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Wang Y, Smolinski NE, Thai TN, Sarayani A, Ewig C, Rasmussen SA, Winterstein AG. Common teratogenic medication exposures-a population-based study of pregnancies in the United States. Am J Obstet Gynecol MFM 2024; 6:101245. [PMID: 38061552 DOI: 10.1016/j.ajogmf.2023.101245] [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: 09/05/2023] [Revised: 11/21/2023] [Accepted: 11/27/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND Risk mitigation for most teratogenic medications relies on risk communication via drug label, and prenatal exposures remain common. Information on the types of and risk factors for prenatal exposures to medications with teratogenic risk can guide strategies to reduce exposure. OBJECTIVE This study aimed to identify medications with known or potential teratogenic risk commonly used during pregnancy among privately insured persons. STUDY DESIGN We used the Merative™ MarketScan® Commercial Database to identify pregnancies with live or nonlive (ectopic pregnancies, spontaneous and elective abortions, stillbirths) outcomes among persons aged 12 to 55 years from 2011 to 2018. Start/end dates of medication exposure and pregnancy outcomes were identified via an adapted algorithm based on validation studies. We required continuous health plan enrollment from 90 days before conception until 30 days after the pregnancy end date. Medications with known or potential teratogenic risk were selected from TERIS (Teratogen Information System) and drug monographs based on the level of risk and quality of evidence (138 with known and 60 with potential risk). We defined prenatal exposure on the basis of ≥1 outpatient pharmacy claim or medical encounter for medication administration during target pregnancy periods considering medication risk profiles (eg, risk only in the first trimester or at a certain dose threshold). Sex hormones and hormone analogs, and abortion and postpartum/abortion hemorrhage treatments were not considered as teratogenic medications because of challenges in separating pregnancy-related indications, nor were opioids (because of complex risk-benefit considerations) or antiobesity medications if their only teratogenic mechanism was weight loss. RESULTS Among all pregnancies, the 10 medications with known teratogenic risk and the highest prenatal exposures were sulfamethoxazole/trimethoprim (1988 per 100,000 pregnancy-years), high-dose fluconazole (1248), topiramate (351), lisinopril (144), warfarin (57), losartan (56), carbamazepine (50), valproate (49), vedolizumab (28 since 2015), and valsartan (25). Prevalence of exposure to sulfamethoxazole/trimethoprim decreased from 2346 to 1453 per 100,000 pregnancy-years from 2011 to 2018, but prevalence of exposure to vedolizumab increased 6-fold since its approval in 2015. Prenatal exposures in the first trimester were higher among nonlive pregnancies than among live-birth pregnancies, with the largest difference observed for warfarin (nonlive 370 vs live birth 78), followed by valproate (258 vs 86) and topiramate (1728 vs 674). Prenatal exposures to medications with potential teratogenic risk were most prevalent for low-dose fluconazole (6495), metoprolol (1325), and atenolol (448). The largest first-trimester exposure differences between nonlive and live-birth pregnancies were observed for lithium (242 vs 89), gabapentin (1639 vs 653), and duloxetine (1914 vs 860). Steady increases in hydralazine and gabapentin exposures were observed during the study years, whereas atenolol exposure decreased (561 to 280). CONCLUSION Several medications with teratogenic risk for which there are potentially safer alternatives continue to be used during pregnancy. The fluctuating rates of prenatal exposure observed for select teratogenic medications suggest that regular reevaluation of risk mitigation strategies is needed. Future research focusing on understanding the clinical context of medication use is necessary to develop effective strategies for reducing exposures to medications with teratogenic risk during pregnancy.
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Affiliation(s)
- Yanning Wang
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL (Ms Wang and Drs Smolinski, Thai, Sarayani, Ewig, and Winterstein); Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL (Ms Wang)
| | - Nicole E Smolinski
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL (Ms Wang and Drs Smolinski, Thai, Sarayani, Ewig, and Winterstein)
| | - Thuy Nhu Thai
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL (Ms Wang and Drs Smolinski, Thai, Sarayani, Ewig, and Winterstein); Faculty of Pharmacy, Ho Chi Minh City University of Technology, Ho Chi Minh City, Vietnam (Dr Thai)
| | - Amir Sarayani
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL (Ms Wang and Drs Smolinski, Thai, Sarayani, Ewig, and Winterstein)
| | - Celeste Ewig
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL (Ms Wang and Drs Smolinski, Thai, Sarayani, Ewig, and Winterstein)
| | - Sonja A Rasmussen
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (Dr Rasmussen)
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL (Ms Wang and Drs Smolinski, Thai, Sarayani, Ewig, and Winterstein); Department of Epidemiology, College of Medicine and College of Public Health and Health Professions, University of Florida, Gainesville, FL (Dr Winterstein); Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, FL (Dr Winterstein).
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Geda YF, Lamiso YY, Berhe TM, Chibsa SE, Sahle T, Assefa K, Mohammed SJ, Abeje S, Gesese MM. Prevalence and associated factors of structural congenital anomalies in resource limited setting, 2023: a systematic review and meta-analysis. Front Pediatr 2023; 11:1146384. [PMID: 38027285 PMCID: PMC10667678 DOI: 10.3389/fped.2023.1146384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 10/10/2023] [Indexed: 12/01/2023] Open
Abstract
Background Several studies have been conducted on structural congenital anomalies (CA). However, there is a paucity of studies that provide a comprehensive review of structural anomalies. We aimed to verify the available research articles to pool the possible risk factors of structural CA in resource-limited settings. Setting The research articles were genuinely searched using PubMed, Scopus, Cochrane Library, Web of Science, free Google database search engines, Google Scholar, and ScienceDirect databases. Published studies were searched and screened for inclusion in the final analysis, and studies without sound methodologies and review and meta-analysis were not included in the analysis. Participants This review analyzed data from 95,755 women who gave birth as reported by primary studies. Ten articles were included in this systematic review and meta-analysis. The articles that had incomplete information and case reports were excluded from the study. Results The overall pooled effect estimate (EI) of structural CA was 5.50 (4.88-6.12) per 100 births. In this systematic review and meta-analysis, maternal illness EI with odds ratio (OR) = 4.93 (95% CI: 1.02-8.85), unidentified drug use with OR = 2.83 (95% CI: 1.19-4.46), birth weight with OR = 4.20 (95% CI: 2.12-6.28), chewing chat with OR = 3.73 (95% CI: 1.20-6.30), chemical exposure with OR = 4.27 (95% CI: 1.19-8.44), and taking folic acid tablet during pregnancy with OR = 6.01 (95% CI: 2.87-14.89) were statistically significant in this meta-regression. Conclusions The overall pooled effect estimate of structural CA in a resource-limited setting was high compared to that in countries with better resources. Maternal illness, unidentified drug use, birth weight, chewing chat, chemical exposure, and never using folic acid were found to be statistically significant variables in the meta-regression. Preconception care and adequate intake of folic acid before and during early pregnancy should be advised. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022384838.
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Affiliation(s)
| | | | | | | | - Tadesse Sahle
- Department of Nursing, Wolkite University, Wolkite, Ethiopia
| | | | | | - Seblework Abeje
- Department of Biochemistry, Wolkite University, Wolkite, Ethiopia
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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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4
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Geda YF, Lamiso YY, Berhe TM, Mohammed SJ, Chibsa SE, Adeba TS, Mossa KA, Abeje S, Gesese MM. Structural congenital anomalies in resource limited setting, 2023: A systematic review and meta-analysis. PLoS One 2023; 18:e0291875. [PMID: 37831686 PMCID: PMC10575536 DOI: 10.1371/journal.pone.0291875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 09/07/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND A number of studies have looked at neonatal structural birth defects. However, there is no study with a comprehensive review of structural anomalies. Therefor we aimed to verify the best available articles to pool possible risk factors of structural congenital anomalies in resource limited settings. SETTING Genuine search of the research articles was done via PubMed, Scopes, Cochrane library, the Web of Science; free Google database search engines, Google Scholar, and Science Direct databases. Published and unpublished articles were searched and screened for inclusion in the final analysis and Studies without sound methodologies, and review and meta-analysis were not included in this analysis. PARTICIPANTS This review analyzed data from 95,755 women who have birthed from as reported by primary studies. Ten articles were included in this systematic review and meta-analysis. Articles which have no full information important for the analysis and case reports were excluded from the study. RESULTS The overall pooled effect estimate of structural congenital anomalies was 5.50 [4.88-6.12]. In this systematic review and meta-analysis maternal illness effect estimate (EI) with odds ratio (OR) = 4.93 (95%CI 1.02-8.85), unidentified drug use OR = 2.83 (95%CI 1.19-4.46), birth weight OR = 4.20 (95%CI 2.12-6.28), chewing chat OR = 3.73 (95%CI 1.20-6.30), chemical exposure OR = 4.27 (95%CI 1.19-8.44) and taking folic acid tablet during pregnancy OR = 6.01 (95%CI 2.87-14.89) were statistically significant in this meta-regression. CONCLUSIONS The overall pooled effect estimate of structural congenital anomalies in a resource limited setting was high compared to better resource countries. On the Meta-regression maternal illness, unidentified drug use, birth weight, chewing chat, chemical exposure and never using folic acid were found to be statistically significant variables Preconception care and adequate intake of folic acid before and during early pregnancy should be advised.
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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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Spiteri JA, Camilleri G, Piccinni C, Sultana J. Safety of drugs used for the treatment of migraine during pregnancy: a narrative review. Expert Rev Clin Pharmacol 2023; 16:207-217. [PMID: 36803196 DOI: 10.1080/17512433.2023.2181157] [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: 02/22/2023]
Abstract
INTRODUCTION Migraine is common in females of childbearing age and negatively impacts quality of life. The majority of those with migraine who become pregnant see an improvement in their condition but not all do. Providing evidence-based recommendations for the pharmacological management of migraine in pregnancy is challenging. AREAS COVERED This narrative review provides an update on the safety of drugs used for migraine in pregnancy. National and international guidelines on the management of episodic migraine in adults were used to select the drugs of relevance to pregnant women. The final list of drugs was chosen by a pain specialist who categorized them according to drug class and use in acute management or prevention. PubMed was searched from inception to 31st July 2022 for evidence on drug safety. EXPERT OPINION Obtaining high-quality drug safety data in pregnant migraineurs is difficult not least because exposing a fetus to research-related risks is often considered unethical. There is reliance on observational studies which often group drugs together and lack specificities pertinent to drug prescribing like timing, dosing and duration. Improved statistical tools, study designs and the creation of international collaborative frameworks are ways to advance knowledge on drug safety in pregnancy.
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Affiliation(s)
- Jessica A Spiteri
- Department of Anaesthesia, Intensive Care and Pain Medicine, Mater Dei Hospital, Triq Dun Karm, Malta
| | - Gabrielle Camilleri
- Department of Clinical Pharmacology and Therapeutics, University of Malta, Msida MSD, Malta
| | - Carlo Piccinni
- Fondazione Ricerca e Salute (ReS)-Research and Health Foundation, Casalecchio di Reno, Italy
| | - Janet Sultana
- Exeter College of Medicine and Health, University of Exeter, Exeter, UK
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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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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: 0] [Impact Index Per Article: 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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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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Giri S, Sahoo S. Pregnancy in Patients with Non-cirrhotic Portal Hypertension: A Literature Review. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRICIA : REVISTA DA FEDERACAO BRASILEIRA DAS SOCIEDADES DE GINECOLOGIA E OBSTETRICIA 2022; 44:609-613. [PMID: 35760363 PMCID: PMC9948258 DOI: 10.1055/s-0042-1748973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Pregnancy in non-cirrhotic portal hypertension (NCPH) is an uncommon condition. Its management is challenging both to the obstetricians as well as to the gastroenterologists due to the lack of more extensive studies and standard clinical practice guidelines. These patients are at increased risk of portal hypertension (PTH) complications, especially variceal bleeding, and with an increased incidence of adverse maternal and fetal outcomes. Hence, a multidisciplinary approach is required for management of pregnancy in NCPH. This short review describes the different aspects of pregnancy with NCPH, emphasizing specific strategies for preventing and managing PTH from the preconceptional period to postpartum.
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Affiliation(s)
- Suprabhat Giri
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Shradhanjali Sahoo
- Department of Maternal and Fetal Medicine, Fernandez Hospital, Hyderabad, Telangana, India
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Harris ML, Egan N, Forder PM, Bateson D, Sverdlov AL, Murphy VE, Loxton D. Patterns of contraceptive use among young Australian women with chronic disease: findings from a prospective cohort study. Reprod Health 2022; 19:111. [PMID: 35525995 PMCID: PMC9078003 DOI: 10.1186/s12978-022-01413-x] [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: 10/25/2021] [Accepted: 04/11/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Given chronic disease is increasing among young women and unintended pregnancies among these women are associated with poor maternal and fetal outcomes, these women would benefit from effective preconception care. However, there is a lack of understanding of how these women use or don't use contraception to inform such interventions. This study examined patterns of contraceptive use among an Australian cohort of young women and investigated the influence of chronic disease on contraceptive use over time. METHODS Using data from 15,244 young women from the Australian Longitudinal Study on Women's Health (born 1989-1995), latent transition analysis was performed to identify distinct contraceptive patterns among women who were at risk of an unintended pregnancy. Multinomial mixed-effect models were used to evaluate the relationship between contraceptive combinations and chronic disease. RESULTS Contraceptive use for women with cardiac and autoinflammatory diseases differed to women without chronic disease over the observation period. Compared to women without chronic disease using the pill, women with cardiac disease had double the odds of using 'other' contraception and condoms (OR = 2.20, 95% CI 1.34, 3.59) and a modest increase in the odds of using the combined oral contraceptive pill and condoms (OR = 1.39, 95% CI 1.03, 1.89). Compared to women without chronic disease who used the pill, women with autoinflammatory disease had increased odds of using LARC and condoms (OR = 1.58, 95% CI 1.04, 2.41), using 'other' contraception and condoms (OR = 1.69, 95% CI 1.11, 2.57), and using the combined oral contraceptive pill and condoms (OR = 1.38, 95% CI 1.09, 1.75). No differences in contraceptive patterns over the observation period were found for women with asthma or diabetes when compared to women without chronic disease. CONCLUSION The findings identified a need for effective contraceptive counselling as part of routine chronic disease care and improved communication between health care providers and women with chronic disease to improve young women's contraceptive knowledge and agency in contraceptive choice, particularly for those with cardiac or autoinflammatory conditions. This may be the key to reducing high-risk unintended pregnancies among this vulnerable population.
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Affiliation(s)
- Melissa L Harris
- Centre for Women's Health Research, College of Health, Medicine and Wellbeing, University of Newcastle, Newcastle, NSW, Australia. .,Hunter Medical Research Institute, Newcastle, NSW, Australia.
| | - Nicholas Egan
- Centre for Women's Health Research, College of Health, Medicine and Wellbeing, University of Newcastle, Newcastle, NSW, Australia.,Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Peta M Forder
- Centre for Women's Health Research, College of Health, Medicine and Wellbeing, University of Newcastle, Newcastle, NSW, Australia.,Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Deborah Bateson
- Family Planning NSW, Ashfield, NSW, Australia.,Discipline of Obstetrics, Gynaecology and Neonatology, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Aaron L Sverdlov
- Hunter Medical Research Institute, Newcastle, NSW, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia.,Cardiovascular Department, John Hunter Hospital, Hunter New England Local Health District, Newcastle, NSW, Australia
| | - Vanessa E Murphy
- Hunter Medical Research Institute, Newcastle, NSW, Australia.,Priority Research Centre for Healthy Lungs, College of Health, Medicine and Wellbeing, University of Newcastle, Newcastle, NSW, Australia
| | - Deborah Loxton
- Centre for Women's Health Research, College of Health, Medicine and Wellbeing, University of Newcastle, Newcastle, NSW, Australia.,Hunter Medical Research Institute, Newcastle, NSW, Australia
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12
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Vu GH, Warden C, Zimmerman CE, Kalmar CL, Humphries LS, McDonald-McGinn DM, Jackson OA, Low DW, Taylor JA, Swanson JW. Poverty and Risk of Cleft Lip and Palate: An Analysis of United States Birth Data. Plast Reconstr Surg 2022; 149:169-182. [PMID: 34936619 PMCID: PMC8691162 DOI: 10.1097/prs.0000000000008636] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND The relationship between poverty and incidence of cleft lip and cleft palate remains unclear. The authors investigated the association between socioeconomic status and cleft lip with or without cleft palate and cleft palate only in the United States after controlling for demographic and environmental risk factors. METHODS The U.S. 2016 and 2017 natality data were utilized. Proxies for socioeconomic status included maternal education, use of the Special Supplemental Nutrition Program for Women, Infants, and Children, and payment source for delivery. Multiple logistic regression controlled for household demographics, prenatal care, maternal health, and infant characteristics. RESULTS Of 6,251,308 live births included, 2984 (0.05 percent) had cleft lip with or without cleft palate and 1180 (0.02 percent) had cleft palate only. Maternal education of bachelor's degree or higher was protective against, and delayed prenatal care associated with, cleft lip with or without cleft palate (adjusted ORs = 0.73 and 1.14 to 1.23, respectively; p < 0.02). Receiving assistance under the Special Supplemental Nutrition Program for Women, Infants, and Children was associated with cleft palate only (adjusted OR = 1.25; p = 0.003). Male sex, first-trimester tobacco smoking, and maternal gestational diabetes were also associated with cleft lip with or without cleft palate (adjusted ORs = 1.60, 1.01, and 1.19, respectively; p < 0.05). Female sex, prepregnancy tobacco smoking, and maternal infections during pregnancy were associated with cleft palate only (adjusted ORs = 0.74, 1.02, and 1.60, respectively; p < 0.05). CONCLUSIONS Increased incidence of orofacial clefts was associated with indicators of lower socioeconomic status, with different indicators associated with different cleft phenotypes. Notably, early prenatal care was protective against the development of cleft lip with or without cleft palate. CLIINCAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Affiliation(s)
- Giap H Vu
- From the Divisions of Plastic and Reconstructive Surgery and Human Genetics, Children's Hospital of Philadelphia; and the University of Pennsylvania Perelman School of Medicine
| | - Clara Warden
- From the Divisions of Plastic and Reconstructive Surgery and Human Genetics, Children's Hospital of Philadelphia; and the University of Pennsylvania Perelman School of Medicine
| | - Carrie E Zimmerman
- From the Divisions of Plastic and Reconstructive Surgery and Human Genetics, Children's Hospital of Philadelphia; and the University of Pennsylvania Perelman School of Medicine
| | - Christopher L Kalmar
- From the Divisions of Plastic and Reconstructive Surgery and Human Genetics, Children's Hospital of Philadelphia; and the University of Pennsylvania Perelman School of Medicine
| | - Laura S Humphries
- From the Divisions of Plastic and Reconstructive Surgery and Human Genetics, Children's Hospital of Philadelphia; and the University of Pennsylvania Perelman School of Medicine
| | - Donna M McDonald-McGinn
- From the Divisions of Plastic and Reconstructive Surgery and Human Genetics, Children's Hospital of Philadelphia; and the University of Pennsylvania Perelman School of Medicine
| | - Oksana A Jackson
- From the Divisions of Plastic and Reconstructive Surgery and Human Genetics, Children's Hospital of Philadelphia; and the University of Pennsylvania Perelman School of Medicine
| | - David W Low
- From the Divisions of Plastic and Reconstructive Surgery and Human Genetics, Children's Hospital of Philadelphia; and the University of Pennsylvania Perelman School of Medicine
| | - Jesse A Taylor
- From the Divisions of Plastic and Reconstructive Surgery and Human Genetics, Children's Hospital of Philadelphia; and the University of Pennsylvania Perelman School of Medicine
| | - Jordan W Swanson
- From the Divisions of Plastic and Reconstructive Surgery and Human Genetics, Children's Hospital of Philadelphia; and the University of Pennsylvania Perelman School of Medicine
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13
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Suazo J. Environmental factors in non-syndromic orofacial clefts: A review based on meta-analyses results. Oral Dis 2022; 28:3-8. [PMID: 33872445 DOI: 10.1111/odi.13880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 04/12/2021] [Accepted: 04/13/2021] [Indexed: 10/21/2022]
Abstract
Non-syndromic orofacial clefts (NSOFCs) are prevalent birth defects with a complex etiology where several interacting genetic and environmental factors have been observed. This narrative review describes maternal exposures that have been significantly associated with protective effects or risk factors. The statistically significant information reported here was found in meta-analysis studies, taking advantage of their precision in defining intervention effects and their management of heterogeneity between studies. In addition, I propose a hypothesis explaining the biological basis for the results of the meta-analyses. This review aims to improve the evidence available in parent counseling, to prevent the occurrence of orofacial clefts by suggesting lifestyle changes.
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Affiliation(s)
- José Suazo
- Institute for Research in Dental Sciences, School of Dentistry, Universidad de Chile, Santiago, Chile
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14
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Tsakiridis I, Giouleka S, Arvanitaki A, Mamopoulos A, Giannakoulas G, Papazisis G, Athanasiadis A, Dagklis T. Chronic hypertension in pregnancy: synthesis of influential guidelines. J Perinat Med 2021; 49:859-872. [PMID: 33872475 DOI: 10.1515/jpm-2021-0015] [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] [Received: 01/12/2021] [Accepted: 03/18/2021] [Indexed: 12/29/2022]
Abstract
Chronic hypertension in pregnancy accounts for a substantial proportion of maternal morbidity and mortality and is associated with adverse perinatal outcomes, most of which can be mitigated by appropriate surveillance and management protocols. The aim of this study was to review and compare recommendations of published guidelines on this condition. Thus, a descriptive review of influential guidelines from the National Institute for Health and Care Excellence, the Society of Obstetric Medicine of Australia and New Zealand, the International Society of Hypertension, the International Society for the Study of Hypertension in Pregnancy, the European Society of Cardiology, the International Federation of Gynecology and Obstetrics, the Society of Obstetricians and Gynaecologists of Canada and the American College of Obstetricians and Gynecologists on chronic hypertension in pregnancy was conducted. All guidelines agree on the definition and medical management, the need for more frequent antenatal care and fetal surveillance and the re-evaluation at 6-8 weeks postpartum. There is also a consensus that the administration of low-dose aspirin is required to prevent preeclampsia, although the optimal dosage remains controversial. No universal agreement has been spotted regarding optimal treatment blood pressure (BP) targets, need for treating mild-to-moderate hypertension and postnatal BP measurements. Additionally, while the necessity of antenatal corticosteroids and magnesium sulfate for preterm delivery is universally recommended, the appropriate timing of delivery is not clearly outlined. Hence, there is a need to adopt consistent practice protocols to optimally manage these pregnancies; i.e. timely detect and treat any potential complications and subsequently reduce the associated morbidity and mortality.
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Affiliation(s)
- Ioannis Tsakiridis
- Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Sonia Giouleka
- Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alexandra Arvanitaki
- Adult Congenital Heart Centre and National Centre for Pulmonary Arterial Hypertension, Royal Brompton Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK.,First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Apostolos Mamopoulos
- Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Giannakoulas
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Georgios Papazisis
- Department of Clinical Pharmacology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Apostolos Athanasiadis
- Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Themistoklis Dagklis
- Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
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15
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Lee KS, Choi YJ, Cho J, Lee H, Lee H, Park SJ, Park JS, Hong YC. Environmental and Genetic Risk Factors of Congenital Anomalies: an Umbrella Review of Systematic Reviews and Meta-Analyses. J Korean Med Sci 2021; 36:e183. [PMID: 34282604 PMCID: PMC8289720 DOI: 10.3346/jkms.2021.36.e183] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/15/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The prevalence of congenital anomalies in newborns in South Korea was 272.9 per 100,000 in 2005, and 314.7 per 100,000 in 2006. In other studies, the prevalence of congenital anomalies in South Korea was equivalent to 286.9 per 10,000 livebirths in 2006, while it was estimated 446.3 per 10,000 births during the period from 2008 to 2014. Several systematic reviews and meta-analyses analyzing the factors contributing to congenital anomalies have been reported, but comprehensive umbrella reviews are lacking. METHODS We searched PubMed, Google Scholar, Cochrane, and EMBASE databases up to July 1, 2019, for systematic reviews and meta-analyses that investigated the effects of environmental and genetic factors on any type of congenital anomalies. We categorized 8 subgroups of congenital anomalies classified according to the 10th revision of the International Statistical Classification of Diseases (ICD-10). Two researchers independently searched the literature, retrieved the data, and evaluated the quality of each study. RESULTS We reviewed 66 systematic reviews and meta-analyses that investigated the association between non-genetic or genetic risk factors and congenital anomalies. Overall, 269 associations and 128 associations were considered for environmental and genetic risk factors, respectively. Congenital anomalies based on congenital heart diseases, cleft lip and palate, and others were associated with environmental risk factors based on maternal exposure to environmental exposures (air pollution, toxic chemicals), parental smoking, maternal history (infectious diseases during pregnancy, pregestational and gestational diabetes mellitus, and gestational diabetes mellitus), maternal obesity, maternal drug intake, pregnancy through artificial reproductive technologies, and socioeconomic factors. The association of maternal alcohol or coffee consumption with congenital anomalies was not significant, and maternal folic acid supplementation had a preventive effect on congenital heart defects. Genes or genetic loci associated with congenital anomalies included MTHFR, MTRR and MTR, GATA4, NKX2-5, SRD5A2, CFTR, and 1p22 and 20q12 anomalies. CONCLUSION This study provides a wide perspective on the distribution of environmental and genetic risk factors of congenital anomalies, thus suggesting future studies and providing health policy implications.
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Affiliation(s)
- Kyung Shin Lee
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Korea
- Environmental Health Center, Seoul National University College of Medicine, Seoul, Korea
| | - Yoon Jung Choi
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Korea
- Environmental Health Center, Seoul National University College of Medicine, Seoul, Korea
| | - Jinwoo Cho
- Department of Statistics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hyunji Lee
- Institute of Environmental Medicine, Seoul National University Medical Research Center, Seoul, Korea
| | - Heejin Lee
- Institute of Environmental Medicine, Seoul National University Medical Research Center, Seoul, Korea
| | - Soo Jin Park
- Department of Surgery, Wonkwang University Sanbon Hospital, Gunpo, Korea
| | - Joong Shin Park
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Yun Chul Hong
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Korea
- Environmental Health Center, Seoul National University College of Medicine, Seoul, Korea
- Institute of Environmental Medicine, Seoul National University Medical Research Center, Seoul, Korea.
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16
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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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17
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Wu Y, Yao JW, Xu LJ, Chen M, Wan L. Risk of congenital malformations in offspring of women using β-blockers during early pregnancy: An updated meta-analysis of observational studies. Br J Clin Pharmacol 2021; 87:806-815. [PMID: 32978831 DOI: 10.1111/bcp.14561] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 09/03/2020] [Accepted: 09/12/2020] [Indexed: 01/11/2023] Open
Abstract
AIMS Beta-blockers are commonly used to treat hypertension that arises during pregnancy. However, reproductive safety concerns have been expressed. Here, we investigated whether the use of β-blockers during early pregnancy increased the risk of congenital malformations. METHODS A systematic literature search was performed in PubMed, Embase and Cochrane Library to identify relevant studies published from database inception until February 2020. Observational studies evaluating associations between maternal β-blocker use and congenital malformations were included in this meta-analysis. Two reviewers independently extracted data and assessed study quality. Meta-analysis of outcomes was performed and a summary odds ratio (OR) was calculated with consideration of heterogeneity. RESULTS Twenty observational studies were identified. Beta-blocker use during early pregnancy was not associated with an increased risk of congenital malformations (OR = 1.01, 95% confidence interval [CI] = 0.93-1.09). Subgroup analysis of organ-specific malformations revealed that β-blocker use was associated with an increased risk of heart malformations (OR = 1.29, 95% CI = 1.02-1.63) and an increased risk of cleft lip or palate (OR = 1.5, 95% CI = 1.18-1.91); however, these associations (OR = 1.11, 95% CI = 0.94-1.32 for heart malformations; OR = 1.34, 95% CI = 0.98-1.85 for cleft lip or palate) disappeared when the adjusted data were pooled. Beta-blocker use was not associated with increased risks of central nervous system malformations, neural tube defects or hypospadias. CONCLUSION Exposure to β-blockers during early pregnancy does not appear to be associated with congenital malformations or heart malformations in offspring. Other organ-specific congenital malformations should be evaluated in further studies.
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Affiliation(s)
- Yin Wu
- Department of Oral Diseases, Ningbo Urology and Nephrology Hospital, Ningbo, Zhejiang, China
| | - Jiang-Wei Yao
- Department of Oral Diseases, Tongxiang Dental Hospital, Tongxiang, Zhejiang, China
| | - Li-Jie Xu
- Department of Oral Diseases, Tongxiang First People's Hospital, Tongxiang, Zhejiang, China
| | - Miao Chen
- Tianshi Dental Clinic of Huzhou, Huzhou, Zhejiang, China
| | - Long Wan
- Department of Oral Diseases, Tongxiang First People's Hospital, Tongxiang, Zhejiang, China
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18
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19
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Sprague R, Kim JW, Kirimlioglu E, Guo X, Günay N, Guzeloglu-Kayisli O, Ozmen A, Schatz F, Imudia AN, Lockwood CJ, Magness RR, Kayisli UA. Catecholestradiol Activation of Adrenergic Receptors Induces Endometrial Cell Survival via p38 MAPK Signaling. J Clin Endocrinol Metab 2021; 106:337-350. [PMID: 33247592 DOI: 10.1210/clinem/dgaa866] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Indexed: 02/03/2023]
Abstract
CONTEXT Enhanced levels of catecholestradiols, 2-hydroxyestradiol (2-OHE2) or 4-hydroxyestradiol (4-OHE2), are reported in endometriosis. During gestation, catecholestradiol activation of adrenergic receptors (AR) elevates estrogen receptor (ER)-independent proliferation of uterine arterial endothelial cells. OBJECTIVE To investigate β-AR-mediated catecholestradiol effects on human endometrial stromal cell (HESC) and epithelial cell survival in endometriosis. DESIGN β-AR immunostaining of eutopic and ectopic endometria (n = 9). Assays for cell viability, 5-bromo-2'-deoxyuridine proliferation, apoptosis, quantitative PCR, and estrogenicity (alkaline phosphatase activity), as well as siRNA β-AR silencing and immunoblot analyses of cultured HESCs or Ishikawa cells treated with control or 2-OHE2 or 4-OHE2 ±β-AR antagonist or ±p38 MAPK inhibitor. SETTING University research institution. PATIENTS Women with or without endometriosis. INTERVENTIONS None. MAIN OUTCOME MEASURES β-AR expression in eutopic vs ectopic endometria and regulation of HESC survival by 2-OHE2 and 4-OHE2. RESULTS Eutopic and ectopic endometrial stromal and epithelial cells displayed β2-AR immunoreactivity with increased staining in the functionalis vs basalis layer (P < 0.05). Both 2-OHE2 and 4-OHE2 enhanced HESC and Ishikawa cell survival (P < 0.05), an effect abrogated by β-AR antagonist propranolol, but not ER antagonist ICI182,780. 2-OHE2 or 4-OHE2 failed to induce cell survival and estrogenic activity in ADRB2-silenced HESCs and in Ishikawa cells, respectively. Although 2-OHE2 inhibited apoptosis and BAX mRNA expression, 4-OHE2 induced proliferation and decreased apoptosis (P < 0.05). Both catecholestradiols elevated phospho-p38 MAPK levels (P < 0.05), which was blocked by propranolol, and p38 MAPK inhibitor reversed catecholestradiol-enhanced HESC survival. CONCLUSIONS Catecholestradiols increase endometrial cell survival by an ER-independent β-AR-mediated p38 MAPK activation, suggesting that agents blocking β-AR (e.g., propranolol) or inhibiting 2-OHE2- or 4-OHE2-generating enzymes (i.e., CYP1A1/B1) could treat endometriosis.
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Affiliation(s)
- Rachel Sprague
- Department of Obstetrics & Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Joung W Kim
- Department of Obstetrics & Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Esma Kirimlioglu
- Department of Obstetrics & Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Xiaofang Guo
- Department of Obstetrics & Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Nihan Günay
- Department of Obstetrics & Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Ozlem Guzeloglu-Kayisli
- Department of Obstetrics & Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Asli Ozmen
- Department of Obstetrics & Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Frederick Schatz
- Department of Obstetrics & Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Anthony N Imudia
- Department of Obstetrics & Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Charles J Lockwood
- Department of Obstetrics & Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Ronald R Magness
- Department of Obstetrics & Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Umit A Kayisli
- Department of Obstetrics & Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
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20
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Saldanha IJ, Cao W, Bhuma MR, Konnyu KJ, Adam GP, Mehta S, Zullo AR, Chen KK, Roth JL, Balk EM. Management of primary headaches during pregnancy, postpartum, and breastfeeding: A systematic review. Headache 2021; 61:11-43. [PMID: 33433020 DOI: 10.1111/head.14041] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 10/28/2020] [Accepted: 11/16/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Primary headaches (migraine, tension headache, cluster headache, and other trigeminal autonomic cephalgias) are common in pregnancy and postpartum. It is unclear how to best and most safely manage them. OBJECTIVE We conducted a systematic review (SR) of interventions to prevent or treat primary headaches in women who are pregnant, attempting to become pregnant, postpartum, or breastfeeding. METHODS We searched Medline, Embase, Cochrane CENTRAL, CINAHL, ClinicalTrials.gov, Cochrane Database of SRs, and Epistemonikos for primary studies of pregnant women with primary headache and existing SRs of harms in pregnant women regardless of indication. No date or language restrictions were applied. We assessed strength of evidence (SoE) using standard methods. RESULTS We screened 8549 citations for studies and 2788 citations for SRs. Sixteen studies (mostly high risk of bias) comprising 14,185 patients (total) and 26 SRs met the criteria. For prevention, we found no evidence addressing effectiveness. Antiepileptics, venlafaxine, tricyclic antidepressants, benzodiazepines, β-blockers, prednisolone, and oral magnesium may be associated with fetal/child adverse effects, but calcium channel blockers and antihistamines may not be (1 single-group study and 11 SRs; low-to-moderate SoE). For treatment, combination metoclopramide and diphenhydramine may be more effective than codeine for migraine or tension headache (1 randomized controlled trial; low SoE). Triptans may not be associated with fetal/child adverse effects (8 nonrandomized comparative studies; low SoE). Acetaminophen, prednisolone, indomethacin, ondansetron, antipsychotics, and intravenous magnesium may be associated with fetal/child adverse effects, but low-dose aspirin may not be (indirect evidence; low-to-moderate SoE). We found insufficient evidence regarding non-pharmacologic treatments. CONCLUSIONS For prevention of primary headache, calcium channel blockers and antihistamines may not be associated with fetal/child adverse effects. For treatment, combination metoclopramide and diphenhydramine may be more effective than codeine. Triptans and low-dose aspirin may not be associated with fetal/child adverse effects. Future research should identify effective and safe interventions in pregnancy and postpartum.
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Affiliation(s)
- Ian J Saldanha
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Wangnan Cao
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Monika Reddy Bhuma
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Kristin J Konnyu
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Gaelen P Adam
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Shivani Mehta
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Andrew R Zullo
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA.,Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Kenneth K Chen
- Department of Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA.,Department of Obstetrics and Gynecology, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Julie L Roth
- Department of Neurology, Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Ethan M Balk
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
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Abstract
BACKGROUND Pregnancy after kidney transplantation is an uncommon event. In addition to the risk to the child and the mother, pregnancy has a certain risk for the transplanted kidney. METHODS We made a retrospective analysis of pregnancy and kidney function over a 49-year period in women with transplanted kidneys monitored at the National Transplant Centre, University Medical Centre Ljubljana, Ljubljana, Slovenia. RESULTS We analyzed 22 pregnancies in 18 women (26-39 years old) 78 ± 37 months after transplantation. Serum creatinine before conception was 92 ± 26 μmol/L; 3 years after delivery, it was 117 ± 67 μmol/L. There were no rejections during pregnancy. Three rejections occurred in the first 9 months after delivery. The median duration of pregnancies was 37 weeks. Preeclampsia occurred in 4 women and severe eclampsia occurred in 2 women. In 19 cases, delivery was by caesarean section. One child was born with trisomy of chromosome 21 and 3 children were born with minor congenital anomalies. CONCLUSIONS Renal function and proteinuria did not deteriorate 3 years after pregnancy, even after 2 pregnancies. Rejections in the early post-pregnancy period were common. Preeclampsia was more frequent than in the average population. The incidence of major congenital anomalies was comparable to that seen in pregnant women without immunosuppression.
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22
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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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Medicines for headache before and during pregnancy: a retrospective cohort study (ATENA study). Neurol Sci 2020; 42:1895-1921. [PMID: 32968869 PMCID: PMC8043957 DOI: 10.1007/s10072-020-04702-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 08/29/2020] [Indexed: 12/28/2022]
Abstract
Objective To investigate headache treatment before and during pregnancy. Background Most headaches in pregnancy are primary disorders. Headaches are likely to ameliorate during pregnancy, although they may also begin or worsen. Most headache medications should be avoided during pregnancy because of potential fetal risks. However, only scarce evidence on headache drug consumption during pregnancy is available. Design ATENA was a retrospective, self-administered questionnaire-based, cohort study on women in either pregnancy or who have just delivered and reporting headache before and/or during pregnancy. Results Out of 271 women in either pregnancy or who have just delivered, 100 (37%) reported headache before and/or during pregnancy and constituted our study sample. Before pregnancy, the attitude toward the use of symptomatic drugs was characterized by both a strong focus on their safety and the willingness to avoid possible dependence from them. Compared to the year before, pregnancy led to changes in behavior and therapeutic habits as shown by a higher proportion of patients looking for information about drugs (44/100 [44%] vs. 36/100 [36%]) and a lower proportion of those treating headache attacks (88/100 [88%] vs. 52/100 [52%]) and by a lower use of nonsteroidal anti-inflammatory drugs (68/100 [68%] vs. 5/100 [5%]) and a much higher use of paracetamol (33/100 [33%] vs. 95/100 [95%]). Conclusions Pregnancy changes how women self-treat their headache, and leads to search for information regarding drug safety, mostly due to the perception of fetal risk of drugs. Healthcare providers have to be ready to face particular needs of pregnant women with headache. Electronic supplementary material The online version of this article (10.1007/s10072-020-04702-0) contains supplementary material, which is available to authorized users.
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Romeo AN, Običan SG. Teratogen update: Antithyroid medications. Birth Defects Res 2020; 112:1150-1170. [PMID: 32738035 DOI: 10.1002/bdr2.1771] [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: 05/19/2020] [Revised: 06/30/2020] [Accepted: 07/01/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Thyroid disorders including hyperthyroidism are common during pregnancy. Untreated hyperthyroidism can result in adverse outcomes for pregnancy. METHODS Iodine, propylthiouracil (PTU), carbimazole (CMZ), and methimazole (MMI) are common medications for hyperthyroidism treatment. The literature regarding antithyroid medication use in pregnancy and breastfeeding is reviewed. RESULTS Animal studies for PTU have suggested congenital anomalies while animal studies for MMI have only indicated adverse outcomes at higher doses than used in humans. Epidemiological studies have noted an increased risk of congenital anomalies for PTU less often than CMZ or MMI but the epidemiological evidence remains mixed. A pattern of anomalies has been described for CMZ and MMI, from both case and epidemiological studies, including choanal atresia, aplasia cutis congenita, and other facial, heart, gastrointestinal, and skin anomalies. Closer examination of cases indicates that a few cases of the anomalies have occurred without exposure to CMZ or MMI and outside of the proposed critical period. PTU has a small risk of hepatotoxicity which rarely results in liver transplantation and death. Some authors have suggested that PTU be prescribed in early pregnancy and switched to MMI in late pregnancy. Untreated hyperthyroidism, from either a lack of medications or switching medications during the first trimester, may also increase the chance of congenital anomalies. Multiple case studies and larger epidemiological studies have failed to provide clear, consistent outcomes for the use of PTU, CMZ, and MMI in pregnancy. MMI and PTU both enter the breastmilk in small amounts. CONCLUSION Additional research is needed to assist in the medical management and exposure counseling of pregnant and breastfeeding women with hyperthyroidism.
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Affiliation(s)
- Alfred N Romeo
- MotherToBaby Utah, Utah Department of Health, Salt Lake City, Utah, USA
| | - Sarah G Običan
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
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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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Lu C, Wang JY, Jia ZL. [Environmental factors of non-syndromic cleft lip and palate]. HUA XI KOU QIANG YI XUE ZA ZHI = HUAXI KOUQIANG YIXUE ZAZHI = WEST CHINA JOURNAL OF STOMATOLOGY 2019; 37:547-550. [PMID: 31721506 DOI: 10.7518/hxkq.2019.05.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Though the mechanism of non-syndromic cleft lip and palate is not completely clear, the disease is affected by the combination of environment and genetics. Special environmental factors have the affect on the incidence of cleft palate. In this paper, the environmental factors related to the occurrence of non-syndromic cleft lip and palate were summarize from three aspects: poor living habits, chemical factors, age and health status of pregnant women during pregnancy. Based on the analysis of this paper, it will help to improve the health and living environment of pregnant women, so as to reduce the incidence of cleft palate.
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Affiliation(s)
- Cheng Lu
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & Dept. of Cleft Lip and Palate Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, China
| | - Jiang-Yue Wang
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & Dept. of Cleft Lip and Palate Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, China
| | - Zhong-Lin Jia
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & Dept. of Cleft Lip and Palate Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, China
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Pregnancy outcome after first trimester exposure to bisoprolol: an observational cohort study. J Hypertens 2019; 36:2109-2117. [PMID: 29985206 DOI: 10.1097/hjh.0000000000001818] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVES Beta-blockers are frequently used during pregnancy, with labetalol and metoprolol being considered as drugs of choice. As there are no prospective pregnancy studies for bisoprolol yet, our aim was to analyze pregnancy outcomes after bisoprolol exposure. METHODS Pregnancies exposed to bisoprolol during the first trimester were retrieved from the German Embryotox pharmacovigilance database. Pregnancy outcomes of prospectively ascertained pregnancies were compared with women neither exposed to beta-blockers nor other antihypertensives. In addition, retrospective reports on adverse drug reactions were screened for patterns of birth defects. RESULTS Inclusion criteria for the prospective study were met by 339 bisoprolol-treated women and 678 patients in the comparison cohort. Neither the risk for spontaneous abortions [adjusted hazard ratio (HRadj.) 1.06; 95% confidence interval (CI) 0.66-1.70] nor for major congenital malformations [adjusted odds ratio (ORadj.) 0.77; 95% CI 0.34-1.75] was increased after first trimester bisoprolol treatment. However, higher rates of preterm births [ORadj. 1.90; 95% CI 1.17-3.11] and reduced birthweights in singleton pregnancies (adjusted standard deviation score difference -0.48; 95% CI -0.62 to -0.34) were noted. Continued treatment with beta-blockers until birth was found to be associated with a higher risk for growth restriction than first trimester exposure only. A sensitivity analysis did not suggest higher rates of adverse pregnancy outcomes in hypertensive women on bisoprolol compared with nonhypertensive bisoprolol-exposed women. CONCLUSION Our study supports the hypothesis that first trimester bisoprolol treatment does not increase the risk for spontaneous abortions or major birth defects. However, an influence of prolonged bisoprolol exposure on fetal growth cannot be ruled out.
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Bateman BT, Huybrechts KF, Hernandez-Diaz S, Kieler H, Zoega H. β-Blocker Use in Pregnancy and the Risk for Congenital Malformations. Ann Intern Med 2019; 170:909-910. [PMID: 31207630 DOI: 10.7326/l19-0157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Brian T Bateman
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (B.T.B., K.F.H.)
| | - Krista F Huybrechts
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (B.T.B., K.F.H.)
| | | | | | - Helga Zoega
- University of New South Wales, Sydney, New South Wales, Australia (H.Z.)
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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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Tamargo J, Caballero R, Delpón E. Pharmacotherapy for hypertension in pregnant patients: special considerations. Expert Opin Pharmacother 2019; 20:963-982. [PMID: 30943045 DOI: 10.1080/14656566.2019.1594773] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Hypertensive disorders of pregnancy (HDP) represent a major cause of maternal, fetal and neonatal morbidity and mortality and identifies women at risk for cardiovascular and other chronic diseases later in life. When antihypertensive drugs are used during pregnancy, their benefit and harm to both mother and fetus should be evaluated. AREAS COVERED This review summarizes the pharmacological characteristics of the recommended antihypertensive drugs and their impact on mother and fetus when administered during pregnancy and/or post-partum. Drugs were identified using MEDLINE and the main international Guidelines for the management of HDP. EXPERT OPINION Although there is a consensus that severe hypertension should be treated, treatment of mild hypertension without end-organ damage (140-159/90-109 mmHg) remains controversial and there is no agreement on when to initiate therapy, blood pressure targets or recommended drugs in the absence of robust evidence for the superiority of one drug over others. Furthermore, the long-term outcomes of in-utero antihypertensive exposure remain uncertain. Therefore, evidence-based data regarding the treatment of HDP is lacking and well designed randomized clinical trials are needed to resolve all these controversial issues related to the management of HDP.
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Affiliation(s)
- Juan Tamargo
- a Department of Pharmacology and Toxicology, School of Medicine , Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, CIBERCV , Madrid , Spain
| | - Ricardo Caballero
- a Department of Pharmacology and Toxicology, School of Medicine , Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, CIBERCV , Madrid , Spain
| | - Eva Delpón
- a Department of Pharmacology and Toxicology, School of Medicine , Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, CIBERCV , Madrid , Spain
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Halpern DG, Weinberg CR, Pinnelas R, Mehta-Lee S, Economy KE, Valente AM. Use of Medication for Cardiovascular Disease During Pregnancy. J Am Coll Cardiol 2019; 73:457-476. [DOI: 10.1016/j.jacc.2018.10.075] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 10/19/2018] [Accepted: 10/23/2018] [Indexed: 01/03/2023]
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Abdou MSM, Sherif AAR, Wahdan IMH, Ashour KSED. Pattern and risk factors of congenital anomalies in a pediatric university hospital, Alexandria, Egypt. J Egypt Public Health Assoc 2019; 94:3. [PMID: 30686831 PMCID: PMC6326997 DOI: 10.1186/s42506-018-0004-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 12/20/2018] [Indexed: 12/01/2022]
Abstract
Background Congenital anomalies (CAs) are structural, functional, or metabolic anomalies that originate during intrauterine life and can interfere with the body functions. In Egypt, the prevalence of CAs is increasing. The study aimed to estimate the frequency, describe the types, and identify the possible risk factors of CAs among infants attending the Pediatric University Hospital, Alexandria, Egypt. Methods A retrospective case series and a case-control study were conducted. Patients’ records for the years 2010–2015 were reviewed, and a sample of 200 infants (100 cases and 100 controls) was taken from infants presented to Pediatrics, Pediatric Surgery, and Genetics Clinics of the hospital. Data were collected using a record review checklist and a predesigned interviewing questionnaire. Results The study revealed that congenital anomalies of the digestive system (38.0%), musculoskeletal system (32.9%), and circulatory system (11.0%) were the most common types of CAs. Males were more affected with CAs than females (63% versus 37%). The major risk factors for CAs were old-aged parents, complications during pregnancy, unprescribed medications and excessive vitamin A intake during pregnancy, exposure to chemicals and pesticides during pregnancy, and living near mobile strengthening stations. Conclusion Congenital malformations of the digestive, musculoskeletal, and circulatory systems were the most common types of CAs in the Pediatric Hospital. To prevent CAs, there is a need to restrict the prescription of medications that may have a teratogenic effect.
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Affiliation(s)
| | - Aida Ali Reda Sherif
- 1Department of Epidemiology, High Institute of Public Health, Alexandria University, Alexandria, Egypt
| | - Iman Mohamed Helmy Wahdan
- 1Department of Epidemiology, High Institute of Public Health, Alexandria University, Alexandria, Egypt
| | - Khaled Saad El Din Ashour
- 2General and Paediatric Surgery, Department of Pediatric Surgery, Faculty of Medicine, Alexandria University, Alexandria, Egypt
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Bateman BT, Heide-Jørgensen U, Einarsdóttir K, Engeland A, Furu K, Gissler M, Hernandez-Diaz S, Kieler H, Lahesmaa-Korpinen AM, Mogun H, Nørgaard M, Reutfors J, Selmer R, Huybrechts KF, Zoega H. β-Blocker Use in Pregnancy and the Risk for Congenital Malformations: An International Cohort Study. Ann Intern Med 2018; 169:665-673. [PMID: 30326014 PMCID: PMC6854680 DOI: 10.7326/m18-0338] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND β-Blockers are a class of antihypertensive medications that are commonly used in pregnancy. OBJECTIVE To estimate the risks for major congenital malformations associated with first-trimester exposure to β-blockers. DESIGN Cohort study. SETTING Health registries in the 5 Nordic countries and the U.S. Medicaid database. PATIENTS Pregnant women with a diagnosis of hypertension and their offspring. MEASUREMENTS First-trimester exposure to β-blockers was assessed. Outcomes were any major congenital malformation, cardiac malformations, cleft lip or palate, and central nervous system (CNS) malformations. Propensity score stratification was used to control for potential confounders. RESULTS Of 3577 women with hypertensive pregnancies in the Nordic cohort and 14 900 in the U.S. cohort, 682 (19.1%) and 1668 (11.2%), respectively, were exposed to β-blockers in the first trimester. The pooled adjusted relative risk (RR) and risk difference per 1000 persons exposed (RD1000) associated with β-blockers were 1.07 (95% CI, 0.89 to 1.30) and 3.0 (CI, -6.6 to 12.6), respectively, for any major malformation; 1.12 (CI, 0.83 to 1.51) and 2.1 (CI, -4.3 to 8.4) for any cardiac malformation; and 1.97 (CI, 0.74 to 5.25) and 1.0 (CI, -0.9 to 3.0) for cleft lip or palate. For CNS malformations, the adjusted RR was 1.37 (CI, 0.58 to 3.25) and the RD1000 was 1.0 (CI, -2.0 to 4.0) (based on U.S. cohort data only). LIMITATION Analysis was restricted to live births, exposure was based on dispensed medication, and cleft lip or palate and CNS malformations had few outcomes. CONCLUSION The results suggest that maternal use of β-blockers in the first trimester is not associated with a large increase in the risk for overall malformations or cardiac malformations, independent of measured confounders. PRIMARY FUNDING SOURCE The Eunice Kennedy Shriver National Institute of Child Health and Human Development and the Söderström König Foundation.
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Affiliation(s)
- Brian T Bateman
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (B.T.B., K.F.H.)
| | | | | | - Anders Engeland
- Norwegian Institute of Public Health, Oslo, and University of Bergen, Bergen, Norway (A.E.)
| | - Kari Furu
- Norwegian Institute of Public Health, Oslo, Norway (K.F., R.S.)
| | - Mika Gissler
- University of Turku, Turku, Finland, and Karolinska Institutet, Stockholm, Sweden (M.G., H.K., J.R.)
| | | | - Helle Kieler
- University of Turku, Turku, Finland, and Karolinska Institutet, Stockholm, Sweden (M.G., H.K., J.R.)
| | | | - Helen Mogun
- Karolinska Institutet, Stockholm, Sweden; National Institute for Health and Welfare, Helsinki, Finland; Brigham and Women's Hospital, Boston, Massachusetts (H.M.)
| | - Mette Nørgaard
- Aarhus University Hospital, Aarhus, Denmark (U.H., M.N.)
| | - Johan Reutfors
- University of Turku, Turku, Finland, and Karolinska Institutet, Stockholm, Sweden (M.G., H.K., J.R.)
| | - Randi Selmer
- Norwegian Institute of Public Health, Oslo, Norway (K.F., R.S.)
| | - Krista F Huybrechts
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (B.T.B., K.F.H.)
| | - Helga Zoega
- University of Iceland, Reykjavik, Iceland, and University of New South Wales, Sydney, New South Wales, Australia (H.Z.)
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Beta-Blocker Use in Pregnancy and Risk of Specific Congenital Anomalies: A European Case-Malformed Control Study. Drug Saf 2018; 41:415-427. [PMID: 29230691 PMCID: PMC5878198 DOI: 10.1007/s40264-017-0627-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Introduction The prevalence of chronic hypertension is increasing in pregnant women. Beta-blockers are among the most prevalent anti-hypertensive agents used in early pregnancy. Objective The objective of this study was to investigate whether first-trimester use of beta-blockers increases the risk of specific congenital anomalies in offspring. Methods A population-based case-malformed control study was conducted in 117,122 registrations of congenital anomalies from 17 European Concerted Action on Congenital Anomalies and Twins (EUROCAT) registries participating in EUROmediCAT with data for all or part of the period between 1995 and 2013. Associations previously reported in the literature (signals) were tested and an exploratory analysis was performed to identify new signals. Odds ratios of exposure to any beta-blocker or to a beta-blocker subgroup were calculated for each signal anomaly compared with two control groups (non-chromosomal, non-signal anomalies and chromosomal anomalies). The exploratory analyses were performed for each non-signal anomaly compared with all the other non-signal anomalies. Results The signals from the literature (congenital heart defects, oral clefts, neural tube defects and hypospadias) were not confirmed. Our exploratory analysis revealed that multi-cystic renal dysplasia had significantly increased odds of occurring after maternal exposure to combined alpha- and beta-blockers (adjusted odds ratio 3.8; 95% confidence interval 1.3–11.0). Conclusion Beta-blocker use in the first trimester of pregnancy was not found to be associated with a higher risk of specific congenital anomalies in the offspring, but a new signal between alpha- and beta-blockers and multi-cystic renal dysplasia was found. Future large epidemiological studies are needed to confirm or refute our findings. Electronic supplementary material The online version of this article (10.1007/s40264-017-0627-x) contains supplementary material, which is available to authorized users.
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Katsi V, Georgiopoulos G, Marketou M, Oikonomou D, Parthenakis F, Makris T, Nihoyannopoulos P, Vardas P, Tousoulis D. Atrial fibrillation in pregnancy: a growing challenge. Curr Med Res Opin 2017; 33:1497-1504. [PMID: 28498066 DOI: 10.1080/03007995.2017.1330257] [Citation(s) in RCA: 7] [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: 10/19/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) constitutes a relatively infrequent pregnancy complication, which may be a therapeutic Gordian knot. Indeed, sparse data exist regarding the prevalence, prognosis, and management of AF during pregnancy. In general, AF occurs as a benign, self-limited arrhythmia, but occasionally may have severe hemodynamic consequences in pregnant patients suffering from heart failure, congenital heart disease, or other comorbidities. Extra-cardiac causes of AF should always be meticulously excluded. REVIEW Treatment decisions are difficult, since medications may cross the placental barrier and potentially affect fetal growth and organogenesis, or even result in fetal bradyarrhythmias. Treatment goals are not differentiated in comparison to those regarding AF occurring in the general population. Still, while maternal treatment is prioritized, issues regarding fetal health must deliberately be considered. Consequently, hemodynamic instability is to be promptly treated with synchronized electrical cardioversion. In contrast, in stable patients, pharmacologic cardioversion, under appropriate antithrombotic regimen, should be attempted. Selection of appropriate antithrombotic therapy, including novel oral anticoagulants, imposes further difficulties on therapeutic decision-making. Further clinical trials are warranted in order to assess the pathophysiology and prognosis of AF in pregnancy and ameliorate the evidence-based therapeutic strategy in this specific group of the population.
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Affiliation(s)
- Vasiliki Katsi
- a First Department of Cardiology , Hippokration Hospital, University of Athens , Athens , Greece
| | - Georgios Georgiopoulos
- a First Department of Cardiology , Hippokration Hospital, University of Athens , Athens , Greece
| | - Maria Marketou
- b Cardiology Department , Heraklion University Hospital , Crete , Greece
| | - Dimitrios Oikonomou
- a First Department of Cardiology , Hippokration Hospital, University of Athens , Athens , Greece
| | | | - Thomas Makris
- c Cardiology Department , Helena Venizelou Hospital , Athens , Greece
| | - Petros Nihoyannopoulos
- a First Department of Cardiology , Hippokration Hospital, University of Athens , Athens , Greece
| | - P Vardas
- b Cardiology Department , Heraklion University Hospital , Crete , Greece
| | - Dimitris Tousoulis
- a First Department of Cardiology , Hippokration Hospital, University of Athens , Athens , Greece
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Abstract
OBJECTIVE To examine the association between first-trimester angiotensin-converting enzyme (ACE) inhibitor exposure and the risk of overall major congenital, cardiac, and central nervous system malformations. METHODS We used a cohort of completed pregnancies linked to liveborn neonates derived from Medicaid claims from 2000 to 2010. We examined the risk of malformations associated with first-trimester exposure to an ACE inhibitor. Propensity score-based methods were used to control for potential confounders including maternal demographics, medical conditions, exposure to other medications, and measures of health care utilization. RESULTS The cohort included 1,333,624 pregnancies, of which 4,107 (0.31%) were exposed to ACE inhibitors during the first trimester. The prevalence of overall malformations in the ACE inhibitor-exposed pregnancies was 5.9% compared with 3.3% in the unexposed (unadjusted relative risk, 1.82; 95% confidence interval [CI] 1.61-2.06), of cardiac malformations was 3.4% compared with 1.2% (relative risk 2.95, 95% CI 2.50-3.47), and of central nervous system malformations was 0.27% compared with 0.18% (relative risk 1.46, 95% CI 0.81-2.64). After restricting the cohort to pregnancies complicated by chronic hypertension (both exposed and unexposed) and accounting for other confounding factors, there was no significant increase in the risk of any of the outcomes assessed. Relative risks associated with first-trimester ACE inhibitor exposure were 0.89 (95% CI 0.75-1.06) for overall malformations, 0.95 (95% CI 0.75-1.21) for cardiac malformations, and 0.54 (95% CI 0.26-1.11) for CNS malformations. CONCLUSIONS After accounting for confounders, among women with hypertension, exposure to ACE inhibitors during the first trimester was not associated with an increased risk of major congenital malformations.
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Duan L, Ng A, Chen W, Spencer HT, Nguyen J, Shen AYJ, Lee MS. β-Blocker Exposure in Pregnancy and Risk of Fetal Cardiac Anomalies. JAMA Intern Med 2017; 177:885-887. [PMID: 28418448 PMCID: PMC5818837 DOI: 10.1001/jamainternmed.2017.0608] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This population-based cohort study examines the risk of fetal cardiac malformations associated with maternal β-blocker exposure.
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Affiliation(s)
- Lewei Duan
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Angie Ng
- Division of Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - Wansu Chen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Hillard T Spencer
- Southern California Permanente Medical Group, Los Angeles, California
| | - Jennifer Nguyen
- Division of Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - Albert Y-J Shen
- Division of Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - Ming-Sum Lee
- Division of Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
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McAllister-Williams RH, Baldwin DS, Cantwell R, Easter A, Gilvarry E, Glover V, Green L, Gregoire A, Howard LM, Jones I, Khalifeh H, Lingford-Hughes A, McDonald E, Micali N, Pariante CM, Peters L, Roberts A, Smith NC, Taylor D, Wieck A, Yates LM, Young AH. British Association for Psychopharmacology consensus guidance on the use of psychotropic medication preconception, in pregnancy and postpartum 2017. J Psychopharmacol 2017; 31:519-552. [PMID: 28440103 DOI: 10.1177/0269881117699361] [Citation(s) in RCA: 114] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Decisions about the use of psychotropic medication in pregnancy are an ongoing challenge for clinicians and women with mental health problems, owing to the uncertainties around risks of the illness itself to mother and fetus/infant, effectiveness of medications in pregnancy and risks to the fetus/infant from in utero exposure or via breast milk. These consensus guidelines aim to provide pragmatic advice regarding these issues. They are divided into sections on risks of untreated illness in pregnancy; general principles of using drugs in the perinatal period; benefits and harms associated with individual drugs; and recommendations for the management of specific disorders.
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Affiliation(s)
- R Hamish McAllister-Williams
- 1 Institute of Neuroscience, Newcastle University, Newcastle, UK.,2 Northumberland Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | - David S Baldwin
- 3 Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,4 University Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | | | - Abby Easter
- 6 Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Eilish Gilvarry
- 2 Northumberland Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK.,7 Institute of Health and Society, Newcastle University, Newcastle, UK
| | - Vivette Glover
- 8 Institute of Reproductive and Developmental Biology, Imperial College London, London, UK
| | - Lucian Green
- 9 Ealing, Hounslow, Hammersmith & Fulham Perinatal Mental Health Service, West London Mental Health Trust, London, UK
| | - Alain Gregoire
- 3 Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,10 Hampshire Perinatal Mental Health Service, Winchester, UK
| | - Louise M Howard
- 11 Section of Women's Mental Health, Institute of Psychiatry Psychology and Neuroscience, King's College London, London, UK.,12 South London and Maudsley NHS Foundation Trust, London, UK
| | - Ian Jones
- 13 National Centre for Mental Health, MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, Cardiff, UK
| | - Hind Khalifeh
- 11 Section of Women's Mental Health, Institute of Psychiatry Psychology and Neuroscience, King's College London, London, UK.,12 South London and Maudsley NHS Foundation Trust, London, UK
| | | | - Elizabeth McDonald
- 15 Royal College of Psychiatrists, London, UK.,16 East London Foundation Trust, London, UK.,17 Tavistock and Portman NHS Foundation Trust, London, UK
| | - Nadia Micali
- 18 Behavioural and Brain Sciences Unit, GOSH Institute of Child Health, University College London, London, UK
| | - Carmine M Pariante
- 12 South London and Maudsley NHS Foundation Trust, London, UK.,19 Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | | | - Ann Roberts
- 20 St Martin's Healthcare Services CIC, Leeds, UK.,21 Hertfordshire Partnership University NHS Foundation Trust, Hatfield, Hertfordshire, UK.,22 Postgraduate School of Medicine, University of Hertfordshire, Hatfield, Hertfordshire, UK
| | - Natalie C Smith
- 23 Tees, Esk and Wear Valleys NHS Foundation Trust, Darlington, County Durham, UK
| | - David Taylor
- 12 South London and Maudsley NHS Foundation Trust, London, UK.,24 Institute of Pharmaceutical Science, King's College London, London, UK
| | - Angelika Wieck
- 25 Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK.,26 University of Manchester, Manchester, UK
| | - Laura M Yates
- 27 UK Teratology Information Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,28 Institute of Genetic Medicine, Newcastle University, Newcastle, UK
| | - Allan H Young
- 12 South London and Maudsley NHS Foundation Trust, London, UK.,19 Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Webster P, Lightstone L, McKay DB, Josephson MA. Pregnancy in chronic kidney disease and kidney transplantation. Kidney Int 2017; 91:1047-1056. [PMID: 28209334 DOI: 10.1016/j.kint.2016.10.045] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 09/28/2016] [Accepted: 10/06/2016] [Indexed: 12/20/2022]
Abstract
Chronic kidney disease (CKD) affects up to 6% of women of childbearing age in high income countries, and is estimated to affect 3% of pregnant women. Advanced renal dysfunction, proteinuria, hypertension, and poorly controlled underlying primary renal disease are all significant risks for adverse maternal, fetal, and renal outcomes. In order to achieve the best outcomes, it is therefore of paramount importance that these pregnancies are planned, where possible, to allow the opportunity to counsel women and their partners in advance and to optimize these risks. These pregnancies should be deemed high risk and they require close antenatal monitoring from an expert multidisciplinary team. We discuss the effect of pregnancy on CKD, and also current guidelines and literature with specific reference to transplantation, autoimmune disease, and medication use in pregnancy. We also discuss the benefits of prepregnancy counseling and give practical recommendations to advise pregnant women with renal disease.
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Affiliation(s)
- Philip Webster
- Section of Renal Medicine and Vascular Inflammation, Department of Medicine, Imperial College London, United Kingdom
| | - Liz Lightstone
- Section of Renal Medicine and Vascular Inflammation, Department of Medicine, Imperial College London, United Kingdom
| | - Dianne B McKay
- Division of Nephrology, Department of Medicine, University of California, San Diego, California, USA
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Landau E, Amar L. Primary aldosteronism and pregnancy. ANNALES D'ENDOCRINOLOGIE 2016; 77:148-60. [PMID: 27156905 DOI: 10.1016/j.ando.2016.04.009] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Accepted: 04/11/2016] [Indexed: 11/30/2022]
Abstract
Hypertension (HT) is a complication of 8% of all pregnancies and 10% of HT cases are due to primary aldosteronism (PA). There is very little data on PA and pregnancy. Given the changes in the renin angiotensin system during pregnancy, the diagnosis of PA is difficult to establish during gestation. It may be suspected in hypertensive patients with hypokalemia. A comprehensive literature review identified reports covering 40 pregnancies in patients suffering from PA. Analysis of these cases shows them to be high-risk pregnancies leading to maternal and fetal complications. Pregnancy must be programmed, and if the patient has a unilateral form of PA, adrenalectomy should be performed prior to conception. It is customary to stop spironolactone prior to conception and introduce antihypertensive drugs that present no risk of teratogenicity. When conventional antihypertensive drugs used during pregnancy fail to control high blood pressure, diuretics, including potassium-sparing diuretics may be prescribed. Adrenalectomy can be considered during the second trimester of pregnancy exclusively in cases of refractory hypertension. A European retrospective study is currently underway to collect a larger number of cases.
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Affiliation(s)
- Ester Landau
- Université Paris-Descartes Faculty of Medicine, 75006 Paris, France
| | - Laurence Amar
- Hypertension Unit, Assistance Publique-Hôpitaux de Paris, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France.
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41
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Marrs JC, Thompson AM. Antihypertensive Therapy in Females: A Clinical Review Across the Lifespan. Pharmacotherapy 2016; 36:638-51. [PMID: 27072935 DOI: 10.1002/phar.1754] [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: 11/07/2022]
Abstract
Hypertension affects one-third of all females in the United States, with the prevalence increasing over a female's lifespan. The approach to treating females with hypertension varies depending on a female's age, race, comorbidities, and whether she is of child-bearing age or pregnant. It is important to factor in the safety and effectiveness of antihypertensive medications across these populations of females. Blood pressure target goals are the same in females as in males regardless of comorbidities or stage of life, with the exception of those females who are pregnant. Recommendations for antihypertensive medication do not differ between females and males based on disease state or stage of life, with the exception of females who are pregnant, breastfeeding, or of child-bearing age. Multiple guidelines recommend avoiding renin-angiotensin system blockers during pregnancy and suggest balancing the risk versus benefit in females of child-bearing age. Further, multiple guidelines provide race-based therapy recommendations for the use of calcium channel blockers and thiazide diuretics in black versus nonblack patients, irrespective of sex. Future research is needed to evaluate whether there are sex differences relative to blood pressure and cardiovascular event-lowering relative to specific antihypertensive medications with a focus on pharmacogenomic differences.
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Affiliation(s)
- Joel C Marrs
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado
| | - Angela M Thompson
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado
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42
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Lee MS, Chen W, Zhang Z, Duan L, Ng A, Spencer HT, Kwan DM, Shen AYJ. Atrial Fibrillation and Atrial Flutter in Pregnant Women-A Population-Based Study. J Am Heart Assoc 2016; 5:e003182. [PMID: 27076563 PMCID: PMC4843529 DOI: 10.1161/jaha.115.003182] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background The goal of this study was to determine the prevalence of atrial fibrillation and atrial flutter (AF) in pregnant women and to examine the impact of AF on maternal and fetal outcomes. Methods and Results Between January 1, 2003 and December 31, 2013, there were 264 730 qualifying pregnancies (in 210 356 women) in the Kaiser Permanente Southern California hospitals, among whom AF was noted in 157 pregnancies (129 women; 61.3 per 100 000 women, or 59.3 per 100 000 pregnancies). Prevalence of AF (per 100 000 women) in white, black, Asian, and Hispanic women was 111.6, 101.7, 45.0, and 34.3, respectively. Older age was associated with higher odds of having AF. Compared to women <25 years of age, the odds ratio (OR) of AF was 4.1 in women age 30 to 34 years, 4.9 in women age 35 to 39 years, and 5.2 in women age ≥40. Odds of AF episodes were higher during the third trimester compared to the first trimester (OR, 3.2; 95% CI: 1.5–7.7). Among AF patients, adverse maternal cardiac events were rare—2 women developed heart failure and there were no strokes or systemic embolic events and no maternal death. There were 156 live births (99.4% of all pregnancies). Compared to women without AF, fetal birth weights were similar, but rate for neonates’ admission to the neonatal intensive care unit was higher (10.8% vs 5.1%; P=0.003). Conclusions AF is rare in pregnant women. Certain factors such as increased maternal age and white race increase the odds of having AF. Major maternal and fetal complications are infrequent, albeit a source of concern.
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Affiliation(s)
- Ming-Sum Lee
- Division of Cardiology, Kaiser Permanente Medical Center, Los Angeles, CA
| | - Wansu Chen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Zilu Zhang
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Lewei Duan
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Angie Ng
- Division of Cardiology, Kaiser Permanente Medical Center, Los Angeles, CA
| | | | - Damon M Kwan
- Division of Cardiology, Kaiser Permanente Medical Center, Los Angeles, CA
| | - Albert Y-J Shen
- Division of Cardiology, Kaiser Permanente Medical Center, Los Angeles, CA
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Sullivan KG, Levin M. Neurotransmitter signaling pathways required for normal development in Xenopus laevis embryos: a pharmacological survey screen. J Anat 2016; 229:483-502. [PMID: 27060969 DOI: 10.1111/joa.12467] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2016] [Indexed: 01/08/2023] Open
Abstract
Neurotransmitters are not only involved in brain function but are also important signaling molecules for many diverse cell types. Neurotransmitters are widely conserved, from evolutionarily ancient organisms lacking nervous systems through man. Here, results are reported from a loss- and gain-of-function survey, using pharmacological modulators of several neurotransmitter pathways to examine possible roles for these pathways in normal embryogenesis. Applying reagents targeting the glutamatergic, adrenergic and dopaminergic pathways to embryos of Xenopus laevis from gastrulation to organogenesis stages, we observed and quantified numerous malformations, including craniofacial defects, hyperpigmentation, muscle mispatterning and miscoiling of the gut. These data implicate several key neurotransmitters in new embryonic patterning roles, reveal novel earlier stages for processes involved in eye development, suggest new targets for subsequent molecular-genetic investigation, and highlight the necessity for in-depth toxicology studies of psychoactive compounds to which human embryos might be exposed during pregnancy.
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Affiliation(s)
- Kelly G Sullivan
- Biology Department, Center for Regenerative and Developmental Biology, Tufts University, Medford, MA, USA
| | - Michael Levin
- Biology Department, Center for Regenerative and Developmental Biology, Tufts University, Medford, MA, USA
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44
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Amundsen S, Nordeng H, Nezvalová-Henriksen K, Stovner LJ, Spigset O. Pharmacological treatment of migraine during pregnancy and breastfeeding. Nat Rev Neurol 2016; 11:209-19. [PMID: 25776823 DOI: 10.1038/nrneurol.2015.29] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Migraine affects up to 25% of women of reproductive age. In the majority of these women, migraine improves progressively during pregnancy, but symptoms generally recur shortly after delivery. As suboptimally treated migraine in pregnancy could have negative consequences for both mother and fetus, the primary aim of clinicians should be to provide optimal treatment according to stage of pregnancy, while minimising possible risks related to drug therapy. Nonpharmacological approaches are always first-line treatment, and should also be used to complement any required drug treatment. Paracetamol is the preferred drug for acute treatment throughout pregnancy. If paracetamol is not sufficiently effective, sporadic use of sumatriptan can be considered. NSAIDs such as ibuprofen can also be used under certain circumstances, though their intake in the first and third trimesters is associated with specific risks and contraindications. Preventive treatment should only be considered in the most severe cases. In women contemplating pregnancy, counselling is essential to promote a safe and healthy pregnancy and postpartum period for the mother and child, and should involve a dialogue addressing maternal concerns and expectations about drug treatment. This Review summarizes current evidence of the safety of the most common antimigraine medications during pregnancy and breastfeeding, and provides treatment recommendations for use in clinical practice.
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45
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Guedes-Martins L. Chronic Hypertension and Pregnancy. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 956:395-407. [DOI: 10.1007/5584_2016_81] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Regensteiner JG, Golden S, Huebschmann AG, Barrett-Connor E, Chang AY, Chyun D, Fox CS, Kim C, Mehta N, Reckelhoff JF, Reusch JEB, Rexrode KM, Sumner AE, Welty FK, Wenger NK, Anton B. Sex Differences in the Cardiovascular Consequences of Diabetes Mellitus: A Scientific Statement From the American Heart Association. Circulation 2015; 132:2424-47. [PMID: 26644329 DOI: 10.1161/cir.0000000000000343] [Citation(s) in RCA: 211] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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49
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Clark SM, Dunn HE, Hankins GDV. A review of oral labetalol and nifedipine in mild to moderate hypertension in pregnancy. Semin Perinatol 2015; 39:548-55. [PMID: 26344738 DOI: 10.1053/j.semperi.2015.08.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Hypertension is the most commonly encountered medical condition in pregnancy, contributing significantly to maternal and perinatal morbidity and mortality. Mild to moderate hypertension in pregnancy is defined as systolic blood pressure of 140-159 mmHg or diastolic blood pressure of 90-109 mmHg (7-9% of pregnancies). When treating hypertension in pregnancy, not only do physiologic changes of pregnancy have an effect on the pharmacokinetics and pharmacodynamics of the drugs used, but the pathophysiology of hypertensive disorders of pregnancy also have an effect. To date, evidence is lacking on the pharmacokinetics and pharmacodynamics of commonly used antihypertensive drugs, which often times leads to suboptimal treatment of hypertensive pregnant women. When considering which agents to use for treatment of mild to moderate hypertension, specifically in gestational and chronic hypertension, oral labetalol and nifedipine are valid options. An overview of the profile for use, safety, and current pharmacokinetic data for each agent is presented here.
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Affiliation(s)
- Shannon M Clark
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, The University of Texas Medical Branch-Galveston, 301 University Blvd., Route 0587, Galveston, TX 77550.
| | - Holly E Dunn
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, The University of Texas Medical Branch-Galveston, 301 University Blvd., Route 0587, Galveston, TX 77550
| | - Gary D V Hankins
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, The University of Texas Medical Branch-Galveston, 301 University Blvd., Route 0587, Galveston, TX 77550
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50
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Abstract
Management of peripartum heart disease in the intensive care unit requires optimization of maternal hemodynamics and maintenance of fetal perfusion. This requires fetal monitoring and should address the parturient's oxygen saturation, hemoglobin, and cardiac output as it relates to uterine blood flow. Pharmacologic strategies have limited evidence pertaining to hemodynamic stabilization and fetal perfusion. There is some evidence that surgical management of critical mitral stenosis should be percutaneous when possible because cardiac bypass is associated with increased fetal mortality. Fetal monitoring strategies should address central organ perfusion because peripheral scalp pH has not been associated with improved fetal outcomes.
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Affiliation(s)
- Huayong Hu
- Department of Anesthesiology, Yale New Haven Hospital, New Haven, CT, USA.
| | - Ioana Pasca
- Department of Anesthesiology, Loma Linda University Medical Center, Loma Linda, CA, USA
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