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Pels A, Ganzevoort W, Kenny LC, Baker PN, von Dadelszen P, Gluud C, Kariya CT, Leemhuis AG, Groom KM, Sharp AN, Magee LA, Jakobsen JC, Mol BWJ, Papageorghiou AT. Interventions affecting the nitric oxide pathway versus placebo or no therapy for fetal growth restriction in pregnancy. Cochrane Database Syst Rev 2023; 7:CD014498. [PMID: 37428872 PMCID: PMC10332237 DOI: 10.1002/14651858.cd014498] [Citation(s) in RCA: 1] [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: 07/12/2023]
Abstract
BACKGROUND Fetal growth restriction (FGR) is a condition of poor growth of the fetus in utero. One of the causes of FGR is placental insufficiency. Severe early-onset FGR at < 32 weeks of gestation occurs in an estimated 0.4% of pregnancies. This extreme phenotype is associated with a high risk of fetal death, neonatal mortality, and neonatal morbidity. Currently, there is no causal treatment, and management is focused on indicated preterm birth to prevent fetal death. Interest has risen in interventions that aim to improve placental function by administration of pharmacological agents affecting the nitric oxide pathway causing vasodilatation. OBJECTIVES The objective of this systematic review and aggregate data meta-analysis is to assess the beneficial and harmful effects of interventions affecting the nitric oxide pathway compared with placebo, no therapy, or different drugs affecting this pathway against each other, in pregnant women with severe early-onset FGR. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (16 July 2022), and reference lists of retrieved studies. SELECTION CRITERIA We considered all randomised controlled comparisons of interventions affecting the nitric oxide pathway compared with placebo, no therapy, or another drug affecting this pathway in pregnant women with severe early-onset FGR of placental origin, for inclusion in this review. DATA COLLECTION AND ANALYSIS We used standard Cochrane Pregnancy and Childbirth methods for data collection and analysis. MAIN RESULTS We included a total of eight studies (679 women) in this review, all of which contributed to the data and analysis. The identified studies report on five different comparisons: sildenafil compared with placebo or no therapy, tadalafil compared with placebo or no therapy, L-arginine compared with placebo or no therapy, nitroglycerin compared with placebo or no therapy and sildenafil compared with nitroglycerin. The risk of bias of included studies was judged as low or unclear. In two studies the intervention was not blinded. The certainty of evidence for our primary outcomes was judged as moderate for the intervention sildenafil and low for tadalafil and nitroglycerine (due to low number of participants and low number of events). For the intervention L-arginine, our primary outcomes were not reported. Sildenafil citrate compared to placebo or no therapy (5 studies, 516 women) Five studies (Canada, Australia and New Zealand, the Netherlands, the UK and Brazil) involving 516 pregnant women with FGR were included. We assessed the certainty of the evidence as moderate. Compared with placebo or no therapy, sildenafil probably has little or no effect on all-cause mortality (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.80 to 1.27, 5 studies, 516 women); may reduce fetal mortality (RR 0.82, 95% CI 0.60 to 1.12, 5 studies, 516 women), and increase neonatal mortality (RR 1.45, 95% CI 0.90 to 2.33, 5 studies, 397 women), although the results are uncertain for fetal and neonatal mortality as 95% confidence intervals are wide crossing the line of no effect. Tadalafil compared with placebo or no therapy (1 study, 87 women) One study (Japan) involving 87 pregnant women with FGR was included. We assessed the certainty of the evidence as low. Compared with placebo or no therapy, tadalafil may have little or no effect on all-cause mortality (risk ratio 0.20, 95% CI 0.02 to 1.60, one study, 87 women); fetal mortality (RR 0.11, 95% CI 0.01 to 1.96, one study, 87 women); and neonatal mortality (RR 0.89, 95% CI 0.06 to 13.70, one study, 83 women). L-Arginine compared with placebo or no therapy (1 study, 43 women) One study (France) involving 43 pregnant women with FGR was included. This study did not assess our primary outcomes. Nitroglycerin compared to placebo or no therapy (1 studies, 23 women) One study (Brazil) involving 23 pregnant women with FGR was included. We assessed the certainty of the evidence as low. The effect on the primary outcomes is not estimable due to no events in women participating in both groups. Sildenafil citrate compared to nitroglycerin (1 study, 23 women) One study (Brazil) involving 23 pregnant women with FGR was included. We assessed the certainty of the evidence as low. The effect on the primary outcomes is not estimable due to no events in women participating in both groups. AUTHORS' CONCLUSIONS Interventions affecting the nitric oxide pathway probably do not seem to influence all-cause (fetal and neonatal) mortality in pregnant women carrying a baby with FGR, although more evidence is needed. The certainty of this evidence is moderate for sildenafil and low for tadalafil and nitroglycerin. For sildenafil a fair amount of data are available from randomised clinical trials, but with low numbers of participants. Therefore, the certainty of evidence is moderate. For the other interventions investigated in this review there are insufficient data, meaning we do not know whether these interventions improve perinatal and maternal outcomes in pregnant women with FGR.
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Affiliation(s)
- Anouk Pels
- Department of Obstetrics and Gynecology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Wessel Ganzevoort
- Department of Obstetrics and Gynecology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Louise C Kenny
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Philip N Baker
- College of Life Sciences, University of Leicester, Leicester, UK
| | | | - Christian Gluud
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, Capital Region, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Chirag T Kariya
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, Canada
| | - Aleid G Leemhuis
- Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Amsterdam, Netherlands
| | - Katie M Groom
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
| | - Andrew N Sharp
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - Laura A Magee
- Department of Obstetrics and Gynaecology, King's College London, London, UK
| | - Janus C Jakobsen
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ben Willem J Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Australia
- Aberdeen Centre for Women's Health Research, Institute of Applied Health Sciences, School of Medicine, Medial Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
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LotfAlizadeh M, MoeinDarbari S, MohebbanAzad N, Ghomian N. Efficacy of inhaled Desmopressin in pregnant women with idiopathic oligohydramnios - a randomized controlled trial. J Med Life 2022; 15:1352-1357. [PMID: 36567840 PMCID: PMC9762361 DOI: 10.25122/jml-2021-0141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 08/22/2022] [Indexed: 12/27/2022] Open
Abstract
The aim of this study was to investigate the therapeutic effect of inhaled Desmopressin (DDAVP) in pregnant women with idiopathic oligohydramnios. This randomized, double-blind clinical trial involved 44 pregnant women at 28-37 weeks of gestation with idiopathic oligohydramnios admitted in 2 academic hospitals in Mashhad, Iran, from 2018 to 2019. In the intervention group, 10µg DDAVP was nasally sprayed. The control group received intravenous maintenance fluid. The hematocrit, electrolytes, blood pressure and urine-specific gravity were evaluated at baseline and 3, 8, and 24 hours later. Amniotic fluid index (AFI) was measured using ultrasound at baseline, 24 and 48 hours later. There was no significant difference in the basic characteristics (age, body mass index, and gestational age) between the two groups. The pattern of changes of AFI (baseline, 24 and 48 hours later) increased in the intervention (4.16±0.86, 7.08±1.453 and 7.76±1.62, p<0.001) and control groups (4.23±0.70, 5.39±1.079 and 5.68±1.10, p<0.001). Serum sodium levels significantly declined in the intervention group (p<0.001) but not in the control group (p=0.07). There were no significant differences in potassium (p=0.89), hematocrit (p=0.23), systolic blood pressure (p=0.21) and diastolic blood pressure (p=0.97). However, urine-specific gravity had an increasing pattern in the intervention group (p<0.001) and a decreasing pattern in the control group (p<0.001). This study showed that Desmopressin inhalation could increase the AFI and urine specific gravity, enhancing oligohydramnios treatment in pregnant women, compared to serum administration.
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Affiliation(s)
- Marziye LotfAlizadeh
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Somayeh MoeinDarbari
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Neshat MohebbanAzad
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Nayereh Ghomian
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran,Corresponding Author: Nayereh Ghomian, Department of Obstetrics and Gynecology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran. E-mail:
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Vahid Dastjerdi M, Ghahghaei-Nezamabadi A, Tehranian A, Mesgaran M. The Effect of Sildenafil on Pregnancy Outcomes in Pregnant Women With Idiopathic Borderline Oligohydramnios: A Randomized Controlled Trial. J Family Reprod Health 2022; 16:124-131. [PMID: 36457659 PMCID: PMC9678853 DOI: 10.18502/jfrh.v16i2.9482] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2024] Open
Abstract
Objective: Borderline oligohydramnios always produces a dilemma of management and counseling among obstetricians. This study was designed to compare the effect of sildenafil plus fluid therapy versus fluid therapy alone on pregnancy outcomes and AFI improvement in pregnant women complicated by idiopathic borderline oligohydramnios. Materials and methods : This randomized clinical trial was conducted in Arash Women's Hospital, Tehran, Iran from 2017 to 2020. Fifty-one pregnant women with idiopathic borderline oligohydramnios were allocated to two groups. Group 1 received fluid therapy and Group 2 received fluid therapy and Sildenafil 25 mg three times daily for six weeks. AFI was measured at the time of randomization, 24 h after treatment and then weekly for six weeks. The changes in AFI, type of delivery, gestational age at delivery, and neonatal outcomes were compared between the two groups. Results: After the intervention, the change in AFI between two groups was not statistically significant. Maternal and fetal outcomes are compared between two groups and there was no significant difference between them. The median (Inter-quartile range) AFI after intervention, in Sildenafil group compared with hydration group, were in 24 hours (8.5 vs. 8, p=0.27), first (9.5 vs. 9.1, p=0.74), second (9 vs 10, p=0.12) third (10.4 vs. 9.4, p=0.33), fourth (10.8 vs 9.1, p=0.1) and Fifth week (10 vs 9.3, p=0.5) of follow-up respectively, but none of them were statistically significant. Conclusion: The findings showed that sildenafil plus fluid therapy do not improve the pregnancy outcomes in women with isolated borderline oligohydramnios compared to fluid therapy alone.
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Affiliation(s)
- Marzieh Vahid Dastjerdi
- Department of Obstetrics and Gynecology, Arash Women’s Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Akram Ghahghaei-Nezamabadi
- Department of Obstetrics and Gynecology, Arash Women’s Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Afsaneh Tehranian
- Department of Obstetrics and Gynecology, Arash Women’s Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Research Development Center, Arash Women’s Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahbobeh Mesgaran
- Department of Obstetrics and Gynecology, Arash Women’s Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Pels A, Derks J, Elvan-Taspinar A, van Drongelen J, de Boer M, Duvekot H, van Laar J, van Eyck J, Al-Nasiry S, Sueters M, Post M, Onland W, van Wassenaer-Leemhuis A, Naaktgeboren C, Jakobsen JC, Gluud C, Duijnhoven RG, Lely T, Gordijn S, Ganzevoort W. Maternal Sildenafil vs Placebo in Pregnant Women With Severe Early-Onset Fetal Growth Restriction: A Randomized Clinical Trial. JAMA Netw Open 2020; 3:e205323. [PMID: 32585017 PMCID: PMC7301225 DOI: 10.1001/jamanetworkopen.2020.5323] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 03/16/2020] [Indexed: 01/28/2023] Open
Abstract
Importance Severe early onset fetal growth restriction caused by placental dysfunction leads to high rates of perinatal mortality and neonatal morbidity. The phosphodiesterase 5 inhibitor, sildenafil, inhibits cyclic guanosine monophosphate hydrolysis, thereby activating the effects of nitric oxide, and might improve uteroplacental function and subsequent perinatal outcomes. Objective To determine whether sildenafil reduces perinatal mortality or major morbidity. Design, Setting, and Participants This placebo-controlled randomized clinical trial was conducted at 10 tertiary referral centers and 1 general hospital in the Netherlands from January 20, 2015, to July 16, 2018. Participants included pregnant women between 20 and 30 weeks of gestation with severe fetal growth restriction, defined as fetal abdominal circumference below the third percentile or estimated fetal weight below the fifth percentile combined with Dopplers measurements outside reference ranges or a maternal hypertensive disorder. The trial was stopped early owing to safety concerns on July 19, 2018, whereas benefit on the primary outcome was unlikely. Data were analyzed from January 20, 2015, to January 18, 2019. The prespecified primary analysis was an intention-to-treat analysis including all randomized participants. Interventions Participants were randomized to sildenafil, 25 mg, 3 times a day vs placebo. Main Outcomes and Measures The primary outcome was a composite of perinatal mortality or major neonatal morbidity until hospital discharge. Results Out of 360 planned participants, a total of 216 pregnant women were included, with 108 women randomized to sildenafil (median gestational age at randomization, 24 weeks 5 days [interquartile range, 23 weeks 3 days to 25 weeks 5 days]; mean [SD] estimated fetal weight, 458 [160] g) and 108 women randomized to placebo (median gestational age, 25 weeks 0 days [interquartile range, 22 weeks 5 days to 26 weeks 3 days]; mean [SD] estimated fetal weight, 464 [186] g). In July 2018, the trial was halted owing to concerns that sildenafil may cause neonatal pulmonary hypertension, whereas benefit on the primary outcome was unlikely. The primary outcome, perinatal mortality or major neonatal morbidity, occurred in the offspring of 65 participants (60.2%) allocated to sildenafil vs 58 participants (54.2%) allocated to placebo (relative risk, 1.11; 95% CI, 0.88-1.40; P = .38). Pulmonary hypertension, a predefined outcome important for monitoring safety, occurred in 16 neonates (18.8%) in the sildenafil group vs 4 neonates (5.1%) in the placebo group (relative risk, 3.67; 95% CI, 1.28-10.51; P = .008). Conclusions and Relevance These findings suggest that antenatal maternal sildenafil administration for severe early onset fetal growth restriction did not reduce the risk of perinatal mortality or major neonatal morbidity. The results suggest that sildenafil may increase the risk of neonatal pulmonary hypertension. Trial Registration ClinicalTrials.gov Identifier: NCT02277132.
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Affiliation(s)
- Anouk Pels
- Department of Obstetrics and Gynecology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Jan Derks
- Wilhelmina Children’s Hospital, Department of Obstetrics, University Medical Center Utrecht, Gynecology and Neonatology, Utrecht, the Netherlands
| | - Ayten Elvan-Taspinar
- Department of Obstetrics and Gynecology, University Medical Center Groningen, Groningen, the Netherlands
| | - Joris van Drongelen
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Marjon de Boer
- Department of Obstetrics and Gynecology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Hans Duvekot
- Department of Obstetrics and Gynecology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Judith van Laar
- Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven, the Netherlands
| | - Jim van Eyck
- Department of Obstetrics and Gynecology, Isala Hospital, Zwolle, the Netherlands
| | - Salwan Al-Nasiry
- Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Marieke Sueters
- Department of Obstetrics and Gynecology, Leiden University Medical Center, Leiden, the Netherlands
| | - Marinka Post
- Department of Obstetrics and Gynecology, Medical Center Leeuwarden, Leeuwarden, the Netherlands
| | - Wes Onland
- Emma Children’s Hospital, Amsterdam UMC, Department of Neonatology, University of Amsterdam, Amsterdam, the Netherlands
| | - Aleid van Wassenaer-Leemhuis
- Emma Children’s Hospital, Amsterdam UMC, Department of Neonatology, University of Amsterdam, Amsterdam, the Netherlands
| | - Christiana Naaktgeboren
- Department of Obstetrics and Gynecology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Janus C. Jakobsen
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Cardiology, Holbæk Hospital, Holbæk, Denmark
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Christian Gluud
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ruben G. Duijnhoven
- Department of Obstetrics and Gynecology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Titia Lely
- Wilhelmina Children’s Hospital, Department of Obstetrics, University Medical Center Utrecht, Gynecology and Neonatology, Utrecht, the Netherlands
| | - Sanne Gordijn
- Department of Obstetrics and Gynecology, University Medical Center Groningen, Groningen, the Netherlands
| | - Wessel Ganzevoort
- Department of Obstetrics and Gynecology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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Rasheedy R, El Bishry G, Tarek R. Maternal low molecular weight heparin versus sildenafil citrate for fetal growth restriction: a randomized, parallel groups, open-label clinical trial. J Perinatol 2020; 40:715-723. [PMID: 31695136 DOI: 10.1038/s41372-019-0544-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 10/09/2019] [Accepted: 10/28/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVES To compare the effect of sildenafil citrate (SC) and low molecular weight heparin (LMWH) on neonatal birth weight (BW) and the fetoplacental blood flow in pregnancies with FGR. STUDY DESIGN A parallel groups, randomized clinical trial was conducted at a university hospital, between June 2017 and September 2018, involving 100 pregnant women with placental mediated FGR between 28 and 35 weeks of gestation who were randomly assigned to receive either SC or LMWH started at FGR diagnosis till delivery. RESULTS The neonatal BW in LMWH group was higher than SC group (p < 0.000) with a longer time from randomization till delivery, LMWH group had significant improvement in Ut A PI, UA PI, and MCA PI compared with SC treated group with p values 0.005, <0.000001, and 0.014, respectively. CONCLUSION The neonatal BW, time from randomization to delivery, and fetoplacental blood flow indices were significantly better with LMWH use compared with SC.
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Affiliation(s)
- R Rasheedy
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Cairo, Egypt.
| | - G El Bishry
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - R Tarek
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Abstract
Placental dysfunction underlies major obstetric diseases such as pre-eclampsia and fetal growth restriction (FGR). Whilst there has been a little progress in prophylaxis, there are still no treatments for placental dysfunction in normal obstetric practice. However, a combination of increasingly well-described in vitro systems for studying the human placenta, together with the availability of more appropriate animal models of pre-eclampsia and FGR, has facilitated a recent surge in work aimed at repurposing drugs and therapies, developed for other conditions, as treatments for placental dysfunction. This review: (1) highlights potential candidate drug targets in the placenta - effectors of improved uteroplacental blood flow, anti-oxidants, heme oxygenase induction, inhibition of HIF, induction of cholesterol synthesis pathways, increasing insulin-like growth factor II availability; (2) proposes an experimental pathway for taking a potential drug or treatment for placental dysfunction from concept through to early phase clinical trials, utilizing techniques for studying the human placenta in vitro and small animal models, particularly the mouse, for in vivo studies; (3) describes the data underpinning sildenafil citrate and adenovirus expressing vascular endothelial growth as potential treatments for placental dysfunction and summarizes recent research on other potential treatments. The importance of sharing information from such studies even when no effect is found, or there is an adverse outcome, is highlighted. Finally, the use of adenoviral vectors or nanoparticle carriers coated with homing peptides to selectively target drugs to the placenta is highlighted: such delivery systems could improve efficacy and reduce the side effects of treating the dysfunctional placenta.
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Affiliation(s)
- Colin P Sibley
- Maternal and Fetal Health Research CentreDivision of Developmental Biology and Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- St Mary's HospitalCentral Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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