Oral antihypertensive therapy for severe hypertension in pregnancy and postpartum: a systematic review

BACKGROUND

Pregnant and postpartum women with severe hypertension are at increased risk of stroke and require blood pressure (BP) reduction. Parenteral antihypertensives have been most commonly studied, but oral agents would be ideal for use in busy and resource-constrained settings.

OBJECTIVES

To review systematically, the effectiveness of oral antihypertensive agents for treatment of severe pregnancy/postpartum hypertension.

SEARCH STRATEGY

A systematic search of MEDLINE, EMBASE and the Cochrane Library was performed.

SELECTION CRITERIA

Randomised controlled trials in pregnancy and postpartum with at least one arm consisting of a single oral antihypertensive agent to treat systolic BP ≥ 160 mmHg and/or diastolic BP ≥ 110 mmHg.

DATA COLLECTION AND ANALYSIS

Cochrane RevMan 5.1 was used to calculate relative risk (RR) and weighted mean difference by random effects.

MAIN RESULTS

We identified 15 randomised controlled trials (915 women) in pregnancy and one postpartum trial. Most trials in pregnancy compared oral/sublingual nifedipine capsules (8-10 mg) with another agent, usually parenteral hydralazine or labetalol. Nifedipine achieved treatment success in most women, similar to hydralazine (84% with nifedipine; relative risk [RR] 1.07, 95% confidence interval [95% CI] 0.98-1.17) or labetalol (100% with nifedipine; RR 1.02, 95% CI 0.95-1.09). Less than 2% of women treated with nifedipine experienced hypotension. There were no differences in adverse maternal or fetal outcomes. Target BP was achieved ~ 50% of the time with oral labetalol (100 mg) or methyldopa (250 mg) (47% labetelol versus 56% methyldopa; RR 0.85 95% CI 0.54-1.33).

CONCLUSIONS

Oral nifedipine, and possibly labetalol and methyldopa, are suitable options for treatment of severe hypertension in pregnancy/postpartum.

Informatics and computational neuroanatomy

Rapid and convenient access to digital image archives, as well as archive-based computational tools, are fundamental to many hypothesis-driven investigations of brain anatomy and function in health and disease. The complexity and density of brain image data requires the design of intelligent tools which allow scientific and clinical data, collected at numerous research centers, to be compared, integrated, and disseminated. We describe our results in the development of image data navigational tools, a World Wide Web repository of image analysis software, and strategies to represent populations of brain image data involving atlas descriptions of its variance.

Animating the 3D structure and function of brain

Three dimensional (3D) reconstructions of brain anatomy and physiology have greatly improved our understanding of complex spatial and densitometric relationships. The complexity and sophistication of these imaging techniques has steadily improved in the last few years and there are many situations in which the static display of 3D models contains more information than can be easily appreciated. Animating a sequence of these displays adds another dimension to the visualization, understanding and communication of 3D data. This paper describes those situations that warrant animations, the techniques necessary to compute them and the results that can be obtained.

Three-dimensional comparison of peripheral benzodiazepine binding and histological findings in rat brain tumor

Experiments were undertaken to determine the in vivo utility of the mixed benzodiazepine ligand [3H]flunitrazepam and the selective peripheral benzodiazepine ligand [3H]PK 11195 [1-(2-chlorophenyl)-N-methyl-N-(1-methylpropyl)-3-isoquinoline carboxamide] to outline the borders of rat C6 glial tumors in three dimensions. Intravenous injection of [3H]flunitrazepam resulted in a tumor/cortex ratio of radioactive densities between 2.7 and 1.5 within the first 60 minutes after injection. [3H]PK 11195 demonstrated a higher tumor/cortex ratio (5.3) than [3H]flunitrazepam. For three-dimensional studies, images were generated from thionin-stained histological sections and autoradiograms. The mixed type benzodiazepine ligand [3H]flunitrazepam was superior in showing some of the normal anatomical structures surrounding the tumor, whereas [3H]PK 11195, a specific peripheral ligand, demonstrated higher tumor/brain contrast and superior topographical correlation between histological and autoradiographic images. Implications of peripheral benzodiazepine receptor ligands for positron emission tomography are discussed.

Digital rat brain: a computerized atlas

Digital brain mapping provides the techniques required for 3 dimensional (3D) reconstruction and display. This paper describes work which extends the data published in the Paxinos and Watson (1982) atlas of the rat brain to a computerized form. The product of these experiments is a 3D digital neuroanatomic atlas. The data were transformed from 2D outlines to 3D volumes each associated with a specific neuroanatomic structure. The system which manages this transformation also provides tools to manipulate the composition, orientation and appearance of the displays interactively.

Evaluation of the Toa E-5000 Automated Hematology Analyzer

A three-phase evaluation of the Toa E-5000 Automated Hematology Analyzer was performed. The first phase consisted of evaluation of linearity, carryover, precisions, accuracy, sample stability, and effectiveness of the mixing and sampling mechanism. The second phase was comparison of erythroid and platelet parameters with results from a Coulter Counter Model S-Plus IV. The third phase consisted of comparison of the trimodal leukocyte differential count of the Toa E-5000 in 300 patients with four other differential methods. The first-phase studies showed excellent performance characteristics. Stability of samples at room temperature was good for a minimum of 12 hours, but storage for longer than 12 hours requires refrigeration to maintain stable values. The erythrocyte and platelet parameters showed good correlation with the Coulter S-Plus IV values except for the erythrocyte distribution width that is calculated differently. The third-phase studies are published elsewhere.

Comparison of four leukocyte differential methods with the National Committee for Clinical Laboratory Standards (NCCLS) reference method

The authors compared four leukocyte differential counting methods with the National Committee for Clinical Laboratory Standards Reference Leukocyte Differential Method H20-T to determine the clinical sensitivity of the methods. The three-part differential performed by the Coulter Counter Model S-Plus IV and the Toa E-5000, when combined with instrument flags and defined laboratory checking limits for red blood cell and platelet values, are safe and efficacious screening methods for the presence of morphologic abnormalities. The Geometric Data Hematrak 590 proved comparable in clinical sensitivity to a random 100-cell eye-count differential.

Evaluation of the Coulter Counter model S-Plus IV

Evaluation of linearity, carry-over, precision, and accuracy of a Coulter Counter model S-Plus IV prototype showed that they meet the manufacturer's specifications. The instrument also was compared with an earlier model. Correlations of the lymphocyte and granulocyte values in the three-part differential count with manual eye-count and a Technicon Hemalog D90 results were very close to the correlation of eye-count to Hemalog D90 results. The percentage of mononuclear cells showed acceptable correlation to the manual eye-count when monocytes were combined with blasts, eosinophils, and basophils. The medical effectiveness of the three-part differential was determined by comparison with manual eye-counts in 1,084 samples. The false positive and false negative values were 7.38% and 7.84%, respectively. The instrument has acceptable limits of operation. When combined with analysis of histograms by trained personnel, the three-part differential count is capable of screening for abnormalities that require further analysis.

Pseudothrombocytopenia: a laboratory artifact with potentially serious consequences

When a low platelet count is unexpected or is unaccompanied by signs or symptoms of hemorrhage, pseudothrombocytopenia should be suspected. The platelet number and morphologic features should be examined on a smear prepared from blood anticoagulated with EDTA. Platelet counts should be repeated either by obtaining a finger-stock specimen with an ammonium oxalate Unopette and counting by phase microscopy or by collecting both an EDTA- and a sodium citrate-anticoagulated venous sample, performing a platelet count on both test tubes, and examining a blood smear from each test tube. If a Coulter Model S Plus IV or V or the Technicon H6000 is used for performance of platelet counts, examination of the histogram display of the Coulter instrument or the peroxidase X-Y display of the Technicon H6000 should alert the instrument operator to the presence of EDTA-induced platelet clumping and prevent the reporting of a spuriously low platelet count.