Oral antihypertensive agents and diuretics in the management of hypertension in postpartum women: a systematic review and meta-analysis

Abstract

Objective: In the puerperium, women with hypertensive disease of pregnancy remain at risk for maternal complications. The antihypertensive agent prescribed antepartum is usually continued postpartum; however, evidence regarding the most effective treatment is lacking. Therefore, we aimed to investigate which antihypertensive agent results in optimal treatment (both effectiveness and safety) of postpartum hypertension.

Design: Systematic review and meta-analysis.

Data sources: MEDLINE (Ovid), Embase.com and CENTRAL were searched through 22 August 2024.

Eligibility criteria: Randomised controlled trials (RCTs) evaluating oral antihypertensives and diuretics in postpartum hypertensive women published after 1990, performing BP measurements in the postpartum period, were identified.

Data extraction and synthesis: Two independent reviewers extracted data and assessed risk of bias. Pooled data were calculated as risk ratio or mean difference using a random effect model.

Results: Fourteen RCTs (1651 women) were included. Seven RCTs compared diuretics with placebo or antihypertensive controlled, two RCTs compared oral antihypertensives with placebo and five RCTs compared labetalol with nifedipine. Pooled data demonstrated a significantly lower BP on day 3 in cases with pre-eclampsia using furosemide (mean difference -4.06, 95% CI -6.81 to -1.31). Furosemide had no significant effect on any of the other outcomes. Faster BP control was observed for labetalol over nifedipine in a single RCT (mean difference 5.20, 95% CI 4.36 to 6.04). No other significant effects were observed.

Conclusions: In this extensive literature review, no medication preference could be stated and a lack of high-quality studies was revealed. Some evidence demonstrates a positive effect on BP control in women with pre-eclampsia using furosemide. Therefore, adding furosemide to initial treatment is considerable. However, antihypertensive preference and furosemide effectiveness should be further researched. We propose a retrospective cohort study using real-life hospital data (from health records), utilising clinical variance in therapeutic strategies currently present.

Prospero registration number: CRD42023410765.

Keywords: Hypertension; Meta-Analysis; Postpartum Women; Systematic Review.

Figure 1. Flow chart for identifying eligible studies (adapted from PRISMA flow diagram)

Figure 2. Risk of bias

Figure 3. Forest plots furosemide versus placebo

Figure 4. Forest plots labetalol versus nifedipine