Correspondence
Myocardial Infarction during Nifedipine Therapy for Preterm Labor
N Engl J Med 1999; 340:154January 14, 1999
- Article
To the Editor:
Recent studies have suggested that nifedipine is a safer, more effective treatment for preterm labor than the sympathomimetic agents routinely in use.1,2 On the basis of these promising results, calcium-channel antagonists are increasingly prescribed for tocolysis. On the other hand, a case–control study of hypertensive patients found that patients who were taking calcium-channel antagonists had an increased risk of myocardial infarction,3 and a meta-analysis found a dose-dependent association between the use of nifedipine and the risk of death.4 These data, however, are not necessarily applicable to pregnant women who are being treated for preterm labor. We describe a myocardial infarction in a young pregnant woman during tocolytic therapy with nifedipine.
A healthy 29-year-old woman was admitted during her first pregnancy because of preterm rupture of the membranes and uterine contractions at 29 weeks. The family history was unremarkable; serum lipid levels and the electrocardiographic findings were normal. Tocolytic therapy was started with intravenous ritodrine at a dose of 200 g per minute. Thirty hours later the patient reported chest pain. The blood pressure was 100/60 mm Hg, and the pulse was 82 beats per minute. Electrocardiography was repeated, and the results were still normal. Ritodrine therapy was stopped, and oral treatment with nifedipine (40-mg slow-release tablets three times daily) was started immediately. Four hours later — 45 minutes after the second dose of nifedipine — the woman reported chest pain, with referred pain in the jaw. The blood pressure was 70/50 mm Hg, and the pulse was 124 beats per minute. The electrocardiogram showed a T-wave inversion in lead III. The serum level of creatine kinase was 282 U per liter (normal, <100), with an MB isoenzyme level of 51 U per liter (normal, <15). The patient had an uncomplicated non–Q-wave myocardial infarction. Although tocolytic therapy was stopped, labor did not progress. Eighteen days later a healthy son was delivered by cesarean section. The woman recovered well; four months later, electrocardiography, exercise testing, and echocardiography showed no abnormalities.
The dose of nifedipine used was large but not larger than the doses used in recent studies.2 The short interval between the cessation of ritodrine therapy and the start of nifedipine therapy may have had a role in the development of the hypotension and myocardial infarction. In pregnancy, the intravascular volume increases, peripheral resistance falls, and cardiac output rises in combination with the occurrence of relative anemia and increased oxygen consumption. Sympathomimetic drugs can cause myocardial ischemia in pregnant women by further increasing oxygen consumption, but acute myocardial necrosis is rare.5 It is possible, however, that under these circumstances, nifedipine poses an extra risk by causing hypotension and reflex tachycardia.
5 ReferencesS. Guid Oei, M.D., Ph.D.
Saint Joseph Hospital, 5500 MB Veldhoven, the NetherlandsS. Koen Oei, M.D.
Tjongerschans Hospital, 8441 PW Heerenveen, the NetherlandsHans A.M. Brölmann, M.D., Ph.D.
Saint Joseph Hospital, 5500 MB Veldhoven, the Netherlands1
Lockwood CJ . Calcium-channel blockers in the management of preterm labour. Lancet 1997;350:1339-1340
CrossRef | Web of Science | Medline2
Papatsonis DN ,Van Geijn HP ,Ader HJ ,Lange FM ,Bleker OP ,Dekker GA . Nifedipine and ritodrine in the management of preterm labor: a randomized multicenter trial. Obstet Gynecol 1997;90:230-234
CrossRef | Web of Science | Medline3
Psaty BM ,Heckbert SR ,Koepsell TD , et al. The risk of myocardial infarction associated with antihypertensive drug therapies. JAMA 1995;274:620-625
CrossRef | Web of Science | Medline4
Furberg CD ,Psaty BM ,Meyer JV . Nifedipine: dose-related increase in mortality in patients with coronary heart disease. Circulation 1995;92:1326-1331
Web of Science | Medline5
Benedetti TJ . Maternal complications of parental beta-sympathomimetic therapy for premature labor. Am J Obstet Gynecol 1983;145:1-6
Web of Science | Medline
- Citing Articles (28)
Citing Articles
1
Agustín Conde-Agudelo, Roberto Romero, Juan Pedro Kusanovic. (2011) Nifedipine in the management of preterm labor: a systematic review and metaanalysis. American Journal of Obstetrics and Gynecology 204:2, 134.e1-134.e20
CrossRef2
Maartje P. G. C. Vinken, C. Rabotti, M. Mischi, J. O. E. H. van Laar, S. G. Oei. (2010) Nifedipine-Induced Changes in the Electrohysterogram of Preterm Contractions: Feasibility in Clinical Practice. Obstetrics and Gynecology International 2010, 1-8
CrossRef3
E. Menthonnex. (2009) Minaccia di parto prematuro. EMC - Urgenze 13:4, 1-12
CrossRef4
Sébastien Perbet, Jean-Michel Constantin, Franck Bolandard, Marie Vignaud, Denis Gallot, Sylvain Chanséaume, Marie Zénut, Jean-Etienne Bazin. (2008) Ventilation non-invasive pour oedème pulmonaire attribué aux tocolytiques lors du travail d’une grossesse gémellaire. Canadian Journal of Anesthesia/Journal canadien d'anesthésie 55:11, 769-773
CrossRef5
Arie Roth, Uri Elkayam. (2008) Acute Myocardial Infarction Associated With Pregnancy. Journal of the American College of Cardiology 52:3, 171-180
CrossRef6
KY Ronald Kam, Ronald F Lamont. (2008) Developments in the pharmacotherapeutic management of spontaneous preterm labor. Expert Opinion on Pharmacotherapy 9:7, 1153-1168
CrossRef7
Ronald F Lamont, KY Ronald Kam. (2008) Atosiban as a tocolytic for the treatment of spontaneous preterm labor. Expert Review of Obstetrics & Gynecology 3:2, 163-174
CrossRef8
Peter Husslein, Luis Cabero Roura, Joachim W. Dudenhausen, Hanns Helmer, René Frydman, Nicola Rizzo, Dirk Schneider. (2007) Atosiban versus usual care for the management of preterm labor. Journal of Perinatal Medicine 35:4, 305-313
CrossRef9
Jens Lyndrup, Ronald F Lamont. (2007) The choice of a tocolytic for the treatment of preterm labor: a critical evaluation of nifedipine versus atosiban. Expert Opinion on Investigational Drugs 16:6, 843-853
CrossRef10
P Husslein, LC Roura, J Dudenhausen, H Helmer, R Frydman, N Rizzo, D Schneider, . (2006) Clinical practice evaluation of atosiban in preterm labour management in six European countries. BJOG: An International Journal of Obstetrics & Gynaecology 113, 105-110
CrossRef11
P Husslein, LC Roura, J Dudenhausen, H Helmer, R Frydman, N Rizzo, D Schneider, . (2006) Clinical practice evaluation of atosiban in preterm labour management in six European countries. BJOG: An International Journal of Obstetrics and Gynaecology 113:s3, 105-110
CrossRef12
R Parasuraman, MM Gandhi, NH Liversedge. (2006) Nifedipine tocolysis associated atrial fibrillation responds to DC cardioversion. BJOG: An International Journal of Obstetrics and Gynaecology 113:7, 844-845
CrossRef13
C. Chapuis, E. Menthonnex, G. Debaty, F.-X. Koch, E. Rancurel, P. Menthonnex, J.-C. Pons. (2006) Œdème aigu du poumon au décours d’une tocolyse par nicardipine et salbutamol lors d’une menace d’accouchement prématuré sur grossesse gémellaire. La Revue Sage-Femme 5:1, 38-41
CrossRef14
E. Beinder. (2006) Drohende Frühgeburt. Der Gynäkologe 39:4, 299-310
CrossRef15
2006. Nifedipine. , 2516-2522.
CrossRef16
2006. Calcium channel blockers. , 598-610.
CrossRef17
Walther N.K.A van Mook, Louis Peeters. (2005) Severe cardiac disease in pregnancy, part II: impact of congenital and acquired cardiac diseases during pregnancy. Current Opinion in Critical Care 11:5, 435-448
CrossRef18
Adrienne Z. Ables, Ana Maria Romero, Suneet P. Chauhan. (2005) Use of Calcium Channel Antagonists for Preterm Labor. Obstetrics and Gynecology Clinics of North America 32:3, 519-525
CrossRef19
Herman P. Geijn, Joris E. Lenglet, Annemieke C. Bolte. (2005) Nifedipine trials: effectiveness and safety aspects. BJOG: An International Journal of Obstetrics & Gynaecology 112, 79-83
CrossRef20
Peter G Pryde, Susan Janeczek, Robert Mittendorf. (2004) Risk–benefit effects of tocolytic therapy. Expert Opinion on Drug Safety 3:6, 639-654
CrossRef21
L KLEIN, H GALAN. (2004) Cardiac disease in pregnancy. Obstetrics and Gynecology Clinics of North America 31:2, 429-459
CrossRef22
S. Yanturali, S. Akay, C. Ayrik, A.A. Cevik. (2004) Adverse events associated with aggressive treatment of increased blood pressure. International Journal of Clinical Practice 58:5, 517-519
CrossRef23
Sheryl Rodts-Palenik, John C. Morrison. (2002) Tocolysis:An Update for the Practitioner. Obstetrical and Gynecological Survey 57:SUPPLEMENT, S9-S34
CrossRef24
Katherine E. Economy, Alfred Z. Abuhamad. (2001) Calcium channel blockers as tocolytics. Seminars in Perinatology 25:5, 264-271
CrossRef25
J LIVINGSTON, B SIBAI. (2001) CHRONIC HYPERTENSION IN PREGNANCY. Obstetrics and Gynecology Clinics of North America 28:3, 447-464
CrossRef26
VERN L. KATZ, RICHARD M. FARMER. (1999) Controversies in Tocolytic Therapy. Clinical Obstetrics and Gynecology 42:4, 802
CrossRef27
Giuseppe Famularo, Fabio Massimo Corsi, Manlio Giacanelli. (1999) Iatrogenic Worsening of Hypokalemia and Neuromuscular Paralysis Associated with the Use of Glucose Solutions for Potassium Replacement in a Young Woman with Licorice Intoxication and Furosemide Abuse. Academic Emergency Medicine 6:9, 960-964
CrossRef28
&NA;. (1999) Nifedipine. Reactions Weekly &NA;:735, 9
CrossRef
