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Fetal safety of calcium channel blockers
Fatoumah Alabdulrazzaq, MD and Gideon Koren, MD, FRCPC, FACMT
Many of my pregnant or lactating patients are taking calcium channel blockers (CCBs) for hypertension. How safe is maternal use of CCBs for fetuses and nursing infants?
Generally, CCBs have not been shown to increase teratogenic risk. Information regarding the safety of CCBs during lactation is limited, although they are not likely to pose a risk to the nursing infant.
Bon nombre de mes patientes enceintes ou qui allaitent prennent des inhibiteurs calciques (IC) pour l'hypertension. Dans quelle mesure l'utilisation maternelle des IC est-elle sécuritaire pour le ftus et les nourrissons allaités?
En règle générale, il n'a pas été démontré que les IC présentaient un risque tératogène. Les renseignements concernant l'innocuité des IC durant l'allaitement sont limités, mais il est improbable qu'ils posent un risque pour le nourrisson allaité.
Calcium channel blockers (CCBs) are commonly used during pregnancy and lactation to treat hypertension, arrhythmia, and preeclampsia. They have also been used as tocolytic agents to prevent premature labour and its complications.
Population-based data from 5 health maintenance organizations in the United States were used to study the risks of perinatal complications and congenital defects among infants exposed in utero to CCBs or ß-blockers. Calcium channel blocker use in the third trimester was associated with increased risk of neonatal seizures, jaundice, and hematologic disorders (relative risk [RR] 3.6, 95% CI 1.3 to 10.4). The risk of neonatal convulsions was in part attributed to the placental transfer of CCBs, leading to a decrease in infants' cellular calcium levels.1 There was no increase in risk of congenital anomalies in either group of infants. The risk of one or more malformations was not elevated in the group of infants exposed to CCBs (RR 0.96, 95% CI 0.47 to 1.97). 1
The Motherisk program reported no increased teratogenic risk of perinatal complications among 78 women exposed to CCBs in the first trimester. Maternal hypertension was the most important factor responsible for babies with low birth weights in this group. 2
The Swedish Medical Birth Register studied a cohort of 1418 pregnancies in which the mothers took anti-hypertensive drugs in early pregnancy; in 217 pregnancies, the mothers took CCBs. Three babies were born with congenital heart defects (RR 1.15). The study concluded that there was little drug specificity in the association between maternal use of antihypertensive drugs and increased risk of infant cardiovascular defects. 3
A Hungarian case-control study identified 22 865 infants with congenital abnormalities and 31 151 healthy population control babies between 1980 and 1996; 586 mothers had been exposed to CCBs during pregnancy compared with 907 mothers in the control group. The overall prevalence ratios for 17 congenital abnormalities varied between 1.1 and 1.4, and there was no significant increase in risk of congenital abnormalities. 4
All CCBs pass into the breast milk in small amounts. 5-7 Both LactMed (Drugs and Lactation Database) and the American Academy of Pediatrics conclude that this class of medications is compatible with breastfeeding. 8 It is advisable to follow up with any exposed infant for signs of hypotension.
Calcium channel blockers can be safely used during pregnancy and breastfeeding.
Motherisk questions are prepared by the Motherisk Team at The Hospital for Sick Children in Toronto, Ont. Dr. Alabdulrazzaq is a member and Dr. Koren is Director of the Motherisk Program. Dr. Koren is supported by the Research Leadership for Better Pharmacotherapy during Pregnancy and Lactation. He holds the Ivey Chair in Molecular Toxicology in the Department of Medicine at the University of Western Ontario in London.
Do you have questions about the effects of drugs, chemicals, radiation, or infections in women who are pregnant or breastfeeding? We invite you to submit them to the Motherisk Program by fax at 416 813-7562; they will be addressed in future Motherisk Updates.
Published Motherisk Updates are available on the Canadian Family Physician website (www.cfp.ca) and also on the Motherisk website.
Can Fam Physician
Vol. 58, No. 7, July 2012 746-747
Copyright © 2012 by The College of Family Physicians of Canada
- Davis RL, Eastman D, McPhillips H, Raebel MA, Andrade SE, Smith D, et al. Risks of congenital malformations and perinatal events among infants exposed to calcium channel and beta-blockers during pregnancy. Pharmacoepidemiol Drug Saf 2011;20(2):138-45. Epub 2010 Nov 15. Medline
- Magee LA, Schick B, Donnenfeld AE, Sage SR, Conover B, Cook L, et al. The safety of calcium channel blockers in human pregnancy: a prospective, multi-center cohort study. Am J Obstet Gynecol 1996;174(3):823-8. CrossRef | Medline
- Lennestål R, Otterblad Olausson P, K?llén B. Maternal use of antihypertensive drugs in early pregnancy and delivery outcome, notably the presence of congenital heart defects in the infants. Eur J Clin Pharmacol 2009;65(6):615-25. Epub 2009 Feb 7. CrossRef | Medline
- Sørensen HT, Czeizel AE, Rockenbauer M, Steffensen FH, Olsen J. The risk of limb deficiencies and other congenital abnormalities in children exposed in utero to calcium channel blockers. Acta Obstet Gynecol Scand 2001;80(5):397-401. Medline
- Ghanem FA, Movahed A. Use of antihypertensive drugs during pregnancy and lactation. Cardiovasc Ther 2008;26(1):38-49. Epub 28 Jun 2008. Medline
- Shannon ME, Malecha SE, Cha AJ. Calcium channel antagonists and lactation: an update. J Hum Lact 2000;16(1):60-4. Abstract/FREE Full Text
- Solans C, Aramayona JJ, Bregante MA, Fraile LJ, Rueda S, Garcia MA. Pharmacokinetics of verapamil in lactating rabbits: prediction of verapamil distribution into rabbit milk. Gen Pharmacol 2000;34(4):237-43. Medline
- American Academy of Pediatrics Committee on Drugs: the transfer of drugs and other chemicals into human milk. Pediatrics 1994;93(1):137-50. Abstract/FREE Full Text