Hypertension in pregnancy

[Assessment of central hemodynamic properties of the arterial wall in women with previous preeclampsia]

BACKGROUND

We investigated viscoelastic properties of the arterial wall in women with previous preeclampsia (PE) compared to those with normal pregnancy (NP).

METHODS

In a cross-sectional study 45 women with previous PE and 55 with NP were included, matched for age (PE 38±6 vs. NP 38±5 years, NS) and body mass index: (PE 25±4 vs. NP 26±4 kg/m(2), NS) studied, respectively, 76±34 and 86±48 months after delivery. We assessed arterial distensibility - pulse wave velocity (PWV, Complior) and reflected waves (augmentation pressure [AP], mmHg) and augmentation index (AIx) - in the central pressure wave and blood pressure (BP) on 24-h ambulatory BP monitoring (ABPM).

RESULTS

PE showed higher (p<0.01) peripheral systolic blood pressure (SBP): PE 131±18 vs. NP 121±19, and central SBP: PE 122±18 vs. NP 110±19 mmHg, with less amplification of central-peripheral pressure: PE 10±4 vs. NP 12±5, p=0.041, and higher (p<0.05) AP: PE 10±3 vs. NP 8±2, and AIx: PE 26±5 vs. NP 20±5 mmHg, but PE and NP did not differ in pulse wave velocity. On ABPM, PE (n=39) vs. NP (n=33) had higher nighttime SBP: PE 121±10 vs. NP 108±10 mmHg and lower percentage nocturnal SBP fall: PE 11±6 vs. NP 18±11%, both p<0.02. During follow-up, the need for antihypertensive medication was seven times higher in PE than in NP.

CONCLUSION

Women with previous PE have a greater risk of hypertension, higher nighttime BP values, blunted nocturnal BP fall and changes in central pressure suggestive of increased reflected waves and peripheral vascular resistance. These factors may contribute to their higher cardiovascular risk after pregnancy.

Effects of age, gender and metabolic factors on endothelium-dependent vasodilation: a population-based study

OBJECTIVES

A progressive decline in endothelium-dependent vasodilation (EDV) in the human forearm with age has previously been reported. The aim of this study was to evaluate the interplay between age, gender and metabolic factors on EDV in healthy subjects in a population-based study.

SETTING

Tertiary university hospital.

SUBJECTS AND DESIGN

Thirty-six healthy men and 30 women, aged 20-69 years, underwent measurements of forearm blood flow (FBF) at rest and during local infusions of 2 and 4 microg min-1 of metacholine (evaluating EDV) and 5 and 10 microg min-1 of sodium nitroprusside (evaluating endothelium-independent vasodilation, EIDV) and during reactive hyperaemia by venous occlusion plethysmography.

RESULTS

Age was inversely related to EDV (r = - 0.41, P < 0.05 in men; r = - 0.61, P < 0.01 in women) and maximal FBF during reactive hyperaemia in both men and women. EIDV was significantly related to age in an inverse way in women only. EDV was more pronounced in females than in males before menopause (48 +/- 3 SD years, 635 +/- 186 vs. 502 +/- 269% in males, P < 0.05), but similar in women and men thereafter (374 +/- 141 vs. 370 +/- 185% in men). The slope of the regression line for the relationship between age and EDV was flatter in premenopausal than in postmenopausal women (- 2.3 vs. - 6.4), whilst this slope was similar in younger and older men (- 5.5 vs. - 5.3). In multiple regression analysis, fasting blood glucose levels and the waist/hip ratio remained the only significant predictors of EDV in men (P < 0.01 for both), whilst age was the only significant independent predictor of EDV in women (P < 0.01).

CONCLUSION

The interplay between age and metabolic factors as determinants of endothelial function is different in healthy men and women.

Functional significance of cell volume regulatory mechanisms

To survive, cells have to avoid excessive alterations of cell volume that jeopardize structural integrity and constancy of intracellular milieu. The function of cellular proteins seems specifically sensitive to dilution and concentration, determining the extent of macromolecular crowding. Even at constant extracellular osmolarity, volume constancy of any mammalian cell is permanently challenged by transport of osmotically active substances across the cell membrane and formation or disappearance of cellular osmolarity by metabolism. Thus cell volume constancy requires the continued operation of cell volume regulatory mechanisms, including ion transport across the cell membrane as well as accumulation or disposal of organic osmolytes and metabolites. The various cell volume regulatory mechanisms are triggered by a multitude of intracellular signaling events including alterations of cell membrane potential and of intracellular ion composition, various second messenger cascades, phosphorylation of diverse target proteins, and altered gene expression. Hormones and mediators have been shown to exploit the volume regulatory machinery to exert their effects. Thus cell volume may be considered a second message in the transmission of hormonal signals. Accordingly, alterations of cell volume and volume regulatory mechanisms participate in a wide variety of cellular functions including epithelial transport, metabolism, excitation, hormone release, migration, cell proliferation, and cell death.

Drug management of hypertensive disorders of pregnancy

Drugs used in the acute and long-term management of hypertension in pregnancy and the preeclampsia-eclampsia syndrome have been reviewed and their therapeutic effects and maternal and fetal adverse effects have been considered. The review also focuses on recent developments in the areas of prevention and management of pre-eclampsia-eclampsia syndrome. Although a number of new drugs have emerged, as potentially useful in the management of hypertension in pregnancy and pre-eclampsia-eclampsia syndrome, some remain at the cornerstone of therapy; for example, methyldopa for long-term treatment of chronic hypertension, hydralazine or nifedipine for rapid reduction of severely elevated blood pressure, and magnesium sulphate for eclampsia. Some of these agents, especially the calcium antagonists, show promise in that their use is associated with fewer side effects. Safety for the fetus, however, has not been adequately evaluated yet. Neither aspirin nor calcium supplements appear to improve the outcome in pregnancy. Currently, the dilemma whether to treat hypertension in pregnancy and pre-eclampsia-eclampsia syndrome with old, established, cost-effective drugs or the promising newer drugs provides an interesting academic challenge.

The new WHO Expert Committee Report on Hypertension Control

A new WHO Expert Committee Report on Hypertension Control has recently been prepared. This paper is not intended to be a detailed summary of this report. It rather intends to identify the principal issues where the new report differs from the previous 1978 WHO report, to point out the aspects where it has substantially incorporated the recommendations made on the 1993 WHO/ISH guidelines, and to mention the issues that have been developed in this report more extensively than in previous WHO or WHO/ISH documents.

Alterations of intrauterine eicosanoid production in pregnancy-induced hypertension: decreased production of 12-hydroxyeicosatetraenoic acid in the placenta

The important role of eicosanoids in pregnancy-induced hypertension is generally accepted. Because of the lack of innervation of the uteroplacental vessels, humoral vasoactive factors are important for the regulation of vascular tone. Until now, mainly the balance of vasodilatative and vasoconstrictive prostaglandins has been studied. We were able to confirm their intrauterine imbalance in hypertensive pregnancies. In addition, the placental production of less known lipoxygenase metabolites has been analyzed in this study. Intrauterine tissues (30-100mg wet weight) were examined for their release of eicosanoids. Short term tissue cultures were performed in Hanks balanced salts solution (HBSS) at 37 degrees C in an atmosphere of 95% air/5% CO2 with and without incorporation of tritiated arachidonic acid. The arachidonate metabolites in culture media were analyzed by High Performance Liquid Chromatography (HPLC) with radioactivity detection or by enzyme immunoassays or radioimmunoassays, respectively. All intrauterine tissues released more lipoxygenase metabolites than cyclooxygenase metabolites with 12-hydroxy-eicosatetraenic acid (12-HETE) as their main metabolite. The placental release of 12-HETE was significantly decreased in hypertensive pregnancies. In hypertensive pregnancies the ratio TXB2/6-keto-PGF1 alpha synthesis was increased. Lipoxygenase metabolites, especially 12-HETE, seem to have important physiological and pathophysiological functions in the intrauterine compartment. Their biological role in this context needs further investigation.