Management of severe pre-eclampsia with prostaglandin A, a useful therapeutic approach

Drugs for treatment of very high blood pressure during pregnancy

BACKGROUND

Very high blood pressure during pregnancy poses a serious threat to women and their babies. The aim of antihypertensive therapy is to lower blood pressure quickly but safety, to avoid complications. Antihypertensive drugs lower blood pressure but their comparative effectiveness and safety, and impact on other substantive outcomes is uncertain.

OBJECTIVES

To compare different antihypertensive drugs for very high blood pressure during pregnancy.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (9 January 2013).

SELECTION CRITERIA

Studies were randomised trials. Participants were women with severe hypertension during pregnancy. Interventions were comparisons of one antihypertensive drug with another.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and assessed trial quality. Two review authors extracted data and checked them for accuracy.

MAIN RESULTS

Thirty-five trials (3573 women) with 15 comparisons were included. Women allocated calcium channel blockers were less likely to have persistent high blood pressure compared to those allocated hydralazine (six trials, 313 women; 8% versus 22%; risk ratio (RR) 0.37, 95% confidence interval (CI) 0.21 to 0.66). Ketanserin was associated with more persistent high blood pressure than hydralazine (three trials, 180 women; 27% versus 6%; RR 4.79, 95% CI 1.95 to 11.73), but fewer side-effects (three trials, 120 women; RR 0.32, 95% CI 0.19 to 0.53) and a lower risk of HELLP (haemolysis, elevated liver enzymes and lowered platelets) syndrome (one trial, 44 women; RR 0.20, 95% CI 0.05 to 0.81).Labetalol was associated with a lower risk of hypotension compared to diazoxide (one trial 90 women; RR 0.06, 95% CI 0.00 to 0.99) and a lower risk of caesarean section (RR 0.43, 95% CI 0.18 to 1.02), although both were borderline for statistical significance.Both nimodipine and magnesium sulphate were associated with a high incidence of persistent high blood pressure, but this risk was lower for nimodipine compared to magnesium sulphate (one trial, 1650 women; 47% versus 65%; RR 0.84, 95% CI 0.76 to 0.93). Nimodipine was associated with a lower risk of respiratory difficulties (RR 0.28, 95% CI 0.08 to 0.99), fewer side-effects (RR 0.68, 95% CI 0.55 to 0.85) and less postpartum haemorrhage (RR 0.41, 95% CI 0.18 to 0.92) than magnesium sulphate. Stillbirths and neonatal deaths were not reported.There are insufficient data for reliable conclusions about the comparative effects of any other drugs.

AUTHORS' CONCLUSIONS

Until better evidence is available the choice of antihypertensive should depend on the clinician's experience and familiarity with a particular drug; on what is known about adverse effects; and on women's preferences. Exceptions are nimodipine, magnesium sulphate (although this is indicated for women who require an anticonvulsant for prevention or treatment of eclampsia), diazoxide and ketanserin, which are probably best avoided.

Drugs for treatment of very high blood pressure during pregnancy

BACKGROUND

Very high blood pressure during pregnancy poses a serious threat to women and their babies. Antihypertensive drugs lower blood pressure. Their comparative effects on other substantive outcomes, however, is uncertain.

OBJECTIVES

To compare different antihypertensive drugs for very high blood pressure during pregnancy.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (28 February 2006) and CENTRAL (The Cochrane Library 2006, Issue 2).

SELECTION CRITERIA

Studies were randomised trials. Participants were women with severe hypertension during pregnancy. Interventions were comparisons of one antihypertensive drug with another.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data.

MAIN RESULTS

Twenty-four trials (2949 women) with 12 comparisons were included. Women allocated calcium channel blockers rather than hydralazine were less likely to have persistent high blood (five trials, 263 women; 6% versus 18%; relative risk (RR) 0.33, 95% confidence interval (CI) 0.15 to 0.70). Ketanserin was associated with more persistent high blood pressure than hydralazine (four trials, 200 women; 27% versus 6%; RR 4.79, 95% CI 1.95 to 11.73), but fewer side-effects (three trials, 120 women; RR 0.32, 95% CI 0.19 to 0.53) and a lower risk of HELLP (Haemolysis, Elevated Liver enzymes and Lowered Platelets) syndrome (one trial, 44 women, RR 0.20, 95% CI 0.05 to 0.81). Labetalol was associated with a higher risk of hypotension (one trial 90 women; RR 0.06, 95% CI 0.00 to 0.99) and caesarean section (RR 0.43, 95% CI 0.18 to 1.02) than diazoxide. Data were insufficient for reliable conclusions about other outcomes. The risk of persistent high blood pressure was greater for nimodipine compared to magnesium sulphate (two trials 1683 women; 47% versus 65%; RR 0.84, 95% CI 0.76 to 0.93). Nimodipine was also associated with a higher risk of eclampsia (RR 2.24, 95% CI 1.06 to 4.73) and respiratory difficulties (RR 0.28, 95% CI 0.08 to 0.99), but fewer side-effects (RR 0.68, 95% CI 0.54 to 0.86) and less postpartum haemorrhage (RR 0.41, 95% CI 0.18 to 0.92) than magnesium sulphate. Stillbirths and neonatal deaths were not reported. There are insufficient data for reliable conclusions about the comparative effects of any other drugs.

AUTHORS' CONCLUSIONS

Until better evidence is available, the choice of antihypertensive should depend on the clinician's experience and familiarity with a particular drug, and on what is known about adverse effects. Exceptions are diazoxide, ketanserin, nimodipine and magnesium sulphate, which are probably best avoided.

Management of severe preeclampsia detected in early labor by prostaglandin A1 or dihydralazine infusions

The presence of severe pregnancy-induced hypertension at the onset of labor requires therapy with a potent hypotensive agent. Prostaglandin A1 is a powerful vasodepressor that augments renal blood flow and glomerular filtration and possesses antiplatelet aggregator and oxytocic properties. A continuous intravenous infusion of prostaglandin A1 (40 to 50 micrograms/min) or dihydralazine (35 to 50 micrograms/min) was administered to 20 women with severe preeclampsia (10 in each group). The induced hypotensive response was similar with both drugs but the maximum reduction in blood pressure was achieved sooner with dihydralazine (4 hours) compared with prostaglandin A1 (7.5 hours). The more gradual hypotensive response is probably less dangerous on placental perfusion than a sudden change. Moreover, the oxytocic property of prostaglandin A1 shortened the time to delivery, which constitutes another potential advantage.