1
|
Vestgaard M, Al-Saudi E, Ásbjörnsdóttir B, Nørgaard LN, Pedersen BW, Ekelund CK, Ringholm L, Andersen LLT, Jensen DM, Tabor A, Damm P, Mathiesen ER. The impact of anti-hypertensive treatment on foetal growth and haemodynamics in pregnant women with pre-existing diabetes - An explorative study. Diabet Med 2022; 39:e14722. [PMID: 34653280 DOI: 10.1111/dme.14722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 10/13/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To explore the impact of anti-hypertensive treatment of pregnancy-induced hypertension on foetal growth and hemodynamics in women with pre-existing diabetes. METHODS A prospective cohort study of 247 consecutive pregnant women with pre-existing diabetes (152 type 1 diabetes; 95 type 2 diabetes), where tight anti-hypertensive treatment was initiated and intensified (mainly with methyldopa) when office blood pressure (BP) ≥135/85 mmHg and home BP ≥130/80 mmHg. Foetal growth was assessed by ultrasound at 27, 33 and 36 weeks and foetal hemodynamics were assessed by ultrasound Doppler before and 1-2 weeks after initiation of anti-hypertensive treatment. RESULTS In 215 initially normotensive women, anti-hypertensive treatment for pregnancy-induced hypertensive disorders was initiated in 42 (20%), whilst 173 were left untreated. Chronic hypertension was present in 32 (13%). Anti-hypertensive treatment for pregnancy-induced hypertensive disorders was not associated with foetal growth deviation (linear mixed model, p = 0.681). At 27 weeks, mainly before initiation of anti-hypertensive treatment, the prevalence of small foetuses with an estimated foetal weight <10th percentile was 12% in women initiating anti-hypertensive treatment compared with 4% in untreated women (p = 0.054). These numbers were close to the prevalence of birth weight ≤10th percentile (small for gestational age (SGA)) (17% vs. 4%, p = 0.003). Pulsatility index in the umbilical and middle cerebral artery remained stable after the onset of anti-hypertensive treatment in a representative subgroup (n = 12, p = 0.941 and p = 0.799, respectively). CONCLUSION There is no clear indication that antihypertensive treatment causes harm in this particular at-high-risk group of pregnant women with diabetes, such that a larger well-designed study to determine the value of tight antihypertensive control would be worthwhile.
Collapse
Affiliation(s)
- Marianne Vestgaard
- Center for Pregnant Women with Diabetes, Departments of Endocrinology and Obstetrics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Obstetrics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Elaf Al-Saudi
- Center for Pregnant Women with Diabetes, Departments of Endocrinology and Obstetrics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Björg Ásbjörnsdóttir
- Center for Pregnant Women with Diabetes, Departments of Endocrinology and Obstetrics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Lone N Nørgaard
- Department of Obstetrics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Lene Ringholm
- Center for Pregnant Women with Diabetes, Departments of Endocrinology and Obstetrics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Dorte M Jensen
- Department of Obstetrics, Odense University Hospital, Odense, Denmark
- Steno Diabetes Center, Odense University Hospital, Odense, Denmark
| | - Ann Tabor
- Department of Obstetrics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Peter Damm
- Center for Pregnant Women with Diabetes, Departments of Endocrinology and Obstetrics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Obstetrics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Elisabeth R Mathiesen
- Center for Pregnant Women with Diabetes, Departments of Endocrinology and Obstetrics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
2
|
Ueda A, Nakakita B, Chigusa Y, Mogami H, Inohaya A, Yamaguchi K, Horie A, Hamanishi J, Mandai M, Kondoh E. Tight systolic blood pressure control early in pregnancy improves pregnancy outcomes in women with chronic hypertension. HYPERTENSION RESEARCH IN PREGNANCY 2019. [DOI: 10.14390/jsshp.hrp2019-014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Akihiko Ueda
- Department of Gynecology and Obstetrics, Kyoto University
| | - Baku Nakakita
- Department of Gynecology and Obstetrics, Kyoto University
| | | | - Haruta Mogami
- Department of Gynecology and Obstetrics, Kyoto University
| | - Asako Inohaya
- Department of Gynecology and Obstetrics, Kyoto University
| | - Ken Yamaguchi
- Department of Gynecology and Obstetrics, Kyoto University
| | - Akihito Horie
- Department of Gynecology and Obstetrics, Kyoto University
| | | | - Masaki Mandai
- Department of Gynecology and Obstetrics, Kyoto University
| | - Eiji Kondoh
- Department of Gynecology and Obstetrics, Kyoto University
| |
Collapse
|
3
|
Ringholm L, Damm P, Mathiesen ER. Improving pregnancy outcomes in women with diabetes mellitus: modern management. Nat Rev Endocrinol 2019; 15:406-416. [PMID: 30948803 DOI: 10.1038/s41574-019-0197-3] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Women with pre-existing (type 1 or type 2) diabetes mellitus are at increased risk of pregnancy complications, such as congenital malformations, preeclampsia and preterm delivery, compared with women who do not have diabetes mellitus. Approximately half of pregnancies in women with pre-existing diabetes mellitus are complicated by fetal overgrowth, which results in infants who are overweight at birth and at risk of birth trauma and, later in life, the metabolic syndrome, cardiovascular disease and type 2 diabetes mellitus. Strict glycaemic control with appropriate diet, use of insulin and, if necessary, antihypertensive treatment is the cornerstone of diabetes mellitus management to prevent pregnancy complications. New technology for managing diabetes mellitus is evolving and is changing the management of these conditions in pregnancy. For instance, in Europe, most women with pre-existing diabetes mellitus are treated with insulin analogues before and during pregnancy. Furthermore, many women are on insulin pumps during pregnancy, and the use of continuous glucose monitoring is becoming more frequent. In addition, smartphone application technology is a promising educational tool for pregnant women with diabetes mellitus and their caregivers. This Review covers how modern diabetes mellitus management with appropriate diet, insulin and antihypertensive treatment in patients with pre-existing diabetes mellitus can contribute to reducing the risk of pregnancy complications such as congenital malformations, fetal overgrowth, preeclampsia and preterm delivery.
Collapse
Affiliation(s)
- Lene Ringholm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark.
- Department of Endocrinology, Rigshospitalet, Copenhagen, Denmark.
- Steno Diabetes Center Copenhagen, Gentofte, Denmark.
| | - Peter Damm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Obstetrics, Rigshospitalet, Copenhagen, Denmark
| | - Elisabeth R Mathiesen
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Department of Endocrinology, Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
4
|
Ma L, Li L, Han P, Meng F, Jiao C, Zhang H. Effect of the drug combination of magnesium sulfate and phentolamine on homocysteine and C-reactive protein in the serum of patients with pregnancy-induced hypertension syndrome. Exp Ther Med 2019; 17:3682-3688. [PMID: 30988752 PMCID: PMC6447783 DOI: 10.3892/etm.2019.7385] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 02/22/2019] [Indexed: 12/22/2022] Open
Abstract
Effect and clinical efficacy of magnesium sulfate combined with phentolamine on homocysteine and C-reactive protein in the serum of patients with pregnancy-induced hypertension syndrome were investigated. A total of 96 patients with pregnancy-induced hypertension syndrome who were diagnosed and treated in Jining No. 1 People's Hospital from February 2016 to January 2018 were retrospectively analyzed. The patients were grouped according to the dosage regimen. The patients who received the combination treatment of magnesium sulfate and phentolamine on the basis of magnesium sulfate were included in the observation group, and the patients who were treated with the intravenous infusion of magnesium sulfate alone were included in the control group. Mean arterial pressure (MAP), the content of 24 h urine protein, systolic blood pressure (SBP), diastolic blood pressure (DBP), Hcy, and CRP of the pregnant women were observed. MAP and the content of 24 h urine protein, SBP and DBP of the patients in the observation group after the treatment were significantly lower than those of the patients in the control group (P<0.001). Hcy and CRP of the patients in the observation group after the treatment were significantly lower than those of the patients in the control group (P<0.001). The total effective rate of the patients in the observation group was significantly higher than that of the patients in the control group (P<0.05). In conclusion, the meliorative effect of magnesium sulphate combined with phentolamine on the level of MAP, the content of 24 h urine protein, SBP, DBP, Hcy and CRP in pregnant woman had a greater impact than that of the single use of the intravenous infusion of magnesium sulfate in the treatment of pregnancy-induced hypertension syndrome, and the clinical efficacy of magnesium sulphate combined with phentolamine was better, thus worthwhile to promote widely in clinic.
Collapse
Affiliation(s)
- Li Ma
- Department of Obstetrics, Jining No. 1 People's Hospital, Jining, Shandong 272011, P.R. China
| | - Liang Li
- Department of Pharmacy, Yidu Central Hospital of Weifang, Weifang, Shandong 262500, P.R. China
| | - Ping Han
- Department of Respiratory Medicine, The People's Hospital of Zhangqiu Area, Jinan, Shandong 250200, P.R. China
| | - Fanchun Meng
- Department of Obstetric Delivery Room, The People's Hospital of Zhangqiu Area, Jinan, Shandong 250200, P.R. China
| | - Chunhong Jiao
- Rehabilitation, The People's Hospital of Zhangqiu Area, Jinan, Shandong 250200, P.R. China
| | - Hongmei Zhang
- Ward 1, Department of Gynecology, Jining No. 1 People's Hospital, Jining, Shandong 272011, P.R. China
| |
Collapse
|
5
|
Ringholm L, Damm JA, Vestgaard M, Damm P, Mathiesen ER. Diabetic Nephropathy in Women With Preexisting Diabetes: From Pregnancy Planning to Breastfeeding. Curr Diab Rep 2016; 16:12. [PMID: 26803648 DOI: 10.1007/s11892-015-0705-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In women with preexisting diabetes and nephropathy or microalbuminuria, it is important to deliver careful preconception counselling to assess the risk for the mother and the foetus, for optimizing glycaemic status and to adjust medical treatment. If serum creatinine is normal in early pregnancy, kidney function is often preserved during pregnancy, but complications such as severe preeclampsia and preterm delivery are still common. Perinatal mortality is now comparable with that in women with diabetes and normal kidney function. Besides strict glycaemic control before and during pregnancy, early and intensive antihypertensive treatment is important to optimize pregnancy outcomes. Methyldopa, labetalol, nifedipine and diltiazem are considered safe, whereas angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers should be stopped before or at confirmation of pregnancy. Supplementation with folic acid in early pregnancy and low-dose aspirin from 10 to 12 weeks reduces the risk of adverse pregnancy outcomes. During breastfeeding, several ACE inhibitors are considered safe.
Collapse
Affiliation(s)
- Lene Ringholm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Department of Endocrinology PE7562, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Steno Diabetes Center, Niels Steensens Vej 2, 2820, Gentofte, Denmark.
| | - Julie Agner Damm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Department of Endocrinology PE7562, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Marianne Vestgaard
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Department of Endocrinology PE7562, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Faculty of Health and Medical Sciences, University of Copenhagen, København, Denmark.
| | - Peter Damm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Faculty of Health and Medical Sciences, University of Copenhagen, København, Denmark.
- Department of Obstetrics, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Elisabeth R Mathiesen
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Department of Endocrinology PE7562, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Faculty of Health and Medical Sciences, University of Copenhagen, København, Denmark.
| |
Collapse
|
6
|
McComb MN, Chao JY, Ng TMH. Direct Vasodilators and Sympatholytic Agents. J Cardiovasc Pharmacol Ther 2015; 21:3-19. [PMID: 26033778 DOI: 10.1177/1074248415587969] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 03/31/2015] [Indexed: 11/16/2022]
Abstract
Direct vasodilators and sympatholytic agents were some of the first antihypertensive medications discovered and utilized in the past century. However, side effect profiles and the advent of newer antihypertensive drug classes have reduced the use of these agents in recent decades. Outcome data and large randomized trials supporting the efficacy of these medications are limited; however, in general the blood pressure-lowering effect of these agents has repeatedly been shown to be comparable to other more contemporary drug classes. Nevertheless, a landmark hypertension trial found a negative outcome with a doxazosin-based regimen compared to a chlorthalidone-based regimen, leading to the removal of α-1 adrenergic receptor blockers as first-line monotherapy from the hypertension guidelines. In contemporary practice, direct vasodilators and sympatholytic agents, particularly hydralazine and clonidine, are often utilized in refractory hypertension. Hydralazine and minoxidil may also be useful alternatives for patients with renal dysfunction, and both hydralazine and methyldopa are considered first line for the treatment of hypertension in pregnancy. Hydralazine has also found widespread use for the treatment of systolic heart failure in combination with isosorbide dinitrate (ISDN). The data to support use of this combination in African Americans with heart failure are particularly robust. Hydralazine with ISDN may also serve as an alternative for patients with an intolerance to angiotensin antagonists. Given these niche indications, vasodilators and sympatholytics are still useful in clinical practice; therefore, it is prudent to understand the existing data regarding efficacy and the safe use of these medications.
Collapse
Affiliation(s)
- Meghan N McComb
- University of Southern California School of Pharmacy, Los Angeles, CA, USA
| | - James Y Chao
- University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Tien M H Ng
- University of Southern California School of Pharmacy, Los Angeles, CA, USA University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| |
Collapse
|
7
|
Pedersen BW, Ringholm L, Damm P, Tabor A, Søgaard K, Hellmuth E, Mathiesen ER. Stable fetal hemodynamics measured by Doppler flow after initiation of anti-hypertensive treatment with methyldopa in pregnant women with diabetes. J Matern Fetal Neonatal Med 2015; 29:550-3. [DOI: 10.3109/14767058.2015.1010198] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Berit Woetmann Pedersen
- Center for Pregnant Women with Diabetes, University of Copenhagen, Copenhagen, Denmark,
- Department of Obstetrics,
| | - Lene Ringholm
- Center for Pregnant Women with Diabetes, University of Copenhagen, Copenhagen, Denmark,
- Department of Endocrinology, University of Copenhagen, Copenhagen, Denmark,
| | - Peter Damm
- Center for Pregnant Women with Diabetes, University of Copenhagen, Copenhagen, Denmark,
- Department of Obstetrics,
- Faculty of Health and Medical Sciences, The Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark, and
| | - Ann Tabor
- Department of Obstetrics,
- Faculty of Health and Medical Sciences, The Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark, and
- Department of Obstetrics, Center for Fetal Medicine, Copenhagen, Denmark
| | - Kirsten Søgaard
- Department of Obstetrics,
- Department of Obstetrics, Center for Fetal Medicine, Copenhagen, Denmark
| | - Ellinor Hellmuth
- Center for Pregnant Women with Diabetes, University of Copenhagen, Copenhagen, Denmark,
- Department of Obstetrics,
| | - Elisabeth R. Mathiesen
- Center for Pregnant Women with Diabetes, University of Copenhagen, Copenhagen, Denmark,
- Department of Endocrinology, University of Copenhagen, Copenhagen, Denmark,
- Faculty of Health and Medical Sciences, The Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark, and
| |
Collapse
|
8
|
Maternal hemodynamics influence fetal hemodynamics in normal and hypertensive pregnancy. Pregnancy Hypertens 2013; 3:10-5. [DOI: 10.1016/j.preghy.2012.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Accepted: 06/24/2012] [Indexed: 11/19/2022]
|