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Hauspurg A, Venkatakrishnan K, Collins L, Countouris M, Larkin J, Quinn B, Kabir N, Catov J, Lemon L, Simhan H. Postpartum Ambulatory Blood Pressure Patterns Following New-Onset Hypertensive Disorders of Pregnancy. JAMA Cardiol 2024:2820070. [PMID: 38865121 PMCID: PMC11170460 DOI: 10.1001/jamacardio.2024.1389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 03/20/2024] [Indexed: 06/13/2024]
Abstract
Importance After a hypertensive disorder of pregnancy, hypertension can worsen in the postpartum period following hospital discharge. Risk factors for ongoing hypertension and associated outcomes have not been well characterized. Objective To identify risk factors and characterize outcomes for individuals with ongoing hypertension and severe hypertension following hospital discharge post partum through a hospital system's remote blood pressure (BP) management program. Design, Setting, and Participants This cohort study involved a population-based sample of individuals with a new-onset hypertensive disorder of pregnancy (preeclampsia or gestational hypertension) and no prepregnancy hypertension who delivered between September 2019 and June 2021. Participants were enrolled in a remote BP monitoring and management program at a postpartum unit at a referral hospital. Data analysis was performed from August 2021 to January 2023. Exposure Inpatient postpartum BP categories. Main Outcomes and Measures The primary outcomes were readmission and emergency department visits within the first 6 weeks post partum. Logistic regression was used to model adjusted odds ratios (aORs) and 95% CIs. Results Of 2705 individuals in the cohort (mean [SD] age, 29.8 [5.7] years), 2214 (81.8%) had persistent hypertension post partum after hospital discharge, 382 (14.1%) developed severe hypertension after discharge, and 610 (22.6%) had antihypertensive medication initiated after discharge. Individuals with severe hypertension had increased odds of postpartum emergency department visits (aOR, 1.85; 95% CI, 1.17-2.92) and hospital readmissions (aOR, 6.75; 95% CI, 3.43-13.29) compared with individuals with BP normalization. When inpatient postpartum BP categories were compared with outpatient home BP trajectories to inform optimal thresholds for inpatient antihypertensive medication initiation, there was significant overlap between postdischarge BP trajectories among those with inpatient systolic BP greater than or equal to 140 to 149 mm Hg and/or diastolic BP greater than or equal to 90 to 99 mm Hg and those with systolic BP greater than or equal to 150 mm Hg and/or diastolic BP greater than or equal to 100 mm Hg. Conclusions and Relevance This cohort study found that more than 80% of individuals with hypertensive disorders of pregnancy had ongoing hypertension after hospital discharge, with approximately 14% developing severe hypertension. These data support the critical role of remote BP monitoring programs and highlight the need for improved tools for risk stratification and consideration of liberalization of thresholds for medication initiation post partum.
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Affiliation(s)
- Alisse Hauspurg
- Magee-Womens Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Kripa Venkatakrishnan
- Department of Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Latima Collins
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Malamo Countouris
- Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jacob Larkin
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Beth Quinn
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Nuzhat Kabir
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Janet Catov
- Magee-Womens Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Lara Lemon
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Hyagriv Simhan
- Magee-Womens Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Premkumar A, Oler AM, Cai SW, Nilsen AM, Miller ES. The association of out-of-hospital postpartum NSAID use and post-discharge hypertension control for people with hypertensive disorders of pregnancy. Pregnancy Hypertens 2023; 33:34-38. [PMID: 37473678 DOI: 10.1016/j.preghy.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 07/11/2023] [Accepted: 07/12/2023] [Indexed: 07/22/2023]
Abstract
OBJECTIVE To evaluate the relationship between amount of NSAID use postpartum and outpatient blood pressure (BP) control. STUDY DESIGN This is a prospective, single-site, cohort study of postpartum people diagnosed with HDP from 2018 to 2020 using the American College of Obstetrician and Gynecologists criteria. All participants were provided an electronic BP cuff for daily evaluation after discharge. Those who provided at least 7 days of data within the first 14 days after discharge were included. Standard PP pain management included ibuprofen 600 mg every 6 h as needed. The exposure was self-reported amount of NSAIDs used within the first 14 days after discharge. The primary outcome was median mean arterial pressure (MAP) over the first 14 days after hospital discharge. Secondary outcomes included median and maximum systolic and diastolic BPs and need for PP readmission for HDP. Regression models were created, controlling for a propensity score for highest quartile of NSAID use. RESULTS 103 participants were approached, of whom 60 met inclusion criteria. Those who had a history of a cesarean delivery were more likely to be in the highest quartile of NSAID use; no other significant differences were noted across quartiles of NSAID use. There was no association between NSAID amount used and median MAP (adjusted β coefficient 0.03, 95% CI: -0.17 to 0.22). There were no significant associations between NSAID amount used and all other secondary outcomes. CONCLUSION Out-of-hospital NSAID use is not associated with worsened PP BP control after hospital discharge among people diagnosed with HDP.
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Affiliation(s)
- Ashish Premkumar
- Department of Obstetrics and Gynecology, Pritzker School of Medicine, University of Chicago, Chicago, IL, USA.
| | - Ann M Oler
- University of Miami Miller School of Medicine, Miami, FL, USA
| | - Stephanie W Cai
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Annika M Nilsen
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Emily S Miller
- Department of Obstetrics and Gynecology, The Warren Alpert School of Medicine, Brown University, Providence, RI, USA
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Hostage J, Kolettis D, Sverdlov D, Ludgin J, Drzymalski D, Sweigart B, Mhatre M, House M. Increased Scheduled Intravenous Ketorolac After Cesarean Delivery and Its Effect on Opioid Use: A Randomized Controlled Trial. Obstet Gynecol 2023; 141:783-790. [PMID: 36897140 DOI: 10.1097/aog.0000000000005120] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 12/01/2022] [Indexed: 03/11/2023]
Abstract
OBJECTIVE To evaluate the efficacy of scheduled ketorolac in reducing opioid use after cesarean delivery. METHODS This was a single-center, randomized, double-blind, parallel-group trial to assess pain management after cesarean delivery with scheduled ketorolac compared with placebo. All patients undergoing cesarean delivery with neuraxial anesthesia received two doses of 30 mg intravenous ketorolac postoperatively and then were randomized to receive four doses of 30 mg of intravenous ketorolac or placebo every 6 hours. Additional nonsteroidal anti-inflammatory drugs were held until 6 hours after the last study dose. The primary outcome was total morphine milligram equivalents (MME) used in the first 72 postoperative hours. Secondary outcomes included the number of patients who used no opioid postoperatively, postoperative pain scores, postoperative change in hematocrit and serum creatinine, and postoperative satisfaction with inpatient care and pain management. A sample size of 74 per group (n=148) provided 80% power to detect a population mean difference in MME of 32.4, with an SD for both groups of 68.7 after accounting for protocol noncompliance. RESULTS From May 2019 to January 2022, 245 patients were screened and 148 patients were randomized (74 per group). Patient characteristics were similar between groups. The median (quartile 1-3) MME from arrival in the recovery room until postoperative hour 72 was 30.0 (0.0-67.5) for the ketorolac group and 60.0 (30.0-112.5) for the placebo group (Hodges-Lehmann median difference -30.0, 95% CI -45.0 to -15.0, P <.001). In addition, participants who received placebo were more likely to have numeric rating scale pain scores higher than 3 out of 10 ( P= .005). The mean±SD decrease from baseline hematocrit to postoperative day 1 was 5.5±2.6% for the ketorolac group and 5.4±3.5% for the placebo group ( P =.94). The mean±SD postoperative day 2 creatinine was 0.61±0.06 mg/dL in the ketorolac group and 0.62±0.08 mg/dL in the placebo group ( P =.26). Participant satisfaction with inpatient pain control and postoperative care was similar between groups. CONCLUSION Compared with placebo, scheduled intravenous ketorolac significantly decreased opioid use after cesarean delivery. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov , NCT03678675.
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Affiliation(s)
- Jean Hostage
- Department of Obstetrics and Gynecology, the Department of Anesthesiology and Perioperative Medicine, and the Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts
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Magee LA, Brown MA, Hall DR, Gupte S, Hennessy A, Karumanchi SA, Kenny LC, McCarthy F, Myers J, Poon LC, Rana S, Saito S, Staff AC, Tsigas E, von Dadelszen P. The 2021 International Society for the Study of Hypertension in Pregnancy classification, diagnosis & management recommendations for international practice. Pregnancy Hypertens 2022; 27:148-169. [DOI: 10.1016/j.preghy.2021.09.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 09/30/2021] [Indexed: 12/13/2022]
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Mozafari S, Esmaeili S, Momenyan S, Zadeh Modarres S, Ozgoli G. Effect of Zingiber officinale Roscoe rhizome (ginger) capsule on postpartum pain: Double-blind randomized clinical trial. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2021; 26:105. [PMID: 35126568 PMCID: PMC8765508 DOI: 10.4103/jrms.jrms_544_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/13/2020] [Accepted: 07/12/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Postpartum pain contributes to increased irritability and excessive stress in the mother and consequently may inhibit successful breastfeeding, reduce a mother's ability to take care of her baby, and cause an imperfect mother-baby interaction. Evidence suggests the positive effect of ginger on reduction in uterus-associated pain. The objective of this study is to investigate the effect of ginger capsules on postpartum pain. MATERIALS AND METHODS The present double-blinded, randomized, placebo-controlled trial was conducted in Mahdiyeh Educational Hospital, Tehran. One hundred and twenty-eight mothers having moderate-to-severe pain following vaginal delivery were included. The participants were divided into two groups (A and B). Interventions were performed every 8 h in 24 h. In the first intervention (2 h after the delivery), Group A received 500 mg of placebo capsules (containing chickpea flour) and Group B received 500 mg of Zintoma (ginger rhizome) capsules. In the second and third interventions, Group A received 250 mg placebo capsules and Group B received 250 mg Zintoma capsules. All participants received 250 mg capsules of mefenamic acid in each intervention in addition to ginger or placebo capsules. The pain severity was measured before and half an hour, an hour, and 2 h after each intervention. Statistical analysis was performed using the SPSS software version. 22. The Chi-square, Fisher's, and t tests and the GEE model were applied to assess the pain severity. RESULTS The average pain severity was not statistically significant between the groups in the beginning of the intervention (P = 0.623). The mean score of pain significantly decreased within the duration of intervention in both groups (P < 0.001); however, the pain severity was significantly lower in the intervention group as compared to the control group at any point after the intervention (P = 0.006). CONCLUSION Ginger can be used as an effective remedy for postpartum pain relief.
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Affiliation(s)
- Shabnam Mozafari
- Department of Midwifery and Reproductive Health, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Somayeh Esmaeili
- Department of Traditional Medicine, Traditional Medicine and Materia Medica Research Center, School of Traditional Medicine, Shahid Beheshti University of Medical Sciences, Terhran, Iran
| | - Somayeh Momenyan
- Department of Biostatistics, Faculty of Paramedical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Shahrzad Zadeh Modarres
- Department of Obstetrics and Gynecology, Mahdieh Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Giti Ozgoli
- Department of Midwifery and Reproductive Health, Midwifery and Reproductive Health Research Center, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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van Dyk D, Dyer RA, Fernandes NL. Preeclampsia in 2021-a Perioperative Medical Challenge for the Anesthesiologist. Anesthesiol Clin 2021; 39:711-725. [PMID: 34776105 DOI: 10.1016/j.anclin.2021.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The authors provide a review of recent advances in the understanding of pathophysiology and perioperative management of preeclampsia and eclampsia, from the perspective of the anesthesiologist. This review includes aspects of assessment of severity of disease, hemodynamic monitoring, peripartum anesthesia care, and postpartum management. The perioperative management of patients with eclampsia is also discussed.
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Affiliation(s)
- Dominique van Dyk
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, D23 Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa.
| | - Robert A Dyer
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, D23 Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa
| | - Nicole L Fernandes
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, D23 Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, Anzio Road, Observatory, 7925, Cape Town, South Africa
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Pharmacologic Stepwise Multimodal Approach for Postpartum Pain Management: ACOG Clinical Consensus No. 1. Obstet Gynecol 2021; 138:507-517. [PMID: 34412076 DOI: 10.1097/aog.0000000000004517] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Poon LC, Magee LA, Verlohren S, Shennan A, von Dadelszen P, Sheiner E, Hadar E, Visser G, Da Silva Costa F, Kapur A, McAuliffe F, Nazareth A, Tahlak M, Kihara AB, Divakar H, McIntyre HD, Berghella V, Yang H, Romero R, Nicolaides KH, Melamed N, Hod M. A literature review and best practice advice for second and third trimester risk stratification, monitoring, and management of pre-eclampsia: Compiled by the Pregnancy and Non-Communicable Diseases Committee of FIGO (the International Federation of Gynecology and Obstetrics). Int J Gynaecol Obstet 2021; 154 Suppl 1:3-31. [PMID: 34327714 PMCID: PMC9290930 DOI: 10.1002/ijgo.13763] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Liona C Poon
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Laura A Magee
- Department of Women and Children's Health, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | | | - Andrew Shennan
- Department of Women and Children's Health, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Peter von Dadelszen
- Department of Women and Children's Health, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Eyal Sheiner
- Department of Obstetrics and Gynecology B, Soroka University Medical Center, Ben-Gurion University of the Negev, Beersheba, Israel
| | - Eran Hadar
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gerard Visser
- Department of Obstetrics, University Medical Center, Utrecht, The Netherlands
| | - Fabricio Da Silva Costa
- Maternal Fetal Medicine Unit, Gold Coast University Hospital and School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Anil Kapur
- World Diabetes Foundation, Bagsvaerd, Denmark
| | - Fionnuala McAuliffe
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
| | - Amala Nazareth
- Jumeira Prime Healthcare Group, Emirates Medical Association, Dubai, United Arab Emirates
| | - Muna Tahlak
- Latifa Hospital for Women and Children, Dubai Health Authority, Emirates Medical Association, Mohammed Bin Rashid University for Medica Sciences, Dubai, United Arab Emirates
| | - Anne B Kihara
- African Federation of Obstetricians and Gynaecologists, Khartoum, Sudan
| | | | - H David McIntyre
- University of Queensland Mater Clinical School, Brisbane, Queensland, Australia
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Thomas Jefferson University, Philadelphia, USA
| | - Huixia Yang
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI, USA
| | | | - Nir Melamed
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Moshe Hod
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Acute pulmonary edema due to severe preeclampsia in advanced maternal age women. Pregnancy Hypertens 2021; 25:150-155. [PMID: 34144403 DOI: 10.1016/j.preghy.2021.05.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/27/2021] [Accepted: 05/24/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Acute pulmonary edema is a rare complication in women with preeclampsia especially at advanced maternal age. We aimed to determine the cardiovascular hemodynamics in advanced maternal age women who developed acute pulmonary edema and preeclampsia. STUDY DESIGN Retrospective cohort study of women aged over 45 years giving birth at single university affiliated tertiary medical center which developed acute pulmonary edema due to severe preeclampsia. Clinical features were identified in order to predict and potentially prevent this severe complication of pregnancy. MAIN OUTCOME MEASURES Advanced maternal age women who developed acute pulmonary edema due to preeclampsia. RESULTS Overall, during the study period 90,540 women delivered in our hospital, of them, 540 women (0.6%) above the age of 45 years gave birth. Of those, 67 women (12.4%) had preeclampsia in which 4 women (6%) were complicated with acute pulmonary edema. The common clinical relevant characteristics for all four women were: preterm delivery by cesarean section for preeclampsia with severe features, non-restrictive fluid management around the time of delivery, post-partum pain control medication with non-steroidal anti-inflammatory drug, blood pressure stabilization with oral labetalol and a sudden hemodynamic deterioration to hypertensive crisis and pulmonary edema between post-operative days 4-9. CONCLUSION Although the precise trigger for the sudden presentation of acute pulmonary edema remains unknown, we suggest that there is a multi-factorial combination of etiologies that are common to women of advanced maternal age and women with preeclampsia that could have contributed to the development of pulmonary edema.
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Bruce KH, Anderson M, Stark JD. Factors associated with postpartum readmission for hypertensive disorders of pregnancy. Am J Obstet Gynecol MFM 2021; 3:100397. [PMID: 33991709 DOI: 10.1016/j.ajogmf.2021.100397] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 04/29/2021] [Accepted: 05/04/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Postpartum readmission has negative implications for patients and health systems. Previous studies suggest that up to 5% of women with hypertensive disorders of pregnancy experience postpartum readmission. Studies examining factors associated with postpartum readmission for hypertension have had small sample sizes and conflicting results. OBJECTIVE This study aimed to characterize the incidence of and risk factors for postpartum readmission for hypertensive disorders of pregnancy among a cohort of women with preexisting hypertensive disorders of pregnancy. STUDY DESIGN This was a retrospective cohort study of pregnant women with known hypertensive disorders of pregnancy who delivered live births in a large managed care organization in 2018. The primary outcome was hospital readmission for a hypertensive diagnosis or stroke within 42 days after delivery. The primary exposure of interest was persistent postpartum hypertension, defined as a maximum systolic blood pressure of ≥140 mm Hg or maximum diastolic blood pressure of ≥90 mm Hg within 24 hours before discharge from delivery hospitalization. Continuous and categorical variables were compared using bivariate analysis. Risk factors independently associated with postpartum readmission were identified using multivariable logistic regression. RESULTS Of 42,022 women who delivered in 2018, 7151 had hypertensive disorders of pregnancy-an incidence of 17%. The rate of postpartum readmission among women with hypertensive disorders of pregnancy was 4.43% (317 of 7151). The following risk factors were associated with increased odds of postpartum readmission in women with hypertensive disorders of pregnancy: systolic blood pressure of ≥140 mm Hg within 24 hours before discharge (adjusted odds ratio, 2.29; 95% confidence interval, 1.71-3.07), diastolic blood pressure of ≥90 mm Hg within 24 hours before discharge (adjusted odds ratio, 1.33; 95% confidence interval, 1.02-1.73), maternal age of ≥30 years (30-34: adjusted odds ratio, 1.57; 95% confidence interval, 1.12-2.19; 35-39: adjusted odds ratio, 2.36; 95% confidence interval, 1.70-3.28; ≥40: adjusted odds ratio, 2.95; 95% confidence interval, 1.95-4.46), receipt of magnesium sulfate (adjusted odds ratio, 1.47; 95% confidence interval, 1.11-1.94), and receipt of inpatient rapid-acting antihypertensive medication (adjusted odds ratio, 1.46; 95% confidence interval, 1.10-1.93). In addition, 1 blood pressure of ≥140/90 mm Hg within 24 hours before discharge increased the odds of readmission (adjusted odds ratio, 1.98; 95% confidence interval, 1.37-2.87). Furthermore, 2 or more elevated blood pressure values further increased the odds (adjusted odds ratio, 3.14; 95% confidence interval, 2.33-4.24). Median postpartum day of readmission was day 5 (interquartile range=3). CONCLUSION Hospital readmission for postpartum hypertension was associated with persistent postpartum hypertension (blood pressure of ≥140/90 mm Hg), increasing maternal age, and more severe antepartum hypertension. Women with these characteristics may be targeted in future quality initiatives to mitigate readmission.
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Affiliation(s)
- Kelly H Bruce
- Department of Obstetrics and Gynecology, Kaiser Foundation Hospitals, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA (Dr Bruce); Kaiser Permanente Northern California Division of Research, Oakland, CA (Ms Anderson); Division of Obstetric Hospitalists, Department of Obstetrics and Gynecology, The Permanente Medical Group, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA (Dr Stark).
| | - Meredith Anderson
- Department of Obstetrics and Gynecology, Kaiser Foundation Hospitals, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA (Dr Bruce); Kaiser Permanente Northern California Division of Research, Oakland, CA (Ms Anderson); Division of Obstetric Hospitalists, Department of Obstetrics and Gynecology, The Permanente Medical Group, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA (Dr Stark)
| | - Joanna D Stark
- Department of Obstetrics and Gynecology, Kaiser Foundation Hospitals, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA (Dr Bruce); Kaiser Permanente Northern California Division of Research, Oakland, CA (Ms Anderson); Division of Obstetric Hospitalists, Department of Obstetrics and Gynecology, The Permanente Medical Group, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA (Dr Stark)
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Premkumar A, Ayala NK, Miller CH, Grobman WA, Miller ES. Postpartum NSAID Use and Adverse Outcomes among Women with Hypertensive Disorders of Pregnancy: A Systematic Review and Meta-analysis. Am J Perinatol 2021; 38:1-9. [PMID: 32682329 DOI: 10.1055/s-0040-1713180] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE This study was aimed to perform a systematic review and meta-analysis of the association between postpartum nonsteroidal anti-inflammatory drug (NSAID) use among women with hypertensive disorders of pregnancy (HDP) and risks of adverse postpartum outcomes. STUDY DESIGN Studies were eligible if they included women who had been diagnosed with HDP and were postpartum, reported exposure to NSAIDs, were written in English, and were published between January 2000 and November 2019. Assessment of bias was performed using the Newcastle-Ottawa scale for observational studies or the Cochrane Collaborative tool for randomized trials. The primary outcome was maternal blood pressure ≥ 150 mm Hg systolic and/or 100 mm Hg diastolic. Secondary outcomes were persistent blood pressures ≥ 160 mm Hg systolic and/or 110 mm Hg diastolic, mean arterial pressure (MAP), initiation or up-titration of antihypertensive medication, length of hospital stay, rehospitalization for blood pressure control, and postpartum opioid use. A random-effect meta-analysis was performed using RevMan, with a p-value < 0.05 used to indicate statistical significance (PROSPERO CRD no.: 42019127043). RESULTS Among 7,395 abstracts identified, seven studies (four randomized and three cohort studies, n = 777 patients) met inclusion criteria. All cohort analyses exhibited low levels of bias, while two randomized controlled trials exhibited a high risk of bias in blinding and inclusion criteria. There was no association between NSAID use and blood pressures ≥ 150 mm Hg systolic and/or 100 mm Hg diastolic (risk ratio [RR]: 1.21, 95% confidence interval [CI]: 0.89-1.64). Conversely, NSAID use was associated with a statistically significant, but clinically insignificant, increase in length of postpartum stay (0.21 days, 95% CI: 0.05-0.38). No other secondary outcomes were significantly different between groups. CONCLUSION Postpartum NSAID use among women with HDP was not associated with maternal hypertension exacerbation. These findings support the recent American College of Obstetricians and Gynecologists' guideline change, wherein preeclampsia is no longer a contraindication to postpartum NSAID use. KEY POINTS · Postpartum (PP) NSAID use does not worsen hypertension in preeclampsia.. · PP NSAID use is associated with a longer, though clinically insignificant, length of stay.. · Our findings support ACOG's recommendations for PP NSAID use..
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Affiliation(s)
- Ashish Premkumar
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois
| | - Nina K Ayala
- Department of Obstetrics and Gynecology, Brown University, Providence, Rhode Island
| | - Corinne H Miller
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois
| | - William A Grobman
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois
| | - Emily S Miller
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois
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Abstract
"Pregnancy-induced hypertension" (HDP) describes a spectrum of disorders, including gestational hypertension, preeclampsia, and chronic hypertension with superimposed preeclampsia. Each of these disease processes can progress to a more pathologic case with worsening hypertensive disease, end-organ damage, and concerning clinical sequelae. Risk factors for HDP include nulliparity, a prior pregnancy complicated by hypertension, and obesity. Close blood pressure monitoring, serologic and urine testing, and prompt clinical follow-up remain the gold standard for antenatal diagnosis and surveillance. Optimizing maternal and neonatal outcomes involves early prenatal diagnosis, a multidisciplinary team-based approach, and referral to an experienced provider for cases with advanced pathology.
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Affiliation(s)
- Whitney A Booker
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University Medical Center, 622 West 168th Street, PH-16, New York, NY 10032, USA.
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Bellos I, Pergialiotis V, Antsaklis A, Loutradis D, Daskalakis G. Safety of non-steroidal anti-inflammatory drugs in postpartum period in women with hypertensive disorders of pregnancy: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:329-339. [PMID: 32068930 DOI: 10.1002/uog.21997] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 02/02/2020] [Accepted: 02/07/2020] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To assess the effect of non-steroidal anti-inflammatory drugs (NSAIDs) on blood pressure when administered for postpartum analgesia in women with hypertensive disorders of pregnancy. METHODS MEDLINE, Scopus, CENTRAL, Clinicaltrials.gov and Google Scholar databases were searched systematically from inception to 5 December 2019 for studies evaluating the safety of postpartum NSAIDs in women with any gestational hypertensive disorder. Randomized controlled trials (RCTs) and cohort studies were eligible for inclusion. Case-control studies, case series and case reports were excluded. The primary outcomes of interest were the incidence of severe hypertension and systolic, diastolic and mean arterial blood pressure. Pooled estimates were obtained by fitting a random-effects statistical model. The quality of evidence was assessed according to Grading of Recommendations, Assessment, Development and Evaluations (GRADE) guidelines. RESULTS Ten studies were included, comprising five RCTs and five retrospective cohort studies and involving a total of 1647 women. All studies were evaluated qualitatively and eight of them were included in the quantitative meta-analysis. Administration of NSAIDs was not associated with a significantly higher risk of severe postpartum hypertension (odds ratio, 1.52 (95% CI, 0.77-3.01)). Similarly, no significant differences were found in postpartum systolic blood pressure (mean difference (MD), -3.03 mmHg (95% CI, -6.21 to 0.15 mmHg)) and mean arterial pressure (MD, -0.38 mmHg (95% CI, -1.88 to 1.11 mmHg)) between women who received NSAIDs and those who did not, whereas postpartum diastolic blood pressure was marginally lower in women treated with NSAIDs (MD, -2.28 mmHg (95% CI, -4.44 to -0.13 mmHg)). The same effects were observed when studies with a large sample size, RCTs, women with severe pre-eclampsia and studies using ibuprofen as the study drug and acetaminophen as the control treatment were examined separately. The credibility of evidence was judged to be very low according to GRADE, owing to concerns about study limitations, inconsistency and imprecision. CONCLUSIONS This meta-analysis suggests that postpartum administration of NSAIDs is not associated with elevated blood pressure in women with hypertensive disorders of pregnancy. However, the existing evidence is of very low quality, thus future large-scale RCTs are warranted to verify the safety of postpartum NSAIDs in this population. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- I Bellos
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Athens University Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - V Pergialiotis
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Athens University Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - A Antsaklis
- First Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - D Loutradis
- First Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - G Daskalakis
- First Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Abstract
PURPOSE OF REVIEW Hypertension affects approximately 10% of pregnancies and may persist in the postpartum period. Furthermore, de novo hypertension may present after delivery, but its exact prevalence is not verified. Both types of hypertension expose the mother to eventually severe complications like eclampsia, stroke, pulmonary edema, and HELLP (hemolysis, elevated liver enzymes, low platelet) syndrome. RECENT FINDINGS Until today, there are limited data regarding the risk factors, pathogenesis, and pathophysiology of postpartum hypertensive disorders. However, there is certain evidence that preeclampsia may in large part be responsible. Women who experienced preeclampsia during pregnancy, although considered cured after delivery and elimination of the placenta, continue to present endothelial and renal dysfunction in the postpartum period. The brain and kidneys are particularly sensitive to this pathological vascular condition, and severe complications may result from their involvement. Large randomized trials are needed to give us the evidence that will allow a timely diagnosis and treatment. Until then, medical providers should increase their knowledge regarding hypertension after delivery because many times there is an underestimation of the complications that can ensue after a misdiagnosed or undertreated postpartum hypertension.
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Affiliation(s)
- V Katsi
- Cardiology Department, Hippokration Hospital, Athens, Greece
| | - G Skalis
- Department of Cardiology, Helena Venizelou Hospital, Athens, Greece.
| | - G Vamvakou
- Department of Cardiology, Helena Venizelou Hospital, Athens, Greece
| | - D Tousoulis
- 1st Department of Cardiology, National and Kapodistrian University of Athens, Athens, Greece
| | - T Makris
- Department of Cardiology, Helena Venizelou Hospital, Athens, Greece
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Wang B, Yang X, Yu H, Man X. The comparison of ibuprofen versus acetaminophen for blood pressure in preeclampsia: a meta-analysis of randomized controlled studies. J Matern Fetal Neonatal Med 2020; 35:592-597. [PMID: 32508173 DOI: 10.1080/14767058.2020.1720641] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Introduction: The comparison of ibuprofen with acetaminophen for blood pressure (BP) in preeclampsia remains controversial. We conduct a systematic review and meta-analysis to compare the impact of ibuprofen versus acetaminophen on BP for preeclampsia.Methods: We search PubMed, Embase, Web of Science, EBSCO, and Cochrane Library databases through October 2019 for randomized controlled trials (RCTs) assessing the effect of ibuprofen versus acetaminophen on BP for preeclampsia. This meta-analysis is performed using the random-effect model.Results: Four RCTs are included in the meta-analysis. Overall in preeclampsia patients, ibuprofen and acetaminophen show similar systolic BP (SBP) (standard mean difference [SMD] = 0.04; 95% CI = -0.26-0.34; p= .81), diastolic BP (DBP) (SMD = 0.15; 95% CI = -0.18-0.48; p = 0.38), mean BP (MAP) (SMD = 0.02; 95% CI = -0.29-0.33; p = .91), severe range BP (SMD = -0.10; 95% CI = -0.40-0.19; p = .50), severe hypertension (SMD = 1.18; 95% CI = 0.85-1.62; p = .32), and satisfaction level (SMD = 1.2; 95% CI = 0.95-1.53; p = .13).Conclusions: Ibuprofen and acetaminophen may have no significant influence on BP for preeclampsia.
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Affiliation(s)
- Baogang Wang
- Department of Cardiac Surgery, The First Hospital of Jilin University, Changchun, P. R. China
| | - Xiaolin Yang
- Department of Geriatrics, The First Hospital of Jilin University, Changchun, P. R. China
| | - Hongbo Yu
- Department of Cardiac Surgery, The First Hospital of Jilin University, Changchun, P. R. China
| | - Xiaxia Man
- Department of Oncological Gynecology, The First Hospital of Jilin University, Changchun, P. R. China
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Penfield CA, McNulty JA, Oakes MC, Nageotte MP. Ibuprofen and Postpartum Blood Pressure in Women With Hypertensive Disorders of Pregnancy: A Randomized Controlled Trial. Obstet Gynecol 2019; 134:1219-1226. [PMID: 31764732 DOI: 10.1097/aog.0000000000003553] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the effect of ibuprofen on blood pressure in women with a diagnosis of hypertensive disorders of pregnancy and mild hypertension during the immediate postpartum period. METHODS In this double-blind controlled trial, we randomly assigned women with a diagnosis of hypertensive disorders of pregnancy and mild hypertension to receive a postpartum analgesic regimen with either ibuprofen or acetaminophen. The primary outcome was average mean arterial pressure during the postpartum hospital stay. Prespecified secondary outcomes included use of breakthrough opioid pain medications, length of hospital stay, and postpartum diuresis, defined as urine output of at least 200 mL/hour for 4 hours. A sample size of 56 participants was needed to detect a difference of 6 mm Hg in average mean arterial pressure between the study groups. RESULTS From January 17, 2017, to February 24, 2018, 61 participants were randomized and completed the trial, 31 participants in the ibuprofen group and 30 in the control group. Baseline characteristics were similar between groups. Postpartum average arterial pressure did not differ between study groups (93±8 mm Hg for those in the ibuprofen group vs 93±7 mm Hg in the control group, P=.93). Breakthrough opioid medications were requested by 24% of the participants in the ibuprofen group compared with 30% in the control group (P=.62). The ibuprofen group did not have a longer length of stay (48 hours vs 43 hours in the control group) or decreased rate of postpartum diuresis (61% in ibuprofen group vs 77% in the control group, P=.2). CONCLUSION In women with hypertensive disorders of pregnancy and mild hypertension, ibuprofen did not increase postpartum blood pressure compared with women not receiving nonsteroidal antiinflammatory drugs. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov NCT03011567.
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Affiliation(s)
- Christina A Penfield
- Department of Obstetrics and Gynecology, University of California Irvine Medical Center, Irvine, and the Department of Obstetrics and Gynecology, Miller Children's and Women's Hospital/Long Beach Memorial Medical Center, Long Beach, California
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Guo Q, Feng P, Yu Q, Zhu W, Hu H, Chen X, Li H. Associations of systolic blood pressure trajectories during pregnancy and risk of adverse perinatal outcomes. Hypertens Res 2019; 43:227-234. [PMID: 31685939 DOI: 10.1038/s41440-019-0350-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 09/18/2019] [Accepted: 09/25/2019] [Indexed: 11/09/2022]
Abstract
This study aimed to explore the association of systolic blood pressure (SBP) trajectories of pregnant women with the risk of adverse outcomes of pregnant women and their fetuses. A register-based cohort of 63,724 pregnant women and their fetuses from January 2013 to December 2017 was investigated. Demographic characteristics, history of disease and family history of disease for pregnant women and perinatal outcomes were recorded, and blood pressure was measured during the whole pregnancy. SBP trajectories were estimated with latent mixture modeling by Proc Traj in SAS using SBP data from the first antenatal care appointment (8-14 weeks), the highest SBP before admission, the admission SBP and the SBP at 2 h postpartum. A censored normal model (CNORM) was considered appropriate, and model fit was assessed using the Bayesian information criterion (BIC). A logistic regression model was used to examine the association between SBP trajectories and the risk of adverse perinatal outcomes. Four distinct SBP trajectory patterns over the pregnancy period were identified and were labeled as low-stable, moderate-stable, high-decreasing and moderate-increasing. Three maternal and three fetal adverse outcomes were selected as the main outcome measures. After adjusting for confounding factors, compared with pregnant women with the low-stable pattern, those with the high-decreasing pattern had a higher risk of developing poor growth outcomes of fetuses, while those with the moderate-increasing pattern had higher risks of developing both adverse maternal and fetal outcomes. Our study results suggest that pregnant women should pay attention to the control of blood pressure throughout pregnancy.
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Affiliation(s)
- Qianlan Guo
- Department of Epidemiology, School of Public Health, Medical College of Soochow University, 215123, Suzhou, China
| | - Pei Feng
- Department of Community Health Care, Maternal and Child Health Bureau of Kunshan, 215300, Kunshan, China
| | - Qian Yu
- Department of Community Health Care, Maternal and Child Health Bureau of Kunshan, 215300, Kunshan, China
| | - Wei Zhu
- Department of Community Health Care, Maternal and Child Health Bureau of Kunshan, 215300, Kunshan, China
| | - Hao Hu
- Department of Epidemiology, School of Public Health, Medical College of Soochow University, 215123, Suzhou, China
| | - Xin Chen
- Department of Epidemiology, School of Public Health, Medical College of Soochow University, 215123, Suzhou, China
| | - Hongmei Li
- Department of Epidemiology, School of Public Health, Medical College of Soochow University, 215123, Suzhou, China. .,Department of Epidemiology, School of Public Health, Medical College of Soochow University, 199 Renai Road, Industrial Park District, Suzhou, China.
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Abstract
Hypertensive disorders of pregnancy constitute one of the leading causes of maternal and perinatal mortality worldwide. It has been estimated that preeclampsia complicates 2-8% of pregnancies globally (). In Latin America and the Caribbean, hypertensive disorders are responsible for almost 26% of maternal deaths, whereas in Africa and Asia they contribute to 9% of deaths. Although maternal mortality is much lower in high-income countries than in developing countries, 16% of maternal deaths can be attributed to hypertensive disorders (). In the United States, the rate of preeclampsia increased by 25% between 1987 and 2004 (). Moreover, in comparison with women giving birth in 1980, those giving birth in 2003 were at 6.7-fold increased risk of severe preeclampsia (). This complication is costly: one study reported that in 2012 in the United States, the estimated cost of preeclampsia within the first 12 months of delivery was $2.18 billion ($1.03 billion for women and $1.15 billion for infants), which was disproportionately borne by premature births (). This Practice Bulletin will provide guidelines for the diagnosis and management of gestational hypertension and preeclampsia.
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Triebwasser JE, Hesson A, Langen ES. A randomized-controlled trial to assess the effect of ibuprofen on postpartum blood pressure in women with hypertensive disorders of pregnancy. Pregnancy Hypertens 2019; 18:117-121. [PMID: 31586784 DOI: 10.1016/j.preghy.2019.09.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/23/2019] [Accepted: 09/21/2019] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Jourdan E Triebwasser
- Department of Obstetrics & Gynaecology, Division of Maternal-Fetal Medicine, Michigan Medicine, University of Michigan, L4000 University Hospital South, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5276, United States.
| | - Ashley Hesson
- Department of Obstetrics & Gynaecology, Division of Maternal-Fetal Medicine, Michigan Medicine, University of Michigan, L4000 University Hospital South, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5276, United States.
| | - Elizabeth S Langen
- Department of Obstetrics & Gynaecology, Division of Maternal-Fetal Medicine, Michigan Medicine, University of Michigan, L4000 University Hospital South, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5276, United States.
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Nonsteroidal Antiinflammatory Drug Administration and Postpartum Blood Pressure in Women With Hypertensive Disorders of Pregnancy. Obstet Gynecol 2019; 132:1471-1476. [PMID: 30399109 DOI: 10.1097/aog.0000000000002979] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate whether postpartum nonsteroidal antiinflammatory drug (NSAID) administration is associated with increased blood pressure in women with hypertensive disorders of pregnancy and to estimate the association between NSAID administration and use of opioid medication. METHODS We conducted a retrospective cohort study of women with hypertensive disorders of pregnancy. Patients were analyzed in two groups according to whether they received NSAIDs postpartum. Study participants were women delivered at a tertiary care center from 2008 to 2015. The primary outcome was change in mean arterial pressure during the postpartum period. Secondary outcomes were postpartum pain scores, cumulative postpartum opioid requirement, initiation or dose escalation of antihypertensive agents, and adverse postpartum outcomes including acute renal failure, change in hematocrit, and maternal readmission for hypertensive disorder. RESULTS Two hundred seventy-six women with hypertensive disorders of pregnancy were included (129 NSAID-unexposed and 147 NSAID-exposed). Postpartum NSAID administration was not associated with a statistically significant change in mean arterial pressure compared with no NSAID administration (-0.7 vs -1.8; mean difference 1.10, 95% CI -1.44 to 3.64). Similarly, no difference was observed between the cohorts in terms of need for initiation or escalation in dose of antihypertensive agents or maternal readmission for hypertensive disorder. The study was underpowered to determine whether NSAID administration was associated with any difference in less frequent secondary outcomes (eg, incidence of acute renal insufficiency, need for postpartum transfusion) or cumulative opioid use. CONCLUSION Nonsteroidal antiinflammatory drug administration to postpartum patients with hypertensive disorders of pregnancy is not associated with a change in blood pressure or requirement for antihypertensive medication.
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Tamargo J, Caballero R, Delpón E. Pharmacotherapy for hypertension in pregnant patients: special considerations. Expert Opin Pharmacother 2019; 20:963-982. [PMID: 30943045 DOI: 10.1080/14656566.2019.1594773] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Hypertensive disorders of pregnancy (HDP) represent a major cause of maternal, fetal and neonatal morbidity and mortality and identifies women at risk for cardiovascular and other chronic diseases later in life. When antihypertensive drugs are used during pregnancy, their benefit and harm to both mother and fetus should be evaluated. AREAS COVERED This review summarizes the pharmacological characteristics of the recommended antihypertensive drugs and their impact on mother and fetus when administered during pregnancy and/or post-partum. Drugs were identified using MEDLINE and the main international Guidelines for the management of HDP. EXPERT OPINION Although there is a consensus that severe hypertension should be treated, treatment of mild hypertension without end-organ damage (140-159/90-109 mmHg) remains controversial and there is no agreement on when to initiate therapy, blood pressure targets or recommended drugs in the absence of robust evidence for the superiority of one drug over others. Furthermore, the long-term outcomes of in-utero antihypertensive exposure remain uncertain. Therefore, evidence-based data regarding the treatment of HDP is lacking and well designed randomized clinical trials are needed to resolve all these controversial issues related to the management of HDP.
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Affiliation(s)
- Juan Tamargo
- a Department of Pharmacology and Toxicology, School of Medicine , Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, CIBERCV , Madrid , Spain
| | - Ricardo Caballero
- a Department of Pharmacology and Toxicology, School of Medicine , Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, CIBERCV , Madrid , Spain
| | - Eva Delpón
- a Department of Pharmacology and Toxicology, School of Medicine , Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, CIBERCV , Madrid , Spain
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Hoppe KK, Williams M, Thomas N, Zella JB, Drewry A, Kim K, Havighurst T, Johnson HM. Telehealth with remote blood pressure monitoring for postpartum hypertension: A prospective single-cohort feasibility study. Pregnancy Hypertens 2019; 15:171-176. [PMID: 30825917 PMCID: PMC6681910 DOI: 10.1016/j.preghy.2018.12.007] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 10/05/2018] [Accepted: 12/29/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Investigate feasibility of telehealth with remote blood pressure monitoring for management of hypertension in postpartum women at risk of severe hypertension after hospital discharge. METHODS In a single-center, prospective single-cohort feasibility study, women with hypertension in pregnancy participated in a postpartum telehealth intervention for blood pressure management after discharge. The primary feasibility outcome measures were recruitment and retention through 6 weeks postpartum. Secondary outcomes included the incidence of severe postpartum hypertension and/or need for blood pressure treatment after discharge, participant satisfaction, and 6-week hospital readmission. Participants received a tablet and equipment to transmit vital signs to a central monitoring site daily. Participants participated in telehealth or telephone visits with a nurse at 48 h and as needed. RESULTS Among 1413 deliveries 263 (19%) women had hypertension in pregnancy and 55/124 (47%) of women approached were consented. The retention rate was 95%. Among study participants, the incidence of severe hypertension after discharge was 9 (16%). 29 (53%) of participants required treatment due to exacerbations in blood pressure after discharge, in which 9(16%) were severe. There were no hospital readmissions. Overall 39 (86%) participants were satisfied with the remote monitoring. CONCLUSIONS Feasibility and participant satisfaction were demonstrated. The incidence of severe hypertension and need for blood pressure treatment after discharge and during 6 weeks postpartum was 16% and 53%. Our results indicate telehealth is a promising strategy for postpartum hypertension management to decrease maternal morbidity and hospital readmission.
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Affiliation(s)
- Kara K Hoppe
- Department of Obstetrics and Gynecology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, United States.
| | - Makeba Williams
- Department of Obstetrics and Gynecology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, United States
| | - Nicole Thomas
- UnityPoint Health-Meriter, Madison, WI, United States
| | - Julia B Zella
- Department of Obstetrics and Gynecology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, United States
| | - Anna Drewry
- Department of Obstetrics and Gynecology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, United States
| | - KyungMann Kim
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, WI, United States
| | - Thomas Havighurst
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, WI, United States
| | - Heather M Johnson
- Division of Cardiovascular Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI, United States
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Effect of ibuprofen vs acetaminophen on postpartum hypertension in preeclampsia with severe features: a double-masked, randomized controlled trial. Am J Obstet Gynecol 2018; 218:616.e1-616.e8. [PMID: 29505772 DOI: 10.1016/j.ajog.2018.02.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 02/13/2018] [Accepted: 02/26/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Nonsteroidal antiinflammatory drug use has been shown to increase blood pressure in nonpregnant adults. Because of this, the American College of Obstetricians and Gynecologists suggests avoiding their use in women with postpartum hypertension; however, evidence to support this recommendation is lacking. OBJECTIVE Our goal was to test the hypothesis that nonsteroidal antiinflammatory drugs, such as ibuprofen, adversely affect postpartum blood pressure control in women with preeclampsia with severe features. STUDY DESIGN At delivery, we randomized women with preeclampsia with severe features to receive around-the-clock oral dosing with either 600 mg of ibuprofen or 650 mg of acetaminophen every 6 hours. Dosing began within 6 hours after delivery and continued until discharge, with opioid analgesics available as needed for breakthrough pain. Study drugs were encapsulated in identical capsules such that patients, nurses, and physicians were masked to study allocation. Exclusion criteria were serum aspartate aminotransferase or alanine aminotransferase >200 mg/dL, serum creatinine >1.0 mg/dL, infectious hepatitis, gastroesophageal reflux disease, age <18 years, or current incarceration. Our primary outcome was the duration of severe-range hypertension, defined as the time (in hours) from delivery to the last blood pressure ≥160/110 mm Hg. Secondary outcomes were time from delivery to last blood pressure ≥150/100 mm Hg, mean arterial pressure, need for antihypertensive medication at discharge, prolongation of hospital stay for blood pressure control, postpartum use of short-acting antihypertensives for acute blood pressure control, and opioid use for breakthrough pain. We analyzed all outcome data according to intention-to-treat principles. RESULTS We assessed 154 women for eligibility, of whom 100 met entry criteria, agreed to participate, and were randomized to receive postpartum ibuprofen or acetaminophen for first-line pain control. Seven patients crossed over or did not receive their allocated study drug, and 93 completed the study protocol in their assigned groups. We found no differences in baseline characteristics between groups, including mode of delivery, body mass index, parity, race, chronic hypertension, and maximum blood pressure prior to delivery. We did not find a difference in the duration of severe-range hypertension in the ibuprofen vs acetaminophen groups (35.3 vs 38.0 hours, P = .30). There were no differences between groups in the secondary outcome measures of time from delivery to last blood pressure ≥150/100 mm Hg, postpartum mean arterial pressure, maximum postpartum systolic or diastolic blood pressures, any postpartum blood pressure ≥160/110 mm Hg, short-acting antihypertensive use for acute blood pressure control, length of postpartum stay, need to extend postpartum stay for blood pressure control, antihypertensive use at discharge, or opioid use for inadequate pain control. In a subgroup analysis of patients who experienced severe-range hypertension, the mean time to blood pressure control in the acetaminophen group was 68.4 hours and ibuprofen group was 56.7 hours (P = .26). At 6 weeks postpartum, there were no differences between groups in the rates of obstetric triage visits, hospital readmissions, continued opioid use, or continued antihypertensive use. CONCLUSION The first-line use of ibuprofen rather than acetaminophen for postpartum pain did not lengthen the duration of severe-range hypertension in women with preeclampsia with severe features.
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Hirshberg JS, Cahill AG. Pain relief: determining the safety of ibuprofen with postpartum preeclampsia. Am J Obstet Gynecol 2018; 218:547-548. [PMID: 29793573 DOI: 10.1016/j.ajog.2018.04.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 04/17/2018] [Indexed: 02/02/2023]
Affiliation(s)
- Jonathan S Hirshberg
- Department of Obstetrics and Gynecology, Washington University School of Medicine in St Louis, St. Louis, MO.
| | - Alison G Cahill
- Department of Obstetrics and Gynecology, Washington University School of Medicine in St Louis, St. Louis, MO
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