Effect of diuretics on fetal growth: A drug effect or confounding by indication? Pooled Danish and Scottish cohort data

The Management of Preeclampsia: A Comprehensive Review of Current Practices and Future Directions

Preeclampsia (PE) is a disease in pregnancy that is characterized by new-onset hypertension end-organ dysfunction, often occurring after 20 weeks of gestation. Risk factors include a prior history of PE, diabetes, kidney disease, obesity, and high maternal age at pregnancy. Current treatment and management guidelines focus on the management of high blood pressure and any potential complications. The only known curative treatment is termination of pregnancy (either induction of delivery or cesarean section). However, the current guidelines and recommendations lack adequate prediction markers and are unable to prevent maternal and fetal mortality. There also exists a need for multidisciplinary collaborative action in view of the quality of life and psycho-educational counseling.

Gordon's syndrome in pregnancy

Gordon's syndrome, also known as pseudohypoaldosteronism type II and familial hyperkalaemic hypertension, is a rare inherited condition characterised by familial hyperkalaemia, normal anion gap hyperchloraemic metabolic acidosis, low renin with normal glomerular filtration rate and hypertension. The outcome of 11 pregnancies in 3 women with Gordon's syndrome is presented and combined with 13 pregnancies in 7 women previously described. Pregnancy in women with Gordon's syndrome appears to be associated with a significant risk of adverse pregnancy outcomes, particularly where there is maternal hypertension preconception. No pregnancy registry exists for Gordon's syndrome. The available data is limited to case reports and small case series and may be affected by bias. A pregnancy registry would be valuable to assist in preconception counselling and management during pregnancy. The goal of this study was to summarise the available cases describing pregnancy outcomes with maternal Gordon's syndrome.

Management of mitral stenosis: a systematic review of clinical practice guidelines and recommendations

A number of guidelines exist with recommendations for diagnosis and management of mitral stenosis (MS). We systematically reviewed existing guidelines for diagnosis and management of MS, highlighting their similarities and differences, in order to guide clinical decision-making. We searched national and international guidelines in MEDLINE and EMBASE (5/4/2011-5/9/2021), the Guidelines International Network, Guideline Library, National Guideline Clearinghouse, National Library for Health Guidelines Finder, Canadian Medical Association Clinical Practice Guidelines Infobase, and websites of relevant organizations. Two independent reviewers screened titles and abstracts, and the full text of potentially relevant articles where needed. Selected guidelines were assessed for rigor of development; only guidelines with Appraisal of Guidelines for Research and Evaluation II instrument score >50% were included in the final analysis. Four guidelines were retained for analysis. There was consensus for percutaneous mitral balloon commissurotomy as first-line treatment of symptomatic severe rheumatic MS with suitable anatomy. In patients with unfavourable anatomy, surgical intervention should be considered. Exercise testing is indicated if discrepancy exists between symptoms and echocardiographic measurements. There was no clear divide between rheumatic MS and degenerative MS for their respective diagnoses and management. Pregnancy in severe MS is discouraged and the stenosis should be treated before conception. Long-term antibiotic prophylaxis is recommended for patients with rheumatic MS. Recommendations for the management of patients with mixed valvular diseases are lacking.

A rare phenomenon of pregorexia in Pakistani women: need to understand the related behaviors

BACKGROUND

In Pakistan, for a decade or so, there has been a huge increase in body ideals, and thinness and eating disorders reported during pregnancy. The purpose of the present research was to study the lived experiences and behaviors characterized by pregorexia in Pakistani young women.

METHOD

A phenomenological approach was used to study eating disorder-related behaviors among pregnant women. A criterion sample of 15 women (22-34 years of age) having difficulty with their body image, the decline in caloric intake, skipping meals, and extensive exercise from a private gynae clinic of Islamabad was selected. The participants were screened on the DSM-5 criteria of anorexia nervosa. They were also asked questions about their diet intake, behaviors executed to lose or maintain weight, use of any medical or chemical substance to control weight, any social activities/behaviors, type of exercise if any, duration or frequency of exercise, and behaviors that made them feel better.

RESULTS

The findings revealed that 93.33% of women met the complete criteria of Anorexia nervosa. 86.6% had never been diagnosed or treated with anorexia nervosa, however, 13.33% were diagnosed with anorexia nervosa comorbid with depression. Results indicated a likelihood of having anorexic tendencies in 40% of women and the other 60% developed the symptoms during pregnancy only. Behaviors related to pregorexia were found to be: skipping meals, eating small portions, control on calorie intake, following diet plans available on YouTube, taking fat burn tea, avoiding the presence of elders of the family while taking meals, eating alone to limit food portion, taking laxatives or medicine to control weight, induced vomiting after eating, eating to match the norm of eating (supervised eating by elders) being pregnant and later self-induced vomiting, or eating slowly and consuming more time, pretending to eat the suitable amount of food. Women also engaged in fast walking, light exercise, and intensive cardio to control weight and stay in body shape. Around 86% reported that controlling weight, calorie intake, and exercising made them feel better.

CONCLUSION

There is a need to understand and differentiate pregorexia from other eating behaviors and problems among pregnant women with respect to cultural context.

In-utero exposure to antihypertensive medication and neonatal and child health outcomes: a systematic review

BACKGROUND

Although medication is generally avoided wherever possible during pregnancy, pharmacotherapy is required for the treatment of pregnancy associated hypertension, which remains a leading cause of maternal and fetal morbidity and mortality. The long-term effects to the child of in-utero exposure to antihypertensive agents remains largely unknown.

OBJECTIVE

The aim of this study was to systematically review published studies on adverse outcomes to the child associated with in-utero exposure to antihypertensive medications.

METHODS

OVID, Scopus, EBSCO Collections, the Cochrane Library, and Web of Science databases were searched for relevant publications published between January 1950 and October 2016 and a total of 688 potentially eligible studies were identified.

RESULTS

Following review, 47 primary studies were eligible for inclusion. The Critical Appraisal Skills Programme checklist was used to assess study quality. Five studies were of excellent quality; the remainder were either mediocre or poor. Increased risk of low birth weight, low size for gestational age, preterm birth, and congenital defects following in-utero exposure to all antihypertensive agents were identified. Two studies reported an increased risk of attention deficit hyperactivity disorder following exposure to labetalol, and an increased risk of sleep disorders following exposure to methyldopa and clonidine.

CONCLUSION

The current systematic review demonstrates a paucity of relevant published high-quality studies. A small number of studies suggest possible increased risk of adverse child health outcomes; however, most published studies have methodological weaknesses and/or lacked statistical power thus preventing any firm conclusions being drawn.

Pregnancy outcomes of anti-hypertensives for women with chronic hypertension: a population-based study

BACKGROUND

The impact of anti-hypertensive treatment on fetus was unclear, and hence, remains controversial. We set out in this study to estimate the prevalence of adverse pregnancy outcomes, including low birth weight, preterm delivery and small for gestational age amongst women with chronic hypertension, and to determine whether the use of anti-hypertensive drugs increases the risk of such adverse pregnancy outcomes.

METHODOLOGY/PRINCIPAL FINDINGS

A total of 2,727 hypertension mothers and 8,181 matched controls were identified from the population-based cohort. These hypertension women were divided into seven sub-groups according to different types of prescribed anti-hypertensive drugs. Multivariable logistic regressions were conducted to estimate the risk of low birth weight, preterm birth and small for gestational age. Increased risk of low birth weight (OR = 2.29, 95% CI = 1.95-2.68), preterm birth (OR = 2.18, 95% CI = 1.89-2.52) and small for gestational age (OR = 1.62, 95% CI = 1.45-1.81) were all discernible within the hypertension group after adjusting for potential confounding factors. The increased ORs were found to differ with different types of anti-hypertensive drugs. Women who received vasodilators were associated with the highest risk of low birth weight (OR = 2.96, 95% CI = 2.06-4.26), preterm birth (OR = 2.92 95% CI = 2.06-4.15) and small for gestational age (OR = 2.12, 95% CI = 1.60-2.82).

CONCLUSIONS/SIGNIFICANCE

This finding is important for practitioners, because it indicates the need for caution while considering the administration of anti-hypertensive drugs to pregnant women. These observations require confirmation in further studies that can better adjust for the severity of the underlying HTN.

Is it safe to use a diuretic to treat seizures early in development ?

There has been considerable interest in using bumetanide, a diuretic chloride importer NKCC1 antagonist, to reduce intracellular chloride ([Cl(-)](i)) in epileptic neurons, thereby shifting the polarity of GABA from excitatory to inhibitory and ameliorating the actions of GABA-acting antiepileptic drugs. However, a recent study raises the important issue of potential deleterious actions of bumetanide on immature neurons, because reduction of (Cl(-))(i) also alleviates a major source of excitation in developing neurons, upon which GABA exerts a trophic action. This review considers the importance of separating intrauterine from postnatal effects of bumetanide in normal versus pathologic neurons.

Use of diuretics during pregnancy

QUESTION

Several of my pregnant patients use diuretics for hypertension. I have heard that diuretics cannot be used in pregnancy because of the reduction of plasma volume and the potential for decreasing placental perfusion, as well as a possible diabetogenic effect.

ANSWER

Many studies--including a meta-analysis of almost 7000 neonates exposed to diuretics during pregnancy--did not find an increased risk of adverse effects, such as birth defects, fetal growth restriction, thrombocytopenia, or diabetes, among neonates exposed to diuretics in utero.

Associations between socio-economic factors and the use of prescription medication during pregnancy: a population-based study among 19,874 Danish women

OBJECTIVE

To examine the association between socio-economic factors and use of prescription medication during pregnancy in a population of Danish women.

METHODS

This was a population-based cohort study. Using record linkage from public administrative registries, we described the use of prescription medication during pregnancy and the financial and educational resources for each pregnant woman in the cohort.

RESULTS

The analyses included all 19,874 primiparous women delivering singletons in North Jutland county, Denmark, in 1991-1998. We identified 24,243 prescriptions filled by the women during their pregnancies. The highest overall prescription medication use was among women with basic schooling (OR 1.3; 95% CI 1.2-1.4), and lowest among women with the highest education (OR: 0.8; 95% CI 0.7-0.9) compared with women who had vocational education. Stratified analysis of therapeutic subgroups revealed that socio-economic factors were associated with the use of anti-infective and anti-asthmatic medications during pregnancy.

CONCLUSION

Maternal educational level, and to a lesser degree household income, paternal educational level and cohabitation status, was associated with the use of prescription medication during pregnancy. However, the analyses did not take into account important clinical variables such as maternal illness, and the results could be affected by differential misclassification of exposure information, by confounding or chance.