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LABETALOL IN PIH CAN IT SUPPLANT
ALPHA METHYL DOPA ?
DR KAVITA PRIYA M.D.(O &G) MEDICAL
SUPERINTENDENT.CENTRAL
HOSPITAL,DHANBAD
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HYPERTENSION IN PREGNANCY
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Hypertension can turn pregnancy into a nightmare.
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Historically, hypertension and pregnancy have intertwined, sometimes causing maternal death. At the turn of the 20th century, one in 100 live births resulted in maternal death, according to WHO.
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American Family Physician. 2001 Jul 15;64(2):263-271
Categories of Hypertension in Pregnancy
HTN in Pregnancy
Pre-eclampsia superimposed on
Chronic HTN
Pre-eclampsia
Gestational HTN
Chronic HTN
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Chronic Hypertension
• “Pre-existing Hypertension”
• Chronic hypertension is caused by Primary = “Essential Hypertension” Secondary HTN = Result of other medical conditions
Systolic pressure ≥140 mmHg, diastolic pressure ≥90 mmHg, or both.
Presents before 20th week of pregnancy or persists longer than 12th weeks postpartum.
American Family Physician.2004; 70(12 ):2317-2324
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Systolic pressure ≥140 mmHg, diastolic pressure ≥90 mmHg, or both.
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• Design: Retrospective, population-based cohort study
• N= 29,842 women who delivered with chronic hypertension
Conclusion: Pregnant women with chronic hypertension have significantly increased risks of maternal and perinatal morbidity and mortality.
The Journal of Reproductive Medicine. 2007 Nov;52(11):1046-51
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• Mild hypertension without proteinuria or other signs of pre-eclampsia.
Gestational Hypertension
• Develops in late pregnancy, after 20th weeks gestation.
• Resolves by 12th weeks postpartum.
• One fourth of women with gestational hypertension develop proteinuria and thus progress to pre-eclampsia.
• Can progress in to pre-eclampsia. * Often when hypertension develops <30 weeks gestation.
American Family Physician.2004; 70(12 ):2317-2324
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• New onset of hypertension and proteinuria after 20 th weeks gestation.
Pre-eclampsia
• Incidence: In India, pre-eclampsia occurs in 10% primigravidae (women
pregnant for 1st time) and 5% in multigravidae (a woman who is pregnant and has been pregnant at least twice before) in hospital.
Systolic blood pressure ≥140 mmHg OR diastolic blood pressure ≥90 mmHg
Proteinuria of 0.3 g or greater in a 24-hour urine
Dutta DC. Textbook of obstetrics. 5th edition. Central publication, 234-255
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Continue…..
American Family Physician.2004; 70(12 ):2317-2324
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Continue…..
American Family Physician.2004; 70(12 ):2317-2324
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Continue…..
American Family Physician.2004; 70(12 ):2317-2324
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BP = or > or 160mm Hg systolic or BP = or > 110mmHg diastolic
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• Eclampsia, a severe complication of pre-eclampsia, is the new onset of seizures in a woman with pre-eclampsia.
• Eclampsia seizures are relatively rare and occur in <1% of women with pre-eclampsia.
Continue…..
Up to 40% of eclamptic seizures
occur before delivery;
approximately 16% occur more than
48hrs after delivery
American Family Physician.2004; 70(12 ):2317-2324
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Risk factors for Pre-eclampsia
Pregnancy associated factors
Chromosomal abnormalities
Hydatidiform mole
Hydrops fetalis
Multifetal pregnancy
Urinary tract infections
Maternal-specific factors
Age <20years & >35 years
Family history of pre-eclampsia
Nulliparity
Pre-eclampsia in previous pregnancy
Specific medical conditions: gestational diabetes, Type 1 diabetes, obesity, chronic hypertension, renal disease
New paternity
First time father
Previously fathered a pre-eclamptic pregnancy in another woman
American Family Physician.2004; 70(12 ):2317-2324
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• Affects 10-25% of patients with chronic hypertension.
Pre-eclampsia superimposed upon Chronic Hypertension
• Pre-existing hypertension with the following additional signs/symptoms:
Hypertension and proteinuria beginning prior to 20 th weeks of gestation.
A sudden increase in blood pressure.
Development of the HELLP (Hemolysis, Elevated liver enzymes, Low platelet count) syndrome.
American Family Physician.2004; 70(12 ):2317-2324
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Gestational HTN Pre-eclampsia Eclampsia
↑BP + Proteinuria + Edema
Systolic pressure ≥ 140 mmHg & diastolic pressure ≥90
mmHg, or both
Severe grade of pre-eclampsia leads to
seizures & dangerous to fetus & mother
American Family Physician.2004; 70(12 ):2317-2324
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Differentiation Algorithm
American Family Physician.2004; 70(12 ):2317-2324
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Etiology
American Journal of Physiology - Heart and Circulatory Physiology. 2008;294:H541–H550
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VasospasmReduced flow
KIDNEY Endotheliosis Proteinurea↓GFR↓ Renal blood flow
VASCULAR↑ Systemic vascular resistance↑ Blood pressure↑ Angiotensin II sensitivity
CARDIAC↓ Cardiac output↑ Plasma volumePulmonary edema
CNSVisual disturbanceSeizures Thrombosis,
HEPATICPeriportal hemorrhagic necrosis ↑ AST↑ ALT
Systemic Diseases and the Kidney. Chapter 10
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Uncontrolled hypertension leads to.…
Intrauterine growth retardation (IUGR)
Low birth weight
Placental abruption (separation of placenta from uterus)
Premature delivery
American Journal of Obstetrics & Gynecology .1999 Jan;180(1 Pt 1):207-13Indian J Pediatr 2007; 74 (7) : 623-625
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Management
• Diet: Should contain adequate amount of protein.
• Rest: Continued till all the pre-eclampsia manifestations subside.
• Antihypertensive: The common oral drugs used are either Labetalol or Methyldopa.
Dutta DC. Textbook of obstetrics. 5th edition. Central publication, 234-255
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(Oral Labetalol 100 mg)
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• Labetalol is a popular first-line antihypertensive of choice in the treatment of hypertension.
• Most preferred antihypertensive drug among UK consultants in the management of severe pre-eclampsia and eclampsia.
• Useful in PIH because reduced placental transfer occurs, mainly due to low lipid solubility.
(Labetalol 100 mg)
Obstetrics, Gynaecology & Reproductive Medicine.2009;19(5):136-141; Br J Obstet Gynaecol. 1992; 99:554-556Ultrasound in Medicine and Biology.2011; 37 (1): 53-58
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Labetalol: Mechanism of Action
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Pharmacokinetics
• Labetalol is completely absorbed.
• About 50% of the drug is bound in the plasma.
• Half-life of labetalol is 6 to 8 hours.
• Peak plasma concentrations is achieved within 2 hours.
• Relative bioavailability of oral labetalol is 100%.
• Metabolized in liver and excreated through urine and bile.
Prac Diab Int.2011:28(3): 139-140Lippincott . 5th edition.
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CLINICAL EVIDENCE
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Oral Labetalol Vs Placebo
• Study Design: Prospective, Randomized, Double blind, Placebo controlled Multicentric trial.
• N =152 patients with non-proteinuric PIH
• Dose: Labetalol (100 mg t.i.d.), was increased to 200 mg t.i.d. where required
• Significant reduction in maternal mean arterial pressure (MAP) was found with labetalol which was sustained over a 5 weeks period (P<0.01).
British Journal of Obstetrics and Gynaecology.1989 Jan; 96(1):38-43
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• Some reduction in preterm delivery, neonatal respiratory distress syndrome and jaundice was observed in the labetalol treated group.
• No perinatal deaths were observed.
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Conclusion: Labetalol appeared to be an effective and safe agent in the management of mild to moderate pregnancy-induced hypertension.
British Journal of Obstetrics and Gynaecology.1989 Jan; 96(1):38-43
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Oral Labetalol Vs Methyldopa
• Study Design: Randomized comparative trial
• N =104 primigravidas (a woman pregnant for the first time) with mild to moderate PIH
• Group A: Labetalol (100 mg t.i.d.) ………n=54 Group B: Methyldopa (250 mg t.i.d.) …...n=50
• Dose of both the drugs were doubled every 48 hrs to maintain MAP≤103.6 mmHg upto maximum dose of 900 mg labetalol and 2250 mg methyldopa per day.
International Journal of Gynecology & Obstetrics.1995 May;49(2):125-30
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• Labetalol demonstrated to have a quicker action, better control of blood pressure.
MAP<103.6 mmHg (equivalent to BP 130/90 mmHg )
International Journal of Gynecology & Obstetrics.1995 May;49(2):125-30
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International Journal of Gynecology & Obstetrics.1995 May;49(2):125-30
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Oral Labetalol MethyldopaHematological
parametersNo abnormality was observed
No abnormality was observed
Renal functionBeneficial effect on renal function by reducing incidence of proteinurea
No beneficial effect was observed
Rate of induction of labor for uncontrolled PIH
48% 63%
Rate of cesarean section for uncontrolled PIH
1% 5.6%
International Journal of Gynecology & Obstetrics.1995 May;49(2):125-30
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International Journal of Gynecology & Obstetrics.1995 May;49(2):125-30
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Side effects Oral Labetalol MethyldopaDrowsiness None 22.2% (12/50)Headache None 14.8% (8/50)Nasal Congestion None 7.4% (4/50)Postural hypotension None 5.6% (3/50)
Conclusion: Labetalol was better tolerated than methyldopa, gives more efficient control of blood pressure and may have a ripening effect on the uterine cervix.
• 50 infants (100%) in labetalol group and 46 (85.2%) in methyldopa group were reviewed at 18 months of age. All had been developing normally, both physically and mentally.
Labetalol safer than Methyldopa
International Journal of Gynecology & Obstetrics.1995 May;49(2):125-30
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• In another comparative study between Labetalol and Methyldopa, a more satisfactory control of blood pressure was obtained with labetalol with minimal side-effects.
• After 2 weeks labetalol treatment renal function had significantly improved with a markedly lower incidence of proteinuria.
• No adverse effects attributable to labetalol were noted in the baby either ante- or post-natally.
Clinical and Experimental Hypertension.. 1980;2(5):865-95
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Blood pressure control was more frequently
achieved in hypertensive pregnancies with
labetalol than with methyldopa as a first line
treatment.
Labetalol was safe to the fetus and newborn and
might offer a better prevention of intrauterine
death than methyldopa.
Archives des Maladies du Cœur et des Vaisseaux.1987;80(6):952-5
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Safety
• Labetalol was generally well tolerated but may cause fatigue, headache, postural hypotension, nasal stiffness, and gastrointestinal symptoms (if it is used in high doses).
• Labetalol treatment was not related to any significant changes in fetal doppler.
• No perinatal deaths were reported with labetalol treatment.
• Labetalol allows safe prolongation of pregnancies complicated by PIH.
International Journal of Gynecology & Obstetrics.1995 May;49(2):125-30; Dollery C. Therapeutic drugs.2nd edition: L1-L7 Ultrasound in Medicine and Biology.2011; 37 (1): 53-58
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National Institute for Health and Clinical Excellence (NICE) guidance on the management of hypertensive disorders during pregnancy recommends oral labetalol as first line treatment to keep diastolic BP between 80-100 mmHg and systolic BP <150 mmHg in the management of gestational hypertension and pre-eclampsia.
National Institute for Health and Clinical Excellence.2010
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American college of obstetricians & Gynecologists (ACOG)
and
Royal college of obstetricians & Gynecologists (RCOG)
also recommends labetalol as a first line treatment in the treatment of Pre-eclampsia.
National Institute for Health and Clinical Excellence.2010
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Textbooks Recommending
Labetalol
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Danforth’s Obstetrics and Gynaecology. 2007;PN-264
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Dutta DC. Textbook of Obstetrics. Central Publication. PN-544
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Limitations of Available
Anti-hypertensives
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ACE Inhibitors &
Angiotensin
Receptor Blockers
Contraindicated in pregnancy
because of adverse fetal
effects.
Diuretics
• Should be avoided in pregnancy, • May interfere with aspects of
fetal neurodevelopment.
Atenolol• Should be avoided due to
concerns with fetal growth.
Adv Chronic Kidney Dis. 2007;14(2):178-90; Semin Nephrol. 2011;31(1):70-85; Am J Psychiatry. 2003 ;160(3):464-8; CMA.1978;118:936; Rev Med Suisse. 2007 Sep 12;3(124):2012
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Women should not become pregnant while taking an ACE inhibitor.
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Methyldopa
Drowsiness, Nasal Congestion, Headache, Postural hypotension & Intrauterine death are reported.
Am J Obstet Gynecol. 2002 Oct;187(4):1046-50.; Intensive Care Med. 2002 Sep;28(9):1281-6; Am J Health Syst Pharm. 2009 Feb 15;66(4):337-44.
Nicardipine • Tachycardia is reported.
Hydralazine• Associated with unpredictable
hypotension.
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Labetalol may be preferred because of a lack
of reflex tachycardia, hypotension, or
increased intracranial pressure.
American Journal of Health-System Pharmacy. 2009 Feb 15;66(4):337-44
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Contraindications
• Labetalol is contraindicated in women with a history of asthma.
• Labetalol should be used with caution in cardiac disease.
Lippincott. 5th edition
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Dosage
• Labetalol 100 mg twice or thrice in a day.
• As directed by physician
OR
• If blood pressure control is unsatisfactory then dose can be doubled every 48 hrs up to maximum 900 mg per day.
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(Oral Labetalol 100 mg)
• First line treatment in the management of gestational hypertension and pre-eclampsia.
• It is quicker and more efficient at controlling blood pressure.
• Improves renal function by reducing incidence of proteinurea.
• May help to ripen uterine cervix thus increase the rate of vaginal delivery.
• Better tolerated than Methyldopa.
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(Oral Labetalol 100 mg)
• Allows safe prolongation of pregnancies complicated by PIH.
• Recommended by NICE guideline.
• No perinatal deaths were reported with labetalol treatment.
• Does not adversely affect fetoplacental blood flow.
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