Prevention and treatment of postpartum hypertension

Long-Term Blood Pressure Control After Hypertensive Pregnancy Following Physician-Optimized Self-Management: The POP-HT Randomized Clinical Trial

Importance

Pregnancy hypertension results in adverse cardiac remodeling and higher incidence of hypertension and cardiovascular diseases in later life.

Objective

To evaluate whether an intervention designed to achieve better blood pressure control in the postnatal period is associated with lower blood pressure than usual outpatient care during the first 9 months postpartum.

Design, Setting, and Participants

Randomized, open-label, blinded, end point trial set in a single hospital in the UK. Eligible participants were aged 18 years or older, following pregnancy complicated by preeclampsia or gestational hypertension, requiring antihypertensive medication postnatally when discharged. The first enrollment occurred on February 21, 2020, and the last follow-up, November 2, 2021. The follow-up period was approximately 9 months.

Interventions

Participants were randomly assigned 1:1 to self-monitoring along with physician-optimized antihypertensive titration or usual postnatal care.

Main Outcomes and Measures

The primary outcome was 24-hour mean diastolic blood pressure at 9 months postpartum, adjusted for baseline postnatal blood pressure.

Results

Two hundred twenty participants were randomly assigned to either the intervention group (n = 112) or the control group (n = 108). The mean (SD) age of participants was 32.6 (5.0) years, 40% had gestational hypertension, and 60% had preeclampsia. Two hundred participants (91%) were included in the primary analysis. The 24-hour mean (SD) diastolic blood pressure, measured at 249 (16) days postpartum, was 5.8 mm Hg lower in the intervention group (71.2 [5.6] mm Hg) than in the control group (76.6 [5.7] mm Hg). The between-group difference was -5.80 mm Hg (95% CI, -7.40 to -4.20; P < .001). Similarly, the 24-hour mean (SD) systolic blood pressure was 6.5 mm Hg lower in the intervention group (114.0 [7.7] mm Hg) than in the control group (120.3 [9.1] mm Hg). The between-group difference was -6.51 mm Hg (95% CI, -8.80 to -4.22; P < .001).

Conclusions and Relevance

In this single-center trial, self-monitoring and physician-guided titration of antihypertensive medications was associated with lower blood pressure during the first 9 months postpartum than usual postnatal outpatient care in the UK.

Trial Registration

ClinicalTrials.gov Identifier: NCT04273854.

Furosemide for postpartum blood pressure control in patients with hypertensive disorders

Objective

diuretics have the potential to reduce intravascular volume, decrease blood pressure The aim of our study is to evaluate the effectiveness of furosemide in postpartum patients with pre-eclampsia and chronic hypertension with superimposed pre-eclampsia.

Methods

This is a retrospective cohort study. Data was extracted from the record of patients who delivered between 2017 and 2020 and had chronic hypertension or, chronic hypertension with superimposed pre-eclampsia, gestational hypertension, or pre-eclampsia. Patients who received intravenous furosemide in the postpartum period were compared to those who did not. The groups were also analyzed for fetal growth restriction, and pregnancy outcomes comparing those who did receive furosemide and those who did not.

Results

The furosemide group had a statistically significant longer postpartum length of stay (p < 0.0001), required more antihypertensive medications (p < 0.0001), medication increases (p < 0.0001), and emergent blood pressure treatment (p < 0.0001), than the group who did not. There was no difference between groups in hospital readmission, or fetal growth restriction.

Conclusion

The postpartum length of stay and rates of readmission were not decreased in the group treated with intravenous furosemide. Future prospective studies that control for pregnancy comorbidities and severity of preeclampsia are needed to determine furosemide's effect on the volume status of the postpartum pre-eclamptic patient and determine its role in the treatment of these women.

Anestesia para pacientes con preeclampsia

Introducción. La preeclampsia es una enfermedad con alta frecuencia a nivel mundial relacionada con la gestación. Las pacientes que la padecen pueden precisar un procedimiento anestésico por diversos motivos, incluidas las complicaciones graves.Objetivo. Realizar una revisión narrativa de la literatura respecto a las pautas principales del tratamiento anestésico de pacientes con preeclampsia.Materiales y métodos. Se realizó una búsqueda estructurada en las bases de datos ProQuest, EBSCO, ScienceDirect, PubMed, LILACS, Embase, Trip Database, SciELO y Cochrane Library con los términos Anesthesia AND pre-eclampsia AND therapeutics; hypertension, Pregnancy-Induced AND anesthesia AND therapeutics; anesthesia AND pre-eclampsia; hypertension, pregnancy induced AND anesthesia. La búsqueda se hizo en inglés con sus equivalentes en español.Resultados. Se encontraron 61 artículos con información relevante para el desarrollo de la presente revisión.Conclusiones. Una valoración preanestésica y la instauración temprana de las técnicas analgésicas y anestésicas pueden mitigar el impacto de complicaciones derivadas del curso de la preeclampsia. Respecto a desenlaces mayores, no existe diferencia significativa entre los distintos tipos de anestesia.

Prevention and treatment of postpartum hypertension

BACKGROUND

Postpartum blood pressure (BP) is highest three to six days after birth when most women have been discharged home. A significant rise in BP may be dangerous (e.g., can lead to stroke), but there is little information about how to prevent or treat postpartum hypertension.

OBJECTIVES

To assess the relative benefits and risks of interventions to: (1) prevent postpartum hypertension, by assessing whether 'routine' postpartum medical therapy is better than placebo/no treatment; and (2) treat postpartum hypertension, by assessing whether (i) one antihypertensive therapy is better than placebo/no therapy for mild-moderate postpartum hypertension; and (ii) one antihypertensive agent offers advantages over another for mild-moderate or severe postpartum hypertension.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2013), bibliographies of retrieved papers, and personal files.

SELECTION CRITERIA

For women with antenatal hypertension, trials comparing a medical intervention with placebo/no therapy. For women with postpartum hypertension, trials comparing one antihypertensive with either another or placebo/no therapy.

DATA COLLECTION AND ANALYSIS

We extracted the data independently and were not blinded to trial characteristics or outcomes. We contacted authors for missing data when possible.

MAIN RESULTS

Nine trials are included.

PREVENTION

Four trials (358 women) compared furosemide, nifedipine capsules, or L-arginine with placebo/no therapy. For women with antenatal pre-eclampsia, postnatal furosemide is associated with a strong trend towards reduced use of antihypertensive therapy in hospital.

TREATMENT

For treatment of mild-moderate postpartum hypertension, three trials (189 women) compared timolol, oral hydralazine, or oral nifedipine with methyldopa. Use of additional antihypertensive therapy did not differ between groups (risk ratio (RR) 0.92, 95% confidence interval (CI) 0.20 to 4.20; three trials), but the trials were not consistent in their effects. The drugs were well tolerated.For treatment of severe postpartum hypertension, two trials (120 women) compared intravenous hydralazine with either sublingual nifedipine or intravenous labetalol. There were no maternal deaths or hypotension. Use of additional antihypertensive therapy did not differ between groups (RR 0.58, 95% CI 0.04 to 9.07; two trials), but the trials were not consistent in their effects.

AUTHORS' CONCLUSIONS

For women with pre-eclampsia, postnatal furosemide may decrease the need for postnatal antihypertensive therapy in hospital, but more data are needed on substantive outcomes before this practice can be recommended. There are no reliable data to guide management of women who are hypertensive postpartum. Any antihypertensive agent used should be based on a clinician's familiarity with the drug. Future studies should include data on postpartum analgesics, severe maternal hypertension, breastfeeding, hospital length of stay, and maternal satisfaction with care.

Etiology and management of postpartum hypertension-preeclampsia

Postpartum hypertension can be related to persistence of gestational hypertension, preeclampsia, or preexisting chronic hypertension, or it could develop de novo postpartum secondary to other causes. There are limited data describing the etiology, differential diagnosis, and management of postpartum hypertension-preeclampsia. The differential diagnosis is extensive, and varies from benign (mild gestational or essential hypertension) to life-threatening such as severe preeclampsia-eclampsia, pheochromocytoma, and cerebrovascular accidents. Therefore, medical providers caring for postpartum women should be educated about continued monitoring of signs and symptoms and prompt management of these women in a timely fashion. Evaluation and management should be performed in a stepwise fashion and may require a multidisciplinary approach that considers predelivery risk factors, time of onset, associated signs/symptoms, and results of selective laboratory and imaging findings. The objective of this review is to increase awareness and to provide a stepwise approach toward the diagnosis and management of women with persistent and/or new-onset hypertension-preeclampsia postpartum period.

Antihypertensive drugs in pregnancy

Blood pressure targets and medications that are safe differ in pregnant women compared with nonpregnant individuals. The principles of treatment for mild, moderate, and severe hypertension in pregnancy, chronic versus gestational versus preeclampsia, and women hypertensive at term versus remote from term are reviewed. The choice of antihypertensive drugs also is discussed; methyldopa, labetalol, and nifedipine, among others, appear safe for use in pregnancy, whereas angiotensin converting enzyme inhibitors and angiotensin receptor blockers should be avoided. The management of increased blood pressure in the postpartum period, and agents to use in lactation, are also discussed.

Postpartum evaluation and long term implications

Hypertension, proteinuria and biochemical changes caused by pre-eclampsia may persist for several weeks and even months postpartum. Hypertension and pre-eclampsia may even develop for the first time postpartum. Care in the six weeks postpartum should include management of hypertension and screening for secondary causes of hypertension including renal disease if abnormalities persist beyond six weeks. Optimal postpartum monitoring for patients with preeclampsia has not been determined, and care needs to be individualized. The postpartum period also provides a window of opportunity for planning for the next pregnancy in addition to discussing long term implications of pre-eclampsia. Increased risk for the development of premature cardiovascular disease is the most significant long term implication of pre-eclampsia. Pre-eclampsia and cardiovascular disease share a common disease pathophysiology. Women who develop pre-eclampsia have pre-existing metabolic abnormalities or may develop them later in life. Women with early onset pre-eclampsia are at the highest risk of ischemic heart disease. Women with a history of pre-eclampsia should adopt a heart healthy lifestyle and should be screened and treated for traditional cardiovascular risk factors according to locally accepted guidelines.

Hypertension in the postpartum woman: clinical update for the hypertension specialist

Hypertension can persist from pregnancy or present de novo in the postpartum period and continue to pose a risk to maternal well-being. These risks are magnified as many patients present after hospital discharge and go unrecognized because of decreased medical surveillance after delivery. Guidelines for the management of postpartum hypertension are lacking, often resulting in imprecise diagnoses and incorrect treatment strategies. As hypertension specialists are called upon to provide advice to obstetricians regarding the management of hypertension in the postpartum period, it becomes important for the hypertension specialist to develop expertise in the evaluation and treatment of hypertensive women during the postpartum period. The purpose of this clinical review article is to provide an approach to the management of postpartum hypertension.

The management of severe hypertension

Although definitions of severe hypertension vary, thresholds of >or=160-170 mm Hg systolic and/or >or=110 mm Hg diastolic are in most common usage. A recent focus has been placed on systolic hypertension given the increased pulse pressure in these women. In pregnancy, there is a general consensus that severe hypertension should be treated. Among woman with pre-eclampsia, attention must be paid to other end organ dysfunction, as blood pressure (BP) management is but one aspect of care. The urgency of antihypertensive therapy will depend primarily on the absolute level of BP. However, most clinicians will also consider both the rate of BP rise and the presence of maternal symptoms. Most commonly, severe hypertension is treated with parenteral labetalol or hydralazine, or oral nifedipine (capsules or PA tablet). Other options will depend on local availability. MgSO(4) should not be relied on as an antihypertensive.

[Hypertensive diseases in pregnancy]

Hypertension affects about 10% of pregnancies and is a leading cause of both maternal and fetal morbidity and mortality worldwide. Hypertension in pregnancy includes a spectrum of conditions, including preeclampsia or eclampsia, chronic arterial hypertension, gestational hypertension, and pulmonary hypertension. In this review article, current data and recommendations are summarized regarding definitions, diagnoses, and treatment options for hypertensive disorders in pregnancy.

[Anesthetic management of parturients with pre-eclampsia and eclampsia]

Preeclampsia is a pregnancy-associated illness affecting multiple organ systems. Symptoms typically occur after the 20th week of gestation and consist of hypertension (>140/90 mmHg) and proteinuria (>300 mg/day). It is one of the leading causes of premature birth worldwide and early diagnosis and treatment are essential for both fetal and maternal health. Therapy is aimed at lowering blood pressure sufficiently to prevent the most severe complications such as intracranial hemorrhages. At the same time attention must be paid to the possible untoward effects of blood pressure medications on uteroplacental perfusion and fetal well being. Magnesium is the cornerstone for both prevention and control of eclamptic cerebrovascular events. In cases of severe preeclampsia and eclampsia prompt delivery is indicated, often carried out by Cesarean section (>34 weeks of gestation). Compared to general anesthesia, regional anesthesia techniques offer certain advantages to both mother and fetus and in the absence of contraindications are the methods of choice.

A review of the methodological features of systematic reviews in maternal medicine

BACKGROUND

In maternal medicine, research evidence is scattered making it difficult to access information for clinical decision making. Systematic reviews of good methodological quality are essential to provide valid inferences and to produce usable evidence summaries to guide management. This review assesses the methodological features of existing systematic reviews in maternal medicine, comparing Cochrane and non-Cochrane reviews in maternal medicine.

METHODS

Medline, Embase, Database of Reviews of Effectiveness (DARE) and Cochrane Database of Systematic Reviews (CDSR) were searched for relevant reviews published between 2001 and 2006. We selected those reviews in which a minimum of two databases were searched and the primary outcome was related to the maternal condition. The selected reviews were assessed for information on framing of question, literature search and methods of review.

RESULTS

Out of 2846 citations, 68 reviews were selected. Among these, 39 (57%) were Cochrane reviews. Most of the reviews (50/68, 74%) evaluated therapeutic interventions. Overall, 54/68 (79%) addressed a focussed question. Although 64/68 (94%) reviews had a detailed search description, only 17/68 (25%) searched without language restriction. 32/68 (47%) attempted to include unpublished data and 11/68 (16%) assessed for the risk of missing studies quantitatively. The reviews had deficiencies in the assessment of validity of studies and exploration for heterogeneity. When compared to Cochrane reviews, other reviews were significantly inferior in specifying questions (OR 20.3, 95% CI 1.1-381.3, p = 0.04), framing focussed questions (OR 30.9, 95% CI 3.7- 256.2, p = 0.001), use of unpublished data (OR 5.6, 95% CI 1.9-16.4, p = 0.002), assessment for heterogeneity (OR 38.1, 95%CI 2.1, 688.2, p = 0.01) and use of meta-analyses (OR 3.7, 95% CI 1.3-10.8, p = 0.02).

CONCLUSION

This study identifies areas which have a strong influence on maternal morbidity and mortality but lack good quality systematic reviews. Overall quality of the existing systematic reviews was variable. Cochrane reviews were of better quality as compared to other reviews. There is a need for good quality systematic reviews to inform practice in maternal medicine.