Prevention and treatment of postpartum hypertension

Background

Postpartum blood pressure (BP) is highest three to six days after birth when most women have been discharged home. A significant rise in BP may be dangerous (e.g., lead to stroke), but there is little information about how to prevent or treat postpartum hypertension.

Objectives

To assess the relative benefits and risks of interventions to:
(1) prevent postpartum hypertension, by assessing whether 'routine' postpartum administration of oral antihypertensive therapy is better than placebo/no treatment; and
(2) treat postpartum hypertension, by assessing whether (i) oral antihypertensive therapy is better than placebo/no therapy for mild-moderate postpartum hypertension; and (ii) one antihypertensive agent offers advantages over another for mild-moderate or severe postpartum hypertension.

Search strategy

We searched the Cochrane Pregnancy and Childbirth Group trials register (March 2004), MEDLINE (1966 to May 2003), EMBASE (1980 to January 2003), bibliographies of retrieved papers and personal files.

Selection criteria

For women with antenatal hypertension, trials comparing a medical intervention with placebo/no therapy. For women with postpartum hypertension, trials comparing one antihypertensive with either another or placebo/no therapy.

Data collection and analysis

We extracted the data independently and were not blinded to trial characteristics or outcomes. We contacted authors for missing data when possible.

Main results

Six trials are included.

Prevention
Three trials (315 women; six comparisons) compared furosemide or nifedipine capsules with placebo/no therapy. There are insufficient data for conclusions about possible benefits and risks of these management strategies. Most outcomes included data from only one trial. No trial reported severe maternal hypertension or breastfeeding.

Treatment
In two trials (106 women; three comparisons), oral timolol or hydralazine were compared with oral methyldopa for treatment of mild to moderate postpartum hypertension. In one trial (38 women; one comparison), oral hydralazine plus sublingual nifedipine were compared with sublingual nifedipine for treatment of severe postpartum hypertension. The need for additional antihypertensive therapy did not differ between groups (relative risk 4.24, 95% confidence interval 0.96 to 18.84; three trials, N = 144 women), but three antihypertensive drugs were studied. All were well tolerated.

Authors' conclusions

There are no reliable data to guide management of women who are hypertensive postpartum or at increased risk of becoming so. If a clinician feels that hypertension is severe enough to treat, the agent used should be based on his/her familiarity with the drug. Future studies of prevention or treatment of postpartum hypertension should include information about use of postpartum analgesics and outcomes of severe maternal hypertension, breastfeeding, hospital length of stay, and maternal satisfaction with care.