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Deng NJ, Xian-Yu CY, Han RZ, Huang CY, Ma YT, Li HJ, Gao TY, Liu X, Zhang C. Pharmaceutical administration for severe hypertension during pregnancy: Network meta-analysis. Front Pharmacol 2023; 13:1092501. [PMID: 36699058 PMCID: PMC9869161 DOI: 10.3389/fphar.2022.1092501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 12/27/2022] [Indexed: 01/11/2023] Open
Abstract
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.
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Affiliation(s)
- Nian-Jia Deng
- Center for Evidence-Based Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Chen-Yang Xian-Yu
- Center for Evidence-Based Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Rui-Zheng Han
- Department of Ultrasound, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Cheng-Yang Huang
- Center for Evidence-Based Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Yu-Tong Ma
- Center for Evidence-Based Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Hui-Jun Li
- Center for Evidence-Based Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Teng-Yu Gao
- Center for Evidence-Based Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Xin Liu
- Center for Evidence-Based Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Chao Zhang
- Center for Evidence-Based Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China,*Correspondence: Chao Zhang,
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Antza C, Dimou C, Doundoulakis I, Akrivos E, Stabouli S, Haidich AB, Goulis DG, Kotsis V. The flipside of hydralazine in pregnancy: A systematic review and meta-analysis. Pregnancy Hypertens 2020; 19:177-186. [PMID: 32044579 DOI: 10.1016/j.preghy.2020.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 01/16/2020] [Indexed: 10/25/2022]
Abstract
The present systematic review and meta-analysis investigated the effects of hydralazine compared with other antihypertensive drugs in maternal, perinatal and neonatal outcomes of pregnant women with hypertensive disorders. Twenty studies with 1283 participants were included. Of them, 626 received hydralazine and 657 other antihypertensive treatments, such as labetalol, nifedipine, ketanserin, diazoxide, urapidil, isradipine and epoprostenol. Women receiving hydralazine had higher heart rate (WMD: 13.4, 95%CI: 0.1 to 26.8 beats/min), increased number of adverse effects (RR: 1.21, 95%CI: 1.01 to 1.45) and gave birth to neonates of lower birthweight (WMD: 13.4, 95%CI: 0.1 to 26.8 beats/min) compared with other antihypertensive treatments at the end of follow-up. When studies, which used antihypertensive agents that are no longer indicated for hypertension in pregnancy, were excluded in the sensitivity analyses, hydralazine found not to have a statistically significant difference compared with labetalol and nifedipine regarding the reduction of maternal blood pressure (WMD: 1.72, 95%CI: -1.47 to 4.9 mmHg for systolic, WMD: 0.26, 95%CI: -1.75 to 2.28 mmHg for diastolic), maternal heart rate (WMD: 13.56, 95%CI: -5.62 to 32.74 beats/min), low birthweight (WMD: -88.62, 95%CI: -243.24 to 66 beats/min) and adverse events (RR: 1.19, 95%CI: 0.99 to 1.43). Hydralazine seems not to be inferior compared to labetalol and nifedipine for safety and efficacy.
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Affiliation(s)
- Christina Antza
- 3(rd) Department of Internal Medicine, Aristotle University of Thessaloniki, Hypertension-24h Ambulatory Blood Pressure Monitoring Center, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Chrisa Dimou
- 3(rd) Department of Internal Medicine, Aristotle University of Thessaloniki, Hypertension-24h Ambulatory Blood Pressure Monitoring Center, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Ioannis Doundoulakis
- 3(rd) Department of Internal Medicine, Aristotle University of Thessaloniki, Hypertension-24h Ambulatory Blood Pressure Monitoring Center, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Evangelos Akrivos
- 3(rd) Department of Internal Medicine, Aristotle University of Thessaloniki, Hypertension-24h Ambulatory Blood Pressure Monitoring Center, Papageorgiou General Hospital, Thessaloniki, Greece; Lab of Computing, Medical Informatics and Biomedical Imaging Technologies, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Stella Stabouli
- 1(st) Department of Pediatrics, Aristotle University Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
| | - Anna Bettina Haidich
- Department of Hygiene, Social-Preventive Medicine & Medical Statistics, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios G Goulis
- Unit of Reproductive Endocrinology, 1(st) Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasilios Kotsis
- 3(rd) Department of Internal Medicine, Aristotle University of Thessaloniki, Hypertension-24h Ambulatory Blood Pressure Monitoring Center, Papageorgiou General Hospital, Thessaloniki, Greece.
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Sridharan K, Sequeira RP. Drugs for treating severe hypertension in pregnancy: a network meta-analysis and trial sequential analysis of randomized clinical trials. Br J Clin Pharmacol 2018; 84:1906-1916. [PMID: 29974489 PMCID: PMC6089822 DOI: 10.1111/bcp.13649] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 05/16/2018] [Accepted: 05/17/2018] [Indexed: 12/29/2022] Open
Abstract
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.
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Affiliation(s)
- Kannan Sridharan
- Department of Pharmacology and Therapeutics, College of Medicine and Medical SciencesArabian Gulf UniversityManamaBahrain
| | - Reginald P. Sequeira
- Department of Pharmacology and Therapeutics, College of Medicine and Medical SciencesArabian Gulf UniversityManamaBahrain
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4
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Abstract
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.
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Affiliation(s)
- Lelia Duley
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, Nottingham, UK.
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5
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Boon N, Goossens GH, Blaak EE, Saris WHM. The effects of hydralazine on lipolysis in subcutaneous adipose tissue in humans. Metabolism 2007; 56:1742-8. [PMID: 17998030 DOI: 10.1016/j.metabol.2007.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2006] [Accepted: 08/03/2007] [Indexed: 10/22/2022]
Abstract
Recent evidence from animal research and in vitro experiments indicates that changes in dietary calcium intake could cause changes in lipolysis through alterations of the intracellular calcium concentration in adipocytes. The objective of the study was to examine whether the calcium antagonist hydralazine affects blood flow and lipolysis in subcutaneous abdominal adipose tissue in vivo in humans. Three different concentrations of hydralazine (12.2, 24.4, and 48.8 micromol/L) were locally administered in adipose tissue using the microdialysis technique to assess effects on lipolysis and blood flow in subcutaneous adipose tissue in the abdominal region. Subjects from the general community were studied ambulatorily at a university hospital. Eight healthy men (age, 33.1 +/- 3.3 years; body mass index, 24.2 +/- 0.2 kg/m(2)) were recruited by local announcement. Subcutaneous adipose tissue in the abdominal region was perfused with increasing concentrations of hydralazine. The main outcome measures were adipose tissue lipolysis and blood flow. Hydralazine had no effect on ethanol outflow-inflow ratios, but significantly increased interstitial glycerol concentration at the highest concentration (P < .05). The present results indicate that hydralazine increases lipolysis in abdominal subcutaneous adipose tissue in healthy lean subjects, but hydralazine had no significant effects on local blood flow in adipose tissue.
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Affiliation(s)
- Niels Boon
- Nutrition and Toxicology Research Institute Maastricht, University of Maastricht, Maastricht, The Netherlands
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6
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Hennessy A, Thornton CE, Makris A, Ogle RF, Henderson-Smart DJ, Gillin AG, Child A. A randomised comparison of hydralazine and mini-bolus diazoxide for hypertensive emergencies in pregnancy: The PIVOT trial. Aust N Z J Obstet Gynaecol 2007; 47:279-85. [PMID: 17627681 DOI: 10.1111/j.1479-828x.2007.00738.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIMS Diazoxide is one of few available agents for treatment of hypertensive emergencies in pregnancy. From previous studies, there is a question concerning safety after moderate-dose administration caused episodes of hypotension. Rapid control of severe hypertension is necessary to reduce maternal morbidity, for example, stroke and placental abruption. This study was designed to compare the efficacy of mini-bolus diazoxide with intravenous (i.v.) hydralazine. DESIGN A randomised controlled trial. SETTING Tertiary referral maternity hospital, Royal Prince Alfred Women and Babies, Sydney Australia. POPULATION Antenatal and postnatal women with severe hypertension. METHODS One hundred and twenty-four hypertensive women were randomised to either i.v. hydralazine (5 mg doses) or mini-bolus diazoxide (15 mg doses). PRIMARY OUTCOME MEASURE Achievement of target blood pressure reduction; secondary measures included requirement for Caesarean section because of fetal deterioration as determined by non-reassuring cardiotocograph (CTG). RESULTS Reduction in systolic and diastolic blood pressure was 34 min for hydralazine and 19 min for diazoxide (P < 0.001). There were no episodes of hypotension after diazoxide and one after hydralazine (after epidural). Episodes of persistent severe hypertension were more common with hydralazine (38%) than with diazoxide (16%), P < 0.01. The Caesarean section rate for no-reassuring CTG was no different between the two groups. Neonatal outcomes were similar. CONCLUSION Diazoxide and hydralazine are safe and effective antihypertensives, showing a controlled and comparable blood pressure reduction in women with hypertensive emergencies in pregnancy. The mini-bolus doses of 15 mg of diazoxide did not precipitate maternal hypotension as previously described and reduces episodes of persistent severe hypertension.
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Affiliation(s)
- Annemarie Hennessy
- Hypertensive Disorders of Pregnancy Unit, Royal Prince Alfred Hospital, Sydney, NSW, Australia.
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7
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Abstract
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.
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Affiliation(s)
- L Duley
- University of Oxford, Nuffield Department of Medicine, Room 5609, Level 5, John Radcliffe Hospital, Headington, Oxford, UK OX3 9DU.
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von Dadelszen P, Magee LA. Antihypertensive Medications in Management of Gestational Hypertension-Preeclampsia. Clin Obstet Gynecol 2005; 48:441-59. [PMID: 15805801 DOI: 10.1097/01.grf.0000160311.74983.28] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Peter von Dadelszen
- Centre for Healthcare Innovation and Improvement, and the Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada.
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9
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Magee LA, Cham C, Waterman EJ, Ohlsson A, von Dadelszen P. Hydralazine for treatment of severe hypertension in pregnancy: meta-analysis. BMJ (CLINICAL RESEARCH ED.) 2003. [PMID: 14576246 DOI: 10.1136/bmj.327.7421.95] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To review outcomes in randomised controlled trials comparing hydralazine against other antihypertensives for severe hypertension in pregnancy. STUDY DESIGN Meta-analysis of randomised controlled trials (published between 1966 and September 2002) of short acting antihypertensives for severe hypertension in pregnancy. Independent data abstraction by two reviewers. Data were entered into RevMan software for analysis (fixed effects model, relative risk and 95% confidence interval); in a secondary analysis, risk difference was also calculated. RESULTS Of 21 trials (893 women), eight compared hydralazine with nifedipine and five with labetalol. Hydralazine was associated with a trend towards less persistent severe hypertension than labetalol (relative risk 0.29 (95% confidence interval 0.08 to 1.04); two trials), but more severe hypertension than nifedipine or isradipine (1.41 (0.95 to 2.09); four trials); there was significant heterogeneity in outcome between trials and differences in methodological quality. Hydralazine was associated with more maternal hypotension (3.29 (1.50 to 7.23); 13 trials); more caesarean sections (1.30 (1.08 to 1.59); 14 trials); more placental abruption (4.17 (1.19 to 14.28); five trials); more maternal oliguria (4.00 (1.22 to 12.50); three trials); more adverse effects on fetal heart rate (2.04 (1.32 to 3.16); 12 trials); and more low Apgar scores at one minute (2.70 (1.27 to 5.88); three trials). For all but Apgar scores, analysis by risk difference showed heterogeneity between trials. Hydralazine was associated with more maternal side effects (1.50 (1.16 to 1.94); 12 trials) and with less neonatal bradycardia than labetalol (risk difference -0.24 (-0.42 to -0.06); three trials). CONCLUSIONS The results are not robust enough to guide clinical practice, but they do not support use of hydralazine as first line for treatment of severe hypertension in pregnancy. Adequately powered clinical trials are needed, with a comparison of labetalol and nifedipine showing the most promise.
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Affiliation(s)
- Laura A Magee
- University of British Columbia, BC Women's Hospital and Health Centre, 4500 Oak Street, Vancouver, BC, Canada V6H 3N1.
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10
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Magee LA, Cham C, Waterman EJ, Ohlsson A, von Dadelszen P. Hydralazine for treatment of severe hypertension in pregnancy: meta-analysis. BMJ 2003; 327:955-60. [PMID: 14576246 PMCID: PMC259162 DOI: 10.1136/bmj.327.7421.955] [Citation(s) in RCA: 213] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/15/2003] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To review outcomes in randomised controlled trials comparing hydralazine against other antihypertensives for severe hypertension in pregnancy. STUDY DESIGN Meta-analysis of randomised controlled trials (published between 1966 and September 2002) of short acting antihypertensives for severe hypertension in pregnancy. Independent data abstraction by two reviewers. Data were entered into RevMan software for analysis (fixed effects model, relative risk and 95% confidence interval); in a secondary analysis, risk difference was also calculated. RESULTS Of 21 trials (893 women), eight compared hydralazine with nifedipine and five with labetalol. Hydralazine was associated with a trend towards less persistent severe hypertension than labetalol (relative risk 0.29 (95% confidence interval 0.08 to 1.04); two trials), but more severe hypertension than nifedipine or isradipine (1.41 (0.95 to 2.09); four trials); there was significant heterogeneity in outcome between trials and differences in methodological quality. Hydralazine was associated with more maternal hypotension (3.29 (1.50 to 7.23); 13 trials); more caesarean sections (1.30 (1.08 to 1.59); 14 trials); more placental abruption (4.17 (1.19 to 14.28); five trials); more maternal oliguria (4.00 (1.22 to 12.50); three trials); more adverse effects on fetal heart rate (2.04 (1.32 to 3.16); 12 trials); and more low Apgar scores at one minute (2.70 (1.27 to 5.88); three trials). For all but Apgar scores, analysis by risk difference showed heterogeneity between trials. Hydralazine was associated with more maternal side effects (1.50 (1.16 to 1.94); 12 trials) and with less neonatal bradycardia than labetalol (risk difference -0.24 (-0.42 to -0.06); three trials). CONCLUSIONS The results are not robust enough to guide clinical practice, but they do not support use of hydralazine as first line for treatment of severe hypertension in pregnancy. Adequately powered clinical trials are needed, with a comparison of labetalol and nifedipine showing the most promise.
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Affiliation(s)
- Laura A Magee
- University of British Columbia, BC Women's Hospital and Health Centre, 4500 Oak Street, Vancouver, BC, Canada V6H 3N1.
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11
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Hnat M, Sibai B. Severe Preeclampsia Remote from Term. Hypertens Pregnancy 2002. [DOI: 10.1201/b14088-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
The treatment of hypertension is preventive medicine. This principle applies in the emergency room as well as the clinic. However, there are crucial contrasts between these two care settings related to specific goals of management for real emergencies and nonemergency conditions. In the emergency room, rapid triage is necessary to separate those who can safely be sent home for future clinic assessment from those who require immediate interventions including short stays in 24-hour observation units or hospitalization for more serious problems. This review focuses on decisions related to hypertension management in the emergency room and over brief periods of observation and treatment. Strategy is supported by evidence-based considerations whenever possible. Where outcome studies are not available, we rely on the rationale derived from relevant clinical research.
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Affiliation(s)
- Robert A Phillips
- Departmnet of Medicine, Lenox Hill Hospital, NYU School of Medicine, New York, NY 10021, USA
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13
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van Schie DL, de Jeu RM, Steyn DW, Odendaal HJ, van Geijn HP. The optimal dosage of ketanserin for patients with severe hypertension in pregnancy. Eur J Obstet Gynecol Reprod Biol 2002; 102:161-6. [PMID: 11950484 DOI: 10.1016/s0301-2115(01)00611-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To establish the optimal dosage of ketanserin in the treatment of severe hypertension in pregnancy. STUDY DESIGN A double blind prospective randomised controlled trail, comparing 10 mg ketanserin given as intravenous boluses either every 10 or 20 min, until the therapeutic goal of 90 mmHg (diastolic blood pressure) was reached, to a maximum of eight boluses. Main outcome measures were treatment failures and caesarean sections for fetal distress. RESULTS There was no difference in reaching the therapeutic goal between patients receiving 10 mg ketanserin either every 10 or 20 min. CONCLUSION Ketanserin appears to be an attractive medicine in the treatment of severe hypertension in pregnancy, but the optimal dosage could not be established.
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Affiliation(s)
- Debby L van Schie
- Department of Obstetrics and Gynaecology, VU Medical Center, Amsterdam, The Netherlands.
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Paruk F, Moodley J. Untoward effects of rapid-acting antihypertensive agents. Best Pract Res Clin Obstet Gynaecol 2001; 15:491-506. [PMID: 11478811 DOI: 10.1053/beog.2001.0196] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Cerebral haemorrhage remains a major cause of hypertensive cerebral mortality. Lowering of raised blood pressure is therefore crucial in the clinical management of hypertensive disorders of pregnancy. This article reviews rapid-acting agents employed in life-threatening situations.
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Affiliation(s)
- F Paruk
- MRC/UN Pregnancy and Hypertension Research Unit and Department of Obstetrics and Gynaecology, Nelson R. Mandela School of Medicine, University of Natal, South Africa
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Bolte AC, van Geijn HP, Dekker GA. Pharmacological treatment of severe hypertension in pregnancy and the role of serotonin(2)-receptor blockers. Eur J Obstet Gynecol Reprod Biol 2001; 95:22-36. [PMID: 11267716 DOI: 10.1016/s0301-2115(00)00368-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Hypertensive disorders of pregnancy are the leading cause of maternal and perinatal mortality and morbidity in developing and developed countries. The etiology of preeclampsia is still unknown. Delivering the baby is the only definite treatment. The benefits of acute pharmacological control of severe hypertension prior to and/or post-delivery are generally accepted. Most drugs commonly used in the management of severe hypertension in pregnancy have significant maternal and/or neonatal adverse side effects. Furthermore, some are not effective to acutely lower the blood pressure in patients with a hypertensive crisis. Until recently not one of the commonly used antihypertensive drugs has been tailored to the pathophysiology of severe preeclampsia, being a clinical syndrome characterized by endothelial cell dysfunction, vasospasm and platelet aggregation. Ketanserin, a serotonin(2)-receptor blocker, is a drug that appears to be tailored for treating this pregnancy-associated enthothelial cell dysfunction. The results of several prospective trials show that there is a definite place for serotonin(2)-receptor blockers in the treatment of pregnancy-induced hypertensive disorders. This review provides a summary on the more established drugs as well as on some of the newer antihypertensive drugs used in pregnancy with emphasis on the existing experience with ketanserin.
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Affiliation(s)
- A C Bolte
- Department of Obstetrics and Gynecology, Free University Hospital, De Boelelaan 1117, 1081HV, Amsterdam, The Netherlands.
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Steyn DW, Odendaal HJ. Serotonin antagonism and serotonin antagonists in pregnancy: role of ketanserin. Obstet Gynecol Surv 2000; 55:582-9. [PMID: 10975485 DOI: 10.1097/00006254-200009000-00024] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED Most agree that antihypertensive medication should be used to treat severe hypertension during pregnancy, but its role in patients with mild to moderate disease is debated. None of the regularly used drugs is completely safe for mother and fetus. Ketanserin decreases systolic and diastolic blood pressure in nonpregnant patients with acute and chronic hypertension. Its selective serotonin S2-receptor antagonist activity encouraged investigations into a possible role in pregnant women. These reports can be divided into four groups. Several studies confirmed that intravenous ketanserin decreases blood pressure significantly in patients with severe preeclampsia. There are indications that it may be at least as effective as dihydralazine, possibly with fewer side effects. Its role in chronic hypertension has not been studied adequately, but one randomized, controlled trial indicated efficacy comparable with that of alpha-methyldopa. Thirdly, it was concluded in a single descriptive study that the administration of ketanserin to patients with HELLP syndrome allowed delivery to be postponed for 5.3 days. Lastly, in a randomized, placebo-controlled trial, the addition of ketanserin to aspirin in patients with mild to moderate midtrimester hypertension was associated with a significant decrease in the number of cases of preeclampsia and severe hypertension, as well as a trend to less perinatal mortality, lower rates of abruptio placentae, and early-onset preeclampsia. Additional studies are needed to adequately assess a possible role for ketanserin with acute hypertension or moderate chronic hypertension. TARGET AUDIENCE Obstetricians & Gynecologists, Family Physicians LEARNING OBJECTIVES After completion of this article, the reader will be able to list the various drugs and their associated side effects that are used to treat hypertensive disorders during pregnancy; to describe the various effects of serotonin on the cardiovascular system; to summarize the literature concerning the use of ketanserin during pregnancy; and to list the potential uses of ketanserin in this setting.
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Affiliation(s)
- D W Steyn
- Department of Obstetrics and Gynecology, Tygerberg Hospital, University of Stellenbosch, South Africa.
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Abstract
BACKGROUND Very high blood pressure during pregnancy poses a serious threat to women and their fetuses. The use of drugs to lower blood pressure may reduce this risk. OBJECTIVES The objective of this review was to compare different antihypertensive drugs used for rapid treatment of severe hypertension during pregnancy. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register. STUDIES All randomised trials. Quasi random designs were excluded. PARTICIPANTS Women with severe hypertension during pregnancy. Women postpartum at trial entry were excluded. INTERVENTIONS Comparisons of one antihypertensive agent with another. OUTCOMES For the women: blood pressure control, eclampsia, serious maternal morbidity (such as kidney failure and liver failure), Caesarean section, and use of health service resources (such as admission to hospital or intensive care unit). For the baby: death, serious neonatal morbidity, infant and child development, and use of health service resources (such as admission to a special care nursery). DATA COLLECTION AND ANALYSIS Data were extracted independently by two reviewers to assess eligibility and describe the trial characteristics, and by one reviewer for the meta-analyses. Discrepancies were resolved by discussion. There was no blinding of authorship or results. Whenever possible, unpublished data were sought from investigators. MAIN RESULTS Thirteen of the 14 trials included in this review were small (range 19-627 women). Of the eight comparisons, five included hydralazine. Diazoxide given as 75mg bolus injections appears to be associated with profound hypotension requiring treatment, and ketanserin is less effective than hydralazine at reducing blood pressure. There is no other evidence that any one of the other antihypertensive agents is better than another for women with severe hypertension during pregnancy. REVIEWER'S CONCLUSIONS Until better evidence is available, the choice of antihypertensive should depend on the experience and familiarity of an individual clinician with a particular drug, and on what is known about adverse maternal and fetal side-effects. Exceptions are diazoxide and ketanserin, which are probably not good choices.
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Affiliation(s)
- L Duley
- Resource Centre for Randomised Trials, Institute of Health Sciences, Old Road, Headington, Oxford, UK, OX3 7LF.
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Abstract
Pre-eclampsia and eclampsia remain one of the leading causes of maternal morbidity and mortality worldwide. They also contribute to perinatal morbidity and mortality as well. Multiple strategies have been proposed for the prevention of pre-eclampsia, with mixed results. Likewise, different strategies for the management of pre-eclampsia have been proposed, also with mixed results. While the prevention of pre-eclampsia remains unachievable, meticulous medical management of mother and fetus will contribute to an overall lowering of pre-eclampsia and eclampsia's contribution to perinatal and maternal morbidity and mortality.
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Affiliation(s)
- J T Repke
- Department of Obstetrics and Gynecology, University of Nebraska Medical Center, Omaha, USA
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