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The Effect of Antihypertensive Drugs on the Fetus

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The Effect of Antihypertensive Drugs on the Fetus Journal of Human Hypertension (2002) 16, 293–298 2002 Nature Publishing Group All rights reserved 0950-9240/02 $25.00 www.nature.com/jhh REVIEW ARTICLE The effect of antihypertensive drugs on the fetus T Rosenthal1 and S Oparil2 1Chorley Hypertension Research Institute, Chaim Sheba Medical Center, Tel Hashomer and Sackler School of Medicine, Tel Aviv University, Israel; 2Department of Medicine, Division of Cardiovascular Disease, Vascular Biology and Hypertension Program, University of at Birmingham Alabama School of Medicine Birmingham, AL, USA A critical review of the literature on the effects of antihy- scores that some antihypertensive drugs can be used pertensive drugs on the fetus in pregnant women is safely at certain stages of pregnancy, while others are presented. The survey covers the alpha-adrenergic suspect and to be avoided at all costs. The lack of pla- receptor agonists, beta-blockers including topical eye cebo-controlled studies on the treatment of severe medications, alpha-beta blockers, calcium antagonists, hypertension in pregnancy due to ethical consider- diuretics, and angiotensin-converting enzyme (ACE) ations is discussed against the background of the inhibitors. The lack of data on angiotensin II receptor pressing need to treat these women despite the poss- blockers is noted although effects are considered to be ible deleterious effects of antihypertensive drugs similar to those reported with ACE inhibitors and there- Journal of Human Hypertension (2002) 16, 293–298. DOI: fore to be avoided. Analysis of the literature under- 10.1038/sj/jhh/1001400 Keywords: hypertension in pregnancy; antihypertensive drugs and fetus; teratology and antihypertensive drugs Introduction Methyldopa The use of antihypertensive drugs in pregnant On the basis of reports of stable uteroplacental blood women with chronic hypertension remains contro- flow and fetal haemodynamics,6 methyldopa has versial in light of the usual fall in blood pressure become the preferred agent as first-line therapy and that occurs during the first half of pregnancy,1 and has been used most commonly in randomised the probable deleterious effects on fetal growth and trials.7 It is considered the safest and most effi- development of antihypertensive drugs and treat- cacious antihypertensive drug for use in pregnancy ment-induced blood pressure declines.2,3 Whether and is therefore recommended by all working or not pre-eclampsia develops, the presence of pro- groups.8 Kirsten and colleagues9 consider it the only teinuria early in pregnancy puts women with acceptable drug during the first trimester of preg- chronic hypertension at higher risk for adverse neo- nancy. natal outcomes.4 Rey and Couturier5 retrospectively evaluated the course of 298 pregnant women with chronic hypertension whose antihypertensive medi- Alpha-and beta-adrenergic blocking cations had been discontinued or reduced in doses agents – labetalol early in pregnancy. Neither superimposed pre- When methyldopa causes somnolence and cannot eclampsia, preterm delivery, abrupto placentae, nor be tolerated, alternatives such as the alpha-beta- perinatal death was less frequent than in treated adrenergic blocking agent, labetalol, may be used. women. Although placebo-controlled trials on anti- Clinical experience with labetalol is extensive and hypertensive drug treatment in pregnancy are lack- it is among the most widely used antihypertensive ing, considerable data have accumulated on this drugs in pregnancy.10 Blood pressure and pro- topic (Table 1). teinuria fell significantly in a placebo controlled trial of labetalol in a cohort of 144 women with preg- nancy-induced mild and moderate hypertension. However, gestation was not significantly prolonged Correspondence: T Rosenthal, MD, Chorley Hypertension and measures of clinical outcome were not signifi- 11 Research Institute, Chaim Sheba Medical Center, Tel Hashomer cantly altered in these women. Possible advan- 52621, Israel. E-mail: trosenthȰsheba.health.govil tages and no evidence of disadvantages for the fetus Antihypertensive drugs and the fetus T Rosenthal and S Oparil 294 Table 1 Antihypertensive therapy of chronic hypertension in later stages. A randomised trial in which atenolol or pregnancy placebo was given before 24 weeks of gestation to normotensive pregnant women with high cardiac Drug Dosage Additional comments output in an attempt to prevent pre-eclampsia revealed similar results, namely smaller babies than Methyldopa 500–3000 mg Considered to be drug of choice 17 18 in 2–4 divided because of extensive experience those getting placebo. Churchill et al, on the doses other hand, found little difference in fetal growth Labetalol 200–1200 mg Similar in efficacy and safety to between women who began atenolol in the second in 2–3 divided methyldopa trimester, women on other antihypertensive drugs, doses and those using no medication. Beta-blockers variable Possibility of fetal bradycardia, A basic concern of these and other authors is the lower birth weight (when used level at which blood pressure should be treated and early in pregnancy) to which blood pressure should be lowered in preg- Calcium variable Accumulating data support nancy. Magee19 raises this question, noting that channel maternal and fetal safety; may many factors are likely to affect fetal growth other blockers interact with magnesium than maternal blood pressure. He points to the con- sulfate nection between antihypertensive treatment and the Alpha- variable Scant data for use in pregnancy goal of best perinatal outcome, which remains to be blockers addressed. An international multicentre randomised Clonidine 0.1–0.8 mg in Limited data controlled trial, Control of Hypertension in Preg- 2–4 divided doses nancy and small for gestational age (SGA) Infants (CHIPS), is currently being designed to answer Thiazide variable May be associated with these questions.20 diuretics diminished volume expansion in pregnancy; may be necessary Since topical eye medications are absorbed in salt-sensitive hypertensives through the nasopharyngeal mucosa and can there- at lower doses fore enter the systemic circulation, beta-blocker eye Angiotensin- contraindicated Contraindicated in pregnancy; drops should be avoided in the first trimester of converting neonatal anuric renal failure pregnancy. This is especially noteworthy because enzyme glaucoma can occur during the second to the fifth inhibitors decade of life, a time when women are at risk for Angiotensin contraindicated Contraindicated in pregnancy; pregnancy. Indeed, Wagebvoort et al21 reported a receptor neonatal anuria renal failure. case in which timolol eye drops were associated antagonists with bradycardia and arrhythmia in the fetus, a From: August P, Falkner B. Hypertension in pregnancy and in phenomenon observed also in sheep by Van 22 children. In: Antman E (ed). Cardiovascular Therapeutics: A Tetten. The literature on the use of other forms of Modified Companion to Braunwald’s Heart Disease. W.B. Saund- eye drops, such as betaxolol and levobunolol in ers Company: Philadelphia, PA, Chapter 38, 2001 (published pregnant women, is lacking.23 last week). were reported in another trial with labetalol, this Alpha adrenergic blocking agents time a double-blind controlled study in 152 women.12 Thus labetalol is generally not considered Although prazosin is rarely used in pregnancy, it to adversely affect the fetus during the third trimes- was recently reported that in the third trimester, ter of pregnancy, and is commonly used to treat fetal concentrations of prazosin are 10–20% of the hypertension at that stage.10 maternal concentrations, suggesting the possibility that prazosin may affect the fetus.24 Prazosin has Beta-adrenergic blocking agents been associated with transverse limb defects in the fetus in a case report.25 Prazosin taken from day 7 The beta-adrenergic receptor antagonists, including of gestation resulted in limb defects, hypoxic renal metoprolol and atenolol, are also considered safe damage, and intrauterine death at 20 weeks. These and effective in late gestation, but have been authors25 attributed the anomalies to drug-induced reported to cause some fetal problems when given in hypotension in the mother, with resultant dimin- early or mid-gestation.13,14 Beta-blockers, especially ished uteroplacental blood flow, fetal hypotension atenolol, have been linked with fetal growth retar- and hypoxia. This is only a speculation, and if this dation when given early in pregnancy.15 A large- were the case, we would expect to see more limb scale retrospective study of atenolol in 78 preg- reduction defects in the population treated with nancies showed that the drug was associated with antihypertensive drugs than we actually do. One fetal growth retardation, particularly when it was should be cautious about drawing conclusions con- given early in pregnancy and continued for a long cerning the adverse effects of drugs on the fetus time.16 These authors urge avoiding atenolol in the based on isolated case reports since fetal defects early stages of pregnancy and exercising caution at occur in a sporadic case in the general population of Journal of Human Hypertension Antihypertensive drugs and the fetus T Rosenthal and S Oparil 295 pregnant women independent of both hypertension 7000 pregnant women receiving diuretics, revealed and antihypertensive therapy. a decrease in the tendency of the women to develop oedema and/or hypertension. Pre-eclampsia, Vasodilators appeared to have been prevented even when oedema was not a diagnostic
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