Sven Montan

Randomised controlled trial of atenolol and pindolol in human pregnancy: effects on fetal haemodynamics.

OBJECTIVE--To compare the effects of uteroplacental circulation of two beta adrenoceptor blockers, atenolol (cardioselective) and pindolol (non-selective with intrinsic sympathomimetic activity). DESIGN--Controlled double blind double dummy study. SETTING--Departments of obstetrics and gynaecology in two Swedish university hospitals. SUBJECTS--29 women with pregnancy induced hypertension in the third trimester, 13 randomised to atenolol and 16 to pindolol. MAIN OUTCOME MEASURES--Pulsatility index in fetal aorta, umbilical artery, and maternal arcuate artery. Volumetric blood flow in fetal aorta and umbilical vein. RESULTS--Mean arterial blood pressure decreased by 9.0 (95% confidence interval -13.0 to -5.0) mm Hg in the atenolol group and by 7.8 (-11.4 to -4.2) mm Hg in the pindolol group. During atenolol treatment the pulsatility index increased significantly from 1.82 (SD 0.20) to 2.07 (0.32) in the fetal thoracic descending aorta, from 1.44 (0.28) to 1.79 (0.27) in the abdominal aorta, and from 0.93 (0.17) to 1.05 (0.19) in the umbilical artery; the volumetric blood flow in the umbilical vein decreased from 106 (28.8) to 84 (22.6) ml/min/kg. No such changes were seen after treatment with pindolol. Birth weight was similar in the two groups but placental weight was significantly different (529 (122) g in atenolol group v 653 (136) g in pindolol group; p = 0.03). CONCLUSION--The hypotensive effect was similar with both drugs, but only the beta 1 blocker atenolol had significant effects on fetal haemodynamics, although within normal ranges. The implications of these findings can be only speculative, but negative fetal consequences of beta 1 adrenoceptor blockade cannot be excluded.

Randomised controlled trial of methyldopa and isradipine in preeclampsia : effects on uteroplacental and fetal hemodynamics

This is a prospective randomised controlled study in 21 women admitted with preeclampsia in the third trimester. The mean arterial blood pressure decreased by 11.1 mmHg (95% confidence interval -14.9 to -7.3 mmHg) in the methyldopa group, and by 9.3 mmHG (95% confidence interval-14.4 to -4.2 mmHG) in the isradipine group. The maternal heart rate decreased by 6.9 beats per min (95% confidence interval -11.6 to -2.2 bpm) during methyldopa treatment, and by 2.5 beats per min (95% confidence interval -9.2 to 4.3) during isradipine treatment. Pulsatility index in maternal and fetal vessels was not affected by either of the two drugs. The birth weight and placental weight and neonatal outcome were similar and uneventful. The hypotensive effect was similar for methyldopa and isradipine. Except reduced maternal heart rate on methyldopa, fetal and uteroplacental hemodynamics were not altered during treatment of preeclampsia with methyldopa or isradipine.

Effect of methyldopa and isradipine on fetal heart rate pattern assessed by computerized cardiotocography in human pregnancy

OBJECTIVE The effects of two antihypertensive drugs, methyldopa and isradipine, on fetal heart rate pattern were analyzed by computerized cardiotocography. STUDY DESIGN The first part of the study was a prospective, randomized, controlled trial of 19 women with preeclampsia in the third trimester given 2.5 mg of oral slow-release isradipine twice a day or 250 mg of methyldopa three times a day. In a second part of the study 23 women with preeclampsia in the third trimester given 5 mg of oral slow-release isradipine twice a day were compared with 23 matched controls without medication. Main outcome measures were maternal blood pressure and mean baseline fetal heart rate, fetal movements, number of accelerations, periods of high and low baseline variability, and mean baseline heart rate variability. RESULTS Compared with the pretreatment value, the mean arterial blood pressure decreased significantly in all drug treatment groups. Fetal heart rate characteristics were not significantly changed during drug treatment or bed rest. CONCLUSION The various features of the fetal heart rate pattern evaluated by computerized methods were not influenced by treatment with methyldopa or isradipine.

Fetal and uteroplacental haemodynamics during short-term atenolol treatment of hypertension in pregnancy

Fetal circulation was studied by means of combined realtime and pulsed Doppler ultrasound in 14 women with pregnancy‐associated hypertension before and during the first and third days of treatment with the β1‐selective blocker, atenolol; in seven of the women the maternal uterine arcuate blood velocity waveform was also studied. Blood flow characteristics were normal both in the fetus and in the maternal arcuate artery, compared with those in uncomplicated pregnancies of corresponding gestational ages. Volume blood flow remained unchanged in the fetal descending aorta, and in the umbilical vein during atenolol treatment, whereas the pulsatility index increased in the fetal descending aorta and in the arcuate artery. This suggests that the peripheral vascular resistance, both on the maternal and fetal side of the placenta, increased during short‐term antihypertensive treament with atenolol.

Hypertension in Pregnancy - Fetal and Infant Outcome a Cohort Study

The influence of hypertension on fetal outcome was investigated in a cohort study over four years (1981–1984). Hypertension occurred in 7.7% of the 9616 pregnancies. The total number of live born infants was 9654: 746 in conjunction with hypertension and 8908 in conjunction with normotension. All pregnancies were dated by an ultrasound scan in week 17. Antihypertensive treatment with beta-adrenoceptor- blockade was given in 266 patients. No significant differences in fetal, neonatal or perinatal mortality rate were observed between hypertensive and normotensive pregnancies when these mortality rates were studied separately. However, the total fetal and infant mortality was found to be significantly higher in hypertensive pregnancies (19.6/1000) as compared with normotensives (9.5/1000). The highest mortality rates were found in pregnancies complicated by proteinuric hypertension (pre-eclampsia) and chronic hypertension. Mortality in hypertensive pregnancies was mainly confined to preterm birth and birth w...

Intrapartum fetal heart rate patterns in pregnancies complicated by hypertension: A cohort study

Intrapartum fetal heart rate patterns were investigated in pregnancies complicated by hypertension in a cohort study. The total number of live births was 2400 and the frequency of hypertension was 8.8%. The study group comprised 2023 normotensive and 200 hypertensive deliveries. Dates of all pregnancies were established at an ultrasound examination in week 17. Ominous intrapartum fetal heart rate patterns were significantly more common in hypertensive deliveries than in normotensive deliveries (20.5% versus 7.6%). The women with hypertension were compared with a group of control women matched for age, parity, induction of labor, and gestational week (20.5% versus 6.5%). In hypertensive women ominous fetal heart rate tracings were frequently associated with primiparity, induced labor, epidural block, delivery of a growth-retarded fetus, and beta 1-adrenergic receptor blockers. Ominous fetal heart rate patterns were less common in hypertensive women without these risk factors; still the significant differences in comparison with normotensive women remained. The hypertensive pregnancies accounted for no less than 21.0% of all ominous intrapartum fetal heart rate patterns, whereas 13% of all cases of ominous intrapartum fetal heart rate patterns could be attributed to the excess frequency in hypertensive pregnancies.

AMNIOCENTESIS IN TREATMENT OF ACUTE POLYHYDRAMNIOSIS IN TWIN PREGNANCIES

Abstract. A rare complication in twin pregnancy is acute polyhydramniosis. If left untreated, the perinatal mortality is 100%. the clinical courses of two cases treated with ultrasound‐guided amniocentesis are presented. in the first case altogether 4 87S ml amniotic fluid was drained. Both twins died within the first 24 hours of life after delivery in gestational week 26. in the second case 2 150 ml amniotic fluid was drained. Both twins survived and were delivered in good condition in gestational week 35. We recommend ultrasound‐guided amniocentesis to be performed in twin pregnancy affected by acute polyhydramniosis.

Computerised cardiotocography following vibro-acoustic stimulation.

To study the effect of vibro-acoustic stimulation (VAS) to the mean fetal heart rate (FHR), period of high and low FHR variation, overall variation (msec and bpm) and short term variation (msec). In a prospective study 17 pregnant women between 34-42 weeks gestation admitted to antenatal ward for obstetric complications two 60 min FHR recording was carried out with an interval of 30 min in between recordings. On a random basis the fetus was stimulated by a vibro-acoustic stimulator for 5 sec at the beginning of one of the two 60 min FHR recordings. Automated analysis of the FHR, tocodynamometry, and maternal perception of fetal movements was done by a commercially available computerized programme (System 8000). It was possible to obtain the two 60 min recordings with signal loss of < 10% in 12 out of 17 patients. No changes were observed when the FHR parameters for 60 min after VAS was compared with the control period. When analyzed in segments of 0 to 10, 11 to 20, 20 to 40 and 41 to 60 min the mean baseline FHR was significantly higher after VAS during the first 10 minutes compared with any 10 or 20 min segment of the control period or any such segments 10 min after VAS. Concomitantly the overall variation and short-term variation was significantly lower during the first 10 minutes following VAS (p < 0.05) compared with the parameters in the corresponding periods during the control period.(ABSTRACT TRUNCATED AT 250 WORDS)

CLASSIFICATION OF THE NONSTRESS TEST AND FETAL OUTCOME IN 1056 PREGNANCIES

Abstract. During a 2 1/2‐year period, 1056 pregnant women (1072 fetuses) were monitored with the nonstress test (NST) in the antenatal period. Testing time was 30 minutes. The NST was classified into one of four classes: normal, suspect pathological, slight pathological, and severe pathological. In 88.5% of the pregnancies, all NSTs were normal. Suspect, slight, or severe pathological NSTs occurred at least once in 8.1%, 2.1%, and 1.3% of the women respectively. All women with a severe pathological NST had high‐risk complications. Lethal malformations excluded, there were only two perinatal deaths among the tested women. In the four different classes, the frequencies of cesarean section were 11%, 17%, 41%, and 79%. One‐minute Apgar scores were <7 in 5%, 12%, 41%, and 64%. The need for referral to neonatal intensive care was 19%, 40%, 41%, and 93% respectively. A normal NST predicted normal fetal outcome in an excellent way, while the three pathological classes appeared to represent different degrees of impending fetal jeopardy.

Fetal and infant outcome of pregnancies with very early rupture of membranes

Fetal and infant outcome was studied in 38 singleton pregnancies complicated by very early rupture of membranes (PROM), in gestational weeks 19‐29, over a 4‐year period, in a Swedish population. The pregnancies were managed according to a specified protocol, including postponement of delivery until 34 weeks of gestation if possible. Stillbirth occurred in 10 cases (26.3%), all with PROM before 26 completed weeks, while 6 other infants died in the neonatal period. Respiratory distress syndrome was evident in half (50.0%) of the 28 liveborn infants. The surviving 22 infants (57.9%) were followed up to 2 years of age. The rate of neurological sequelae at follow‐up was 22.7 % (5/22). The fetal outcome of the 20 pregnancies with rupture of membranes before 26 completed weeks was poor; only 7 infants of the 10 born alive survived the neonatal period. The short‐term fetal outcome in the group with rupture of membranes in 26‐29 completed weeks was better: 15 of the 18 infants survived, but 4 had neurological sequelae. PROM before 29 completed weeks of gestation is associated with severe short‐term and long‐term fetal complications, in cases where the pregnancy is prolonged for several weeks.