interdisciplinary treatment are recommended in pregnant ICD carriers.
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Affiliation(s)
- Albert Topf
- Department of Internal Medicine II, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria; (N.B.); (K.K.); (M.M.); (M.C.B.); (J.K.); (U.C.H.); (L.J.M.); (M.L.)
- Correspondence:
| | - Nina Bacher
- Department of Internal Medicine II, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria; (N.B.); (K.K.); (M.M.); (M.C.B.); (J.K.); (U.C.H.); (L.J.M.); (M.L.)
| | - Kristen Kopp
- Department of Internal Medicine II, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria; (N.B.); (K.K.); (M.M.); (M.C.B.); (J.K.); (U.C.H.); (L.J.M.); (M.L.)
| | - Moritz Mirna
- Department of Internal Medicine II, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria; (N.B.); (K.K.); (M.M.); (M.C.B.); (J.K.); (U.C.H.); (L.J.M.); (M.L.)
| | - Robert Larbig
- Division of Cardiology, Hospital Maria Hilf Mönchengladbach, 41063 Mönchengladbach, Germany;
- Division of Electrophysiology, Department of Cardiovascular Medicine, University of Münster, 48149 Münster, Germany
| | - Mathias C. Brandt
- Department of Internal Medicine II, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria; (N.B.); (K.K.); (M.M.); (M.C.B.); (J.K.); (U.C.H.); (L.J.M.); (M.L.)
| | - Johannes Kraus
- Department of Internal Medicine II, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria; (N.B.); (K.K.); (M.M.); (M.C.B.); (J.K.); (U.C.H.); (L.J.M.); (M.L.)
| | - Uta C. Hoppe
- Department of Internal Medicine II, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria; (N.B.); (K.K.); (M.M.); (M.C.B.); (J.K.); (U.C.H.); (L.J.M.); (M.L.)
| | - Lukas J. Motloch
- Department of Internal Medicine II, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria; (N.B.); (K.K.); (M.M.); (M.C.B.); (J.K.); (U.C.H.); (L.J.M.); (M.L.)
| | - Michael Lichtenauer
- Department of Internal Medicine II, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria; (N.B.); (K.K.); (M.M.); (M.C.B.); (J.K.); (U.C.H.); (L.J.M.); (M.L.)
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32
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Kayser A, Beck E, Hoeltzenbein M, Zinke S, Meister R, Weber-Schoendorfer C, Schaefer C. Neonatal effects of intrauterine metoprolol/bisoprolol exposure during the second and third trimester: a cohort study with two comparison groups. J Hypertens 2021; 38:354-361. [PMID: 31584512 DOI: 10.1097/hjh.0000000000002256] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Our aim was to evaluate the effects of beta-blockers during the second and third trimester on fetal growth, length of gestation and postnatal symptoms in exposed infants. METHODS The current prospective observational cohort study compares 294 neonates of hypertensive mothers on metoprolol or bisoprolol during the second and/or third trimester with 225 methyldopa-exposed infants and 588 infants of nonhypertensive mothers. The risks for reduced birth weight, prematurity, neonatal bradycardia, hypoglycaemia and respiratory disorders were analysed. RESULTS The rate of small-for-gestational-age children was significantly higher in long-term beta-blocker exposed infants (24.1%) compared with the methyldopa cohort [10.2%, odds ratio (OR)adj 2.5, 95% confidence interval (CI) 1.2-5.2] and the nonhypertensive cohort (9.9%, ORadj 4.3, 95% CI 2.6-7.1). The risk for preterm birth was significantly increased compared with nonhypertensive pregnancies (ORadj 2.2, 95% CI 1.3-3.8) but not compared with the methyldopa cohort. Neonatal adverse outcomes occurred more frequently in the study cohort (11.5%) compared with the nonhypertensive comparison group (6.5%) and the methyldopa cohort (8.4%), but without statistical significance (ORadj 1.5, 95% CI 0.7-3.0 and ORadj 1.5, 95% CI 0.7-3.3, respectively). CONCLUSION Long-term intrauterine exposure to metoprolol or bisoprolol may increase the risk of being born small-for-gestational-age. It is still a matter of debate to which extent maternal hypertension contributes to the lower birth weight. Serious neonatal symptoms are rare. Altogether, metoprolol and bisoprolol are well tolerated treatment options, but a case-by-case decision on close neonatal monitoring is recommended.
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Affiliation(s)
- Angela Kayser
- Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Pharmakovigilanz- und Beratungszentrum für Embryonaltoxikologie, Institut für Klinische Pharmakologie und Toxikologie
| | - Evelin Beck
- Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Pharmakovigilanz- und Beratungszentrum für Embryonaltoxikologie, Institut für Klinische Pharmakologie und Toxikologie
| | - Maria Hoeltzenbein
- Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Pharmakovigilanz- und Beratungszentrum für Embryonaltoxikologie, Institut für Klinische Pharmakologie und Toxikologie
| | - Sandra Zinke
- Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Pharmakovigilanz- und Beratungszentrum für Embryonaltoxikologie, Institut für Klinische Pharmakologie und Toxikologie
| | - Reinhard Meister
- Beuth Hochschule für Technik - University of Applied Sciences, Berlin, Germany
| | - Corinna Weber-Schoendorfer
- Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Pharmakovigilanz- und Beratungszentrum für Embryonaltoxikologie, Institut für Klinische Pharmakologie und Toxikologie
| | - Christof Schaefer
- Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Pharmakovigilanz- und Beratungszentrum für Embryonaltoxikologie, Institut für Klinische Pharmakologie und Toxikologie
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Iliodromitis K, Kociszewski J, Bogossian H. Atrial fibrillation during pregnancy: a 9-month period with limited options. Herzschrittmacherther Elektrophysiol 2021; 32:158-163. [PMID: 33822238 DOI: 10.1007/s00399-021-00751-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 03/15/2021] [Indexed: 12/18/2022]
Abstract
Pregnancy is a physiological condition with reversible hemodynamic, neurohormonal and coagulation changes to the maternal body during this 9‑month period. The occurrence of atrial fibrillation (AF) is altogether rare among pregnant women, but necessitates immediate treatment und further work-up. Despite numerous pharmacological and invasive therapeutic modalities for AF in non-pregnant patients, very few options are considered safe enough for the fetus and the mother during pregnancy. Commonly used medications such as beta blockers, calcium channel antagonists, antiarrhythmic drugs and anticoagulation therapy must be carefully individualized according to the week of gestation and possible underlying comorbidities of the mother, thus highlighting the importance of an interdisciplinary evaluation by a cardiologist and a gynecologist. The current review summarizes the existing knowledge and treatment options for AF in pregnancy and suggests a simplified algorithm for this clinical constellation.
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Affiliation(s)
- Konstantinos Iliodromitis
- Klinik für Kardiologie und Rhythmologie, Evangelisches Krankenhaus Hagen, Brusebrinkstraße 20, 58135, Hagen, Germany
| | - Jacek Kociszewski
- Department of Gynecology, Evangelisches Krankenhaus Hagen, Hagen, Germany
| | - Harilaos Bogossian
- Klinik für Kardiologie und Rhythmologie, Evangelisches Krankenhaus Hagen, Brusebrinkstraße 20, 58135, Hagen, Germany.
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Fischer AJ, Diller GP, Uebing A, Nürnberg JH, Hebe J. Antiarrhythmic drugs-safety and efficacy during pregnancy. Herzschrittmacherther Elektrophysiol 2021; 32:145-151. [PMID: 33779803 DOI: 10.1007/s00399-021-00759-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/18/2021] [Indexed: 11/24/2022]
Abstract
When deciding on antiarrhythmic drug (AAD) treatment, a thorough knowledge of the physiological adaptation processes that occur during pregnancy and their effect on metabolism and the efficacy of AAD is mandatory. Beyond the desired effects of AAD therapy, side effects can occur in pregnant women. Furthermore, potential harm to fetal development-depending on gestational age-needs to be considered. A thorough evaluation of potential risks opposed to expected benefits for mother and fetus should be carried out before initiation of AAD treatment. Regular maternal echocardiography and fetal sonographic examination during pregnancy under AAD treatment are advisable. If possible, serum concentrations of AAD should be measured on a regular basis. Due to electrolyte and volume imbalances after delivery, maternal monitoring is recommended for approximately 48 h under AAD therapy. Current guidelines are based on almost historic analyses, where AAD were often prescribed for other indications than rhythm disorders. In clinical practice, AAD predominantly used during pregnancy are intravenous adenosine for acute treatment of atrioventricular nodal dependent tachycardias, whereas betablockers, sotalol, and flecainide can be orally administered for long-term therapy.
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Affiliation(s)
- Alicia Jeanette Fischer
- Department of Cardiology III-Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Albert-Schweitzer-Str. 33, 48149, Münster, Germany.
| | - Gerhard-Paul Diller
- Department of Cardiology III-Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Albert-Schweitzer-Str. 33, 48149, Münster, Germany
| | - Anselm Uebing
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany
| | | | - Joachim Hebe
- Electrophysiology Bremen, Heart Center Bremen, Bremen, Germany
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Welzel T, Donner B, van den Anker JN. Intrauterine Growth Retardation in Pregnant Women with Long QT Syndrome Treated with Beta-Receptor Blockers. Neonatology 2021; 118:406-415. [PMID: 34186538 DOI: 10.1159/000516845] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 04/22/2021] [Indexed: 11/19/2022]
Abstract
Pregnant women with inherited long QT syndrome (iLQTS) are at an increased risk for preterm delivery and intrauterine growth retardation (IUGR) due to their underlying disease. Additionally, they are at a risk of arrhythmogenic events, particularly during the postpartum period because of physiological changes and increased emotional/physical stress. β-receptor blockers can effectively prevent life-threatening Torsades de Pointes ventricular tachycardia and they are the treatment of choice in iLQTS. Use of β-receptor blockers in pregnancy is recommended, although IUGR is commonly reported for prenatally exposed infants. IUGR, particularly in preterm infants, can result in adverse neonatal outcomes. This review was performed to support clinicians in their selection of β-receptor blocker treatment for their pregnant iLQTS women by (i) summarizing the available literature addressing the impact of different β-receptor blockers on IUGR and (ii) reporting additional aspects which might influence the β-receptor blocker selection. In general, experts recommend to use nonselective β-receptor blockers, such as nadolol and propranolol, for iLQTS management as these drugs seem to be superior in effectiveness. However, β-1-selective receptor blockers, such as bisoprolol or metoprolol, seem to affect less likely uterine contraction, peripheral vasodilation, and are associated with lower IUGR rates and fetal hypoglycemia. They are therefore recommended, except atenolol, as first-line therapy for pregnant women. Additionally, maternal factors such as iLQTS genotype, other underlying comorbidities (e.g., diabetes mellitus type 1, asthma bronchiale), and uteroplacental dysfunction or fetal factors have to be taken into account. Therefore, each woman with iLQTS who wants to become pregnant should be well-advised for a personalized β-receptor blocker therapy according to the individual risk-benefit evaluation by a multidisciplinary team of cardiologists, gynecologists, pediatric cardiologists, neonatologists, and clinical pharmacologists. During pregnancy, a close monitoring of IUGR and, after birth, monitoring of bradycardia, hypoglycemia, and respiratory depression in the neonate is mandatory. This review summarizes available data on β-receptor blocker-related risk for IUGR in prenatally exposed infants and illustrates which factors might influence β-receptor blocker selection with the aim to support clinicians in their pharmacological management of their pregnant iLQTS patients.
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Affiliation(s)
- Tatjana Welzel
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital of Basel, (UKBB), University of Basel, Basel, Switzerland
| | - Birgit Donner
- Pediatric Cardiology, University Children's Hospital of Basel (UKBB), University of Basel, Basel, Switzerland
| | - Johannes N van den Anker
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital of Basel, (UKBB), University of Basel, Basel, Switzerland.,Division of Clinical Pharmacology, Children's National Hospital, Washington, District of Columbia, USA
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Schumer A, Contag S. Catecholaminergic polymorphic ventricular tachycardia in pregnancy: a case report. J Med Case Rep 2020; 14:238. [PMID: 33292493 PMCID: PMC7724802 DOI: 10.1186/s13256-020-02569-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 10/28/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a genetic disorder that can cause fatal tachyarrhythmias brought on by physical or emotional stress. There is little reported in the literature regarding management of CPVT in pregnancy much less during labor. Case presentation A gravida 2, para 1 presented to our high-risk clinic at 15 weeks gestation with known CPVT. The Caucasian female patient had been diagnosed after experiencing a cardiac arrest following a motor vehicle accident and found to have a pathogenic cardiac ryanodine receptor mutation. An implantable cardioverter defibrillator was placed at that time. Her pregnancy was uncomplicated, and she was medically managed with metoprolol, flecainide, and verapamil. Her labor course and successful vaginal delivery were uncomplicated and involved a multidisciplinary team comprising specialists in electrophysiology, maternal fetal medicine, anesthesiology, general obstetrics, lactation, and neonatology. Conclusions CPVT is likely underdiagnosed and, given that cardiovascular disease is a leading cause of death in pregnancy, it is important to bring further awareness to the diagnosis and management of this inherited arrhythmia syndrome in pregnancy.
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Affiliation(s)
- Amy Schumer
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota, 420 Delaware Street SE, Minneapolis, MN, 55455, USA.
| | - Stephen Contag
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota, 420 Delaware Street SE, Minneapolis, MN, 55455, USA
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Bejan-Angoulvant T, Angoulvant D. Mise au point sur les bêtabloquants en 2020. Rev Med Interne 2020; 41:741-747. [DOI: 10.1016/j.revmed.2020.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 04/07/2020] [Indexed: 10/24/2022]
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Lanssens D, Thijs IM, Gyselaers W. Design of the Pregnancy REmote MOnitoring II study (PREMOM II): a multicenter, randomized controlled trial of remote monitoring for gestational hypertensive disorders. BMC Pregnancy Childbirth 2020; 20:626. [PMID: 33059633 PMCID: PMC7565319 DOI: 10.1186/s12884-020-03291-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 09/27/2020] [Indexed: 12/24/2022] Open
Abstract
Background Observational data from the retrospective, non-randomized Pregnancy REmote MOnitoring I (PREMOM I) study showed that remote monitoring (RM) may be beneficial for prenatal observation of women at risk for gestational hypertensive disorders (GHD) in terms of clinical outcomes, health economics, and stakeholder perceptions. PREMOM II is a prospective, randomized, multicenter follow-up study that was performed to explore these promising results. Methods After providing written consent, 3922 pregnant women aged ≥18 years who are at increased risk of developing GHD will be randomized (1:1:1 ratio) to (a) conventional care (control group), (b) a patient self-monitoring group, and (c) a midwife-assisted RM group. The women in each group will be further divided (1:1 ratio) to evaluate the outcomes of targeted or non-targeted (conventional) antihypertensive medication. Women will be recruited in five hospitals in Flanders, Belgium: Ziekenhuis Oost-Limburg, Universitaire Ziekenhuis Antwerpen, Universitaire Ziekenhuis Leuven, AZ Sint Jan Brugge–Oostende, and AZ Sint Lucas Brugge. The primary outcomes are: (1) numbers and types of prenatal visits; (2) maternal outcomes; (3) neonatal outcomes; (4) the applicability and performance of RM; and (5) compliance with RM and self-monitoring. The secondary outcomes are: (1) cost-effectiveness and willingness to pay; (2) patient-reported outcome measures (PROMS) questionnaires on the experiences of the participants; and (3) the maternal and perinatal outcomes according to the type of antihypertensive medication. Demographic, and maternal and neonatal outcomes are collected from the patients’ electronic records. Blood pressure and compliance rate will be obtained from an online digital coordination platform for remote data handling. Information about the healthcare-related costs will be obtained from the National Coordination Committee of Belgian Health Insurance Companies (Intermutualistisch Agentschap). PROMS will be assessed using validated questionnaires. Discussion To our knowledge, this is the first randomized trial comparing midwife-assisted RM and self-monitoring of prenatal blood pressure versus conventional management among women at increased risk of GHD. Positive results of this study may lead to a practical framework for caregivers, hospital management, and payers to introduce RM into the prenatal care programs of high-risk pregnancies. Trial registration This study was registered on clinicaltrials.gov, identification number NCT04031430. Registered 24 July 2019, https://clinicaltrials.gov/ct2/show/NCT04031430?cond=premom+ii&draw=2&rank=1.
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Affiliation(s)
- Dorien Lanssens
- Ziekenhuis Oost-Limburg, Future Health Department, Limburg Clinical Research Center/Mobile Health Unit, Genk, Belgium. .,Department of Obstetrics and Gynaecology, Ziekenhuis Oost-Limburg, Genk, Belgium. .,Faculty of Medicine and Life Sciences, Limburg Clinical Research Center/Mobile Health, UnitUHasselt - ZOL, Hasselt University, Martelarenlaan 42, 3500, Hasselt, Belgium.
| | - Inge M Thijs
- Ziekenhuis Oost-Limburg, Future Health Department, Limburg Clinical Research Center/Mobile Health Unit, Genk, Belgium.,Faculty of Medicine and Life Sciences, Limburg Clinical Research Center/Mobile Health, UnitUHasselt - ZOL, Hasselt University, Martelarenlaan 42, 3500, Hasselt, Belgium
| | - Wilfried Gyselaers
- Department of Obstetrics and Gynaecology, Ziekenhuis Oost-Limburg, Genk, Belgium.,Faculty of Medicine and Life Sciences, Limburg Clinical Research Center/Mobile Health, UnitUHasselt - ZOL, Hasselt University, Martelarenlaan 42, 3500, Hasselt, Belgium
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Bellos I, Pergialiotis V, Papapanagiotou A, Loutradis D, Daskalakis G. Comparative efficacy and safety of oral antihypertensive agents in pregnant women with chronic hypertension: a network metaanalysis. Am J Obstet Gynecol 2020; 223:525-537. [PMID: 32199925 DOI: 10.1016/j.ajog.2020.03.016] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 03/11/2020] [Accepted: 03/12/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE DATA Chronic hypertension is associated with adverse perinatal outcomes, although the optimal treatment is unclear. The aim of this network metaanalysis was to simultaneously compare the efficacy and safety of antihypertensive agents in pregnant women with chronic hypertension. STUDY Medline, Scopus, CENTRAL, Web of Science, Clinicaltrials.gov, and Google Scholar databases were searched systematically from inception to December 15, 2019. Both randomized controlled trials and cohort studies were held eligible if they reported the effects of antihypertensive agents on perinatal outcomes among women with chronic hypertension. STUDY APPRAISAL AND SYNTHESIS METHODS The primary outcomes were preeclampsia and small-for-gestational-age risk. A frequentist network metaanalytic random-effects model was fitted. The main analysis was based on randomized controlled trials. The credibility of evidence was assessed by taking into account within-study bias, across-studies bias, indirectness, imprecision, heterogeneity, and incoherence. RESULTS Twenty-two studies (14 randomized controlled trials and 8 cohorts) were included, comprising 4464 women. Pooling of randomized controlled trials indicated that no agent significantly affected the incidence of preeclampsia. Atenolol was associated with significantly higher risk of small-for-gestational age compared with placebo (odds ratio, 26.00; 95% confidence interval, 2.61-259.29) and is ranked as the worst treatment (P-score=.98). The incidence of severe hypertension was significantly lower when nifedipine (odds ratio, 0.27; 95% confidence interval, 0.14-0.55), methyldopa (odds ratio, 0.31; 95% confidence interval, 0.17-0.56), ketanserin (odds ratio, 0.29; 95% confidence interval, 0.09-0.90), and pindolol (odds ratio, 0.17; 95% confidence interval, 0.05-0.55) were administered compared with no drug intake. The highest probability scores were calculated for furosemide (P-score=.86), amlodipine (P-score=.82), and placebo (P-score=.82). The use of nifedipine and methyldopa were associated with significantly lower placental abruption rates (odds ratio, 0.29 [95% confidence interval, 0.15-0.58] and 0.23 [95% confidence interval, 0.11-0.46], respectively). No significant differences were estimated for cesarean delivery, perinatal death, preterm birth, and gestational age at delivery. CONCLUSION Atenolol was associated with a significantly increased risk for small-for-gestational-age infants. The incidence of severe hypertension was significantly lower when nifedipine and methyldopa were administered, although preeclampsia risk was similar among antihypertensive agents. Future large-scale trials should provide guidance about the choice of antihypertensive treatment and the goal blood pressure during pregnancy.
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Affiliation(s)
- Ioannis Bellos
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Athens University Medical School, National and Kapodistrian University of Athens, Athens, Greece.
| | - Vasilios Pergialiotis
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Athens University Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Angeliki Papapanagiotou
- Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Loutradis
- First Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgios Daskalakis
- First Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Abstract
The main inherited cardiac arrhythmias are long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia and Brugada syndrome. These rare diseases are often the underlying cause of sudden cardiac death in young individuals and result from mutations in several genes encoding ion channels or proteins involved in their regulation. The genetic defects lead to alterations in the ionic currents that determine the morphology and duration of the cardiac action potential, and individuals with these disorders often present with syncope or a life-threatening arrhythmic episode. The diagnosis is based on clinical presentation and history, the characteristics of the electrocardiographic recording at rest and during exercise and genetic analyses. Management relies on pharmacological therapy, mostly β-adrenergic receptor blockers (specifically, propranolol and nadolol) and sodium and transient outward current blockers (such as quinidine), or surgical interventions, including left cardiac sympathetic denervation and implantation of a cardioverter-defibrillator. All these arrhythmias are potentially life-threatening and have substantial negative effects on the quality of life of patients. Future research should focus on the identification of genes associated with the diseases and other risk factors, improved risk stratification and, in particular for Brugada syndrome, effective therapies.
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Manolis TA, Manolis AA, Apostolopoulos EJ, Papatheou D, Melita H, Manolis AS. Cardiac arrhythmias in pregnant women: need for mother and offspring protection. Curr Med Res Opin 2020; 36:1225-1243. [PMID: 32347120 DOI: 10.1080/03007995.2020.1762555] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Cardiac arrhythmias are the most common cardiac complication reported in pregnant women with and without structural heart disease (SHD); they are more frequent among women with SHD, such as cardiomyopathy and congenital heart disease (CHD). While older studies had indicated supraventricular tachycardia as the most common tachyarrhythmia in pregnancy, more recent data indicate an increase in the frequency of arrhythmias, with atrial fibrillation (AF) emerging as the most frequent arrhythmia in pregnancy, attributed to an increase in maternal age, cardiovascular risk factors and CHD in pregnancy. Importantly, the presence of any tachyarrhythmia during pregnancy may be associated with adverse maternal and fetal outcomes, including death. Thus, both the mother and the offspring need to be protected from such consequences. The use of antiarrhythmic drugs (AADs) depends on clinical presentation and on the presence of underlying SHD, which requires caution as it promotes pro-arrhythmia. In hemodynamically compromised women, electrical cardioversion is successful and safe to both mother and fetus. Use of beta-blockers appears quite safe; however, caution is advised when using other AADs, while no AAD should be used, if at all possible, during the first trimester when organogenesis takes place. Regarding the anticoagulation regimen in patients with AF, warfarin should be substituted with heparin during the first trimester, while direct oral anticoagulants are not indicated given the lack of data in pregnancy. Finally, for refractory arrhythmias, ablation and/or device implantation can be performed with current techniques in pregnant women, when needed, using minimal exposure to radiation. All these issues and relevant current guidelines are herein reviewed.
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Cuneo BF, Kaizer AM, Clur SA, Swan H, Herberg U, Winbo A, Rydberg A, Haugaa K, Etheridge S, Ackerman MJ, Dagradi F, Killen SA, Wacker-Gussmann A, Benson DW, Wilde A, Pan Z, Lam A, Spazzolini C, Horigome H, Schwartz PJ. Mothers with long QT syndrome are at increased risk for fetal death: findings from a multicenter international study. Am J Obstet Gynecol 2020; 222:263.e1-263.e11. [PMID: 31520628 DOI: 10.1016/j.ajog.2019.09.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 09/03/2019] [Accepted: 09/04/2019] [Indexed: 01/20/2023]
Abstract
BACKGROUND Most fetal deaths are unexplained. Long QT syndrome is a genetic disorder of cardiac ion channels. Affected individuals, including fetuses, are predisposed to sudden death. We sought to determine the risk of fetal death in familial long QT syndrome, in which the mother or father carries the long QT syndrome genotype. In addition, we assessed whether risk differed if the long QT syndrome genotype was inherited from the mother or father. OBJECTIVE This was a retrospective review of pregnancies in families with the 3 most common heterozygous pathogenic long QT syndrome genotypes in KCNQ1 (LQT1), KCNH2 (LQT2), or SCN5A (LQT3), which occur in approximately 1 in 2000 individuals. The purpose of our study was to compare pregnancy and birth outcomes in familial long QT syndrome with the normal population and between maternal and paternal carriers of the long QT syndrome genotype. We hypothesized that fetal death before (miscarriage) and after (stillbirths) 20 weeks gestation would be increased in familial long QT syndrome compared with the normal population and that the parent of origin would not affect birth outcomes. STUDY DESIGN Our study was a multicenter observational case series of 148 pregnancies from 103 families (80 mothers, 23 fathers) with familial long QT syndrome (60 with LQT1, 29 with LQT2, 14 with LQT3) who were recruited from 11 international centers with expertise in hereditary heart rhythm diseases, pediatric and/or adult electrophysiology, and high-risk pregnancies. Clinical databases from these sites were reviewed for long QT syndrome that occurred in men or women of childbearing age (18-40 years). Pregnancy outcomes (livebirth, stillbirth, and miscarriage), birthweights, and gestational age at delivery were compared among long QT syndrome genotypes and between maternal vs paternal long QT syndrome-affected status with the use of logistic regression analysis. RESULTS Most offspring (80%; 118/148) were liveborn at term; 66% of offspring (73/110) had long QT syndrome. Newborn infants of mothers with long QT syndrome were delivered earlier and, when the data were controlled for gestational age, weighed less than newborn infants of long QT syndrome fathers. Fetal arrhythmias were observed rarely, but stillbirths (fetal death at >20 weeks gestation) were 8 times more frequent in long QT syndrome (4% vs approximately 0.5%); miscarriages (fetal death at ≤20 weeks gestation) were 2 times that of the general population (16% vs 8%). The likelihood of fetal death was significantly greater with maternal vs paternal long QT syndrome (24.4% vs 3.4%; P=.036). Only 10% of all fetal deaths underwent postmortem long QT syndrome testing; 2 of 3 cases were positive for the family long QT syndrome genotype. CONCLUSION This is the first report to demonstrate that mothers with long QT syndrome are at increased risk of fetal death and to uncover a previously unreported cause of stillbirth. Our results suggest that maternal effects of long QT syndrome channelopathy may cause placental or myometrial dysfunction that confers increased susceptibility to fetal death and growth restriction in newborn survivors, regardless of long QT syndrome status.
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Wertaschnigg D, Wang R, Reddy M, Costa FDS, Mol BWJ, Rolnik DL. Treatment of severe hypertension during pregnancy: we still do not know what the best option is. Hypertens Pregnancy 2019; 39:25-32. [PMID: 31880480 DOI: 10.1080/10641955.2019.1708383] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Intracranial hemorrhage and stroke are primary causes of maternal mortality in pregnancies affected by hypertensive disorders. As such antihypertensive therapy plays a crucial role in the management of severe hypertension. However, the target level to achieve the best outcome for both - mother and fetus - is still unclear. Moreover, given the lack of well-designed randomized controlled trials with standardized key outcomes, the current choice of antihypertensive medications depends rather on clinicians' preference. Furthermore, data on long-term outcomes of offspring is not available. Therefore, there is an urgent need for randomized trials comparing different anti-hypertensive options to address efficacy and safety questions.
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Affiliation(s)
- Dagmar Wertaschnigg
- Department of Obstetrics and Gynecology, Monash University, Clayton, Australia.,Department of Obstetrics and Gynecology, Paracelsus Medical University, Salzburg, Austria
| | - Rui Wang
- Department of Obstetrics and Gynecology, Monash University, Clayton, Australia
| | - Maya Reddy
- Department of Obstetrics and Gynecology, Monash University, Clayton, Australia.,Monash Women's, Monash Health, Clayton, Australia
| | - Fabricio Da Silva Costa
- Department of Obstetrics and Gynecology, Monash University, Clayton, Australia.,Department of Gynecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Ben Willem J Mol
- Department of Obstetrics and Gynecology, Monash University, Clayton, Australia.,Monash Women's, Monash Health, Clayton, Australia
| | - Daniel L Rolnik
- Department of Obstetrics and Gynecology, Monash University, Clayton, Australia.,Monash Women's, Monash Health, Clayton, Australia
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Characteristics and outcomes of pregnant women with cardiomyopathy stratified by etiologies: A population-based study. Int J Cardiol 2019; 305:87-91. [PMID: 31889561 DOI: 10.1016/j.ijcard.2019.12.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 11/21/2019] [Accepted: 12/12/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND Heart failure is an uncommon diagnosis among pregnant women with limited data on this condition. We sought to describe the characteristics and outcomes of pregnant women with heart failure stratified by etiologies of cardiomyopathy. METHODS This is a retrospective population-based cohort study across medical centers in Southern California in the United States. Pregnant women with heart failure were identified using ICD-9 codes and adjudicated by manual review of the medical records. Obstetric complications, fetal birthweight, and maternal mortality outcomes were evaluated. RESULTS Between 2003 and 2014, there were 488 pregnancies (0.1% of all pregnancies) complicated by heart failure, of which 333 (68.2%) were due to peripartum cardiomyopathy (PPCM) and 155 (31.8%) were due to other etiologies (non-PPCM). Compared to patients with non-PPCM, patients with PPCM were more likely to be Black Americans (26.7% vs 15.5%) or Asian Americans (16.8% vs 7.1%). A high proportion of PPCM patients had preeclampsia (11.1% vs 5.2%, p = 0.04). Infants born to mothers with non-PPCM were more likely to be small for gestational age (SGA) (SGA <3% 4.1% vs 9.7%, p < 0.001; SGA <10% 20% vs 8.8%, p = 0.001). No significant difference in maternal mortality was observed between PPCM and non-PPCM patients. CONCLUSIONS PPCM is the most common etiology of HF during pregnancy. Infants born to mothers with PPCM were likely to be small for gestational age.
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Abstract
PURPOSE OF REVIEW While the prognosis of peripartum cardiomyopathy (PPCM) is generally more favorable than other cardiomyopathies, PPCM can be associated with cardiogenic shock and significant maternal morbidity in young women. The management of a pregnant woman in cardiogenic shock necessitates consideration of harm to the fetus. This review focuses on the management of these women. RECENT FINDINGS A number of advances have increased the repertoire of therapies available to manage PPCM. Increased understanding of PPCM pathophysiology has led to a number of new and experimental medications. In the current era, mechanical circulatory support has been gaining a stronger presence in critical care and can be used in cardiogenic shock of the pregnant patient refractory to medical therapy. We discuss medical therapies, mechanical circulatory support, arrhythmia management, and a delivery plan in the setting of cardiogenic shock secondary to PPCM.
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Wiles K, Chappell L, Clark K, Elman L, Hall M, Lightstone L, Mohamed G, Mukherjee D, Nelson-Piercy C, Webster P, Whybrow R, Bramham K. Clinical practice guideline on pregnancy and renal disease. BMC Nephrol 2019; 20:401. [PMID: 31672135 PMCID: PMC6822421 DOI: 10.1186/s12882-019-1560-2] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 09/16/2019] [Indexed: 01/13/2023] Open
Affiliation(s)
- Kate Wiles
- NIHR Doctoral Research Fellow in Obstetric Nephrology, Guy's and St. Thomas' NHS Foundation Trust and King's College London, London, UK.
| | - Lucy Chappell
- Guy's and St. Thomas' NHS Foundation Trust and King's College London, London, UK
| | | | - Louise Elman
- Expert Patient, c/o The Renal Association, Bristol, UK
| | - Matt Hall
- Nottingham University Hospital, Nottingham, UK
| | - Liz Lightstone
- Imperial College London and Imperial College Healthcare NHS Trust, London, UK
| | | | | | - Catherine Nelson-Piercy
- Guy's and St. Thomas' NHS Foundation Trust and Imperial College Healthcare NHS Trust, London, UK
| | | | | | - Kate Bramham
- King's College Hospital NHS Foundation Trust and King's College London, London, UK
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Georgiopoulos G, Tsiachris D, Kordalis A, Kontogiannis C, Spartalis M, Pietri P, Magkas N, Stefanadis C. Pharmacotherapeutic strategies for atrial fibrillation in pregnancy. Expert Opin Pharmacother 2019; 20:1625-1636. [PMID: 31136204 DOI: 10.1080/14656566.2019.1621290] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Georgios Georgiopoulos
- Department of Cardiology, Athens Medical Center, Athens, Greece
- Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | - Christos Kontogiannis
- Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Michael Spartalis
- Division of Cardiology, Onassis Cardiac Surgery Center, Athens, Greece
| | | | - Nikolaos Magkas
- 1stDepartment of Cardiology, Hippocration Hospital, National and Kapodistrian University of Athens, Athens, Greece
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