Pain relief: determining the safety of ibuprofen with postpartum preeclampsia

Improving preeclampsia risk prediction by modeling pregnancy trajectories from routinely collected electronic medical record data

Preeclampsia is a heterogeneous and complex disease associated with rising morbidity and mortality in pregnant women and newborns in the US. Early recognition of patients at risk is a pressing clinical need to reduce the risk of adverse outcomes. We assessed whether information routinely collected in electronic medical records (EMR) could enhance the prediction of preeclampsia risk beyond what is achieved in standard of care assessments. We developed a digital phenotyping algorithm to curate 108,557 pregnancies from EMRs across the Mount Sinai Health System, accurately reconstructing pregnancy journeys and normalizing these journeys across different hospital EMR systems. We then applied machine learning approaches to a training dataset (N = 60,879) to construct predictive models of preeclampsia across three major pregnancy time periods (ante-, intra-, and postpartum). The resulting models predicted preeclampsia with high accuracy across the different pregnancy periods, with areas under the receiver operating characteristic curves (AUC) of 0.92, 0.82, and 0.89 at 37 gestational weeks, intrapartum and postpartum, respectively. We observed comparable performance in two independent patient cohorts. While our machine learning approach identified known risk factors of preeclampsia (such as blood pressure, weight, and maternal age), it also identified other potential risk factors, such as complete blood count related characteristics for the antepartum period. Our model not only has utility for earlier identification of patients at risk for preeclampsia, but given the prediction accuracy exceeds what is currently achieved in clinical practice, our model provides a path for promoting personalized precision therapeutic strategies for patients at risk.

Pharmacologic Stepwise Multimodal Approach for Postpartum Pain Management: ACOG Clinical Consensus No. 1

SUMMARY

Pain in the postpartum period is common and considered by many individuals to be both problematic and persistent (1). Pain can interfere with individuals' ability to care for themselves and their infants, and untreated pain is associated with risk of greater opioid use, postpartum depression, and development of persistent pain (2). Clinicians should therefore be skilled in individualized management of postpartum pain. Though no formal time-based definition of postpartum pain exists, the recommendations presented here provide a framework for management of acute perineal, uterine, and incisional pain. This Clinical Consensus document was developed using an a priori protocol in conjunction with the authors listed. This document has been revised to incorporate more recent evidence regarding postpartum pain.

A randomized-controlled trial to assess the effect of ibuprofen on postpartum blood pressure in women with hypertensive disorders of pregnancy

OBJECTIVES

To test the hypothesis that ibuprofen is equivalent to acetaminophen in its effect on postpartum blood pressure in women with gestational hypertension or preeclampsia without severe features.

STUDY DESIGN

Single-center randomized, crossover, equivalence trial among women with hypertensive disorders of pregnancy without severe features after vaginal delivery. Participants were assigned in a double-blind fashion to ibuprofen 600 mg or acetaminophen 650 mg every 6 h for 24 h followed by crossover to the other drug. We assessed clinical blood pressures and ambulatory blood pressure monitor measurements. Intention-to-treat analyses were performed using a linear mixed model adjusted for time period.

MAIN OUTCOME MEASURES

The mean difference in systolic blood pressure through 24 h of drug exposure with an equivalence margin of 10 mmHg.

RESULTS

Of 185 screened women, 74 enrolled prior to delivery. Forty-three women remained eligible and were randomized to ibuprofen first (n = 20, 46.5%) or acetaminophen first (n = 23, 53.5%). A total of 37 women (86.0%) received study drug (ibuprofen first n = 19, acetaminophen first n = 18). Most participants were white (91.9%) and had gestational hypertension (86.5%); mean (SD) age was 31.0 (6.5) years. The mean adjusted difference in systolic blood pressure was 1.0 mmHg (95% CI, -3.7 to 5.7 mmHg), which was within the equivalence margin. A linear mixed model did not demonstrate a main effect of group assignment, nor did it show an interaction effect with time period.

CONCLUSIONS

Among women with gestational hypertension and preeclampsia without severe features, ibuprofen is an equally safe option as acetaminophen with respect to postpartum blood pressure concerns.