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! 2014 Informa Healthcare USA, Inc. DOI: 10.3109/0886022X.2014.926216

CLINICAL STUDY

Melatonin secretion is impaired in women with preeclampsia and an

abnormal circadian blood pressure rhythm
Sofia Bouchlariotou1, Vassilios Liakopoulos1, Myrto Giannopoulou1, Spyridon Arampatzis1,
Theodoros Eleftheriadis1, Peter R. Mertens1, Elias Zintzaras2,3, Ioannis E. Messinis4, and Ioannis Stefanidis1
Faculty of Medicine, Department of Nephrology, School of Medicine, University of Thessaly, Larissa, Greece, 2Department of Biomathematics,
School of Medicine, University of Thessaly, Larissa, Greece, 3Institute for Clinical Research and Health Policy Studies, Tufts University School of
Medicine, Boston, MA, USA, and 4Department of Obstetrics and Gynecology, School of Medicine, University of Thessaly, Larissa, Greece

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Abstract

Keywords

Non-dipping circadian blood pressure (BP) is a common finding in preeclampsia, accompanied

by adverse outcomes. Melatonin plays pivotal role in biological circadian rhythms. This study
investigated the relationship between melatonin secretion and circadian BP rhythm in
preeclampsia. Cases were women with preeclampsia treated between January 2006 and June
2007 in the University Hospital of Larissa. Volunteers with normal pregnancy, matched for
chronological and gestational age, served as controls. Twenty-four hour ambulatory BP
monitoring was applied. Serum melatonin and urine 6-sulfatoxymelatonin levels were
determined in day and night time samples by enzyme-linked immunoassays. Measurements
were repeated 2 months after delivery. Thirty-one women with preeclampsia and 20 controls
were included. Twenty-one of the 31 women with preeclampsia were non-dippers. Compared
to normal pregnancy, in preeclampsia there were significantly lower night time melatonin
(48.4 24.7 vs. 85.4 26.9 pg/mL, p50.001) levels. Adjustment for circadian BP rhythm status
ascribed this finding exclusively to non-dippers (p50.01). Two months after delivery, in 11 of
the 21 non-dippers both circadian BP and melatonin secretion rhythm reappeared. In contrast,
in cases with retained non-dipping status (n 10) melatonin secretion rhythm remained
impaired: daytime versus night time melatonin (33.5 13.0 vs. 28.0 13.8 pg/mL, p 0.386).
Urinary 6-sulfatoxymelatonin levels were, overall, similar to serum melatonin. Circadian BP and
melatonin secretion rhythm follow parallel course in preeclampsia, both during pregnancy
and, at least 2 months after delivery. Our findings may be not sufficient to implicate a
putative therapeutic effect of melatonin, however, they clearly emphasize that its involvement in the pathogenesis of a non-dipping BP in preeclampsia needs intensive further
investigation.

Blood pressure, circadian rhythm, melatonin,

preeclampsia

Introduction
Blood pressure (BP) in healthy individuals follows a characteristic circadian pattern with a nocturnal decline of 1020%
followed by an increase early in the morning.1,2 In some
patients with hypertension or chronic kidney disease however,
BP fails to dip during night and these individuals have been
called non-dippers, in contrast with those with a normal
nocturnal dip, who are called dippers.2,3 The clinical
relevance of establishing a non-dipping BP pattern lies in its
proven association with more severe hypertensive target organ
damage and increased cardiovascular risk both in hypertensive and normotensive subjects.46 Left ventricular

Address correspondence to Ioannis Stefanidis, MD, Professor of

Medicine/Nephrology, Chief of the Department of Nephrology, Faculty
of Medicine, University of Thessaly, Panepistimiou 1, 41110 Larissa,
Greece. Tel: +30-2410681667-8; Fax: +30-2410670242; E-mail:
stefanid@med.uth.gr

History
Received 25 November 2013
Revised 9 March 2014
Accepted 11 May 2014
Published online 16 June 2014

hypertrophy, carotid intima-media thickening, microalbuminuria and cerebrovascular disease are more prevalent in
non-dippers than in dippers.7,8
In normal pregnancy, the circadian rhythm of BP is similar
to that in the non-pregnant state.9 Patients with preeclampsia
are frequently characterized by abnormal circadian BP rhythm
with elevated BP during sleep.10,11 An interesting observation
is that the reduction in nocturnal BP fall has a high prevalence
among pregnant women with severe preeclampsia and that
these women have a greater frequency of adverse maternal
and fetal outcomes.12 Although the reasons for this nocturnal
hypertension in preeclampsia are poorly understood, there is
evidence that abnormalities in sympathetic nervous system
activity could play a pivotal role.13 Furthermore, the mechanisms underlying the link between non-dipping pattern of
nocturnal BP and worse pregnancy outcomes, although still
unclear, may be related to endothelial dysfunction.14,15
Melatonin, a hormone produced by the pineal gland at
night, plays an important role in the regulation of biological

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S. Bouchlariotou et al.

circadian rhythms, including BP and sleep.16,17 The influence

of melatonin in the control of cardiovascular rhythmicity is
supported by animal studies. Pinealectomy of laboratory rats
results in hypertension,18 while the hypertensive effect of
pinealectomy is blocked by administration of exogenous
melatonin.19 In humans, administration of exogenous melatonin decreases BP in normotensive patients,20,21 in patients
with essential hypertension22,23 and adolescents with diabetes
mellitus type 1.24 Recent reports have suggested that melatonin is also a significant modulator of immune response25
and a physiologically important antioxidant.26 In addition,
some of the antioxidant actions of melatonin are a consequence of its metabolites.27 As a result, melatonin may be
involved in the pathophysiology of many diseases and its
concentrations have been studied in various clinical populations. The changes of melatonin secretion and their role in the
pathogenesis, the clinical features and the prognosis of
preeclampsia have not been fully clarified.
The aim of the present study was to evaluate whether
melatonin is associated with the regulation of the circadian
rhythm of BP in pregnant women with preeclampsia and
further to investigate whether this putative association
changes in this group after delivery.

Methods
Participants and study design
All pregnant women, hospitalized between January 2006 and
June 2007 in the University Hospital of Larissa, were
screened for participation in the study. Inclusion criterion
was the diagnosis of preeclampsia according to the definition
of the National High Blood Pressure Education Program
(NHBPEP): Working Group for hypertension in pregnancy.28
In all cases, recruitment and study sampling was before the
administration of any antihypertensive medication. Exclusion
criteria were pre-gestational hypertension, diabetes, chronic
renal, liver or heart disease, cancer and depression. Healthy
volunteers with normal pregnancy, matched to cases with
preeclampsia for chronological and gestational age, served as
controls. The study protocol was approved by the ethics
committee of the University Hospital of Larissa. All women
gave written informed consent to participate in the study.
Each subject underwent a thorough physical examination
and laboratory parameters, that is, creatinine (mg/dL), urea
(mg/dL) and uric acid (mg/dL) serum levels as well as
proteinuria (mg/d), were registered as determined by common
methodology applied in the routine central laboratory of the
hospital. Body mass index (BMI; kg/m2) was calculated from
the body weight (W) and height (H) according to Quetelets
formula: BMI W/H2 (the weight in kilograms divided by
the square of the height in meters).29
According to NHBPEP, preeclampsia was defined as
hypertension (systolic BP 140 mmHg and diastolic BP
90 mmHg) and proteinuria (0.3 g in a 24-h urine collection sample) presenting after 20 weeks of gestation.28
Preeclampsia was classified as severe on the basis of diastolic
BP 110 mmHg or severe proteinuria (2 g in a 24-h urine
collection) or the presence of headache, visual disturbances,
upper abdominal pain, oliguria, thrombocytopenia, elevated
liver enzymes, convulsions or pulmonary edema.

Ren Fail, Early Online: 17

Twenty-four hour blood pressure monitoring

BP was measured in hourly intervals for 24 h with an
ambulatory BP monitor (ABPM; Tenso24 , Welch Allyn
Speidel & Keller, Jungingen, Germany) and analyzed by
specialized software (QTrack 98 , Welch Allyn, Skaneateles
Falls, NY). BP monitoring was considered successful if all
readings were technically accepted. A non-dipping pattern
was defined as a difference in the mean arterial pressure
(MAP) of less than 10% between the daytime (6:00 AM to
9:00 PM) and night time hours (9:00 PM to 6:00 AM). MAP
was calculated using the standard formula: MAP Diastolic
BP + 1/3(Systolic BP  Diastolic BP).
Twenty-four-hour BP was recorded in all women during
pregnancy (gestational age 35.5 2.5 weeks) and 2 months
after delivery. In most women with preeclampsia hypertension
recedes within 3 months after delivery.30 In our study, we
controlled women only 2 months postpartum. This was to
some degree a convenience time-point. We anticipated that
many participants, especially healthy pregnant women, would
have been lost to follow-up if they were examined at a later
time-point.
Assessment of 24 h BP was done under hospitalization in
all participants in the study (both cases and controls). The
reassessment 2 months after delivery was also done during an
in-hospital stay. In accordance with previous reports,31,32
measurements were performed with the appropriate size of
cuff, which was placed in the non-dominant arm. The
monitoring device was attached by one of the medical doctors
participating in the study and was detached by the same
person in the next morning. Absence of sleep disturbances
was ascertained by direct questioning by the medical doctor
after detachment of the device. All study participants were
instructed to be ambulatory during the day of the measurement and to keep their arm still at the time of BP
measurements. Furthermore, they were asked to go to bed
no later than 9.00 pm and not to arise before 6.00 am.
This way we tried to eliminate any effect of differences in
activity between the two groups (cases and controls) and
between the two assessments in the group of women with
preeclampsia.33
Melatonin secretion measurements
Serum melatonin concentrations were measured in the middle
of the dark and light phase, for example, at 14.00 and 24.00
hour. During nocturnal blood sampling the subjects were in
recumbent position on a bed without light from 23.00 hour till
the end of night sampling. After centrifugation, the blood
serum was frozen at 80  C until the measurement of
melatonin.
Serum melatonin concentrations were measured by commercially available enzyme-linked immunoassay (ELISA;
IBL, Hamburg, Germany). The lower detection limit was
1.6 pg/mL, and intra-assay and inter-assay coefficients of
variance were 3% and 6.4%, respectively.
Although serum melatonin profile faithfully reflects the
pineal activity, there is evidence that melatonin secretion is
pulsatile.34 In addition, serum melatonin has a very short halflife (220 min).35 Taking this information into account, we
also measured urinary 6-sulfatoxymelatonin (6-SMT; the

Melatonin in preeclampsia

DOI: 10.3109/0886022X.2014.926216

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main melatonin metabolite), which closely parallels the pineal

activity, in order to enhance the reliability of melatonin
detection.
Urine samples were collected during daytime (07.00
22.00) and during night time (22.007.00). Total urine
volume was recorded for each collection and urine samples
were frozen at 20  C until measurements. Excretion of
6-SMT was determined by commercially available ELISA
(IBL, Hamburg, Germany). The lower detection limit was
1 ng/mL, and intra-assay and inter-assay coefficients of
variance were 5.8% and 5.1%, respectively.
In all cases, serum melatonin and urinary 6-sulfatoxymelatonin (6-SMT) were measured in a different day from that
when 24 h BP was assessed because BP registration during
night time could disturb sleep and thus alter melatonin
secretion. All women were reassessed with the same methodology 2 months after delivery.
Statistical analysis
Results were expressed as a mean value and standard
deviation (mean SD). Normality of continuous variables
was tested by the KolmogorovSmirnov test. Pair-wise
comparisons of continuous variables were performed by
either the t-test or the Wilcoxon signed rank test for paired
and the MannWhitney U test for unpaired data, as appropriate. General linear model was applied for inter-group
(i.e., dippers and non-dippers) comparison of serum melatonin and urine 6-SMT. Confounding factors, that is, age,
gestational age, severity of preeclampsia, existence of
BP rhythm (dipping), BMI (kg/m2) and serum creatinine
(mg/dL), were inserted as covariates in the model. Categorical
variables were compared by means of the Fishers exact test.
Potential determinants of the BP dipping status were
investigated in a binomial logistic regression model.
Covariates, age, gestational age, the BMI, proteinuria, and
nocturnal serum melatonin (model 1) or urine 6-STM
(model 2) as measures of night time melatonin secretion,
were added in the model as appropriate. Dipping status was
the dependent variable (outcome) and odds ratio (OR) was
calculated as the antilogarithm of the b-coefficient (expb) of

each independent variable. The goodness of fit of the logistic

model was assessed by the HosmerLemeshow test and
colinearity was checked using the colinearity matrix. Overall,
p-values 50.05 were considered as statistically significant.

Results
Thirty-one women with preeclampsia and 20 controls (healthy
pregnant women) were included in the study. Twenty-four
hour ABPM was conducted successfully in all pregnant
women (n 51). Standard clinical and laboratory features of
all women included in this study are presented in Table 1.
There was primigravidity in 22 women with preeclampsia and
in 12 controls. No differences in the maternal age, gestational
age at sampling, creatinine and urea between women with
normal pregnancy and the preeclampsia group was observed.
Gestational age was higher than 32 weeks in all cases.
As expected, in the preeclampsia group compared to normal
pregnancy, we found significantly higher daytime and night
time MAP (p50.001), serum uric acid (p50.001) and urine
protein excretion (p50.001). BMI (kg/m2) was also significantly higher in preeclampsia (p50.01) (Table 1).
According to ABPM, all healthy pregnant women, that
constituted the control group, were classified as dippers, that
is, their daytime MAP was significantly higher than their
night time MAP (84.3 6.9 vs. 73.6 6 mmHg; p50.001). In
addition, there was a physiological rhythm of melatonin
secretion, that is, night time were significantly higher than
daytime serum melatonin levels (85.4 2.9 vs. 28.3 10 pg/
mL, p50.01). On general linear model analysis no significant
relationship (p 0.623) was observed between the night time
MAP (dependent variable) and night time serum melatonin
(covariate) in this group. The circadian BP rhythm was
physiological in all normal pregnancies and was thus not
added as a covariate in the model.
Among pregnant women with preeclampsia (n 31)
studied, 21 (68%) were classified as non-dippers and
10 (32%) as dippers. Daytime serum melatonin did not
differ between women with preeclampsia and healthy pregnant women (29.8 13.6 vs. 28.3 10 pg/mL, p 0.847). In
contrast, night time levels were significantly lower in

Table 1. Clinical and laboratory features of women with normal pregnancy (NP, n 20), preeclampsia (PE, n 31), dippers (n 10) and non-dippers
(n 21) with preeclampsia, during pregnancy.
Pregnant women

Age(years)
Gestational age (weeks)
Primigravidity [n (%)]
Severe PE [n (%)]
BMI(kg/m2)
Daytime MAP (mmHg)
Night time MAP (mmHg)
Creatinine (mg/dL)
Urea (mg/dL)
Uric acid (mg/dL)
Proteinuria (mg/d)

Pregnant women with preeclampsia (PE)

NP (n 20)

PE (n 31)

pa

Dippers (n 10)

Non-dippers (n 21)

pa

29.9 5.7
35.5 2.5
12 (60)
n.a.
26 1
84.3 6.9
73.6 6
0.74 0.13
19.7 5.7
3.9 0.78
70 56

29.1 5.1
34.8 3
22 (71)
10 (32.3)
30 2.3
110.5 4.1
104.8 7.5
0.81 0.17
23.6 7.5
6.5 1.28
2022 2286

0.601
0.558
0.545b
n.a.
0.000
0.000
0.000
0.135
0.093
0.000
0.000

28.2 7.2
34.7 3.9
6 (60)
1 (10)
28.3 1.5
108.5 3.4
96 4
0.82 1.7
21.2 7.7
5.9 1.1
956 607

29.6 3.9
35.1 2.7
16 (76.2)
9 (42.9)
30 2.3
111.5 4.1
109 4.5
0.81 1.8
24.9 7.3
6.8 1.3
2530 2614

0.306
0.819
0.417b
0.106b
0.002
0.048
0.000
0.849
0.204
0.072
0.079

Note: Data are mean SD. Serum creatinine in mg/dL may be converted to mmol/L by multiplying by 88.4; urea in mg/dL to mmol/L by multiplying by
0.357; uric acid in mg/dL to mmol/L by multiplying by 59.48.
a
MannWhitney U test was used for assessing the differences between the two groups.
b
For categorical data a Fishers exact test was performed.

S. Bouchlariotou et al.

Ren Fail, Early Online: 17

Figure 1. Daytime and night time levels of

melatonin (A; pg/mL) and
6-Sulfatoxymelatonin (B; 6-SMT; ng/mL)
in the two groups of women with
preeclampsia, that is, dippers (n 10) and
non-dippers (n 21), during pregnancy.
Note: * represents a statistically significant
difference between the night time and
daytime levels within the respective group
(p50.01) and the # a statistically significant
difference of the respective day or night time
levels between the two groups (dippers and
non-dippers; p50.01).

(37.5 19.8 vs. 71.2 17.5 pg/mL, p50.01). In contrast,

daytime melatonin concentrations in non-dippers were similar
to that in dippers (32.2 13.6 vs. 24.8 13 pg/mL, p 0.096)
(Figure 1a).
On binomial logistic regression, night time serum melatonin was an independent predictor of the BP dipping status in
women with preeclampsia (Cox and Snell R2 0.519;
Nagelkerke R2 0.725; p 0.004). Age, gestational age, BMI
(kg/m2), proteinuria (mg/d) and night time melatonin levels
(pg/mL) were the independent variables (factors or covariates) in this logistic model (model 1; Table 2). The goodnessof-fit analysis by the HosmerLemeshow test indicated
adequacy of the model in predicting the non-dipping status
(p 0.647).
Two months after delivery, 10 from 21 non-dippers
retained the non-dipping status (non-converters; 10/21,
47.6%) whereas in 11 a normalization of the circadian BP
rhythm (converters; 11/21, 52.4%) was observed. Thus,
among women with a history of preeclampsia (n 31) 10
were non-dippers and 21 dippers after pregnancy. Again,
daytime melatonin levels were comparable between the two
groups (non-dippers and dippers; 33.5 13 vs. 26.5 10.1 pg/
mL, p 0.268), while the non-dippers exhibited a significantly lower nocturnal melatonin secretion in comparison to
dippers (28 13.8 vs. 60.5 30.2 pg/mL, p50.01)
(Figure 2a). Moreover, in the group with normalization of
the BP rhythm (converters) there was now a normal daynight
rhythm of melatonin secretion, as well, that is, nocturnal

(A)
80

Dippers
Non-dippers

*#

60

40

20

(B)

6-Sulfatoxymelatonin [ng/mL]

preeclampsia compared to normal pregnancy (48.4 24.7 vs.

85.4 2.9 pg/mL, p50.01). After the addition of circadian
BP rhythm status as a covariate in a general linear model, this
difference became non-significant (p 0.108) and could be
ascribed to the non-dipping status of women with preeclampsia (p50.001).
The comparison between non-dippers and dippers with
preeclampsia indicated a statistically significant higher BMI,
daytime MAP and night time MAP in non-dippers (Table 1).
Mean levels of serum uric acid and proteinuria were increased
in the non-dippers group, however difference did not reach
statistical significance (p 0.072 and p 0.079, respectively). Severe preeclampsia was present in nine cases (9/21,
42.8%) of the non-dippers group and in one case (1/10, 10 %)
of the dippers group (p 0.106). The above findings are not
statistically significant (Table 1) but clearly implicate that the
non-dippers group in the study includes more cases with
severe preeclampsia than the dippers group. In order to
account for these differences, comparisons of melatonin levels
in non-dippers and dippers with preeclampsia were performed
by general linear model using the severity of preeclampsia
and proteinuria as covariates in the model.
Daytime and night time melatonin secretion in pregnant
women with preeclampsia separated according to the dipping
profile of BP is presented in Figure 1. The daynight rhythm
of melatonin secretion was disturbed in the group of nondippers with preeclampsia and their night time melatonin
levels were significantly lower compared to dippers

Melatonin [pg/mL]

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80

60

*#

40

20

Daytime

Nighttime

Daytime

Nighttime

Table 2. Binomial logistic regression analysis showed that night time serum melatonin (model 1) and 6-sulfatoxymelatonin (model 2) as measures of
melatonin secretion were independent predictors of blood pressure dipping status in women with preeclampsia (n 31).
Binomial logistic regression
Model 1

Melatonin (pg/mL)
Age (years)
Gestational age (weeks)
BMI (kg/m2)
Log proteinuria (mg/d)
Constant

Model 2

OR

0.911
1.180
1.592
2.699
0.157
0.0

0.035*
0.238
0.176
0.143
0.460
0.124

95% CI for OR
0.835
0.896
0.811
0.714
0.010

0.993
1.554
3.122
10.203
2.141

6-SMT (ng/mL)
Age (years)
Gestational age (weeks)
BMI (kg/m2)
log Proteinuria (mg/d)
Constant

OR

0.866
1.239
1.854
6.825
0.865
0.0

0.026*
0.233
0.210
0.074
0.958
0.071

95% CI for OR
0.762
0.872
0.707
0.833
0.040

0.983
1.760
4.861
55.921
19.513

Note: Dipping status was the outcome variable and independent variables (covariates) were the BMI (kg/m2), proteinuria (mg/d) and serum melatonin
(pg/mL; model 1) or 6-sulfatoxymelatonin (6-SMT ng/mL; model 2). Proteinuria was not following a normal distribution and therefore it was inserted
after logarithmical transformation in order to increase stability of the model. Odds ratio (OR) was calculated as the antilogarithm of the b-coefficient
of each independent variable (expb), (*p50.05).

Melatonin in preeclampsia

DOI: 10.3109/0886022X.2014.926216

80

Dippers
Non-dippers

*#

60

40

20

80

*#

60

40

20

Daytime

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(B)

6-Sulfatoxymelatonin [ng/mL]

(A)

Melatonin [pg/mL]

Figure 2. Daytime and night time levels

of melatonin (A; pg/mL) and 6-sulfatoxymelatonin (B; 6-SMT; ng/mL) in the two
groups of women with preeclampsia, that is,
dippers (n 21) and non-dippers (n 10), 2
months after delivery. Note: * represents a
statistically significant difference between the
night time and daytime levels within the
respective group (p50.01) and the # a
statistically significant difference of the
respective day or night time levels between
the two groups (dippers and non-dippers;
p50.01).

melatonin levels were significantly higher than daytime levels

(44.9 11.7 vs. 26.3 11.1 pg/mL, p 0.01).
Overall, urinary 6-SMT levels followed a very similar
pattern with the serum levels of melatonin. Findings concerning 6-SMT levels of women with preeclampsia during
and after pregnancy are presented on Figures 1(b) and 2(b)
and the respective logistic regression analysis (model 2) on
Table 2.

Discussion
Since the development and clinical application of the ABPM,
various studies have shown that the circadian BP rhythm is
lost in up to 70% of patients with preeclampsia.11,36,37 In the
present study, the prevalence of sleep hypertension among
31 women with preeclampsia was 68%. Furthermore, we
found that non-dippers and dippers with preeclampsia differ
not only in their hemodynamic response during night, but also
in their physiological response to darkness, as shown by the
blunted nocturnal melatonin secretion in non-dippers.
More specifically, daytime serum melatonin did not differ
between women with preeclampsia and healthy pregnant
women. Night time melatonin secretion was disturbed, not in
all women with preeclampsia, but merely in those with a nondipping BP rhythm. Thus, in preeclampsia an impaired
rhythm of melatonin secretion was present only in women
with a non-dipping BP. Our findings suggest that melatonin
secretion might closely interact with the circadian rhythm of
BP in preeclampsia. The exact pathogenetic link is not yet
clarified however a hypothesis for a certain causative
interrelationship could be justified.
Melatonin influences rhythmic changes in BP by affecting
the master clock localized in the suprachiasmatic nucleus of
the hypothalamus and subsequently the tone of sympathetic
and parasympathetic nervous systems.38 The physiological
nocturnal fall in BP is probably associated with the nocturnal
decrease in adrenergic activity and the increase in parasympathetic activity.39
In addition, several investigators have shown that nocturnal
surge of endogenous melatonin may contribute directly to
arterial vasodilatation that leads in turn to nocturnal BP fall in
normotensives and dippers with essential hypertension.4042
Especially, Jonas et al. 42 reported that while the dippers with
essential hypertension presented the physiological nocturnal
increase in urinary 6-SMT, this surge of melatonin production

Nighttime

Daytime

Nighttime

was missing in the non-dippers with essential hypertension in

whom nocturnal urinary 6-SMT concentrations were not
significantly different from daily levels. The study presented
here shows that above findings are also true in pregnant
women with preeclampsia. Moreover, in animal models
melatonin has been proven as a pathogenetic link in the
development of stress induced and metabolic syndromerelated hypertension.43,44 Therefore, it is probable that the
significant association of melatonin with circadian rhythm of
BP is observed in any forms of hypertension.
Furthermore, there is considerable piece of evidence in a
number of studies that administration of melatonin reduces
nocturnal BP.2024 These observations, of a direct effect of
melatonin on BP, strongly support the notion that the
impaired melatonin secretion favors predisposition to an
abnormal circadian BP rhythm and is a cause of the nondipping pattern of BP.
During pregnancy the pineal gland is not the exclusive
source of melatonin, which is also secreted from the placenta.
In addition, according to Lanoix et al. (2012), preeclampsia
leads to depressed melatonin levels in the placenta.45 Reduced
melatonin levels in preeclampsia, showed in this study, might
be in part due to reduced placental secretion. Studies in
animal models of hypertension in pregnancy suggest that
shallow placentation and reduction in uteroplacental perfusion during pregnancy triggers the release of biologically
active factors which affect the sympathetic tone and lead to
generalized vasoconstriction, hypertension and disturbance of
the circadian BP rhythm.46 Dysfunction of the autonomic
nervous system is suspected to be a major contributor to the
increase in peripheral vascular resistance in preeclampsia.
Schobel et al. 47 using the microneurographic technique for
obtaining direct intraneural recordings of postganglionic
sympathetic nerve activity, clearly showed that preeclampsia
is a state of sympathetic overactivity. This overactivity has
been incriminated in the loss of nocturnal BP dip.48 Impaired
nocturnal melatonin secretion, shown in this study, might be
an additional probable contributor of the autonomic nervous
system dysfunction and thus indirectly of nocturnal hypertension in preeclampsia.
Moreover, endothelial dysfunction is a key component
in preeclampsia15 and its adverse fetal and maternal
outcomes. It has been suggested that administration of
melatonin may lead to prevention of endothelial structural
alterations.49

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S. Bouchlariotou et al.

Melatonin, a potent free radical scavenger of the highly

toxic hydroxyl radical and other reactive oxygen species,
increases the levels of several antioxidative enzymes and
inhibits the pro-oxidative enzyme nitric oxide synthase.26
Preeclampsia is an oxidative stress related condition.
Melatonin levels may be depressed because melatonin, as a
radical scavenger, is being consumed very rapidly by the
enhanced reactive oxygen species in this disorder. Current
evidence shows that decreased endogenous antioxidative
defence related to impaired melatonin secretion could
reinforce and facilitate the cascade of events related to
systematic inflammation and endothelial dysfunction which
characterized rheumatoid arthritis or metabolic syndrome.26,49 Furthermore, previous studies have showed a
decreased nocturnal serum melatonin in coronary heart
disease and during acute myocardial infarction.50,51 This
approach raises new questions regarding the mechanism of
endothelial dysfunction in preeclampsia and suggests that
melatonin might be somehow involved.
These important observations showing that melatonin is
associated with various mechanisms inducing hypertension in
preeclampsia are in full agreement with the hypothesis that
altered melatonin secretion is not a result of a non-dipping
pattern of BP, but rather one of the causes of this abnormal
circadian rhythm in preeclampsia. Our findings are also
important in light of the on-going clinical trial related to the
use of melatonin to treat preeclampsia.52 There is ample
evidence that melatonin reduces arterial BP and being nontoxic during pregnancy it may be also useful in reducing
severity of preeclampsia.
Furthermore, enhanced BMI was found in pregnant women
with preeclampsia and in particular in non-dippers in
comparison with dippers. However, in binomial regression
BMI was not an independent predictor of dipping status in
preeclampsia. Nevertheless, an involvement of BMI and
obesity in pathogenesis of preeclampsia needs also further
study.
Finally, we found that in women with history of
preeclampsia the circadian BP rhythm and the melatonin
rhythm follow a parallel course, at least 2 months after
pregnancy. The reappearance of the BP rhythm and the
melatonin rhythm is simultaneous, while in those who remain
non-dippers the melatonin rhythm is still altered. From this
finding it becomes more obvious first, that both circadian
rhythm abnormalities observed, namely the non-dipping BP
and the impairment of nocturnal melatonin secretion, are
consequences of preeclampsia and not vice versa, and second,
that between them there is probably a very close etiopathogenic link. Whether these abnormalities are also part of the
vicious circle that causes severe preeclampsia or even
eclampsia was not meant to be clarified by this study.
A previous study53 concerning also women with history of
preeclampsia (n 8) demonstrated that, although the circadian rhythm of BP normalizes, the melatonin rhythm remains
altered 612 months after pregnancy. In this study, in contrast
to our findings, Tranquilli et al.53 showed that women with
preeclampsia and a disturbed circadian BP rhythm have
higher melatonin levels than healthy (normotensive) pregnant
women. These different results cannot be explained but they
may reflect different methods in melatonin determination.

Ren Fail, Early Online: 17

Measurements of 6-SMT provide additional credibility to our

findings. Moreover, Tranquili et al.53 included only nondippers with preeclampsia and did not comment on the
severity of preeclampsia in their group.
Epidemiological evidence also demonstrate that women
with a history of preeclampsia exhibit a greater risk of heart
disease later in life compared with women who had normal
pregnancies.51 In addition, the non-dipping pattern of circadian BP has been associated with a large increase in
cardiovascular morbidity, reflecting an increased risk of
target organ damage.54 Our results showed a decreased
melatonin secretion in women with a recent history of
preeclampsia and nocturnal hypertension. This finding suggests that melatonin rhythm may be involved with the
outcome of women with a history of preeclampsia and
nocturnal hypertension.
One weak point of our study, and probably of many other
studies concerning hypertensive disorders in pregnancy, is the
fact that the exact status before pregnancy (existence of
essential hypertension, disturbed BP rhythm) remains principally unknown. Furthermore, in our study no investigations
were performed on a later time-point than the 2 months. Reexamination of all patients and controls independent of
pregnancy would serve as a valuable additional validation of
our findings.
In conclusion, we have provided evidence that nocturnal
melatonin secretion is impaired in preeclamptic women with
non-dipping pattern of circadian BP compared to preeclamptic women with normal nocturnal BP dip and healthy pregnant
women. We also found that after pregnancy women with
history of preeclampsia who retain their nocturnal hypertension continue to exhibit an impaired melatonin secretion. We
thus propose that melatonin might play a role in the altered
circadian rhythm of BP in women with preeclampsia.
A possible involvement of melatonin in the pathogenesis of
preeclampsia needs to be further investigated in prospective
studies.

Declaration of interest
The authors report no conflicts of interest.

References
1. Somers VK, Dyken ME, Mark AL, Abboud FM. Sympathetic-nerve
activity during sleep in normal subjects. N Engl J Med. 1993;328:
303307.
2. OBrien E, Sheridan J, OMalley K. Dippers and non-dippers.
Lancet. 1988;2:397. doi: 10.1016/S0140-6736(88)92867-X.
3. White WB. Ambulatory blood pressure as a predictor of target
organ disease and outcome in the hypertensive patient. Blood Press
Monit. 1999;4:181184.
4. Mancia G, Parati G. The role of blood pressure variability in endorgan damage. J Hypertens Suppl. 2003;21:S17S23.
5. White WB. Relevance of blood pressure variation in the circadian
onset of cardiovascular events. J Hypertens Suppl. 2003;21:
S9S15.
6. Ohkubo T, Imai Y, Tsuji I, et al. Relation between nocturnal decline
in blood pressure and mortality. The Ohasama Study. Am J
Hypertens. 1997;10:12011207.
7. Cuspidi C, Macca G, Sampieri L, et al. Target organ damage and
non-dipping pattern defined by two sessions of ambulatory blood
pressure monitoring in recently diagnosed essential hypertensive
patients. J Hypertens. 2001;19:15391545.

Ren Fail Downloaded from informahealthcare.com by University of Laval on 06/30/14

For personal use only.

DOI: 10.3109/0886022X.2014.926216

8. Verdecchia P, Schillaci G, Guerrieri M, et al. Circadian blood

pressure changes and left ventricular hypertrophy in essential
hypertension. Circulation. 1990;81:528536.
9. Oney T, Meyer-Sabellek W. Variability of arterial blood pressure in
normal and hypertensive pregnancy. J Hypertens Suppl. 1990;8:
S77S81.
10. Ayala DE, Hermida RC, Mojon A, Fernandez JR, Iglesias M.
Circadian blood pressure variability in healthy and complicated
pregnancies. Hypertension. 1997;30:603610.
11. Brown MA, Davis GK, McHugh L. The prevalence and clinical
significance of nocturnal hypertension in pregnancy. J Hypertens.
2001;19:14371444.
12. Koenen SV, Franx A, Mulder EJ, Bruinse HW, Visser GH.
Fetal and maternal cardiovascular diurnal rhythms in pregnancies
complicated by pre-eclampsia and intrauterine growth restriction. J
Matern Fetal Neonatal Med. 2002;11:313320.
13. Metsaars WP, Ganzevoort W, Karemaker JM, Rang S, Wolf H.
Increased sympathetic activity present in early hypertensive
pregnancy is not lowered by plasma volume expansion.
Hypertens Pregn. 2006;25:143157.
14. Young BC, Levine RJ, Karumanchi SA. Pathogenesis of
preeclampsia. Annu Rev Pathol. 2010;5:173192.
15. Bouchlariotou S, Liakopoulos V, Dovas S, et al. Nocturnal
hypertension is associated with an exacerbation of the endothelial
damage in preeclampsia. Am J Nephrol. 2008;28:424430.
16. Brzezinski A. Melatonin in humans. N Engl J Med. 1997;336:
186195.
17. Penev PD, Zee PC. Melatonin: a clinical perspective. Ann Neurol.
1997;42:545553.
18. Zanoboni A, Forni A, Zanoboni-Muciaccia W, Zanussi C. Effect of
pinealectomy on arterial blood pressure and food and water intake
in the rat. J Endocrinol Invest. 1978;1:125130.
19. Holmes SW, Sugden D. Proceedings: the effect of melatonin on
pinealectomy-induced hypertension in the rat. Br J Pharmacol.
1976;56:360P361P.
20. Nishiyama K, Yasue H, Moriyama Y, et al. Acute effects of
melatonin administration on cardiovascular autonomic regulation in
healthy men. Am Heart J. 2001;141:13A17A.
21. Cagnacci A, Cannoletta M, Renzi A, Baldassari F, Arangino S,
Volpe A. Prolonged melatonin administration decreases nocturnal
blood pressure in women. Am J Hypertens. 2005;18:16141618.
22. Grossman E, Laudon M, Yalcin R, et al. Melatonin reduces night
blood pressure in patients with nocturnal hypertension. Am J Med.
2006;119:898902.
23. Scheer FA, Van Montfrans GA, van Someren EJ, Mairuhu G, Buijs
RM. Daily nighttime melatonin reduces blood pressure in male
patients with essential hypertension. Hypertension. 2004;43:
192197.
24. Cavallo A, Daniels SR, Dolan LM, Bean JA, Khoury JC. Blood
pressure-lowering effect of melatonin in type 1 diabetes. J Pineal
Res. 2004;36:262266.
25. Calvo JR, Gonzalez-Yanes C, Maldonado MD. The role of
melatonin in the cells of the innate immunity: a review. J Pineal
Res. 2013;55:103120.
26. Reiter RJ, Melchiorri D, Sewerynek E, et al. A review of the
evidence supporting melatonins role as an antioxidant. J Pineal
Res. 1995;18:111.
27. Galano A, Tan DX, Reiter RJ. On the free radical scavenging
activities of melatonins metabolites, AFMK and AMK. J Pineal
Res. 2013;54:245257.
28. Working Group on High Blood Pressure in Pregnancy. Report of
the National High Blood Pressure Education Program Working
Group on High Blood Pressure in Pregnancy. Am J Obstet Gynecol.
2000;183:S1S22.
29. Garrow JS, Webster J. Quetelets index (W/H2) as a measure of
fatness. Int J Obes. 1985;9:147153.
30. Podymow T, August P. Postpartum course of gestational hypertension and preeclampsia. Hypertens Pregn. 2010;29:294300.
31. OShea JC, Murphy MB. Factors confounding assessment
of ambulatory blood pressure monitors, studied during formal
evaluation of the Tycos Quiet-Trak. Am J Hypertens. 1997;10:
175180.

Melatonin in preeclampsia

32. Al Hermi B, Abbas B. The role of ambulatory blood pressure

measurements in adolescence and young adults. Transplant Proc.
2004;36:18181819.
33. Baumgart P, Walger P, Fuchs G, Dorst KG, Vetter H, Rahn KH.
Twenty-four-hour blood pressure is not dependent on endogenous
circadian rhythm. J Hypertens. 1989;7:331334.
34. Follenius M, Weibel L, Brandenberger G. Distinct modes of
melatonin secretion in normal men. J Pineal Res. 1995;18:
135140.
35. Claustrat B, Brun J, Chazot G. The basic physiology and
pathophysiology of melatonin. Sleep Med Rev. 2005;9:1124.
36. Halligan A, Shennan A, Lambert PC, de Swiet M, Taylor DJ.
Diurnal blood pressure difference in the assessment of preeclampsia. Obstet Gynecol. 1996;87:205208.
37. Hermida RC, Ayala DE, Mojon A, et al. Blood pressure patterns in
normal pregnancy, gestational hypertension, and preeclampsia.
Hypertension. 2000;36:149158.
38. Zeman M, Dulkova K, Bada V, Herichova I. Plasma melatonin
concentrations in hypertensive patients with the dipping and nondipping blood pressure profile. Life Sci. 2005;76:17951803.
39. Pickering TG. The clinical significance of diurnal blood pressure
variations. Dippers and nondippers. Circulation. 1990;81:700702.
40. Mahle CD, Goggins GD, Agarwal P, Ryan E, Watson AJ. Melatonin
modulates vascular smooth muscle tone. J Biol Rhythms. 1997;12:
690696.
41. Lusardi P, Preti P, Savino S, Piazza E, Zoppi A, Fogari R. Effect of
bedtime melatonin ingestion on blood pressure of normotensive
subjects. Blood Press Monit. 1997;2:99103.
42. Jonas M, Garfinkel D, Zisapel N, Laudon M, Grossman E. Impaired
nocturnal melatonin secretion in non-dipper hypertensive patients.
Blood Press. 2003;12:1924.
43. Xia CM, Shao CH, Xin L, et al. Effects of melatonin on blood
pressure in stress-induced hypertension in rats. Clin Exp Pharmacol
Physiol. 2008;35:12581264.
44. Leibowitz A, Peleg E, Sharabi Y, Shabtai Z, Shamiss A,
Grossman E. The role of melatonin in the pathogenesis of
hypertension in rats with metabolic syndrome. Am J Hypertens.
2008;21:348351.
45. Lanoix D, Guerin P, Vaillancourt C. Placental melatonin production
and melatonin receptor expression are altered in preeclampsia: new
insights into the role of this hormone in pregnancy. J Pineal Res.
2012;53:417425.
46. Stennett AK, Khalil RA. Neurovascular mechanisms of hypertension in pregnancy. Curr Neurovasc Res. 2006;3:131148.
47. Schobel HP, Fischer T, Heuszer K, Geiger H, Schmieder RE.
Preeclampsia a state of sympathetic overactivity. N Engl J Med.
1996;335:14801485.
48. Birkenhager AM, van den Meiracker AH. Causes and consequences
of a non-dipping blood pressure profile. Neth J Med. 2007;65:
127131.
49. OBrien IA, Lewin IG, OHare JP, Arendt J, Corrall RJ. Abnormal
circadian rhythm of melatonin in diabetic autonomic neuropathy.
Clin Endocrinol (Oxf). 1986;24:359364.
50. Dominguez-Rodriguez A, Abreu-Gonzalez P, Garcia MJ,
Sanchez J, Marrero F, Armas-Trujillo D. Decreased nocturnal
melatonin levels during acute myocardial infarction. J Pineal Res.
2002;33:248252.
51. Manten GT, Sikkema MJ, Voorbij HA, Visser GH, Bruinse HW,
Franx A. Risk factors for cardiovascular disease in women with a
history of pregnancy complicated by preeclampsia or intrauterine
growth restriction. Hypertens Pregn. 2007;26:3950.
52. Hobson SR, Lim R, Gardiner EE, Alers NO, Wallace EM. Phase I
pilot clinical trial of antenatal maternally administered melatonin to
decrease the level of oxidative stress in human pregnancies affected
by pre-eclampsia (PAMPR): study protocol. BMJ Open. 2013;3:
e003788.
53. Tranquilli AL, Turi A, Giannubilo SR, Garbati E. Circadian
melatonin concentration rhythm is lost in pregnant women with
altered blood pressure rhythm. Gynecol Endocrinol. 2004;18:
124129.
54. Maggioni C, Cornelissen G, Otsuka K, Halberg F, Consonni D,
Nicolini U. Circadian rhythm of maternal blood pressure and fetal
growth. Biomed Pharmacother. 2005;59:S86S91.