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Obstetrics and gynaecology
Research
Postpartum management of hypertensive disorders of pregnancy: a systematic review
  1. Alexandra E Cairns1,
  2. Louise Pealing1,
  3. James M N Duffy1,
  4. Nia Roberts2,
  5. Katherine L Tucker1,
  6. Paul Leeson3,
  7. Lucy H MacKillop4,
  8. Richard J McManus1
  1. 1 Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
  2. 2 Knowledge Centre, Bodleian Libraries, University of Oxford, Oxford, UK
  3. 3 Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, University of Oxford, Oxford, UK
  4. 4 Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Oxford, UK
  1. Correspondence to Dr Alexandra E Cairns; alexandra.cairns{at}phc.ox.ac.uk

Abstract

Objectives Hypertensive disorders of pregnancy (HDP) affect one in ten pregnancies and often persist postpartum when complications can occur. We aimed to determine the effectiveness and safety of pharmacological interventions, other interventions and different care models for postpartum hypertension management.

Design A systematic review was undertaken. Nine electronic databases, including Medline, were searched from inception to 16 March 2017. After duplicate removal, 4561 records were screened. Two authors independently selected studies, extracted study characteristics and data, and assessed methodological quality.

Setting Randomised controlled trials, case–control studies and cohort studies from any country and healthcare setting.

Participants Postnatal women with HDP.

Interventions Therapeutic intervention for management of hypertension, compared with another intervention, placebo or no intervention.

Primary and secondary outcome measures Outcome data were collected for maternal mortality and severe morbidity; systolic, diastolic and mean arterial blood pressure (BP) control; and safety data. Secondary outcome data collected included the length of postnatal hospital stay and laboratory values.

Results 39 studies were included (n=2901). Results were heterogeneous in terms of intervention, comparison and outcome requiring a narrative approach. There were insufficient data to recommend any single pharmacological intervention. 18 studies reported calcium-channel blockers, vasodilators and beta-blockers lowered BP postpartum. 12 of these reported safety data. Limited data existed regarding management in the weeks following hospital discharge. Neither loop diuretics (three studies) nor corticosteroids (one study) produced clinical benefit. Uterine curettage significantly reduced BP over the first 48 hours postpartum (range 6–13 mm Hg) compared with standard care (eight studies), with safety data only reported by four of eight studies.

Conclusion There was insufficient evidence to recommend a particular BP threshold, agent or model of care, but three classes of antihypertensive appeared variably effective. Further comparative research, including robust safety data, is required. Curettage reduced BP, but without adequate reporting of harms, so it cannot currently be recommended.

  • preeclampsia
  • gestational hypertension
  • postpartum
  • hypertensive disorders of pregnancy
  • antihypertensive medication
  • systematic review

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/

https://doi.org/10.1136/bmjopen-2017-018696

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    Footnotes

    • Contributors AEC drafted the protocol with JMND, and drafted and piloted the data extraction sheet. These were reviewed by RJMcM, LP, KLT, LHM and PL. NR and AEC wrote the search strategy, and the online searches were conducted by NR. AEC and LP reviewed the search results independently and carried out the data extraction. This manuscript was drafted by AEC and reviewed by RJMcM, JMND, LP, NR, KLT, LHM and PL. AEC will be the guarantor.

    • Funding The research was funded by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care Oxford at Oxford Health NHS Foundation Trust, and via a Research Professorship awarded to RJMcM (NIHR-RP-02-12-015). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement Extra data can be accessed via the Dryad data repository at http://datadryad.org/ with the doi:10.5061/dryad.pb6f2.