Archives of Perinatal Medicine 13(3), 35-39, 2007

ORIGINAL PAPER

The effect of L-arginine treatment on the neonatal outcome from pregnancies complicated by intrauterine growth restriction and gestational hypertension
ANNA DERA, MARIOLA ROPACKA, JOANNA KOWALSKA, WIESAW MARKWITZ, PIOTR NYCZ, GRZEGORZ H. BRBOROWICZ
Gestational hypertension and what follows fetal hypotrophy are associated with elevated prenatal mortality and morbidity. The main aim of this study was to evaluate the effect of L-arginine administration on the outcome of neonates from pregnancies complicated by hypotrophy and gestational hypertension. The study was undertaken in Pozna Medical University, Department of Perinatology and Gynecology. The study group included 69 randomly chosen pregnant women diagnosed with gestational hypertension or whose fetuses were diagnosed with intrauterine growth restriction (IUGR). Some women were affected by both of these pathologies. 42 women received 3 g of L-arginine daily as a supplement to standard therapy and 27 women received placebo (control group) as well as routine therapy. The ultrasound and clinical examination were done on the first day of hospitalization, and then every two weeks in both groups. In the group treated with L-arginine we observed higher birth weight at delivery ( < 0.05), gestational age ( < 0.05), and Apgar score at 1 and 5 minute (respectively < 0.005, < 0.001) compared to placebo group. There was significantly lower number of cesarean sections in the group receiving L-arginine than in the group receiving placebo (respectively < 0.01). There were no significant differences in IUGR (at entry and at delivery) between two groups. We also observed that the incidence of fetal complication such as ICH and RDS in the L-arginine group is significant lower (respectively < 0.05, < 0.005) compared to placebo group. Our study demonstrated that L-arginine administration to pregnant women with gestational hypertension and IUGR may improve fetal condition and neonatal outcome after delivery (significantly decrease serious complication such as ICH, RDS) by prolonging pregnancy (latency) and what follows delivering a child with higher birth weight, better Apgar score as well as acid-base parameters and decrease the rate of cesarean sections. However, these benefits require confirmation by larger, more-powered study. gestational hypertension, IUGR, L-arginine, neonatal outcome
Objective: Methods: Results: p p p p p p p Conclusion: Key words:

Abstract

Introduction
Gestational hypertension as well as IUGR are known to be significant complications of pregnancy and are known to be associated with inadequate uteroplacental blood flow. They are the leading cause of premature birth as well as increased infant mortality and morbidity [1]. The pathomechanism of IUGR is an impaired fetomaternal circulation which leads to decreased distribution of oxygen and of nutritional substances to the fetus. Intrauterine growth restriction constitutes an important clinical problem associated with increased prenatal morbidity [2], higher incidence of neuro-developmental impairment [3], and increased risk of adult disease, such as diabetes and cardiovascular disease [4, 5]. The primary pathophysiology of hypertension is placental and it begins with abnormal trophoblastic implantation and subsequent reduction in placental perfusion, which may result in fetal hypoxemia and IUGR [6]. Measurements of maternal placental blood flow and volume blood flow in the umbilical circulation clearly suggest that blood flows are reduced on both sides of the placental exchange barrier in association with hypertension and IUGR. The reduction in placental blood flows contribute to fetal hypoxia in IUGR. Nitric oxide (NO) is an important regulator of placental perfusion, as it plays a role in placental vascular endothelial function being a potent vasodilator and antiplatelet agent [6]. Nitric oxide is synthesized from the physiologic precursor L-arginine by the stereo-specific enzyme NO synthase in what is called the L-arginine/NO pathway, and L-arginine is the only substrate for the production of NO. It has been demonstrated that inhibition of nitric oxide syn-

thesis affect fetal growth [7-10] and that plasma concentrations of L-arginine is lower in pregnancies complicated by fetal growth restriction [11, 12]. The involvement of the L-arginine pathway in the regulation of vascular tone suggests a possible role in the pathogenesis of hypertension and IUGR sustained by placenta insufficiency. Knowing the properties and effect of L-arginine we may predict its action [13]. Recently, several reports have been published on the use of L-arginine for treating intrauterine growth restriction (IUGR), indicating different conclusions [14-16]. Several authors have demonstrated a positive effect of L-arginine on uteroplacental circulation and at the same time fetal outcome but there are others who denied the hypotensive effect of L-arginine [17]. There are numerous treatment methods for these two pathologies but the results and outcomes are not always satisfactory. The aim of this study was to determine whether L-arginine given in a daily dose of 6,0 g might improve the outcome of neonates from pregnancies complicated by gestational hypertension and IUGR.

Material and methods

We included 69 women with singleton pregnancies complicated by gestational hypertension and/or IUGR over 25 week of gestation. The gestational age was confirmed by a first trimester ultrasound scan. Ultrasonographic examinations as well as blood tests were performed after receiving written consent from the patient. The study protocol was approved by the Ethic Committee of the Pozna Medical University.
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Participants

Department of Perinatology and Gynecology, Medical University in Pozna, Poland

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A. Dera, M. Ropacka, J. Kowalska, W. Markwitz, P. Nycz, G.H. Brborowicz

Study groups

The study group included 69 women between 25 and 34 week of pregnancy complicated by gestational hypertension, IUGR or both. Group 1 included pregnant women with gestational hypertension, which was defined as an elevated blood pressure (>140/90 mm Hg) in at least two measurements 6 hours apart with or without proteinuria and edema, with an onset after 20 week of pregnancy. From this group we excluded all patients with diabetes, chronic hypertension, renal disease and endocrinopathies. Group 2 included pregnant women, which fetuses indicated signs of growth restriction based on abdominal circumference (AC) or calculated on the base of ultrasonographic evaluation of estimated fetal birth weight (EFBW) below the 10 percentile. Both groups were divided in subgroups based on the administered therapy: A. L-arginine (3.0 g per day) B. Placebo (3.0 g per day) All Doppler examinations were performed in the Ultrasonographic Lab of the Pozna Medical University Clinic of Perinatology and Gynecology between the years 2003-2006. Accurate Doppler measurements of blood flow in umbilical artery and middle cerebral artery, were done in all patients using Voluson 730 Expert apparatus equipped with 3.5 MHz ultrasound transducer. Doppler imagining was used to optimize the insonation by pulsed Doppler examination. All angles of insonation were as close to 0 degrees as possible, and always less than 30 degrees. Measurements were repeated for at least three separate cardiac cycles. In the course of obtaining of waveform from mid portion (free-floating loop) of the umbilical cord, during quiescence, the Doppler gate were placed within the walls of selected vessel, to avid aliasing and the inclusion of both arteries in the same sample gate. For measurement of the middle cerebral artery an axial view of the fetal head was obtained at the level of cerebral peduncles. The color Doppler was used to visualize the circle of Willis and the Doppler sample volume was placed within approximately 1 cm of the origin of the middle cerebral artery which was identified as a major branch running anterolateral from the circle of Willis to ward the lateral edge of the orbit. The first measureconvex

ment was done prior to administration of therapy, one week after and then every two weeks until delivery. We estimated the average velocity of blood flow as well as pulsatility index (PI), resistance index (RI), systolic/diastolic index (S/D). Singleton pregnancies < 25 week of gestation; Multiple pregnancies; Congenital malformations; Gestational week which was not confirmed by first trimester ultrasonography; Maternal age <18 years; Pregnancies complicated by diabetes, chronic hypertension, renal disease, endocrinopathies and other systemic diseases such as lupus erythromatosus. In all patients after delivery we analyzed following parameters: Gestational age at delivery; Birth weight; Deviation of the average birth weight for given gestational week (given in percentiles); Mode of delivery. Postnatal clinical assessment was done by independent neonatologists which evaluated following parameters after delivery; neonatal body weight, blood acid-base parameters obtained during delivery from umbilical vein and artery, Apgar score in the first and fifth minute of the newborn live, infection incidence, the incidence and grade of intracerebral hemorrhage as well as incidence of RDS. The continuous variables, presented as mean standard deviation (S.D) as well as confidence intervals were tested for normality and frequency distribution and were compared Rusing Students t-test and non-parametric Mann-Whitney U-test. All statistical analysis were performed with STATISTICA v. 5.0. The power of tests was calculated using Power Analysis program (a part of Statistica v. 5.0). < 0.05 was considered statistically significant.
p

Exclusion criteria

Results Table 1 summarizes the maternal and infant clinical characteristics of the two groups. There were no initial differences between the groups with regard to maternal age, nulliparity, weight gain, and mean gestation age at entry, EFBW, duration of therapy and IUGR at entry.

Table 1. Clinical characteristics. Values show the mean standard deviation Variables Maternal Maternal age (y) Nulliparity (%) Gestation at entry (wk) Weight gain (KG) Duration of therapy (days) Fetal EFBW at entry (g) IURG at entry (%) Arginine group (n = 42) 28 5 57.14 31.09 2.98 11.63 4.83 35.6 16.1 1108.5 474.2 50.00 Placebo group (n = 27) 28 4 59.26 29.88 3.22 10.07 3.5 31.9 19.4 1153.4 490.8 55.56 p NS NS NS NS NS NS NS

NS not significant; EFBW estimated fetal body weight; IUGR intrauterine growth restriction

Effect of L-arginine treatment on the neonatal outcome from pregnancies complicated by IUGR and gestational hypertension Table 2. Infant data at delivery Sex (M/F) (%) Birth weight (g) Gestational at delivery (wk) Apgar score at 1 minute Apgar score at 5 minute pHa BEa pO2a pCO2a pHv BEv pO2v pCO2v Placental weight (g) Cesarean section (%) IUGR at delivery (%) Arginine group (n = 42) 45.24/54.76 2261.43 764.85 36.21 2.53 8 (7-9) 9 (8-10) 7.25 0.09 -3.17 4.75 9.76 5.58 56.86 14.23 7.32 0.08 -2.22 5.12 16.18 5.71 46.82 8.37 488.57 167.03 59.5 57.14 Placebo group (n = 27) 51.85/48.15 1864.07 922.17 34.29 3.42 5 (2-7) 7 (2-7) 7.17 0.12 -5.28 5.84 7.91 4.59 56.28 9.87 7.22 0.13 -5.38 4.81 11.87 4.52 51.72 9.56 432.03 163.55 88.9 51.85 p NS < .05 < .05 < .005 < .001 < .05 NS NS NS < .005 < .005 < .005 < .05 NS < .05 NS

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Table 3. Neonatal outcome. Incidence in % pHa < 7.20 (%) pHv < 7.20 (%) Infection incidence (%) ICH (%) Grade 0 Grade 1 Grade 2 RDS (%) Arginine group (n = 42) 30.95 7.14 19.05 4.76 95.24 0 4.76 23.81 Placebo group (n = 27) 48.15 25.93 14.81 29.63 70.37 18.52 11.11 62.96 p NS < .05 NS < .05 < .005 < .005 < .05 < .005

ICH = intracranial haemorrhage

Infant mean birth weight, was significantly higher in the L-arginine group compared with placebo (2261.43 764.85 vs. 1864.07 922.17), mean gestation age at delivery was significant greater in the L-arginine group compared to placebo (36.21 2.53 vs. 34.29 3.42) (Table 2). Mean values of Apgar score recorded after 1st and 5th minute after delivery were significantly higher in the L-arginine group as compared to placebo (8(7-9) vs. 5(2-7) and 9(8-10) vs. 7(2-7) (Table 2). There was no significant difference in the number of females and males between groups. There was a significant reduction in number of cesarean section in the L-arginine group (59.5%) versus placebo (88.9%) (Table 2). In spite of significant differences between the two groups in the scope of acid-base balance pointing out better outcome of the newborns in the L-arginine group, the results in both groups didnt indicate significant disturbances which could

influence the final state of the newborn (Table 2). Interesting data was obtained from analysis of the infant condition directly after the birth in the two groups. We observed significant statistical decrease in the frequency of the newborn acidosis in the L-arginine group compared to placebo (7.14% vs. 25.93% p < 0.05). The incidence of ICH was significantly lower in L-arginine group (4.76%), especially Grade 1 (Table 3). The respiratory distress syndrome incidence was also higher in the L-arginine group compared to placebo (23.81 % vs 62.96%, p < 0.005) (Table 3). The obtained results can not be only associated with administration of L-arginine. One of the reasons of such a neonatal outcome may be prematurity in both groups, apart from the fact that in group 1 the infants were statistically more mature which resulted in statistically greater birth weight in this group. There was significantly lower fetal body weight at

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A. Dera, M. Ropacka, J. Kowalska, W. Markwitz, P. Nycz, G.H. Brborowicz

delivery in the placebo group (p < 0.05) (Table 2). In the study we didnt find significant differences in the incidence of IUGR after delivery as well as in the weight of the placenta. In ours examination, we didn't note any side effects or negative influence on neonate related to the taken doses of L-arginine. The study suggests that L-arginine administration to pregnant women with gestational hypertension and IUGR, can significant influence the state of the newborn after delivery and significantly decrease serious complications such as ICH, RDS.

Discussion
Gestational hypertension and IUGR are clinically very serous complications of pregnancy. Due to its adverse effect on the pregnancy, fetus and neonatal outcome there have been different approaches to treat these conditions which have not always been satisfactory. Knowing that gestational hypertension is associated with reduced placental perfusion and what follows intrauterine growth restriction we would like to try improving the uteroplacental circulation. Due to the fact that fetoplacental vessels lack innervations the control of fetoplacental circulation is dependent on locally produced and circulating vasoactive factors. eNO, as a potent vasodilator may play a pivotal role in the control of fetoplacental vascular tone, and it is regarded as a platelet anti-aggregating agent in the uteroplacental circulation [17]. L-arginine reverses fetal growth restriction induced by inhibition of nitric oxide synthesis[4-6, 15] and by hypoxia. Nitric oxide improves uteroplacental blood flow and thereby increases oxygen delivery to the fetus. This study was undertaken to demonstrate the effect of L-arginine the only precursor of NO, on the pregnancy and neonatal outcome by indirectly influencing the uteroplacental circulation. The aim of our study was to demonstrate the effect of L-arginine treatment on the neonatal outcome from pregnancies complicated by gestational hypertension and IUGR. In this study we have demonstrated that administration of 6 g of L-arginine daily to patients with gestational hypertension and IUGR can be beneficial for the prevention of serious complication of the newborn after delivery. Our results indicated that administration of L-arginine in the dose indicated above can positively influence the gestational age at delivery and what follows increase fetal birth weight and Apgar score at 1st and 5th minute, decrease the incidence of acidosis and serious complications such as ICH and RDS. To our knowledge there are several studies in which the authors administrated L-arginine in either pregnancies complicated by hypertension or IUGR. The difference from our study was associated with the dose of L-arginine, duration of treatment, mode of administration and various outcomes. The most recent study done by Rytlewski et al. indicated that administration of 3 g of L-arginine daily represents efficient strategy to improve fetal condition and neonatal outcome in women with preeclampsia. This study demonstrated similar results such as decreased rate of IUGR, increased gestational age at delivery; inc. estimated fetal birth weight during the

treatment and higher Apgar score. In this study there was no difference in the rate of c-sections between groups but there was increase in the rate of vaginal deliveries in the L-arginine group [6]. Another study done by Facchinetti et al. indicated that administration of L-arginine in the dose of 30 g iv daily may benefit patients with preeclampsia [17]. On the other hand, study done by Staff et al. where 12 g of L-arginine was administered for up to 5 days to patients with preeclampsia didnt reduce mean diastolic blood pressure [15]. Xiao et al. administered 20 g of L-arginine iv daily for 7 days to patients with IUGR indicating that the mean birth weight was significantly higher compared to control group [18]. Sieroszewski et al. recently demonstrated improvement of fetal growth and increase in birth weight in patients with IUGR who received 3 g of L-arginine for 20 days. All of his results indicate that L-arginine has a significant positive effect on the neonatal outcome by improving the uteroplacental circulation and decreasing the complications associated with prematurity. In summary we have demonstrated that oral administration of L-arginine to women with pregnancies complicated by IUGR and hypertension may represent efficient and safe strategy to improve the fetal condition and neonatal outcome. These benefits should be confirmed by larger, more-powered study.

Acknowledgments References

The work was supported by KBN 3PO5E 072 24

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[16] Facchinetti F., Longo M., Piccinini F. et al. (1999) L-arginine infusion reduces blood pressure in preeclamptic women through nitric oxide release. J. Soc. Gynecol. Invest. 6: 202-7. [17] Li Y., Zheng J., Bird I.M. Magness R.R. (2003) Effects of pulsatile shear stress on nitric oxide production and endothelial cell nitric oxide synthase expression by ovine fetoplacental artery endothelial cells. Biol. Reprod. 69: 1053-9. [18] Xiao X.M., Li L.P. (2004) L-arginine treatment for asymmetric fetal growth restriction. International Journal of Gynecology and Obstetrics 88: 15-18. J Anna Dera Department of Perinatology and Gynecology Medical University in Pozna 60-535 Pozna, ul. Polna 33, Poland