Oral nifedipine versus intravenous labetalol for severe hypertension during pregnancy: a systematic review and meta-analysis

Daily Versus BID Nifedipine GITS in Severe Preeclampsia: Randomized Controlled Trial

BACKGROUND

Optimal dosing of nifedipine gastrointestinal therapeutic system (GITS) in pregnancies complicated by preeclampsia with severe features is unknown. We assessed whether nifedipine GITS 30 mg BID improved blood pressure control when compared with nifedipine GITS 60 mg daily.

METHODS

Unblinded, randomized controlled trial, at a single academic hospital from December 2021 to December 2023. Individuals between 220/7 and 335/7 weeks of gestation diagnosed with preeclampsia with severe features were randomized to nifedipine GITS 60 mg QD or 30 mg BID once the decision to increase the total daily dose was made. The primary outcome was the percentage of suboptimal blood pressures on hours 24 to 48 after randomization, defined as the ratio of systolic ≥150 mm Hg and diastolic ≥100 mm Hg blood pressure episodes divided by the total number of blood pressures taken during the collection time period.

RESULTS

The percentage of suboptimal blood pressure from hours 24 to 48 was similar between groups (60 mg daily: 34.2±29.4% versus 30 mg BID: 32.8±34.0%; P=0.87). The need for any emergent antihypertensive treatment during the blood pressure collection period was higher in the 60 mg daily group (46.2% versus 14.8%; P=0.03). Secondary outcomes including gestational age at delivery and number of increases in long-acting antihypertensive regimen were similar.

CONCLUSIONS

Nifedipine GITS dosed 60 mg daily and 30 mg BID has similar rates of suboptimal blood pressure in individuals with preeclampsia with severe features. However, there is a reduction in the need for emergent antihypertensive treatment for severe range blood pressures with BID dosing, which would favor its use in this population.

Evaluation of the cardiotoxicity of Echinochrome A using human induced pluripotent stem cell-derived cardiac organoids

Echinochrome A (EchA), a marine-derived natural product, has shown promise in treating cardiovascular and inflammatory diseases due to its antioxidant and anti-inflammatory properties. However, its cardiac safety remains underexplored. In this study, we utilized human induced pluripotent stem cell-derived cardiac organoids (hCOs) to validate their ability to model the cardiac safety profile of EchA in a human-relevant system. While EchA's therapeutic effects have been reported, prior studies have not evaluated its cardiotoxicity or arrhythmogenic potential in a high-fidelity 3D human cardiac model. The hCOs, characterized by expression of key cardiac markers (cTnT) and functional ion channels (Cav1.2, Nav1.5, hERG), exhibited structural and electrophysiological properties reflective of human cardiac physiology. Using multi-electrode array (MEA) analysis, we assessed the effects of EchA at concentrations ranging from 0.1 to 30 µM on electrophysiological parameters, including beat period, field potential amplitude, field potential duration, and spike slope. EchA treatment induced no significant changes in these parameters, confirming its non-toxic electrophysiological profile. Cellular viability and lactate dehydrogenase (LDH) assays revealed no cytotoxic effects of EchA across tested concentrations. Contractility assays further demonstrated that EchA did not affect contraction velocity, relaxation velocity, or time to 50 % maximal contraction and relaxation. This study fills a critical gap and highlights the translational relevance of hCOs for cardiotoxicity assessment, demonstrating EchA's cardiac safety and supporting its potential therapeutic and environmental applications.

Exploring Pharmacological and Non-Pharmacological Approaches to Managing Hypertension During Pregnancy: A Systematic Review

This systematic review aimed to explore the efficacy of both pharmacological and non-pharmacological interventions in managing hypertension during pregnancy. It analyzed high-quality randomized controlled trials (RCTs), focusing on outcomes related to maternal and fetal health. The findings demonstrated that antihypertensive medications, particularly labetalol and nifedipine, effectively reduced the risks of severe preeclampsia (PE), preterm birth, and other complications. Remote monitoring of blood pressure (BP) showed promise in improving postpartum care and addressing health disparities. While dietary interventions such as the Dietary Approaches to Stop Hypertension (DASH) diet offered metabolic benefits, their impact on preventing PE was inconclusive. The review highlights the need for a comprehensive approach to hypertension management, integrating medication, lifestyle interventions, and innovative monitoring strategies. It also emphasizes the importance of further research to refine non-pharmacological interventions and assess their long-term effectiveness. We believe these insights will help guide clinical practice, enhance maternal and fetal outcomes, and inform future research directions.

Optimal treatment for women with acute hypertension in pregnancy; a randomized trial comparing intravenous labetalol versus nicardipine

OBJECTIVES

Blood pressure control in severe hypertension of pregnancy is crucial for mother and neonate. In absence of evidence, guidelines recommend either intravenous labetalol or nicardipine. We compared the effectiveness and safety of these two drugs in women with severe hypertension in pregnancy.

STUDY DESIGN

We performed an open label randomized controlled trial. Women with a singleton pregnancy complicated by severe hypertension (systolic ≥ 160 mmHg and/or diastolic ≥ 110 mmHg) requiring intravenous antihypertensive treatment were randomized to intravenous labetalol or intravenous nicardipine. The primary outcome was a composite adverse neonatal outcome defined as severe Respiratory Distress Syndrome (RDS), Broncho Pulmonary Dysplasia (BPD), Intraventricular Hemorrhage (IVH) IIB or worse, Necrotizing Enterocolitis (NEC), or perinatal death defined as fetal death or neonatal death before discharge from the neonatal intensive care unit (NICU). Based on a power analysis, we estimated that 472 women (236 per group) needed to be included to detect a difference of 15% in the primary outcome with 90% power. The study was halted prematurely at 30 inclusions because of slow recruitment and trial fatigue.

RESULTS

Between August 2018 and April 2022, we randomized 30 women of which 16 were allocated to intravenous nicardipine and 14 to intravenous labetalol. The composite adverse neonatal outcome was not significantly different between the two groups (25 % versus 43 % OR 0.28 (95 % CI 0.05-1.43), p = 0.12)). Respiratory distress syndrome occurred more often in the labetalol group than in the nicardipine group (42.9 % versus 12.5 %). Neonatal hypoglycemia occurred more often in the nicardipine group than in the labetalol group (31 % versus 7 %). Time until blood pressure control was faster in women treated with nicardipine than in women treated with labetalol (45 (15-150 min vs. 120 (60-127,5) min).

CONCLUSION

In our prematurely halted small RCT, we were unable to provide evidence for the optimal choice of treatment for severe hypertension to improve neonatal outcome and/or to obtain faster blood pressure control. Differences in Respiratory distress syndrome and neonatal hypoglycemia between the groups might be the result of coincidental finding due to the small groups included in the study. A larger randomized trial would be needed to determine the safest and most efficacious (intravenous) therapy for severe hypertension in pregnancy. This study emphasizes the challenges of conducting a RCT for the optimal treatment for these women.

Effectiveness and safety of intravenous labetalol in severe pre-eclampsia and eclampsia at a teaching institution in Chhattisgarh

Introduction

Severe hypertension in pregnancy deserves prompt recognition and urgent effective reduction in order to reduce the risk of complications such as eclampsia and HELLP syndrome and to achieve desirable neonatal outcomes. There is a need for effective and safe parenteral antihypertensive treatment.

Subjects and Methods

We studied the effectiveness and safety of intravenous labetalol use in severe hypertension in pregnancy and post-partum period in a teaching hospital in Chhattisgarh in 101 women. IV labetalol was given as bolus doses till the blood pressures were controlled. Neonatal outcomes were recorded, and adverse effects such as hypotension, hypoglycemia, and neonatal asphyxia were documented.

Results

Intravenous labetalol given as a single bolus of 20 mg was efficacious in controlling blood pressures in 93 out of 101 (93%) women, and the rest were controlled with 1 or 2 additional doses in 1-3 hours. No neonatal deaths happened beyond the 13 intrauterine fetal deaths at presentation. No women developed any episodes of hypotension, tachycardia of more than 100, or nausea or vomiting on labetalol.

Conclusion

Intravenous labetalol, even as a single bolus dose, is highly efficacious and is free of any major adverse effects.

Pulse Pressure as a Hemodynamic Parameter in Preeclampsia with Severe Features Accompanied by Fetal Growth Restriction

Background: Modern management of preeclampsia can be optimized by tailoring the targeted treatment of hypertension to an individual's hemodynamic profile. Growing evidence suggests different phenotypes of preeclampsia, including those with a hyperdynamic profile and those complicated by uteroplacental insufficiency. Fetal growth restriction (FGR) is believed to be a result of uteroplacental insufficiency. There is a paucity of research examining the characteristics of patients with severe preeclampsia who do and who do not develop FGR. We aimed to elucidate which hemodynamic parameters differed between these two groups. Methods: All patients admitted to a single referral center with severe preeclampsia were identified. Patients were included if they had a live birth at 23 weeks of gestation or higher. Multiple gestations and pregnancies complicated by fetal congenital anomalies and/or HELLP syndrome were excluded. FGR was defined as a sonographic estimation of fetal weight (EFW) < 10th percentile or abdominal circumference (AC) < 10th percentile. Results: There were 76% significantly lower odds of overall pulse pressure upon admission for those with severe preeclampsia comorbid with FGR (aOR = 0.24, 95% CI = 0.07-0.83). Advanced gestational age on admission was associated with lower odds of severely abnormal labs and severely elevated diastolic blood pressure in preeclampsia also complicated by FGR. Conclusions: Subtypes of preeclampsia with and without FGR may be hemodynamically evaluated by assessing pulse pressure on admission.

A Comparative Study of Oral Nifedipine and Intravenous Labetalol for Acute Hypertensive Management in Pregnancy: Assessing Feto-Maternal Outcomes in a Hospital-based Randomized Control Trial

Background and Objective

Hypertension is one of the most common medical complications during pregnancy and a leading cause of maternal mortality and morbidity. Severe preeclampsia is defined as blood pressure (BP) >160/110 mmHg with warning signs such as headache, blurring of vision, and epigastric pain. Nifedipine (C17H18N2O6), labetalol (C19H24N2O3), and hydralazine (C8H8N4) are commonly used drugs, and all are recommended as first-line agents. Hydralazine is associated with a higher incidence of adverse outcomes, so oral nifedipine has been proposed as a first-line alternative to intravenous labetalol. Consequently, this study aims to compare the efficacy and safety of oral nifedipine with that of intravenous labetalol. The objective is to compare the ability/effectiveness of oral nifedipine and intravenous labetalol to normalize acute hypertension in severe preeclampsia and to assess the birth outcome. Relations between different factors were established by appropriate statistical tests. The p-value <0.05 was considered statistically significant.

Methods

The study was conducted on 120 antenatal women with blood pressure ≥160/110 mmHg admitted to our hospital, a tertiary care center, from January 1st, 2020 to June 30th, 2021. Patients were randomized by a single blinding method to receive intravenous labetalol and oral nifedipine. The primary outcome measures were the time taken to control the blood pressure and the number of doses of drugs required. The secondary outcome measures were the birth outcome like a method of delivery, side effect profile, and the number of admissions in the neonatal intensive care unit.

Results

A total of 120 patients were included with 60 patients in each group. The labetalol group took 48.67 ± 17.80 minutes and the nifedipine group took 64.33 ± 9.81 minutes to achieve a target BP of <=140/90 mmHg (p < 0.05). No side effects were seen in 70% of patients in the labetalol group and 71.67% in the nifedipine group (p > 0.05).

Conclusion and Global Health Implications

Intravenous labetalol is faster in restoring blood pressure in pregnant women with preeclampsia than oral nifedipine and may be used as a first-line drug in the acute control of blood pressure in a hypertensive emergency during pregnancy. More studies are needed in order to evaluate the findings from this pilot study in a large sample of patients.

Disease features and management of cardiomyopathies in women

Over the last years, there has been a growing interest in the clinical manifestations and outcomes of cardiomyopathies in women. Peripartum cardiomyopathy is the only women-specific cardiomyopathy. In cardiomyopathies with X-linked transmission, women are not simply healthy carriers of the disorder, but can show a wide spectrum of clinical manifestations ranging from mild to severe manifestations because of heterogeneous patterns of X-chromosome inactivation. In mitochondrial disorders with a matrilinear transmission, cardiomyopathy is part of a systemic disorder affecting both men and women. Even some inherited cardiomyopathies with autosomal transmission display phenotypic and prognostic differences between men and women. Notably, female hormones seem to exert a protective role in hypertrophic cardiomyopathy (HCM) and variant transthyretin amyloidosis until the menopausal period. Women with cardiomyopathies holding high-risk features should be referred to a third-level center and evaluated on an individual basis. Cardiomyopathies can have a detrimental impact on pregnancy and childbirth because of the associated hemodynamic derangements. Genetic counselling and a tailored cardiological evaluation are essential to evaluate the likelihood of transmitting the disease to the children and the possibility of a prenatal or early post-natal diagnosis, as well as to estimate the risk associated with pregnancy and delivery, and the optimal management strategies.

Contemporary Management of Cardiomyopathy and Heart Failure in Pregnancy

Cardiovascular disease is the primary cause of pregnancy-related mortality and morbidity in the United States, and maternal mortality has increased over the last decade. Pregnancy and the postpartum period are associated with significant vascular, metabolic, and physiologic adaptations that can unmask new heart failure or exacerbate heart failure symptoms in women with known underlying cardiomyopathy. There are unique management considerations for heart failure in women throughout pregnancy, and it is imperative that clinicians caring for pregnant women understand these important principles. Early involvement of multidisciplinary cardio-obstetrics teams is key to optimizing maternal and fetal outcomes. In this review, we discuss the unique challenges and opportunities in the diagnosis of heart failure in pregnancy, management principles along the continuum of pregnancy, and the safety of heart failure therapies during and after pregnancy.

Oral nifedipine versus intravenous labetalol for hypertensive emergencies during pregnancy: a systematic review and meta-analysis

Aim: The optimal drug management strategy for severe hypertension during pregnancy remains inconclusive. Some randomized controlled trials found that oral nifedipine was more effective than intravenous labetalol in hypertensive emergencies during pregnancy, while others found otherwise. As a result, we conducted a meta-analysis to assess the effectiveness of oral nifedipine versus intravenous labetalol for hypertensive emergencies during pregnancy.Methods: We searched PubMed, Embase, and the Cochrane Library for randomized controlled trials that compared oral nifedipine versus IV labetalol in hypertensive emergencies during pregnancy.Results: 12 RCTs enrolling 1151 participants (573 in the labetalol group and 578 in the nifedipine group) were included in the meta-analysis. Patients who received oral nifedipine reached their target blood pressure more rapidly than those who received intravenous labetalol (MD 7.64, 95%CI 4.08-11.20, p < .0001). The nifedipine group required fewer doses to achieve the target blood pressure (MD 0.62, 95%CI 0.36 to 0.88, p < .00001). There were no meaningful differences on the maternal complications between the two groups, mainly including eclampsia (OR 1.51; 95% CI, 0.75-3.05; p = .25), headache (OR 0.86; 95% CI, 0.52-1.44; p = .57), nausea/vomiting (OR 1.50; 95% CI, 0.76-2.93; p = .24), hypotension (OR 0.49; 95% CI, 0.12-1.99; p = .32), dizziness (OR 2.01; 95% CI, 0.77-5.25; p = .16), HELLP (OR 0.27; 95% CI, 0.05-1.64; p = .16), palpitations (OR 0.63; 95% CI, 0.32-1.27; p = .20), flushing (OR 0.77; 95%CI, 0.18-3.22; p = .72). There were no significant difference in the neonatal complications, including NICU admission (OR 1.24; 95% CI, 0.87-1.77; p = .23), 5 min Apgar score < 7 (OR 1.07; 95% CI, 0.82-1.39; p = .63), neonatal deaths (OR 1.08; 95%CI, 0.66-1.76; p = .77), FHR abnormality (OR 0.94; 95%CI, 0.47-1.88; p = .86).Conclusion: In conclusion, oral nifedipine could achieve target blood pressure more rapidly and required fewer doses than intravenous labetalol in the management of hypertensive emergencies during pregnancy.

Treatment of acute-onset hypertension in pregnancy: A network meta-analysis of randomized controlled trials comparing anti-hypertensives and route of administration

BACKGROUND

Consensus on the relative efficacy of available antihypertensive agents used in pregnancy is lacking.

OBJECTIVE

To compare treatment success with antihypertensives and categorize by route of administration.

SEARCH STRATEGY

MEDLINE, Embase, PubMed, Web of Science, Scopus, CINAHL, and clinicaltrials.gov were searched without date restriction.

DATA COLLECTION

Peer-reviewed randomized controlled trials (RCTs) comparing pharmacologic agents used to treat hypertension in parturients were included. Evaluated treatment groups included IV-labetalol (BBIV), IV-hydralazine (DIV), oral-nifedipine (CCBPO), sublingual nifedipine (CCBSL), IV-calcium channel blocker (nonspecific)(CCBIV), IV-nitroglycerine (NTG), epoprostenol infusion (PRO), IV-ketanserin (5HT2B), IV-diazoxide (BZO), oral-nifedipine + methyldopa (CCBAG), oral-methyl-dopa (AAG), and oral prazosin (ABPO).

ANALYSIS

Seventy-four studies (8324 patients) were eligible post PRISMA guidelines screening. Results were pooled using a Bayesian-approach for success of treatment (study defined target blood pressure), time to achieve target pressure, and neonatal intensive-care admissions.

RESULTS

Treatment success (primary outcome, 55 trials with 5518 patients) was analyzed. Surface under the cumulative ranking curve (SUCRA) was categorized for 13 drugs, CCBPO (0.84) followed by CCBSL (0.78) were most likely to be effective in achieving target blood pressure. After sub-grouping by presence/absence of preeclampsia, CCB-PO ranked highest for both [(0.82) vs. (0.77), respectively]. Serotonin antagonists (0.99) and nitroglycerin (0.88) ranked highest for time to target pressure. NICU admissions were lowest for alpha-2 agonists (0.89), followed by BB PO (0.82) and hydralazine IV (0.49).

CONCLUSION

Oral calcium-channel blockers ranked highest for treatment success. Ketanserin achieved target blood pressure fastest, warranting additional research. The results should be interpreted with caution as SUCRA values may not indicate whether the differences between interventions have clinically meaningful effect sizes.

Antihypertensives in Pregnancy

Hypertensive disorders of pregnancy (HDP) can result in significant maternal morbidity and even mortality. Available data suggest that many antihypertensives can be safely used in pregnant patients, albeit with close supervision of parameters like fetal growth and amniotic fluid volume. This article summarizes current guidelines on the diagnosis and treatment of hypertension in pregnancy and provides an in-depth guide to the available safety and efficacy data for antihypertensives during pregnancy and postpartum.

Pharmaceutical administration for severe hypertension during pregnancy: Network meta-analysis

Aims: To evaluate the efficacy of different pharmacologic treatment for severe hypertension during pregnancy. Methods: Two reviewers searched Ovid MEDLINE, Ovid EMbase, and the Cochrane Library for randomized clinical trials from the establishment of the database to 15 July 2021 that were eligible for inclusion and analyzed the pharmaceuticals used for severe hypertension in pregnancy. Results: 29 relevant trials with 2,521 participants were involved. Compared with diazoxide in rate of achieving target blood pressure, other pharmaceuticals, including epoprostenol (RR:1.58, 95%CI:1.01-2.47), hydralazine\dihydralazine (RR:1.57, 95%CI:1.07-2.31), ketanserin (RR:1.67, 95%CI:1.09-2.55), labetalol (RR:1.54, 95%CI:1.04-2.28), nifedipine (RR:1.54, 95%CI:1.04-2.29), and urapidil (RR:1.57, 95%CI:1.00-2.47), were statistically significant in the rate of achieving target blood pressure. According to the SUCRA, diazoxide showed the best therapeutic effect, followed by nicardipine, nifedipine, labetalol, and nitroglycerine. The three pharmaceuticals with the worst therapeutic effect were ketanserin, hydralazine, and urapidil. It is worth noting that the high ranking of the top two pharmaceuticals, including diazoxide and nicardipine, comes from extremely low sample sizes. Other outcomes were reported in the main text. Conclusion: This comprehensive network meta-analysis demonstrated that the nifedipine should be recommended as a strategy for blood pressure management in pregnant women with severe hypertension. Moreover, the conventional pharmaceuticals, including labetalol and hydralazine, showed limited efficacy. However, it was important to note that the instability of hydralazine reducing blood pressure and the high benefit of labetalol with high dosages intakes should also be of concern to clinicians.

Practical guide for the management of hypertensive disorders during pregnancy

Hypertensive disorders of pregnancy, including gestational hypertension, preeclampsia, and eclampsia, are a worldwide health problem. Hypertensive disorders of pregnancy affect more than 10% of pregnancies and are associated with increased mortality and morbidity for both mother and fetus. Although patients' outcomes and family's experience will always be the primary concern regarding hypertensive complications during pregnancy, the economic aspect of this disease is also worth noting. Compared with normotensive pregnancies, those related with hypertension resulted in an excess increase in hospitalization and healthcare cost. Hence, the focus of this review is to analyze hypertensive disorders of pregnancy and to present practical tips with clear instructions for the clinical management of hypertensive disorders of pregnancy. This overview offers a detailed approach from the diagnosis to treatment and follow-up of a pregnant women with hypertension, evidence based, to support these instructions.

Maternal beta-blocker dose and risk of small-for gestational-age in women with heart disease

INTRODUCTION

Beta-blockers are prescribed for many pregnant women with heart disease, but whether there is a dose-dependent effect on fetal growth remains to be examined. We aimed to investigate if antenatal beta-blocker use and dose were associated with delivering a small-for-gestational-age infant among women with heart disease.

MATERIAL AND METHODS

Our cohort included women with heart disease who delivered at Oslo University Hospital between 2006 and 2015. Maternal heart disease was classified into modified WHO risk scores. Women with beta-blocker treatment were dichotomized into whether they had been treated with a low or high dose based on clinical factors. We compared the risk of delivering a small-for-gestational-age infant in women exposed to high doses, low doses, or with no exposure to antenatal beta-blockers while adjusting for severity of maternal heart disease in logistic regression models.

RESULTS

Of a total of 540 pregnancies among women with heart disease, 163 (30.2%) were exposed to beta-blocker treatment. The majority were treated with metoprolol (86.5%). Almost twice as many babies in the beta-blocker group were small-for-gestational-age, compared with the non-exposed group (19.8 vs 9.5%, P < 0.001). Women using a high-dose beta-blocker had a five-fold increased risk of delivering a small-for-gestational-age infant compared with non-exposure (adjusted odds ratio [aOR] 4.89, 95% confidence interval [CI] 2.22-10.78, P < 0.001). Women using a low dose of beta-blocker had a two-fold increased risk of delivering a small-for-gestational-age infant; however, the confidence interval included the null (aOR 1.75, 95% CI 0.83-3.72, P = 0.143). Results when restricting the analyses to metoprolol showed the same pattern, but with attenuation of risks.

CONCLUSIONS

We found a five-fold increased risk of delivering a small-for-gestational-age infant in women with heart disease treated with a high dose of beta-blocker, and a two-fold increased risk among those treated with a low dose, showing an apparent dose-response relation. Close monitoring of fetal growth is warranted among women with heart disease treated with beta-blockers. As drug therapy in pregnancy concerns both mother and fetus, an optimum balance for both should be the goal.

Different dosage regimens of nifedipine, labetalol, and hydralazine for the treatment of severe hypertension during pregnancy: a network meta-analysis of randomized controlled trials

OBJECTIVES

This network meta-analysis aimed to compare the efficacy and safety of intravenous (IV) hydralazine, oral nifedipine, and IV labetalol with different dosage regimens in the treatment of severe hypertension during pregnancy.

METHODS

A comprehensive literature search was performed on PubMed, Embase, the Cochrane Library, and ClinicalTrials.gov for randomized controlled trials (RCTs) exploring the effects of hydralazine, nifedipine, and labetalol in the treatment of severe hypertension during pregnancy.

RESULTS

A total of 21 RCTs with 2183 patients comparing 7 regimens (oral nifedipine 50,60,90 mg; hydralazine 15,25 mg; and labetalol 220,300 mg) were identified. Compared with IV labetalol 300 mg, nifedipine 50,60, and 90 mg significantly improved the successful treatment rate of severe hypertension during pregnancy, nifedipine 50 and 90 mg and IV hydralazine 25 mg required significantly fewer doses to achieve target blood pressure (BP), and nifedipine 50 mg took significantly shorter time to achieve target BP. Subgroup analysis showed that only nifedipine 50 mg tablets, not capsules, required a significantly shorter time and fewer doses to achieve target BP than IV labetalol 300 mg. Moreover, nifedipine 60,90 mg showed superior effectiveness than IV hydralazine 15,25 mg in the successful treatment rate of severe hypertension during pregnancy. SUCRA analysis suggested that nifedipine 50,60,90 mg as the better regimens with the lower rates of overall ADR and neonatal complications.

CONCLUSION

These findings demonstrated the superiority of oral nifedipine 50,60,90 mg, especially oral nifedipine 50 mg tablets, in the treatment of severe hypertension during pregnancy than IV labetalol 300 mg, while oral nifedipine 60,90 mg also showed superiority in the successful treatment rate of severe hypertension during pregnancy than IV hydralazine 15,25 mg. However, the limitations of the underlying data indicate that future large-scale and rigorous RCTs are needed to confirm such findings.

Hypertensive Disorders of Pregnancy: Common Clinical Conundrums

Importance

Hypertensive complications of pregnancy comprise 16% of maternal deaths in developed countries and 7.4% of deaths in the United States. Rates of preeclampsia increased 25% from 1987 to 2004, and rates of severe preeclampsia have increased 6.7-fold between 1980 and 2003.

Objective

The aim of this study was to review current and available evidence for common clinical questions regarding the management of hypertensive disorders of pregnancy.

Evidence Acquisition

Original research articles, review articles, and guidelines on hypertension in pregnancy were reviewed.

Results

Severe gestational hypertension should be managed as preeclampsia with severe features. Serum uric acid levels can be useful in predicting development of superimposed preeclampsia for women with chronic hypertension. When presenting with preeclampsia with severe features before 34 weeks, expectant management should be considered only when both maternal and fetal conditions are stable. In the setting of hypertensive disorders of pregnancy, oral antihypertensive medications should be initiated when systolic blood pressure is greater than 160 mm Hg or when diastolic blood pressure is greater than 110 mm Hg, with the most ideal agents being labetalol or nifedipine. Furthermore, although risk of preeclampsia recurrence in future pregnancy is low, women with a history of preeclampsia should be managed with 81 mg aspirin daily for preeclampsia prevention.

Conclusions and Relevance

Despite the frequency with which hypertensive disorders of pregnancy are encountered clinically, situations arise frequently with limited evidence to guide providers in their management. An urgent need exists to better understand this disease to optimize outcomes for impacted patients.

Clinical practice guideline for the prevention and management of hypertensive disorders of pregnancy

Objectives: To provide clinical recommendations based on evidence for the the prevention and management of HDP in EsSalud. Methods: A CPG for the the prevention and management of HDP in EsSalud was developed. To this end, a guideline development group (local GDG) was established, including medical specialists and methodologists. The local GDG formulated 8 clinical questions to be answered by this CPG. Systematic searches of systematic reviews and—when it was considered pertinent—primary studies were searched in PubMed y Central during 2021. The evidence to answer each of the posed clinical questions was selected. The quality of the evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. In periodic work meetings, the local GDG used the GRADE methodology to review the evidence and formulate the recommendations, the points of good clinical practice and flowcharts for the prevention, management and follow-up. Finally, the CPG was approved with Resolution 112-IETSI-ESSALUD-2021. Results: This CPG addressed 8 clinical questions, divided into three topics: prevention, management and follow-up of the HDP. Based on these questions, 11 recommendations (6 strong recommendations and 5 weak recommendations), 32 points of good clinical practice, and 3 flowcharts were formulated. Conclusions: The main recommendations in the guideline are the use of magnesium sulfate for the treatment of severe pre-eclampsia and eclampsia. The guideline must be updated in three years’ time.

Nifedipine or amlodipine? The choice for hypertension during pregnancy: a systematic review and meta-analysis

BACKGROUND

There is a lack of sufficient evidence regarding efficacy and safety of amlodipine on treating hypertension during pregnancy.

OBJECTIVE

To compare antihypertensive efficacy, pregnancy outcome and safety of amlodipine with nifedipine on hypertension during pregnancy.

METHODS

A systematic search of PubMed, Embase, Cochrane Library, clinicaltrials.gov, Chinese National Knowledge Infrastructure, Wanfang Database and China Biology Medicine disc of randomized controlled trials (RCTs) up to April l5, 2021 was conducted on RCTs comparing amlodipine to nifedipine for the treatment of hypertension during pregnancy. Screening, data extraction, and quality assessment were done by two independent reviewers. To estimate relative effects from all available evidence, a meta-analysis was conducted.

RESULTS

Seventeen RCTs were included. Amlodipine was found the efficacy is slightly superior to nifedipine on treating hypertension during pregnancy (RR 1.06, 95% CI 1.01 to 1.10) with a decreased risk for maternal side effects (RR 0.42, 95% CI 0.29 to 0.61). Subgroup analysis found amlodipine can get a better control on SBP (RR - 11.68, 95% CI - 17.98 to - 5.37) and DBP (RR - 7.44, 95% CI - 13.81 to - 1.06) compared with intermediate-/long-acting nifedipine. In addition, there was no difference between amlodipine and nifedipine on pregnancy outcomes including caesarean section, premature labour, placental abruption, FGR, fetal distress, neonatal asphyxia.

CONCLUSIONS

Given the results of this systematic review and meta-analysis, amlodipine can be effectively and safely used for hypertension during pregnancy.

Postpartum preeclampsia or eclampsia: defining its place and management among the hypertensive disorders of pregnancy

High blood pressure in the postpartum period is most commonly seen in women with antenatal hypertensive disorders, but it can develop de novo in the postpartum time frame. Whether postpartum preeclampsia or eclampsia represents a separate entity from preeclampsia or eclampsia with antepartum onset is unclear. Although definitions vary, the diagnosis of postpartum preeclampsia should be considered in women with new-onset hypertension 48 hours to 6 weeks after delivery. New-onset postpartum preeclampsia is an understudied disease entity with few evidence-based guidelines to guide diagnosis and management. We propose that new-onset hypertension with the presence of any severe features (including severely elevated blood pressure in women with no history of hypertension) be referred to as postpartum preeclampsia after exclusion of other etiologies to facilitate recognition and timely management. Older maternal age, black race, maternal obesity, and cesarean delivery are all associated with a higher risk of postpartum preeclampsia. Most women with delayed-onset postpartum preeclampsia present within the first 7 to 10 days after delivery, most frequently with neurologic symptoms, typically headache. The cornerstones of treatment include the use of antihypertensive agents, magnesium, and diuresis. Postpartum preeclampsia may be associated with a higher risk of maternal morbidity than preeclampsia with antepartum onset, yet it remains an understudied disease process. Future research should focus on the pathophysiology and specific risk factors. A better understanding is imperative for patient care and counseling and anticipatory guidance before hospital discharge and is important for the reduction of maternal morbidity and mortality in the postpartum period.

Preeclampsia and Related Problems

Hypertensive disorders of pregnancy can be classified as chronic hypertension (present before pregnancy), gestational hypertension (onset after 20 weeks of pregnancy), and preeclampsia (onset after 20 weeks of pregnancy, along with proteinuria and other organ dysfunction). Preeclampsia and related disorders are a major cause of maternal and fetal morbidity and mortality. Preeclampsia is believed to result from an angiogenic imbalance in the placenta circulation. Antenatal screening and early diagnosis may help improve outcomes. Severe preeclampsia is characterized by SBP ≥160 mm Hg, or DBP ≥110 mm Hg, thrombocytopenia (platelet count <100 × 109/L), abnormal liver function, serum creatinine >1.1 mg/dL, or a doubling of the serum creatinine concentration in the absence of other renal diseases, disseminated intravascular coagulation, pulmonary edema, new-onset headache, or visual disturbances. Severe preeclampsia or eclampsia (preeclampsia with seizures) needs ICU management and is the main cause of morbidity and mortality. Severe hypertension can also result in life-threatening intracranial hemorrhage. Blood pressure control, seizure prevention, and appropriate timing of delivery are the cornerstones of the management of preeclampsia. Besides intravenous antihypertensive drugs, intravenous magnesium sulfate is the drug of choice to prevent or treat seizures, when preparing for urgent delivery. At present, delivery remains the most effective treatment for preeclampsia, and organ dysfunction rapidly recovers after delivery. Novel therapeutic interventions are under development to reduce complications.

How to cite this article

Narkhede AM, Karnad DR. Preeclampsia and Related Problems. Indian J Crit Care Med 2021;25(Suppl 3):S261-S266.

Gestational Hypertension and Preeclampsia: An Overview of National and International Guidelines

Importance

Gestational hypertension and preeclampsia are leading causes of maternal and perinatal morbidity and mortality worldwide. Τhe lack of effective screening and management policies appears to be one of the main reasons.

Objective

The aim of this study was to review and compare recommendations from published guidelines on these common pregnancy complications.

Evidence Acquisition

A descriptive review of guidelines from the National Institute for Health and Care Excellence, the Society of Obstetric Medicine of Australia and New Zealand, the International Society of Hypertension, the International Society for the Study of Hypertension in Pregnancy, the European Society of Cardiology, the International Federation of Gynecology and Obstetrics, the Society of Obstetricians and Gynaecologists of Canada, the American College of Obstetricians and Gynecologists, the International Society of Ultrasound in Obstetrics and Gynecology, the World Health Organization, and the US Preventive Services Task Force on gestational hypertension and preeclampsia was carried out.

Results

There is an overall agreement that, in case of suspected preeclampsia or new-onset hypertension, blood and urine tests should be carried out, including dipstick test for proteinuria, whereas placental growth factor-based testing is only recommended by the National Institute for Health and Care Excellence and the European Society of Cardiology. In addition, there is a consensus on the recommendations for the medical treatment of severe and nonsevere hypertension, the management of preeclampsia, the appropriate timing of delivery, the optimal method of anesthesia and the mode of delivery, the administration of antenatal corticosteroids and the use of magnesium sulfate for the treatment of eclamptic seizures, the prevention of eclampsia in cases of severe preeclampsia, and the neuroprotection of preterm neonates. The reviewed guidelines also state that, based on maternal risk factors, pregnant women identified to be at high risk for preeclampsia should receive low-dose aspirin starting ideally in the first trimester until labor or 36 to 37 weeks of gestation, although the recommended dose varies between 75 and 162 mg/d. Moreover, most guidelines recommend calcium supplementation for the prevention of preeclampsia and discourage the use of other agents. However, controversy exists regarding the definition and the optimal screening method for preeclampsia, the need for treating mild hypertension, the blood pressure treatment targets, and the postnatal blood pressure monitoring.

Conclusions

The development and implementation of consistent international protocols will allow clinicians to adopt effective universal screening, as well as preventive and management strategies with the intention of improving maternal and neonatal outcomes.

Pulse pressure as a predictor of response to treatment for severe hypertension in pregnancy

BACKGROUND

Pulse pressure is a proposed means of tailoring antihypertensive therapy for treatment of acute-onset, severe hypertension in pregnancy.

OBJECTIVE

This study aimed to determine whether pulse pressure predicts response to the various first-line antihypertensive medications.

STUDY DESIGN

This is a retrospective cohort study from a single academic tertiary care center between 2015 and 2018. Patients were screened for inclusion if they had severe hypertension (defined as systolic blood pressure of ≥160 mm Hg or diastolic blood pressure of ≥110 mm Hg) lasting at least 15 minutes and were initially treated with intravenous labetalol, intravenous hydralazine, or immediate-release oral nifedipine. If a patient had multiple episodes of acute treatment during the pregnancy, only one episode was included in the analysis. The primary outcome was time to resolution (in minutes) of severe hypertension. To adjust for factors that may have affected time to resolution, we first compared baseline characteristics on the basis of the antihypertensive agent received. We then assessed the association between baseline characteristics and resolution of severe hypertension within 60 minutes of treatment. Regression analysis incorporated pulse pressure and antihypertensive agents into a model to predict resolution within 60 minutes of onset of severe hypertension.

RESULTS

A total of 479 women hospitalized with severe maternal hypertension met the inclusion criteria. Hydralazine was the initial antihypertensive agent administered to 113 women, whereas 233 received labetalol, and 133 received nifedipine. Those who initially received nifedipine had a shorter mean time to resolution of severe hypertension (32.6 minutes vs 46.3 for hydralazine and 50.3 for labetalol; P<.01) and were more likely to have resolution of severe hypertension within 60 minutes (91.0% vs 77.9% for hydralazine and 76.8% for labetalol; P<.01). Nifedipine also resulted in a lower mean posttreatment blood pressure. Regression analysis revealed that a lack of resolution of severe hypertension within 60 minutes was independently associated with 2 measures of hypertension severity (mean arterial pressure of ≥125 mm Hg and the need for ≥2 doses of medication) and pulse pressure of >75 mm Hg at the time of treatment, initial treatment with labetalol, and gestational age of <37 weeks at the time of the hypertensive event (or at delivery if treatment was after delivery). The model's bias-corrected bootstrapped area under the receiver operating characteristic curve was 0.85 (95% confidence interval, 0.79-0.88). Interaction terms between pulse pressure and each antihypertensive agent were not significant and therefore not incorporated into the final model.

CONCLUSION

Pulse pressure did not predict response to the various first-line antihypertensive agents. Initial treatment with oral nifedipine was associated with a higher likelihood of resolution of severe hypertension within 60 minutes of treatment than with intravenous labetalol.

Peripartum management of hypertension: a position paper of the ESC Council on Hypertension and the European Society of Hypertension

Hypertensive disorders are the most common medical complications in the peripartum period associated with a substantial increase in morbidity and mortality. Hypertension in the peripartum period may be due to the continuation of pre-existing or gestational hypertension, de novo development of pre-eclampsia or it may be also induced by some drugs used for analgesia or suppression of postpartum haemorrhage. Women with severe hypertension and hypertensive emergencies are at high risk of life-threatening complications, therefore, despite the lack of evidence-based data, based on expert opinion, antihypertensive treatment is recommended. Labetalol intravenously and methyldopa orally are then the two most frequently used drugs. Short-acting oral nifedipine is suggested to be used only if other drugs or iv access are not available. Induction of labour is associated with improved maternal outcome and should be advised for women with gestational hypertension or mild pre-eclampsia at 37 weeks' gestation. This position paper provides the first interdisciplinary approach to the management of hypertension in the peripartum period based on the best available evidence and expert consensus.

Comparative efficacy and safety of oral antihypertensive agents in pregnant women with chronic hypertension: a network metaanalysis

OBJECTIVE DATA

Chronic hypertension is associated with adverse perinatal outcomes, although the optimal treatment is unclear. The aim of this network metaanalysis was to simultaneously compare the efficacy and safety of antihypertensive agents in pregnant women with chronic hypertension.

STUDY

Medline, Scopus, CENTRAL, Web of Science, Clinicaltrials.gov, and Google Scholar databases were searched systematically from inception to December 15, 2019. Both randomized controlled trials and cohort studies were held eligible if they reported the effects of antihypertensive agents on perinatal outcomes among women with chronic hypertension.

STUDY APPRAISAL AND SYNTHESIS METHODS

The primary outcomes were preeclampsia and small-for-gestational-age risk. A frequentist network metaanalytic random-effects model was fitted. The main analysis was based on randomized controlled trials. The credibility of evidence was assessed by taking into account within-study bias, across-studies bias, indirectness, imprecision, heterogeneity, and incoherence.

RESULTS

Twenty-two studies (14 randomized controlled trials and 8 cohorts) were included, comprising 4464 women. Pooling of randomized controlled trials indicated that no agent significantly affected the incidence of preeclampsia. Atenolol was associated with significantly higher risk of small-for-gestational age compared with placebo (odds ratio, 26.00; 95% confidence interval, 2.61-259.29) and is ranked as the worst treatment (P-score=.98). The incidence of severe hypertension was significantly lower when nifedipine (odds ratio, 0.27; 95% confidence interval, 0.14-0.55), methyldopa (odds ratio, 0.31; 95% confidence interval, 0.17-0.56), ketanserin (odds ratio, 0.29; 95% confidence interval, 0.09-0.90), and pindolol (odds ratio, 0.17; 95% confidence interval, 0.05-0.55) were administered compared with no drug intake. The highest probability scores were calculated for furosemide (P-score=.86), amlodipine (P-score=.82), and placebo (P-score=.82). The use of nifedipine and methyldopa were associated with significantly lower placental abruption rates (odds ratio, 0.29 [95% confidence interval, 0.15-0.58] and 0.23 [95% confidence interval, 0.11-0.46], respectively). No significant differences were estimated for cesarean delivery, perinatal death, preterm birth, and gestational age at delivery.

CONCLUSION

Atenolol was associated with a significantly increased risk for small-for-gestational-age infants. The incidence of severe hypertension was significantly lower when nifedipine and methyldopa were administered, although preeclampsia risk was similar among antihypertensive agents. Future large-scale trials should provide guidance about the choice of antihypertensive treatment and the goal blood pressure during pregnancy.

A cohort study of antihypertensive use during pregnancy in South Korea, 2013-2017

OBJECTIVES

Hypertensive disorder is a common medical condition in pregnancy. However, the recommendations for antihypertensive use during pregnancy are based on limited evidence and various factors affect their selection in clinical practice. We aim to assess the prevalence of antihypertensive use and describe which medications are being used in pregnancy.

STUDY DESIGN

We conducted a cohort study of all pregnancies resulted in a live birth between 2013 and 2017, by using the Health Insurance Review and Assessment (HIRA) database of South Korea. Based on duration of drug supplied, we examined antihypertensive use during the pre-pregnancy, pregnancy, and postpartum periods. We described the patterns of discontinuing, continuing, switching, and initiating antihypertensive medications during pregnancy.

RESULTS

We included 2,030,821 pregnancies, of whom 0.9%, 3.1%, and 1.8% were dispensed antihypertensives in the pre-pregnancy, pregnancy, and postpartum periods, respectively. The most frequent medications used were dihydropyridines (40.7%), beta-blockers (38.4%) and Angiotensin II Receptor Blockers (16.8%) in the first trimester, and dihydropyridines (89.7%) and vasodilators (11.5%) in the third trimester. Among women exposed to antihypertensives during pregnancy, this was the first use in 86.3% of women. Among women receiving antihypertensives before pregnancy, 77.9% discontinued treatment during pregnancy, whereas 13.2% continued to take their pre-pregnancy medications.

CONCLUSION

The prevalence of antihypertensive use during pregnancy was 3.1% in South Korea. Overall, while dihydropyridines were predominant, other types of antihypertensives were also commonly dispensed during pregnancy. It suggests a need to investigate the effect of exposure to various types of antihypertensives of which safety remains unclear during pregnancy.

Oral Nifidepine versus IV labetalol in severe preeclampsia: A randomized control trial

Objective:

To compare oral Nifidepine and IV labetalol in terms of rapidity of BP control in severe preeclampsia.

Methods:

All patients coming to Services Hospital from March 2017 to February 2019 with diagnosis of severe preeclampsia ≥ 24 weeks gestation were randomized to either receive Nifidepine or Labetalol. Primary outcome measure was time taken to control BP and number of doses required. Secondary outcome measures were side effects of drugs, APGAR score, NICU admission and perinatal mortality.

Results:

Two hundred four patients were included in trial with 102 patients in each group. Labetalol took 22.6± 13.5minutes and Nifidepine took 22.09± 11.7 minutes to achieve target BP (p>0.05). Labetalol required 2.3± 1.58 doses and Nifidepine 2.2± 1.58 doses to control BP ( p>0.05). No maternal side effects were seen in 86 (84.31%) and 92(90.19%) patients in both groups (p>0.05). Mean gestational age at birth was 34.8 ±2.73weeks in Labetalol and 35.2±2.48 weeks in Nifidepine group (p>0.05). In labetalol group, 43 (42.15%) babies had APGAR Score < 7/10 and 23(22.54%) babies required admission to NICU while in Nifidepine group 42 (41.17%) babies had Apgar score < 7/10 & 30(29.4%) babies were admitted to NICU(p>0.05). There were 21(20.5%) perinatal deaths in labetalol Group-And 19(18.6%) in Nifidepine group (p>0.05)

Conclusion:

Oral Nifidepine and IV labetalol are equally efficacious in controlling BP in patients with severe pre eclampsia without any significant side effects.

Intravenous labetalol versus oral nifedipine for acute hypertension in pregnancy: effects on cerebral perfusion pressure

BACKGROUND

Pregnant women with preeclampsia have been found to have elevated cerebral perfusion pressure and impaired cerebral autoregulation compared with normal pregnant women. Transcranial Doppler is a noninvasive technique used to estimate cerebral perfusion pressure. The effects of different antihypertensive medications on cerebral perfusion pressure in preeclampsia are unknown.

OBJECTIVE

To compare the change in cerebral perfusion pressure before and after intravenous labetalol vs oral nifedipine in the setting of acute severe hypertension in pregnancy.

STUDY DESIGN

This is a prospective cohort study of pregnant women between 24 and 42 weeks' gestation with severe hypertension (systolic blood pressure ≥160 mm Hg and/or diastolic blood pressure ≥110 mm Hg). Women who consented to the study and received either intravenous labetalol or oral nifedipine were included. Exclusion criteria included active labor or receipt of any antihypertensive medication within 2 hours of initial cerebral perfusion pressure measurement. Peripheral blood pressure and transcranial Doppler studies for middle cerebral artery hemodynamics were performed prior to the administration of antihypertensive medications and repeated 30 minutes after medication administration.

RESULTS

A total of 16 women with acute severe hypertension were enrolled; 8 received intravenous labetalol and 8 received oral nifedipine. There were no significant differences between the labetalol and nifedipine groups in baseline characteristics such as maternal age, race and ethnicity, payment, hospital site, body mass index, nulliparity, gestational age, preexisting diabetes mellitus or chronic hypertension, fetal growth restriction, magnesium sulfate administration, and symptomatology (P>.05). When examined 30 minutes after the administration of either intravenous labetalol or oral nifedipine, there was a significantly greater decrease in systolic blood pressure (-9.8 mm Hg vs -39 mm Hg; P=.003), mean arterial pressure (-7.1 mm Hg vs -22.3 mm Hg; P=.02), and cerebral perfusion pressure (-2.5 mm Hg vs -27.7 mm Hg; P=.01) in the nifedipine group. There was no statistically significant decrease in diastolic blood pressure (-12.9 mm Hg vs -5.4 mm Hg; P=.15). The change in middle cerebral artery velocity by transcranial Doppler was compared between the groups and was not different (0.07 cm/s vs 0.16 cm/s; P=.64).

CONCLUSION

Oral nifedipine resulted in a significant decrease in cerebral perfusion pressure, whereas labetalol did not, after administration for acute severe hypertension among women with preeclampsia. This decrease seems to be driven by a decrease in peripheral arterial blood pressure rather than a direct change in cerebral blood flow.

Efficacy of Diltiazem for the Control of Blood Pressure in Puerperal Patients with Severe Preeclampsia: A Randomized, Single-Blind, Controlled Trial

BACKGROUND

Postpartum preeclampsia is a serious disease related to high blood pressure that occurs commonly within the first six days after delivery.

OBJECTIVE

To evaluate if diltiazem improves blood pressure parameters in early puerperium patients with severe preeclampsia. Methodology. A randomized, single-blind longitudinal clinical trial of 42 puerperal patients with severe preeclampsia was carried out. Patients were randomized into two groups: the experimental group (n = 21) received diltiazem (60 mg) and the control group (n = 21) received nifedipine (10 mg). Both drugs were orally administered every 8 hours. Systolic, diastolic, and mean blood pressures as well as the heart rate were recorded and analyzed (two-way repeated measures ANOVA) at baseline and after 6, 12, 18, 24, 30, 36, 42, and 48 hours. Primary outcome measures were all the aforementioned blood pressure parameters. Secondary outcome measures included the number of hypertension and hypotension episodes along with the length of stay in the intensive care unit.

RESULTS

No statistical differences were found between groups (diltiazem vs. nifedipine) regarding basal blood pressure parameters. Interarm differences in blood pressure (systolic, diastolic, and mean) and heart rate were statistically significant between treatment groups from 6 to 48 hours. Patients in the diltiazem group had lower blood pressure levels than patients in the nifedipine group. Significantly, patients who received diltiazem had fewer hypertension and hypotension episodes and stayed fewer days in the intensive care unit than those treated with nifedipine.

CONCLUSIONS

Diltiazem controlled arterial hypertension in a more effective and uniform manner in patients under study than nifedipine. Patients treated with diltiazem had fewer collateral effects and spent less time in the hospital. This trial is registered with NCT04222855.

Stroke in Pregnancy: A Focused Update

Ischemic stroke (IS) and hemorrhagic stroke (HS) can be devastating complications during pregnancy and the puerperium that are thought to occur in approximately 30 in 100,000 pregnancies. In high-risk groups, such as women with preeclampsia, the incidence of both stroke subtypes, combined, is up to 6-fold higher than in pregnant women without these disorders. IS or HS may present in young women with atypical symptoms including headache, seizure, extremity weakness, dizziness, nausea, behavioral changes, and visual symptoms. Obstetric anesthesiologists who recognize these signs and symptoms of pregnancy-related stroke are well positioned to facilitate timely care. Acute stroke of any type is an emergency that should prompt immediate coordination of care between obstetric anesthesiologists, stroke neurologists, high-risk obstetricians, nurses, and neonatologists. Historically, guidelines have not addressed the unique situation of maternal stroke, and pregnant women have been excluded from the large stroke trials. More recently, several publications and professional societies have highlighted that pregnant women suspected of having IS or HS should be evaluated for the same therapies as nonpregnant women. Vaginal delivery is generally preferred unless there are obstetric indications for cesarean delivery. Neuraxial analgesia and anesthesia are frequently safer than general anesthesia for cesarean delivery in the patient with a recent stroke. Potential exceptions include therapeutic anticoagulation or intracranial hypertension with risk of herniation. General anesthesia may be appropriate when cesarean delivery will be combined with intracranial neurosurgery.

Values of serum sFlt-1, PLGF levels, and sFlt-1/PLGF ratio in diagnosis and prognosis evaluation of preeclamptic patients

PURPOSE

To explore the values of serum sFlt-1, PLGF levels and sFlt-1/PLGF ratio in the diagnosis and prognosis evaluation of preeclamptic patients.

METHODS

From March 2017 to October 2018, 60 cases of early onset preeclampsia (E-PE), 116 cases of late onset preeclampsia (L-PE) and 50 cases of gestational hypertension (GH) were selected. Fifty women who had vaginal bleeding or abdominal distention before 34 gestational weeks were selected as an early control group, and 50 pregnant women awaiting delivery were selected as a late control group. Serum sFlt-1 and PLGF levels were measured, and changes of sFlt-1/PLGF ratio were analyzed. Their correlations with neonatal birth weight were analyzed, and ROC curves were plotted for E-PE diagnosis.

RESULTS

The sFlt-1/PLGF ratio of patients with E-PE was significantly higher than those of other groups, and negatively correlated with neonatal birth weight. When the ratio was used as a diagnostic index, AUC was 0.975. The ratio of patients with severe L-PE exceeded that of cases with mild L-PE. In all preeclamptic patients, the ratio was elevated with increasing maternal and neonatal complications.

CONCLUSION

sFlt-1/PLGF ratio is valuable for assessing the severity of preeclampsia and diagnosing E-PE, and can be used to predict neonatal birth weight.

Use of Antihypertensive Medications and Uterotonics During Delivery Hospitalizations in Women With Asthma

OBJECTIVE

To estimate whether the diagnosis of asthma is associated with the use of specific uterotonic and antihypertensive medications during delivery hospitalizations.

METHODS

We used Perspective, an administrative database, to determine whether women hospitalized for delivery complicated by postpartum hemorrhage or preeclampsia received uterotonics and antihypertensive medications differentially based on the absence or presence of asthma from 2006 to 2015. Given that carboprost and intravenous (IV) labetalol may be associated with asthma exacerbation, adjusted models for receipt of these medications were created with adjusted risk ratios with 95% CIs as measures of effect. Risk for status asthmaticus based on receipt of carboprost and IV labetalol was analyzed.

RESULTS

Over the study period, a total of 5,691,178 women were analyzed, of whom 239,915 (4.2%) had preeclampsia and 139,841 postpartum hemorrhage (2.5%). Carboprost was used less frequently in patients with asthma compared with patients with no asthma (11.4% vs 18.0%) in comparison with IV labetalol, which was used more commonly when a diagnosis of asthma was present (18.5% vs 16.7%). In unadjusted analysis, the presence of asthma was associated with a 37% decrease in likelihood of carboprost use and an 11% increase in likelihood of labetalol use. In adjusted analysis, the presence of asthma was associated with a 32% decrease in likelihood of carboprost use (adjusted risk ratio 0.68, 95% CI 0.62-0.74) compared with a 7% decrease in labetalol use (adjusted risk ratio 0.93, 95% CI 0.90-0.97). Risk for status asthmaticus was significantly increased with use of IV labetalol compared with other antihypertensive medications (6.5 vs 1.7/1,000 delivery hospitalizations, P<.01).

CONCLUSION

There may be an opportunity to reduce use of β-blockers and carboprost among patients with asthma. Given their association with status asthmaticus, these drugs should be used cautiously in women with asthma.

Methyldopa versus nifedipine or no medication for treatment of chronic hypertension during pregnancy: A multicenter randomized clinical trial

OBJECTIVE

To assess the maternal and fetal outcome in women with mild to moderate chronic hypertension on antihypertensive drug (methyldopa or nifedipine) therapy compared to no medication.

METHODS

This multicenter randomized clinical trial was conducted at Menoufia University hospital, Shibin El-kom Teaching hospital and 11 Central hospitals at Menoufia governorate, Egypt.490 pregnant women with mild to moderate chronic hypertension were randomized into three groups; methyldopa group (n = 166), nifedipine group (n = 160) and control or no medication group (n = 164) who were followed from the beginning of pregnancy till the end of puerperium to record maternal and fetal outcome.

RESULTS

Mothers in the control (no medication) group were more prone for the development of severe hypertension, preeclampsia, renal impairment, ECG changes, placental abruption and repeated hospital admissions (p < 0.001) when compared to mothers in both treatment groups (methyldopa and nifedipine). Neonates in the control (no medication) group were more prone for prematurity and admission to neonatal ICU (p < 0.001).

CONCLUSION

Antihypertensive drug therapy is advisable in mild to moderate chronic hypertension during pregnancy to decrease maternal and fetal morbidity. When considering which agents to use for treatment, oral methyldopa and nifedipine are valid options.

Pre-eclampsia through the eyes of the obstetrician and anesthesiologist

Due to the high risk of morbidity and mortality from unrecognized and untreated pre-eclampsia, clinicians should have a high index of suspicion to evaluate, treat and monitor patients presenting with signs concerning for pre-eclampsia. Early blood pressure management and seizure prophylaxis during labor are critical for maternal safety. Intrapartum, special anesthetic considerations should be employed to ensure the safety of the parturient and fetus. Patients who have pre-eclampsia should be aware that they are at high risk for the future development of cardiovascular disease.

Hypertension in pregnancy: Pathophysiology and treatment

Hypertensive disorders of pregnancy, an umbrella term that includes preexisting and gestational hypertension, preeclampsia, and eclampsia, complicate up to 10% of pregnancies and represent a significant cause of maternal and perinatal morbidity and mortality. Despite the differences in guidelines, there appears to be consensus that severe hypertension and non-severe hypertension with evidence of end-organ damage need to be controlled; yet the ideal target ranges below 160/110 mmHg remain a source of debate. This review outlines the definition, pathophysiology, goals of therapy, and treatment agents used in hypertensive disorders of pregnancy.

IV labetalol and oral nifedipine in acute control of severe hypertension in pregnancy-A randomized controlled trial

OBJECTIVE

To compare the efficacy of intravenous labetalol with oral nifedipine in the treatment of severe hypertension in pregnancy with blood pressure ≥160/110 mm Hg.

DESIGN, SETTING AND PARTICIPANTS

We conducted a parallel double-blinded randomized controlled trial between December 2014 to December 2016 in 120 antenatal women of gestational age >28 weeks, admitted with severe hypertension of blood pressure ≥160/110 mm Hg to maternity ward at a tertiary hospital. The labetalol group received 20 mg initially followed by escalating doses of 40 mg, 80 mg, 80 mg and 80 mg (5 doses) every 15 min to a maximum of 300 mg. Nifedipine group received 10 mg initially followed by repeated doses of 20 mg every 15 min (total 5 doses) to a maximum of 90 mg. Vital signs were recorded every 15 min. -The time taken and the number of doses required to achieve the target blood pressure (150/100 mmHg). Survival analysis was used to compare the efficacy of treatment regimens.

RESULTS

Sixty women were randomised to each group and none were lost to follow-up. None of the patients in nifedipine group required labetalol, whereas three patients in labetalol group achieved target BP only after receiving nifedipine was administered after the maximum dose of labetalol.The mean time taken to achieve the target blood pressure in the labetalol group was higher (36.75 min) than in the nifedipine group (27.25 min) [mean difference 9.5 min,p = 0.002]. Nifedipine group required significantly lower doses (1.82 ± 0.83) as compared to labetalol (2.45 ± 1.32) [p = 0.002]. Nifedipine was 1.8 times more likely to achieve target blood pressure (Hazard Ratio = 1.8).

CONCLUSIONS

Both intravenous Labetalol and oral Nifedipine were effective in controlling blood pressure. Nifedipine reduced BP more rapidly than Labetalol. Oral Nifedipine may be a better alternative because of its ease of oral administration and a flat dosing regimen.

Does nifedipine improve outcomes of embryo transfer?: Interim analysis of a randomized, double blinded, placebo-controlled trial

BACKGROUND

Implantation failure is the main factor affecting the success rate of in vitro fertilization (IVF) procedures. Studies have reported that uterine contractions (UC) at the time of embryo transfer (ET) were inversely related to implantation and pregnancy rate, hence reducing the success of IVF treatments. Various pharmacological agents, with the exception of calcium channel blockers, have been investigated to improve ET outcomes by reducing UC. Thus, a double-blinded randomized, placebo-controlled trial was conducted to determine whether nifedipine, a calcium channel blocker with potent smooth muscle relaxing activity and an excellent safety profile, can improve the outcome of patients undergoing ET treatments.

METHODS

Ninety-three infertile women were recruited into 1 of 2 groups: placebo (n = 47) or nifedipine 20 mg (n = 46). Study participants were admitted 30 minutes prior to ET and given either tablet after their baseline vital signs were recorded. They then underwent ET and were observed for adverse events for another 30 minutes post-ET. Follow up of the participants' outcomes was conducted via electronic medical records. The primary outcomes are implantation and clinical pregnancy rates. Secondary outcomes include any maternal or fetal adverse events, miscarriage, pregnancy, live births, and neonatal outcomes. Resulting data were then analyzed using t test, Pearson chi-square test, and Fisher exact test to compare outcomes between the 2 groups.

RESULTS

No statistical differences in the implantation rate (42.6% vs 39.1%, P = .737, rate ratio 0.868, 95% confidence interval [CI]: 0.379-1.986) and the clinical pregnancy rate (23.4% vs 26.1%, P = .764, rate ratio 1.155, 95% CI: 0.450-2.966) were detected between the placebo and the treatment groups. In addition, no statistical significance between the placebo and the treatment groups for any secondary outcomes were detected.

CONCLUSIONS

This double blinded, randomized, and placebo-controlled trial demonstrated that the single use of 20 mg nifedipine given 30 minutes before embryo transfer did not improve the implantation rate or the clinical pregnancy rate of the infertility treatment. Further studies are required to demonstrate the clinical benefits and risks of nifedipine usage in embryo transfer.

State-of-the-Art Diagnosis and Treatment of Hypertension in Pregnancy

Hypertension complicates up to 10% of pregnancies worldwide. Pregnancy hypertension is defined as systolic blood pressure (BP) equal to or greater than 140 mm Hg or diastolic BP equal to or greater than 90 mm Hg, usually on the basis of measurements in office/clinic settings and using various BP devices. Hypertensive disorders of pregnancy are classified into (1) chronic hypertension diagnosed before pregnancy or before 20 weeks' gestation, (2) gestational hypertension diagnosed at equal to or greater than 20 weeks, or (3) preeclampsia, defined restrictively as gestational hypertension with proteinuria or broadly as gestational hypertension with proteinuria or an end-organ manifestation consistent with preeclampsia. Absolute BP values equal to or greater than 140/90 mm Hg are associated with increased maternal and perinatal risks, particularly with preeclampsia. This review focuses on antihypertensive therapy of hypertensive disorders of pregnancy as a specific management strategy. Underpinning this therapy is the need for accurate measurement of BP, agreed-upon classification of pregnancy hypertension, agreed-upon BP thresholds for enhanced surveillance and antihypertensive treatment, and collaborative teamwork in management. Challenges relate to the methodology of studies on which care is based, as well as aspects of the care itself, particularly the unregulated use of home BP monitoring. Pitfalls include the unsubstantiated belief that nifedipine and magnesium sulfate cannot be used together and the perception that severe hypertension and nonsevere hypertension are separate entities rather than lying along a spectrum of BP values. The following must be addressed by future research: guidance for nuanced care as women transition between severe and nonsevere hypertension, personalized antihypertensive therapy, and incorporation of women's values into research priorities and clinical practice when antihypertensive care is chosen.

Drugs for treating severe hypertension in pregnancy: a network meta-analysis and trial sequential analysis of randomized clinical trials

AIMS

Several antihypertensive drugs are used in the treatment of severe hypertension in pregnancy. The present study is a network meta-analysis comparing the efficacy and safety of these drugs.

METHODS

Electronic databases were searched for randomized clinical trials comparing drugs used in the treatment of severe hypertension in pregnancy. The number of women achieving the target blood pressure (BP) was the primary outcome. Doses required and time taken for achieving the target BP, failure rate, and incidences of maternal tachycardia, palpitation, hypotension, headache, and neonatal death and stillbirth were the secondary outcomes. Mixed treatment comparison pooled estimates were generated using a random-effects model. Odds ratios for the categorical and mean difference for the numerical outcomes were the effect estimates.

RESULTS

Fifty-one studies were included in the systematic review and 46 in the meta-analysis. No significant differences in the number of patients achieving target BP was observed between any of the drugs. Diazoxide [-15 (-20.6, -9.4)], nicardipine [-11.8 (-22.3, -1.2)], nifedipine/celastrol [-19.3 (-27.4, -11.1)], nifedipine/vitamin D [-17.1 (-25.7, -9.7)], nifedipine/resveratrol [-13.9 (-22.6, -5.2)] and glyceryl trinitrate [-33.8 (-36.7, -31)] were observed to achieve the target BP (in minutes) more rapidly than hydralazine. Nifedipine required fewer doses than hydralazine for achieving the target BP. Glyceryl trinitrate and labetalol were associated with fewer incidences of tachycardia and palpitation respectively than hydralazine. Trial sequential analysis concluded adequate evidence for hydralazine and nifedipine compared with labetalol. Moderate quality of evidence was observed for direct comparison estimate between labetalol and hydralazine but was either low or very low for other comparisons.

CONCLUSION

The present evidence suggests similar efficacy between nifedipine, hydralazine and labetalol in the treatment of severe hypertension in pregnancy. Subtle differences may exist in their safety profile. The evidence is inadequate for other drugs.

Recent advances in the diagnosis and management of pre-eclampsia

Pre-eclampsia is a leading cause of maternal mortality, responsible annually for over 60,000 maternal deaths around the globe. Pre-eclampsia is a multisystem disease featuring hypertension, proteinuria, and renal, hepatic, and neurological involvement. Diagnosis is often elusive, as clinical presentation is highly variable. Even those with severe disease can remain asymptomatic. Angiogenic factors are emerging as having a role in the diagnosis of pre-eclampsia and in prognostication of established disease. In this article, we summarize new developments and focus on angiogenic biomarkers for prediction of disease onset. We also discuss recent advances in management strategies for patients with hypertensive disorders of pregnancy.

Lipid profile and cytokines in hypertension of pregnancy: A comparison of preeclampsia therapies

Hypertensive disorders complicating pregnancy can be classified as gestational hypertension, mild preeclampsia, and severe preeclampsia. It is necessary to evaluate and predict the grade in advance. The first study comprised 40 healthy pregnancies, 40 gestational hypertension, 40 mild preeclampsia, and 40 severe preeclampsia cases. The participants' lipid profile and cytokine levels were statistically compared. The efficacy and safety of oral nifedipine (n = 71) and intravenous labetalol (n = 72) for the treatment of severe preeclampsia were evaluated in the next study according to maternal and neonatal outcomes. The levels of lipid profile and cytokines were linked with the presence and severity of hypertensive disorders complicating pregnancy. Both oral nifedipine and intravenous labetalol are effective for safely reducing blood pressure to target levels in patients with severe preeclampsia. Our study suggests that lipid profile and cytokines can be used in the evaluation of the severity of hypertensive disorders complicating pregnancy, and oral nifedipine requires more study.

A double-blinded, randomized, placebo-controlled trial assessing the effects of nifedipine on embryo transfer: Study protocol

INTRODUCTION

Implantation failure is the main factor affecting the success rate of in vitro fertilization (IVF) procedures. Studies have reported that uterine contractions (UCs) at the time of embryo transfer (ET) were inversely related to implantation and pregnancy rate, hence reducing the success of IVF treatment. Various pharmacological agents, with the exception of calcium channel blocker (CCB), have been investigated to reduce UC. In this regard, we are presenting a proposal for a double-blind randomized placebo-controlled trial. The trial aims to determine whether nifedipine, a CCB with potent smooth muscle relaxing activity and an excellent safety profile, can improve the outcome of ET.

METHODS AND ANALYSES

We will recruit 100 infertile women into one of 2 groups: placebo (n = 50) and nifedipine 20 mg (n = 50). Study participants will be admitted 30 minutes prior to ET and given either tablet after their baseline vital signs have been recorded. They will then undergo ET and be observed for adverse events for another 30 minutes post-ET. The primary outcome will be implantation rate and clinical pregnancy rate. Secondary outcomes include adverse events, miscarriage and pregnancy, and neonatal outcomes. Resulting data will then be analyzed using t test, Chi-square test, and multivariate test to compare outcomes between the 2 groups for any statistical significance. This protocol has been designed in accordance with the SPIRIT 2013 Guidelines.

A trial of oral nifedipine and oral labetalol in preeclampsia hypertensive emergency treatment

This observational retrospective cohort study was conducted to compare oral nifedipine and labetalol for emergency treatment of hypertension in preeclamptic patients. Time (minutes) and necessary doses were outlined to achieve blood pressure lower than 150/95 mmHg. In 14 patients with preeclampsia, 55 hypertensive emergencies were identified (BP >150/95). Of these emergencies, 43 were treated with oral nifedipine 10 mg (10 patients) and 12 with oral labetalol 100 mg (4 patients). To achieve a target blood pressure under 150/95, these doses were repeated as necessary every 20 min, up to a maximum of 4 doses. Oral nifedipine reduced BP more rapidly (31.30 vs. 53.50 min, p = .03). No maternal or foetal adverse events were observed and no major differences were found according to the type of delivery. Oral nifedipine is faster than and at least as safe as labetalol in pre-eclampsia hypertensive emergency treatment.