Antihypertensive Therapy in Pregnancy Directed by Noninvasive Hemodynamic Monitoring

Easterling, Thomas R.; Benedetti, Thomas J.; Schmucker, Barbara; Carlson, Karen L.

doi:10.1055/s-2007-999553

Cited by 44 publications

(26 citation statements)

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“…As recently reviewed, few trials have evaluated hemodynamic‐guided antihypertensive therapy in pregnant women 7. Similar to the non‐pregnant literature, antihypertensive therapy based on cardiac output and total peripheral resistance may be an effective therapeutic strategy to improve maternal blood pressure control 23, 26, 27, 28, 29. Hemodynamic‐guided antihypertensive therapy for pregnant women presenting with any type of hypertension significantly reduced the rates of severe maternal hypertension from 18% to 3.5%, when compared with standard care 30.…”

Section: Discussionmentioning

confidence: 99%

Phenotypes of Pregnant Women Who Subsequently Develop Hypertension in Pregnancy

McLaughlin

Zhang

Lye

et al. 2018

JAHA

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BackgroundHypertensive disorders complicating pregnancy are a major cause of maternal death. Our objective was to evaluate maternal clinical, hemodynamic, and placental prognostic indicators in a consolidated manner to identify women who develop hypertension in pregnancy.Methods and ResultsTwenty‐six normotensive pregnant women from a specialized Placenta Clinic at increased risk of developing de novo hypertension and 20 normotensive healthy pregnant controls were recruited at 22 to 26 weeks' gestation. Fourteen maternal clinical, hemodynamic, and placental characteristics were assessed in the second trimester and aggregated. Principal component analysis of this combined data set determined that 3 dimensions accounted for 56% of the cohort variability. The first dimension accounted for 31% of the cohort variability, with significant contributions from total peripheral resistance, endoglin, and cardiac output. The second dimension was predominantly influenced by body mass index and mean arterial pressure, while uric acid and myeloperoxidase mainly contributed to the third dimension. Unsupervised clustering identified 3 groups within this combined data set. Total peripheral resistance was the most significant distinguishing parameter between these groups (P<0.0001), followed by placental growth factor, endoglin, and cardiac output (P<0.0001). Using these 4 parameters, a receiver operating curve was constructed with an area under the curve of 0.975 (95% confidence interval 0.93–1) for the prediction of developing hypertension in pregnancy.ConclusionsConsolidated assessment of prognostic indicators in the second trimester of pregnancy may be useful to characterize and distinguish pathways by which women may develop hypertension in pregnancy. This approach could contribute to the development of pathway‐specific preventative and antihypertensive treatment strategies.

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Section: Discussionmentioning

confidence: 99%

Phenotypes of Pregnant Women Who Subsequently Develop Hypertension in Pregnancy

McLaughlin

Zhang

Lye

et al. 2018

JAHA

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“…In Figure 1, the vector labeled “hydralazine” demonstrates the hemodynamic changes observed in 10 pregnant hypertensive women with elevated vascular resistance treated with oral hydralazine. 16 The observed vector of effect runs perpendicular to lines of resistance as would be expected with the assumed mechanism of action. A modest reduction in mean arterial pressure, (−6.9±7.0 mmHg, 6% below baseline), is accompanied by a substantial increase in cardiac output (2.0±1.3 L/min, 38% above baseline).…”

Section: Pharmacodynamics Of Antihypertensive Agents In Pregnancymentioning

confidence: 65%

Pharmacological management of hypertension in pregnancy

Easterling

2014

Seminars in Perinatology

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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 paper 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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“…35 We treated subjects with elevated CO with atenolol, based on our previous studies that evaluated the hemodynamic responses of antihypertensive therapy during pregnancy and the prevention of preeclampsia with atenolol therapy. 15,36 Subjects 2 and 3 responded well, with no hypertensive complications until the late third trimester, at which time subject 3 developed preeclampsia. However, subjects 4 and 5 developed hypertensive complications characterized by vasoconstriction much earlier in pregnancy despite treatment.…”

Section: Discussionmentioning

confidence: 95%

“…15 Subjects with low-resistance, high-CO (Ն7.5 L/min) hypertension were treated with a beta-blocker (i.e., atenolol). Subjects with high-CO hypertension secondary to an elevated stroke volume were treated with furosemide in addition to atenolol.…”

Section: Methodsmentioning

confidence: 99%

Maternal hemodynamics and pregnancy outcome in women with prior orthotopic liver transplantation

Carr¹,

Larson

Schmucker³

et al. 2000

Liver Transpl

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The aim of this study is to evaluate the hemodynamics and pregnancy outcome of women with prior orthotopic liver transplantation. Hemodynamic measurements by Doppler technique were performed on pregnant subjects with prior orthotopic liver transplantation. Maternal characteristics, renal function, pregnancy complications, delivery indications, delivery mode, and neonatal outcomes were evaluated. Six pregnancies occurred in 5 women after orthotopic liver transplantation at the University of Washington Medical Center (Seattle, WA) between 1991 and 1999. Four of the 6 pregnancies were complicated by chronic hypertension, fetal growth restriction, and preterm delivery. Two pregnancies had worsening hypertension characterized by vasoconstriction in the second trimester despite antihypertensive therapy. These 2 subjects were administered cyclosporine for maintenance immunosuppression and had greater mean arterial pressures preconception and in the first trimester than the other subjects. One of these pregnancies resulted in fetal demise at 25 weeks' gestation. The other subject was delivered at 28 weeks' gestation for nonreassuring fetal status and superimposed preeclampsia. All pregnancies were complicated by renal insufficiency; however, the 2 subjects with poor obstetric outcome had preconception serum creatinine levels greater than 1.5 mg/dL and creatinine clearances less than 40 mL/min. Pregnancies complicated by second-trimester vasoconstriction and moderate renal insufficiency are at risk for preeclamspia, fetal growth restriction, and fetal demise. Good obstetric outcome can occur in women with mild renal insufficiency and well-controlled chronic hypertension. Improved hypertensive control preconception may decrease the risk for preeclampsia and poor obstetric outcome. Copyright 2000 by the American Association for the Study of Liver DiseasesP regnancies in women with prior orthotopic liver transplantation are complicated by fetal growth restriction (9% to 20%), preterm delivery (40% to 86%), cesarean delivery (45% to 71%), and preeclampsia (20% to 71%). 1-5 Significant preeclampsia rates of 27% to 71% have been reported by several investigators who evaluated smaller series of patients. 1,3 However, larger studies 2,5 and registry data 4 report preeclampsia rates in the range of 13.6% to 21%. Most of the women included in these reports were administered cyclosporine, prednisone, and azathioprine as maintenance immunosuppression. Recently, pregnancy outcomes were published for women administered tacrolimus (FK506) for maintenance immunosuppression. These women had lower rates of preeclampsia (0% to 4%), severe chronic hypertension (0% to 11%), and fetal growth restriction (0% to 4%) and similar rates of cesarean delivery (44%) and preterm delivery (48%) as patients administered cyclosporine. 6,7 The increased rate of pregnancy complications is not surprising because both cyclosporine and FK506 are known to cause renal insufficiency and hypertension. [8][9][10][11] Our institution has previously described pregna...

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Antihypertensive Therapy in Pregnancy Directed by Noninvasive Hemodynamic Monitoring

Cited by 44 publications

References 0 publications

Phenotypes of Pregnant Women Who Subsequently Develop Hypertension in Pregnancy

Phenotypes of Pregnant Women Who Subsequently Develop Hypertension in Pregnancy

Pharmacological management of hypertension in pregnancy

Maternal hemodynamics and pregnancy outcome in women with prior orthotopic liver transplantation

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