Transplacental passage of isradipine in the treatment of pregnancy-induced hypertension

Glycemia in newborns of hypertensive mothers according to maternal treatment

PURPOSE: To evaluate the evolution of glycemic levels in newborns of hypertensive mothers according to maternal treatment. METHODS: Prospective randomized study, including 93 newborns of mothers treated with isradipine (n = 39), atenolol (n = 40), or low sodium diet (control group - n=14). Glycemia was determined at birth (mother and newborn by the oxidase glucose method) and in the 1st, 3rd, 6th, 12th, and 24th hours after birth (newborn by a test strip method). The evolution of glycemia was analyzed in each group (Friedman test). The groups were compared regarding glycemia (Kruskall-Wallis test), and linear regression models were constructed for the analyses (independent variable = maternal glycemia; dependent variables = umbilical cord, 3rd, and 6th hour glycemia). RESULTS: There were no statistically significant differences among the mean blood glucose levels of the 3 groups in any of the assessments. There was a correlation between maternal and umbilical cord blood glucose in the isradipine (r = 0.61; P <.05) and control (r = 0.84; P <.05) groups. Regarding glycemia levels of the mothers and newborns in the third and sixthhours postpartum, this correlation was present only in the control group (maternal x third hour: r = 0.65; P <.05; maternal x sixth hour: r = 0.68; P <.05). There were no correlations in the atenolol group. Hypoglycemia was detected in 51.3% of the isradipine group, 60% of the atenolol group, and 35.7% of the control group, and it was more frequent in the first hour postpartum in all groups. CONCLUSIONS: The results suggest a similar effect of the 3 types of treatment upon newborn glycemia. The correlation analysis suggests that isradipine could have effects upon newborn glycemia only after birth (correlation only in umbilical cord blood), whereas atenolol could act earlier (there was no correlation at any moment). The results also point to the need for glycemic control from the first hour postpartum of newborns of hypertensive mothers whether they have or have not undergone treatment with antihypertensive drugs.

Influence of magnesium sulphate and isradipine on human placental cotyledon fetal vessels in vitro

Increased systemic vascular resistance and blood pressure during pregnancy may be due to impaired prostacycline PGI(2)-thromboxan (TX) A(2) balance. The aim of the study was to compare the influence of magnesium sulphate and isradipine on the placental vascular resistance induced by stable thromboxan A(2) analogue U 46619 in experimental bilateral perfusion of the human placental cotyledon. The research used the experimental model described by Schneider et al. [Am. J. Obstet. Gynecol. 114 (1972) 822]. The control group consisted of six placental lobule perfusions lasting 120 min each. Constant increase in perfusion pressure of mean value 185% of the initial pressure was obtained from about the 60th min of the experiment and maintained till the end. Having obtained constant increase in perfusion pressure from the 60th min of the experiment, magnesium sulphate and isradipine were administered along with thromboxan A(2) analogue U 46619 into the fetal circulation. Both drugs lowered perfusion pressure, experimentally increased by thromboxan A(2) analogue U 46619. The onset of magnesium sulphate activity was quicker than isradipine. According to the results of our in vitro study, magnesium sulphate and isradipine may have a beneficial effect on vascular resistance of cotyledon vessels in PIH in vivo, too.

Antihypertensive drugs during pregnancy

Hypertensive disorders are the most common medical disorders during pregnancy. Their presence is associated with increased adverse maternal and fetal outcomes both acute and long-term. Antihypertensive agents are widely used in the treatment of these pregnancies despite absent evidence of either benefits or harms from this therapy. Multiple agents are available and various guidelines recommend different agents and various doses and regimens in the absence of information about the pharmacokinetics, disposition, and pharmacodynamic effects of these drugs in pregnancy. Randomized trials comparing antihypertensive therapy to a placebo are lacking and the available data have not shown clinical benefits because of inadequate sample size to rule out even moderate to large effects on perinatal outcome. In addition, data on teratogenic effects, adverse fetal-neonatal effects, and long-term infant outcome are also scant. These problems resulted from lack of interest and support by the government and pharmaceutical companies to conduct research in pregnant women because of regulatory and medical-legal concerns. Consequently, there is an urgent need to conduct clinical research in this area.

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.

Placental transfer of drugs administered to the mother

Drugs administered to mothers have the potential to cross the placenta and reach the fetus. Under particular circumstances, the comparison of the drug concentration in the maternal and fetal plasma may give an idea of the exposure of the fetus to the maternally administered drugs. In this review drugs are classified according to their type of transfer across the placenta. Several drugs rapidly cross the placenta and pharmacologically significant concentrations equilibrate in maternal and fetal plasma. Their transfer is termed 'complete'. Other drugs cross the placenta incompletely, and their concentrations are lower in the fetal than in maternal plasma. The majority of drugs fit into 1 of these 2 groups. A limited number of drugs reach greater concentrations in fetal than maternal plasma. It is said that these drugs have an 'exceeding' transfer. The impression prevails that suxamethonium chloride (succinylcholine chloride) and doxorubicin do not cross the placenta. However, a careful analysis of the literature suggests that this impression is wrong and that all drugs cross the placenta, although the extent transfer varies considerably. The following parameters were considered as possible factors determining the extent of placental transfer: (i) the molecular weight of the drug; (ii) the pKa (pH at which the drug is 50% ionised); and (iii) the extent of drug binding to the plasma protein. Drugs with molecular weights greater than 500D have an incomplete transfer across the human placenta. Strongly dissociated acid drug molecules should have an incomplete transfer, but this does not seem to be an absolute rule. For example, ampicillin and methicillin transfer completely and they are strongly dissociated at physiological pH. The extent of drug binding to plasma protein does not influence the type of drug transfer across the human placenta.