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Postpartum management of hypertensive disorders of pregnancy: a systematic review.

ABSTRACT: OBJECTIVES:Hypertensive disorders of pregnancy (HDP) affect one in ten pregnancies and often persist postpartum when complications can occur. We aimed to determine the effectiveness and safety of pharmacological interventions, other interventions and different care models for postpartum hypertension management. DESIGN:A systematic review was undertaken. Nine electronic databases, including Medline, were searched from inception to 16 March 2017. After duplicate removal, 4561 records were screened. Two authors independently selected studies, extracted study characteristics and data, and assessed methodological quality. SETTING:Randomised controlled trials, case-control studies and cohort studies from any country and healthcare setting. PARTICIPANTS:Postnatal women with HDP. INTERVENTIONS:Therapeutic intervention for management of hypertension, compared with another intervention, placebo or no intervention. PRIMARY AND SECONDARY OUTCOME MEASURES:Outcome data were collected for maternal mortality and severe morbidity; systolic, diastolic and mean arterial blood pressure (BP) control; and safety data. Secondary outcome data collected included the length of postnatal hospital stay and laboratory values. RESULTS:39 studies were included (n=2901). Results were heterogeneous in terms of intervention, comparison and outcome requiring a narrative approach. There were insufficient data to recommend any single pharmacological intervention. 18 studies reported calcium-channel blockers, vasodilators and beta-blockers lowered BP postpartum. 12 of these reported safety data. Limited data existed regarding management in the weeks following hospital discharge. Neither loop diuretics (three studies) nor corticosteroids (one study) produced clinical benefit. Uterine curettage significantly reduced BP over the first 48?hours postpartum (range 6-13?mm Hg) compared with standard care (eight studies), with safety data only reported by four of eight studies. CONCLUSION:There was insufficient evidence to recommend a particular BP threshold, agent or model of care, but three classes of antihypertensive appeared variably effective. Further comparative research, including robust safety data, is required. Curettage reduced BP, but without adequate reporting of harms, so it cannot currently be recommended.

SUBMITTER: Cairns AE

PROVIDER: S-EPMC5719299 | biostudies-literature | 2017 Nov

REPOSITORIES: biostudies-literature

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Postpartum management of hypertensive disorders of pregnancy: a systematic review.

Cairns Alexandra E AE Pealing Louise L Duffy James M N JMN Roberts Nia N Tucker Katherine L KL Leeson Paul P MacKillop Lucy H LH McManus Richard J RJ

BMJ open 20171128 11

<h4>Objectives</h4>Hypertensive disorders of pregnancy (HDP) affect one in ten pregnancies and often persist postpartum when complications can occur. We aimed to determine the effectiveness and safety of pharmacological interventions, other interventions and different care models for postpartum hypertension management.<h4>Design</h4>A systematic review was undertaken. Nine electronic databases, including Medline, were searched from inception to 16 March 2017. After duplicate removal, 4561 record ...[more]

PMID: 29187414

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Project description:BackgroundClinical practice guidelines (CPGs) are developed to assist health care providers in decision-making. We systematically reviewed existing CPGs on the HDPs (hypertensive disorders of pregnancy) to inform clinical practice.Methodology & principal findingsMEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register, Health Technology Assessments, and Database of Abstracts of Reviews of Effects (Ovid interface), Grey Matters, Google Scholar, and personal records were searched for CPGs on the HDPs (Jan/03 to Nov/13) in English, French, Dutch, or German. Of 13 CPGs identified, three were multinational and three developed for community/midwifery use. Length varied from 3-1188 pages and three guidelines did not formulate recommendations. Eight different grading systems were identified for assessing evidence quality and recommendation strength. No guideline scored ≧80% on every domain of the AGREE II, a tool for assessing guideline methodological quality; two CPGs did so for 5/6 domains. Consistency was seen for (i) definitions of hypertension, proteinuria, chronic and gestational hypertension; (ii) pre-eclampsia prevention for women at increased risk: calcium when intake is low and low-dose aspirin, but not vitamins C and E or diuretics; (iii) antihypertensive treatment of severe hypertension; (iv) MgSO4 for eclampsia and severe pre-eclampsia; (v) antenatal corticosteroids at <34 wks when delivery is probable within 7 days; (vi) delivery for women with severe pre-eclampsia pre-viability or pre-eclampsia at term; and (vii) active management of the third stage of labour with oxytocin. Notable inconsistencies were in: (i) definitions of pre-eclampsia and severe pre-eclampsia; (ii) target BP for non-severe hypertension; (iii) timing of delivery for women with pre-eclampsia and severe pre-eclampsia; (iv) MgSO4 for non-severe pre-eclampsia, and (v) postpartum maternal monitoring.ConclusionsExisting international HDP CPGs have areas of consistency with which clinicians and researchers can work to develop auditable standards, and areas of inconsistency that should be addressed by future research.

Project description:BackgroundHypertensive disorders of pregnancy (HDP) is one of the most common pregnancy complications and causes of maternal morbidity and mortality. Assisted reproductive technology (ART) has been associated with adverse pregnancy outcomes, including HDP. However, the impact of multiple pregnancies, oocyte donation, as well as fresh and frozen embryo transfer needs to be further studied. We conducted a systematic review and meta-analyses to evaluate the association between ART and HDP or preeclampsia relative to spontaneous conception (SC).MethodsWe identified studies from EMBASE, MEDLINE, and Cochrane Library (up to April 8, 2020) and manually using structured search strategies. Cohort studies that included pregnancies after in vitro fertilization (IVF) with or without intracytoplasmic sperm fertilization (ICSI) relative to SC with HDP or preeclampsia as the outcome of interest were included. The control group was women who conceived spontaneously without ART or fertility medications. The pooled results were reported in odds ratios (OR) with 95% confidence intervals based on random effects models. Numbers needed to harm (NNH) were calculated based on absolute risk differences between exposure and control groups.ResultsEighty-five studies were included after a screening of 1879 abstracts and 283 full text articles. Compared to SC, IVF/ICSI singleton pregnancies (OR 1.70; 95% CI 1.60-1.80; I2 = 80%) and multiple pregnancies (OR 1.34; 95% CI 1.20-1.50; I2 = 76%) were both associated with higher odds of HDP. Singleton pregnancies with oocyte donation had the highest odds of HDP out of all groups analyzed (OR 4.42; 95% CI 3.00-6.51; I2 = 83%). Frozen embryo transfer resulted in higher odds of HDP (OR 1.74; 95% CI 1.58-1.92; I2 = 55%) than fresh embryo transfer (OR 1.43; 95% CI 1.33-1.53; I2 = 72%). The associations between IVF/ICSI pregnancies and SC were similar for preeclampsia. Most interventions had an NNH of 40 to 100, while singleton and multiple oocyte donation pregnancies had particularly low NNH for HDP (16 and 10, respectively).ConclusionsOur meta-analysis confirmed that IVF/ICSI pregnancies are at higher odds of HDP and preeclampsia than SC, irrespective of the plurality. The odds were especially high in frozen embryo transfer and oocyte donation pregnancies.

Project description:ObjectivesThe aim of this study was to understand the associations between hypertensive disorders of pregnancy (HDP) and postpartum complications throughout the newly defined 12-week postpartum transition.Study designWe conducted a retrospective cohort study of the associations of HDP (any/subtype) with postpartum complications among 2.5 million California births, 2008-2012. We identified complications from discharge diagnoses from maternal hospital encounters (emergency department visits and readmissions) in the 12 weeks after giving birth. We compared rates of complications, overall and by diagnostic category, between groups defined by HDP. In survival analyses, we calculated the adjusted hazard ratios of postpartum complications associated with HDP. We adjusted for maternal age, race/ethnicity, prepregnancy obesity, chronic diabetes, gestational diabetes, insurance, delivery mode, gestational age and birth outcome (term and size).ResultsAmong women with and without HDP, 12.8 and 7.7%, respectively, had a hospital encounter within 12 weeks of giving birth [adjusted hazard ratio 1.5, 95% confidence interval (95% CI): 1.5-1.5]. HDP was associated with increased risk across all major categories of complications: hypertension-related, adjusted hazard ratio 11.8 (95% CI: 11.2-12.3); childbirth-related, 1.4 (1.3-1.4); and other, 1.4 (1.4-1.4). Risk of any complication differed by hypertensive subtype: chronic hypertension with super-imposed preeclampsia, adjusted hazard ratio 1.8 (95% CI: 1.7-1.8); chronic hypertension, 1.6 (1.6-1.7); preeclampsia/eclampsia, 1.3 (1.3-1.4); and gestational hypertension, 1.2 (1.2-1.3). Over a quarter (28.9%) of maternal hospital encounters occurred more than 6 weeks after giving birth; this did not differ substantially by HDP status.ConclusionWomen with HDP are at an increased risk for virtually all postpartum complications, including those not related to hypertension, and may benefit from enhanced and comprehensive postpartum care.

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Postpartum management of hypertensive disorders of pregnancy: a systematic review.

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Postpartum management of hypertensive disorders of pregnancy: a systematic review.

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