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Maykin MM, Mercer E, Saiki KM, Kaneshiro B, Miller CB, Tsai PJS. Furosemide to lower antenatal severe hypertension: a randomized placebo-controlled trial. Am J Obstet Gynecol MFM 2024; 6:101348. [PMID: 38485054 DOI: 10.1016/j.ajogmf.2024.101348] [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: 01/29/2024] [Revised: 03/06/2024] [Accepted: 03/07/2024] [Indexed: 04/01/2024]
Abstract
BACKGROUND Hypertensive disorders of pregnancy are a leading cause of perinatal morbidity, and timely treatment of severely elevated blood pressure is recommended to prevent serious sequelae. In acute hypertension marked by increased blood volume, it is unknown whether diuretics used as an adjunct to antihypertensive medications lead to more effective blood pressure control. OBJECTIVE This study aimed to evaluate whether the addition of intravenous furosemide to first-line antihypertensive agents reduces systolic blood pressure in acute-onset, severe antenatal hypertension with wide (≥60 mm Hg) pulse pressure. STUDY DESIGN In this double-blinded randomized trial, participants received 40 mg of intravenous furosemide or placebo in addition to a first-line antihypertensive agent. The primary outcome was mean systolic blood pressure during the first hour after intervention. Secondary outcomes included corresponding diastolic blood pressure; systolic blood pressure, diastolic blood pressure, and pulse pressure at 2 hours after intervention; total reduction from qualifying blood pressure; duration of blood pressure control; need for additional antihypertensive doses within 1 hour; and electrolytes and urine output. A sample size of 35 participants per group was planned to detect a 15-mm Hg difference in blood pressure. RESULTS Between January 2021 and March 2022, 65 individuals were randomized: 33 to furosemide and 32 to placebo. Baseline characteristics were similar between the groups. There was no difference in the primary outcome of mean 1-hour systolic blood pressure (147 [14.8] vs 152 [13.8] mm Hg; P=.200). We found a reduction in 2-hour systolic blood pressure (139 [18.5] vs 154 [18.4] mm Hg; P=.007) and a decrease in 2-hour pulse pressure (55 [12.5] vs 67 [15.1]; P=.003) in the furosemide group. Subgroup analysis according to hypertension type showed a significant reduction in 2-hour systolic blood pressure and 2-hour pulse pressure among patients with new-onset hypertension, but not among those with preexisting hypertension. Urine output was greater in the furosemide group, with no difference in electrolytes and creatinine before and after intervention. CONCLUSION Intravenous furosemide in conjunction with a first-line antihypertensive agent did not significantly reduce systolic blood pressure in the first hour after administration. However, both systolic blood pressure and pulse pressure at 2 hours were decreased in the furosemide group. These findings suggest that a 1-time dose of intravenous furosemide is a reasonable adjunct to achieve blood pressure control, particularly in patients in whom increased volume is suspected.
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Affiliation(s)
- Melanie M Maykin
- Department of Obstetrics, Gynecology, and Women's Health, John A. Burns School of Medicine of the University of Hawaii, Honolulu, HI.
| | - Elizabeth Mercer
- Department of Obstetrics, Gynecology, and Women's Health, John A. Burns School of Medicine of the University of Hawaii, Honolulu, HI
| | - Kevin M Saiki
- Department of Obstetrics, Gynecology, and Women's Health, John A. Burns School of Medicine of the University of Hawaii, Honolulu, HI
| | - Bliss Kaneshiro
- Department of Obstetrics, Gynecology, and Women's Health, John A. Burns School of Medicine of the University of Hawaii, Honolulu, HI
| | - Corrie B Miller
- Department of Obstetrics, Gynecology, and Women's Health, John A. Burns School of Medicine of the University of Hawaii, Honolulu, HI
| | - Pai-Jong Stacy Tsai
- Department of Obstetrics, Gynecology, and Women's Health, John A. Burns School of Medicine of the University of Hawaii, Honolulu, HI
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Malhamé I, Dong S, Syeda A, Ashraf R, Zipursky J, Horn D, Daskalopoulou SS, D'Souza R. The use of loop diuretics in the context of hypertensive disorders of pregnancy: a systematic review and meta-analysis. J Hypertens 2023; 41:17-26. [PMID: 36453652 DOI: 10.1097/hjh.0000000000003310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
AIMS Addressing volume expansion may improve the management of hypertension across the pregnancy continuum. We conducted a systematic review to summarize the evidence on the use of loop diuretics in the context of hypertensive disorders during pregnancy and the postpartum period. METHODS AND RESULTS Medline, Embase, Cochrane library, ClinicalTrials.gov, and Google Scholar were searched for original research articles published up to 29 June 2021. Of the 2801 results screened, 15 studies were included: eight randomized controlled trials, six before-after studies, and one cohort study. Based on random effects meta-analysis of before-after studies, antepartum use of loop diuretics was associated with lower DBP [mean difference -17.73 mmHg, (95% confidence intervals -34.50 to -0.96); I2 = 94%] and lower cardiac output [mean difference -0.75 l/min, (-1.11 to -0.39); I2 = 0%], with no difference in SBP, mean arterial pressure, heart rate, or total peripheral resistance. Meta-analysis of randomized controlled trials revealed that postpartum use of loop diuretics was associated with decreased need for additional antihypertensive patients [relative risk 0.69, (0.50-0.97); I2 = 14%], and an increased duration of hospitalization [mean difference 8.80 h, (4.46-13.14); I2 = 83%], with no difference in the need for antihypertensive therapy at hospital discharge, or persistent postpartum hypertension. CONCLUSION Antepartum use of loop diuretics lowered DBP and cardiac output, while their postpartum use reduced the need for additional antihypertensive medications. There was insufficient evidence to suggest a clear benefit. Future studies focusing on women with hypertensive pregnancy disorders who may most likely benefit from loop diuretics are required.
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Affiliation(s)
- Isabelle Malhamé
- Department of Medicine, McGill University Health Centre
- Research Institute of the McGill University Health Centre, Montréal, Quebéc
| | - Susan Dong
- Faculty of Medicine, University of Toronto
| | - Ambreen Syeda
- Department of Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto
| | - Rizwana Ashraf
- Department of Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto
- Department of Obstetrics & Gynaecology, McMaster University, Hamilton
| | - Jonathan Zipursky
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto
- Institute of Health Policy, Management, and Evaluation, University of Toronto
| | - Daphne Horn
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Stella S Daskalopoulou
- Department of Medicine, McGill University Health Centre
- Research Institute of the McGill University Health Centre, Montréal, Quebéc
| | - Rohan D'Souza
- Department of Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto
- Department of Obstetrics & Gynaecology, McMaster University, Hamilton
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Tamás P, Kovács K, Várnagy Á, Farkas B, Alemu Wami G, Bódis J. Preeclampsia subtypes: Clinical aspects regarding pathogenesis, signs, and management with special attention to diuretic administration. Eur J Obstet Gynecol Reprod Biol 2022; 274:175-181. [PMID: 35661540 DOI: 10.1016/j.ejogrb.2022.05.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/18/2022] [Accepted: 05/27/2022] [Indexed: 11/04/2022]
Abstract
During normal pregnancy, blood volume increases by nearly two liters. Distinctively, the absence coupled with the extreme extent regarding the volume expansion, are likely accompanied with pathological conditions. Undoubtedly, preeclampsia, defined as the appearance of hypertension and organ deficiency, such as proteinuria during the second half of pregnancy, is not a homogenous disease. Clinically speaking, two main types of preeclampsia can be distinguished, in which a marked difference between them is vascular condition, and consequently, the blood volume. The "classic" preeclampsia, as a two-phase disease, described in the first, latent phase, in which, placenta development is diminished. Agents from this malperfused placenta generate a maternal disease, the second phase, in which endothelial damage leads to hypertension and organ damage due to vasoconstriction and thrombotic microangiopathy. In this hypovolemia-associated condition, decreasing platelet count, signs of hemolysis, renal and liver involvement are characteristic findings; proteinuria is marked and increasing. In the terminal phase, visible edema develops due to increasing capillary transparency, augmenting end-organ damages. "Classic" preeclampsia is a severe and quickly progressing condition with placental insufficiency and consequent fetal growth restriction and oligohydramnios. The outcome of this condition often leads to fetal hypoxia, eclampsia or placental abruption. The management is limited to a diligent prolongation of pregnancy to accomplish improved neonatal pulmonary function, careful diminishing high blood pressure, and delivery induction in due time. The other subtype, associated with relaxed vasculature and high cardiac output, is a maternal disease, in which obesity is an important risk factor since predisposes to enhanced water retention, hypertension, and a weakened endothelial dysfunction. Initially, enhanced water retention leads to lowered extremity edema, which oftentimes progresses to a generalized form and hypertension. In several cases, proteinuria appears most likely due to tissue edema. This condition already fully meets preeclampsia criteria. Laboratory alterations, including proteinuria, are modest and platelet count remains within the normal range. Fetal weight is also normal or frequently over average due to enhanced placental blood supply. It is very likely, further water retention leads to venous congestion, a parenchyma stasis, responsible for ascites, eclampsia, or placental abruption. During the management of this hypervolemia-associated preeclampsia, the administration of diuretic furosemide treatment seemingly offers promise.
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Affiliation(s)
- Péter Tamás
- National Laboratory for Human Reproduction, University of Pécs, Pécs, Hungary; Department of Obstetrics and Gynaecology, Medical School, University of Pécs, Pécs, Hungary; Doctoral School of Health Sciences, Faculty of Health Sciences, University of Pécs, Pécs, Hungary; Institute of Emergency Care and Pedagogy of Health, Faculty of Health Sciences, University of Pécs, Pécs, Hungary.
| | - Kálmán Kovács
- National Laboratory for Human Reproduction, University of Pécs, Pécs, Hungary; Department of Obstetrics and Gynaecology, Medical School, University of Pécs, Pécs, Hungary; Hungarian Academy of Sciences - University of Pécs Human Reproduction Scientific Research Group, University of Pécs, Pécs, Hungary
| | - Ákos Várnagy
- National Laboratory for Human Reproduction, University of Pécs, Pécs, Hungary; Department of Obstetrics and Gynaecology, Medical School, University of Pécs, Pécs, Hungary; Hungarian Academy of Sciences - University of Pécs Human Reproduction Scientific Research Group, University of Pécs, Pécs, Hungary
| | - Bálint Farkas
- National Laboratory for Human Reproduction, University of Pécs, Pécs, Hungary; Department of Obstetrics and Gynaecology, Medical School, University of Pécs, Pécs, Hungary; Hungarian Academy of Sciences - University of Pécs Human Reproduction Scientific Research Group, University of Pécs, Pécs, Hungary
| | - Girma Alemu Wami
- Doctoral School of Health Sciences, Faculty of Health Sciences, University of Pécs, Pécs, Hungary
| | - József Bódis
- National Laboratory for Human Reproduction, University of Pécs, Pécs, Hungary; Department of Obstetrics and Gynaecology, Medical School, University of Pécs, Pécs, Hungary; Doctoral School of Health Sciences, Faculty of Health Sciences, University of Pécs, Pécs, Hungary; Hungarian Academy of Sciences - University of Pécs Human Reproduction Scientific Research Group, University of Pécs, Pécs, Hungary
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McLaughlin K, Snelgrove JW, Sienas LE, Easterling TR, Kingdom JC, Albright CM. Phenotype‐Directed Management of Hypertension in Pregnancy. J Am Heart Assoc 2022; 11:e023694. [PMID: 35285667 PMCID: PMC9075436 DOI: 10.1161/jaha.121.023694] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Hypertensive disorders of pregnancy are among the most serious conditions that pregnancy care providers face; however, little attention has been paid to the concept of tailoring clinical care to reduce associated adverse maternal and perinatal outcomes based on the underlying disease pathogenesis. This narrative review discusses the integration of phenotype‐based clinical strategies in the management of high‐risk pregnant patients that are currently not common clinical practice: real‐time placental growth factor testing at Mount Sinai Hospital, Toronto and noninvasive hemodynamic monitoring to guide antihypertensive therapy at the University of Washington Medical Center, Seattle. Future work should focus on promoting more widespread integration of these novel strategies into obstetric care to improve outcomes of pregnancies at high risk of adverse maternal‐fetal outcomes from these complications of pregnancy.
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Affiliation(s)
- Kelsey McLaughlin
- Department of Obstetrics and Gynecology Division of Maternal‐Fetal Medicine Sinai Health SystemUniversity of Toronto Toronto Canada
| | - John W. Snelgrove
- Department of Obstetrics and Gynecology Division of Maternal‐Fetal Medicine Sinai Health SystemUniversity of Toronto Toronto Canada
| | - Laura E. Sienas
- Department of Obstetrics and Gynecology Division of Maternal‐Fetal Medicine University of Washington Medical Center Seattle WA
| | - Thomas R. Easterling
- Department of Obstetrics and Gynecology Division of Maternal‐Fetal Medicine University of Washington Medical Center Seattle WA
| | - John C. Kingdom
- Department of Obstetrics and Gynecology Division of Maternal‐Fetal Medicine Sinai Health SystemUniversity of Toronto Toronto Canada
| | - Catherine M. Albright
- Department of Obstetrics and Gynecology Division of Maternal‐Fetal Medicine University of Washington Medical Center Seattle WA
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Gyselaers W. Hemodynamic pathways of gestational hypertension and preeclampsia. Am J Obstet Gynecol 2022; 226:S988-S1005. [PMID: 35177225 DOI: 10.1016/j.ajog.2021.11.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 11/02/2021] [Accepted: 11/03/2021] [Indexed: 12/01/2022]
Abstract
Gestational hypertension and preeclampsia are the 2 main types of hypertensive disorders in pregnancy. Noninvasive maternal cardiovascular function assessment, which helps obtain information from all the components of circulation, has shown that venous hemodynamic dysfunction is a feature of preeclampsia but not of gestational hypertension. Venous congestion is a known cause of organ dysfunction, but its potential role in the pathophysiology of preeclampsia is currently poorly investigated. Body water volume expansion occurs in both gestational hypertension and preeclampsia, and this is associated with the common feature of new-onset hypertension after 20 weeks of gestation. Blood pressure, by definition, is the product of intravascular volume load and vascular resistance (Ohm's law). Fundamentally, hypertension may present as a spectrum of cardiovascular states varying between 2 extremes: one with a predominance of raised cardiac output and the other with a predominance of increased total peripheral resistance. In clinical practice, however, this bipolar nature of hypertension is rarely considered, despite the important implications for screening, prevention, management, and monitoring of disease. This review summarizes the evidence of type-specific hemodynamic profiles in the latent and clinical stages of hypertensive disorders in pregnancy. Gestational volume expansion superimposed on an early gestational closed circulatory circuit in a pressure- or volume-overloaded condition predisposes a patient to the gradual deterioration of overall circulatory function, finally presenting as gestational hypertension or preeclampsia-the latter when venous dysfunction is involved. The eventual phenotype of hypertensive disorder is already predictable from early gestation onward, on the condition of including information from all the major components of circulation into the maternal cardiovascular assessment: the heart, central and peripheral arteries, conductive and capacitance veins, and body water content. The relevance of this approach, outlined in this review, openly invites for more in-depth research into the fundamental hemodynamics of gestational hypertensive disorders, not only from the perspective of the physiologist or the scientist, but also in assistance of clinicians toward understanding and managing effectively these severe complications of pregnancy.
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Affiliation(s)
- Wilfried Gyselaers
- Department of Obstetrics, Ziekenhuis Oost-Limburg, Genk, Belgium; and Faculty of Medicine and Life Sciences, Department Physiology, Hasselt University, Belgium.
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6
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Hogg JP, Szczepanski JL, Collier C, Martin JN. Immediate postpartum management of patients with severe hypertensive disorders of pregnancy: pathophysiology guiding practice. J Matern Fetal Neonatal Med 2020; 35:2009-2019. [PMID: 32519919 DOI: 10.1080/14767058.2020.1776251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Developing clinically-focused evidence and experience-based approaches to improve maternity care is a national priority. Safety and quality collaborative initiatives related to management of hypertensive disorders of pregnancy are vital in the implementation of improved care. We reviewed the obstetric literature to construct a concise summary of the core pathophysiologic issues, practice principles and clinical interventions which are foundational for physicians providing immediate postpartum care for patients with severe pregnancy-related hypertension (including those with eclampsia, HELLP syndrome, and superimposed preeclampsia inclusive of those with gestational hypertension that develop severe range blood pressures). While based largely upon the American College of Obstetrics and Gynecology (ACOG) Hypertension Task Force Guidelines released in 2013 as well as updated 2018 guidelines set forth by ACOG for hypertensive disorders of pregnancy, this summary goes beyond the basic safety bundles for hypertension management and lays a pathophysiologic foundation for the immediate postpartum care of patients with severe hypertensive disorders of pregnancy.
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Affiliation(s)
- James P Hogg
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Jamie L Szczepanski
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Charlene Collier
- Department of Obstetrics and Gynecology, Division of Women's Health, University of Mississippi Medical Center, Jackson, MS, USA
| | - James N Martin
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Mississippi Medical Center, Jackson, MS, USA
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7
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Gyselaers W, Thilaganathan B. Preeclampsia: a gestational cardiorenal syndrome. J Physiol 2019; 597:4695-4714. [PMID: 31343740 DOI: 10.1113/jp274893] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 06/13/2019] [Indexed: 12/12/2022] Open
Abstract
It is generally accepted today that there are two different types of preeclampsia: an early-onset or placental type and a late-onset or maternal type. In the latent phase, the first one presents with a low output/high resistance circulation eventually leading in the late second or early third trimester to an intense and acutely aggravating systemic disorder with an important impact on maternal and neonatal mortality and morbidity; the other type presents initially as a high volume/low resistance circulation, gradually evolving to a state of circulatory decompensation usually in the later stages of pregnancy, with a less severe impact on maternal and neonatal outcome. For both processes, numerous dysfunctions of the heart, kidneys, arteries, veins and interconnecting systems are reported, most of them presenting earlier and more severely in early- than in late-onset preeclampsia; however, some very specific dysfunctions exist for either type. Experimental, clinical and epidemiological observations before, during and after pregnancy are consistent with gestation-induced worsening of subclinical pre-existing chronic cardiovascular dysfunction in early-onset preeclampsia, and thus sharing the pathophysiology of cardiorenal syndrome type II, and with acute volume overload decompensation of the maternal circulation in late-onset preeclampsia, thus sharing the pathophysiology of cardiorenal syndrome type 1. Cardiorenal syndrome type V is consistent with the process of preeclampsia superimposed upon clinical cardiovascular and/or renal disease, alone or as part of a systemic disorder. This review focuses on the specific differences in haemodynamic dysfunctions between the two types of preeclampsia, with special emphasis on the interorgan interactions between heart and kidneys, introducing the theoretical concept that the pathophysiological processes of preeclampsia can be regarded as the gestational manifestations of cardiorenal syndromes.
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Affiliation(s)
- Wilfried Gyselaers
- Department of Obstetrics & Gynaecology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium.,Department Physiology, Hasselt University, Agoralaan, 3590, Diepenbeek, Belgium
| | - Basky Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, UK.,Molecular and Clinical Sciences Research Institute, St George's University of London, UK
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Maternal Venous Hemodynamic Dysfunction in Proteinuric Gestational Hypertension: Evidence and Implications. J Clin Med 2019; 8:jcm8030335. [PMID: 30862007 PMCID: PMC6462953 DOI: 10.3390/jcm8030335] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 02/26/2019] [Accepted: 03/05/2019] [Indexed: 01/21/2023] Open
Abstract
This review summarizes current knowledge from experimental and clinical studies on renal function and venous hemodynamics in normal pregnancy, in gestational hypertension (GH) and in two types of preeclampsia: placental or early-onset preeclampsia (EPE) and maternal or late-onset (LPE) preeclampsia, presenting at <34 weeks and ≥34 weeks respectively. In addition, data from maternal venous Doppler studies are summarized, showing evidence for (1) the maternal circulation functioning closer to the upper limits of capacitance than in non-pregnant conditions, with intrinsic risks for volume overload, (2) abnormal venous Doppler measurements obtainable in preeclampsia, more pronounced in EPE than LPE, however not observed in GH, and (3) abnormal venous hemodynamic function installing gradually from first to third trimester within unique pathways of general circulatory deterioration in GH, EPE and LPE. These associations have important clinical implications in terms of screening, diagnosis, prevention and management of gestational hypertensive diseases. They invite for further hypothesis-driven research on the role of retrograde venous congestion in the etiology of preeclampsia-related organ dysfunctions and their absence in GH, and also challenge the generally accepted view of abnormal placentation as the primary cause of preeclampsia. The striking similarity between abnormal maternal venous Doppler flow patterns and those observed at the ductus venosus and other abdominal veins of the intra-uterine growth restricted fetus, also invites to explore the role of venous congestion in the intra-uterine programming of some adult diseases.
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Mounier-Vehier C, Amar J, Boivin JM, Denolle T, Fauvel JP, Plu-Bureau G, Tsatsaris V, Blacher J. Hypertension and pregnancy: expert consensus statement from the French Society of Hypertension, an affiliate of the French Society of Cardiology. Fundam Clin Pharmacol 2016; 31:83-103. [DOI: 10.1111/fcp.12254] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Accepted: 11/10/2016] [Indexed: 01/13/2023]
Affiliation(s)
| | - Jacques Amar
- French Society of Hypertension; 5 rue des Colonnes du Trône 75012 Paris France
| | - Jean-Marc Boivin
- French Society of Hypertension; 5 rue des Colonnes du Trône 75012 Paris France
| | - Thierry Denolle
- French Society of Hypertension; 5 rue des Colonnes du Trône 75012 Paris France
| | - Jean-Pierre Fauvel
- French Society of Hypertension; 5 rue des Colonnes du Trône 75012 Paris France
| | - Geneviève Plu-Bureau
- College of Medical Gynecology Teachers; Hôpital Port-Royal; Unité de Gynécologie médicale; 123 boulevard Port-Royal 75014 Paris France
| | - Vassilis Tsatsaris
- French National College of Gynecologists-Obstetricians; 91 Boulevard de Sébastopol 75002 Paris France
| | - Jacques Blacher
- French Society of Hypertension; 5 rue des Colonnes du Trône 75012 Paris France
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Tamás P, Hantosi E, Farkas B, Ifi Z, Betlehem J, Bódis J. Preliminary study of the effects of furosemide on blood pressure during late-onset pre-eclampsia in patients with high cardiac output. Int J Gynaecol Obstet 2016; 136:87-90. [PMID: 28099709 DOI: 10.1002/ijgo.12019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 08/13/2016] [Accepted: 10/13/2016] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To examine the effect of furosemide on hypertension and edema in patients with pre-eclampsia experiencing high cardiac output. METHODS The present cohort study enrolled patients with pre-eclampsia who were admitted to the pregnancy pathology unit of the Department of Obstetrics and Gynecology, University of Pécs, Hungary, between January 1 and December 31, 2015. Eligible patients had singleton pregnancies with no fetal anomalies, high blood volume, visible edema, and a hematocrit concentration below 37 L/L. Blood pressure was measured and impedance cardiography was used to determine cardiac output for all patients before they received a 40-mg dose of furosemide; after 60 minutes blood pressure and cardiac output were measured again. RESULTS The study enrolled 14 patients. Lower cardiac output (P=0.002), systolic blood pressure (P=0.002), and diastolic blood pressure (P=0.002) were recorded after furosemide administration, with patient heart rates remaining stable. CONCLUSION The heart-rate stability suggests that the change of cardiac output was due to a decrease in blood volume. These data suggest that diuretics could be useful in the management of late-onset pre-eclampsia, indicating that an increase in water retention could play a role in the development of late-onset pre-eclampsia.
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Affiliation(s)
- Péter Tamás
- Doctoral School of Health Sciences, Faculty of Health Sciences, University of Pécs, Pécs, Hungary.,Department of Obstetrics and Gynecology, Faculty of Medicine, University of Pécs, Pécs, Hungary
| | - Eszter Hantosi
- Doctoral School of Health Sciences, Faculty of Health Sciences, University of Pécs, Pécs, Hungary.,Department of Obstetrics and Gynecology, Faculty of Medicine, University of Pécs, Pécs, Hungary
| | - Bálint Farkas
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Pécs, Pécs, Hungary.,MTA-PTE Human Reproduction Scientific Research Group, Pécs, Hungary
| | - Zsolt Ifi
- Doctoral School of Health Sciences, Faculty of Health Sciences, University of Pécs, Pécs, Hungary.,Department of Obstetrics and Gynecology, Faculty of Medicine, University of Pécs, Pécs, Hungary
| | - József Betlehem
- Doctoral School of Health Sciences, Faculty of Health Sciences, University of Pécs, Pécs, Hungary
| | - József Bódis
- Doctoral School of Health Sciences, Faculty of Health Sciences, University of Pécs, Pécs, Hungary.,Department of Obstetrics and Gynecology, Faculty of Medicine, University of Pécs, Pécs, Hungary.,MTA-PTE Human Reproduction Scientific Research Group, Pécs, Hungary
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Seguro F, Duly Bouhanick B, Chamontin B, Amar J. [Management of arterial hypertension before 20weeks gestation in pregnant women]. Presse Med 2016; 45:627-30. [PMID: 27554460 DOI: 10.1016/j.lpm.2016.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 06/05/2016] [Indexed: 10/21/2022] Open
Abstract
In the first 6 months of pregnancy, the primary goal of antihypertensive treatment is to prevent the complications of severe hypertension. Initiation of antihypertensive drug treatment is recommended in pregnant women with severe hypertension (blood pressure>160/110mmHg). Initiation of antihypertensive drug treatment should also be considered in pregnant women at high cardiovascular risk (diabetes, chronic kidney disease, personal history of cardiovascular disease) with moderate hypertension (blood pressure between 140-159/90-109mmHg). A systolic blood pressure goal<160 and a diastolic blood pressure goal between 85 and 100mmHg is recommended in pregnancy. Labetalol, nifedipine, nicardipine and alphamethyldopa should be considered preferential antihypertensive drugs in pregnancy. Salt restriction, physical exercise and weight loss have not demonstrated any effect in the prevention of preeclampsia and serious maternal complications of hypertension.
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Affiliation(s)
- Florent Seguro
- CHU de Toulouse, université Paul-Sabatier, service d'hypertension artérielle et de thérapeutique, 31059 Toulouse, France
| | - Béatrice Duly Bouhanick
- CHU de Toulouse, université Paul-Sabatier, service d'hypertension artérielle et de thérapeutique, 31059 Toulouse, France
| | - Bernard Chamontin
- CHU de Toulouse, université Paul-Sabatier, service d'hypertension artérielle et de thérapeutique, 31059 Toulouse, France
| | - Jacques Amar
- CHU de Toulouse, université Paul-Sabatier, service d'hypertension artérielle et de thérapeutique, 31059 Toulouse, France.
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12
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Mounier-Vehier C, Amar J, Boivin JM, Denolle T, Fauvel JP, Plu-Bureau G, Tsatsaris V, Blacher J. Hypertension artérielle et grossesse. Consensus d’experts de la Société française d’hypertension artérielle, filiale de la Société française de cardiologie. Presse Med 2016; 45:682-99. [DOI: 10.1016/j.lpm.2016.05.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Accepted: 05/10/2016] [Indexed: 01/17/2023] Open
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Abstract
Hypertension in pregnancy remains a significant public health problem. Pharmacological management of blood pressure in pregnancy is impacted by changes in maternal drug disposition and by the pharmacodynamic effects of specific agents. This article will review the impact of pregnancy on pathways of drug elimination and the associated clinical implications, the pharmacodynamic effects of specific drugs and classes of drugs in pregnancy, and the data to date on the impact of antihypertensive therapy on mothers and their fetuses.
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Affiliation(s)
- Thomas R Easterling
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA 98195.
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Vigil-De Gracia P, Dominguez L, Solis A. Management of chronic hypertension during pregnancy with furosemide, amlodipine or aspirin: a pilot clinical trial. J Matern Fetal Neonatal Med 2013; 27:1291-4. [PMID: 24102416 DOI: 10.3109/14767058.2013.852180] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To determine the maternal and neonatal efficacy and safety with furosemide, amlodipine or aspirin in women with mild/moderate chronic hypertension during pregnancy. METHODS A pilot clinical trial was performed in a tertiary teaching hospital in Panama. Pregnant patients with mild/moderate chronic hypertension at ≤20 weeks of gestation were invited to take part in the study. Mild/moderate chronic hypertension was defined as a pregnancy with systolic blood pressure of 140-159 mmHg or diastolic blood pressure of 90-109 mmHg. Women in the furosemide group received 20 mg of furosemide oral each day, those in the amlodipine group received 5 mg of amlodipine oral each day and those in the aspirin group received 75 mg of orally-administered acetylsalicylic acid each day. RESULTS We enrolled 63 patients during the study period, 21 women were randomised to each group (aspirin, amlodipine and furosemide). We found no difference in maternal complications, pre-term births, mean birth weight or in the proportion of small for gestational age infants among treatment groups. Severe hypertension and aggregate pre-eclampsia were similar among treatment groups. CONCLUSION This pilot trial demonstrates that both furosemide and amlodipine might have the same effect during pregnancy. However, a large clinical trial is necessary to prove this.
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Affiliation(s)
- Paulino Vigil-De Gracia
- Department of Obstetrics and Gynecology, Critical Care and Maternal Fetal Unit, Caja de Seguro Social , Panama City , Panama
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Spezielle Arzneimitteltherapie in der Schwangerschaft. ARZNEIMITTEL IN SCHWANGERSCHAFT UND STILLZEIT 2012. [PMCID: PMC7271212 DOI: 10.1016/b978-3-437-21203-1.10002-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Pharmacodynamics of clonidine therapy in pregnancy: a heterogeneous maternal response impacts fetal growth. Am J Hypertens 2010; 23:1234-40. [PMID: 20725050 DOI: 10.1038/ajh.2010.159] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Clonidine, a centrally acting antihypertensive agent, has been used successfully in pregnancy. We sought to describe the pharmacodynamic effects of clonidine in pregnancy and the associated impact on fetal growth. METHODS A retrospective cohort study was performed. Maternal hemodynamics were measured before and after treatment. Responses to clonidine were categorized by the predominant hemodynamic effect: decreased vascular resistance, decreased cardiac output (CO), or mixed. Multinomial logistic regression was used to evaluate predictors of hemodynamic response to clonidine and association between response group and birth weight. RESULTS Sixty-six pregnant women were studied. Treatment was associated with a reduction of mean arterial pressure (MAP) (-9.2 mm Hg, P < 0.001), a reduction in total peripheral resistance (TPR) (-194 dyne·cm·sec⁻⁵, P < 0.001), and an increase in CO (+0.5 l/min, P < 0.001). The hemodynamic response was characterized by decreased resistance in 34 women; decreased CO in 22; and mixed effect in 10. No maternal demographic characteristics were associated with a reduction in CO. Mean birth weight percentile was lower in the group that experienced a reduction in CO compared to the group with a reduction in vascular resistance (26.1 vs. 43.6, P = 0.02). The rate of birth weight <10th percentile was also higher in the group experiencing decreased CO (41 vs. 8.8%, P = 0.008). CONCLUSIONS The hemodynamic effect of clonidine in pregnancy is heterogeneous. The category of effect, reduction in vascular resistance vs. reduction in CO, significantly impacts fetal growth. A reduction in heart rate (HR) after therapy identifies pregnancies at risk for reduced fetal growth.
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Mitrovic V, Seferovic P, Dodic S, Krotin M, Neskovic A, Dickstein K, de Voogd H, Böcker C, Ziegler D, Godes M, Nakov R, Essers H, Verboom C, Hocher B. Cardio-renal effects of the A1 adenosine receptor antagonist SLV320 in patients with heart failure. Circ Heart Fail 2009; 2:523-31. [PMID: 19919976 DOI: 10.1161/circheartfailure.108.798389] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Blocking the tubuloglomerular feedback mechanism with adenosine A1 receptor antagonists seems to improve diuresis and sodium excretion without compromising the glomerular filtration rate in patients with heart failure. However, the direct cardiac effects of this compound class have not been investigated to date. METHODS AND RESULTS In total, 111 patients (109 men and 2 women) received a 1-hour infusion of 5, 10, and 15 mg SLV320, an adenosine A1 receptor antagonist, placebo, or 40 mg furosemide. Mean age was 57.9 years, mean ejection fraction was 28.1%, 82 patients were of New York Heart Association class II, and 29 patients were of New York Heart Association class III. Hemodynamic parameters (heart rate, blood pressure, pulmonary capillary wedge pressure, mean pulmonary arterial pressure, systemic vascular resistance, right atrial pressure, and cardiac output) were determined. Kidney function was assessed by cystatin C measurements and by analysis of urine output and urine electrolytes. In addition, pharmacokinetics of SLV320 and ex vivo inhibition of adenosine A1 receptor activity were performed. SLV320 was well tolerated, and no serious adverse events were observed. Heart rate, blood pressure, pulmonary capillary wedge pressure, mean pulmonary arterial pressure, right atrial pressure, and cardiac output were not altered by any dose of SLV320. Pulmonary capillary wedge pressure was significantly (P=0.04) decreased by furosemide (-6.2+/-5.9 mm Hg). Systemic vascular resistance was significantly (P=0.04) increased in the furosemide group (+166.70+/-261.87 dynes . s(-1) . cm(-5)), whereas all SLV320 groups showed no significant alterations of systemic vascular resistance. Changes from baseline cystatin C plasma concentrations decreased after 10 mg SLV320 (-0.093+/-0.137 mg/L, P=0.046), whereas furosemide resulted in a significant (P=0.03) increase of cystatin C (+0.052+/-0.065 mg/L) versus baseline. All values represent mean changes+/-SD from baseline at 3 hours postdosing: SLV320 (10 and 15 mg) increased significantly sodium excretion and diuresis compared with placebo during the 0- to 6-hour collection period postdosing. CONCLUSIONS SLV320 infusion shows no immediate effects on cardiac hemodynamics. SLV320 might improve glomerular filtration rate while simultaneously promoting natriuresis and diuresis. Clinical Trial Registration- clinicaltrials.gov Indentifier: NCT00160134.
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Affiliation(s)
- Veselin Mitrovic
- Kerckhoff-Klinik, Department of Cardiology and Cardiosurgery, Bad Nauheim, Germany
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KAGER CCM, DEKKER GA, STAM MC. Measurement of cardiac output in normal pregnancy by a non-invasive two-dimensional independent Doppler device. Aust N Z J Obstet Gynaecol 2009; 49:142-4. [DOI: 10.1111/j.1479-828x.2009.00948.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Anderson GD, Carr DB. Effect of Pregnancy on the Pharmacokinetics of Antihypertensive Drugs. Clin Pharmacokinet 2009; 48:159-68. [DOI: 10.2165/00003088-200948030-00002] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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