BJOG Exchange
A report from #BlueJC: Should we use oral or parenteral medications for severe hypertension in pregnancy? Paper discussed: Firoz T, Magee L, MacDonell K, Payne B, Gordon R, Vidler M, von Dadelszen P; the Community Level Interventions for Pre-eclampsia (CLIP) Working Group. Oral antihypertensive therapy for severe hypertension in pregnancy and postpartum: a systematic review. BJOG 2014;121:1210–20. Location: Twitter. Number of participants 22. Date of journal club: 27 August 2014. Number of tweets 86. Paper summary: Participants Intervention Comparison Outcomes Study design Findings
Severe hypertension (systolic blood pressure ≥ 160 mmHg/diastolic blood pressure ≥ 110 mmHg) in any hypertensive disorders in pregnancy Oral antihypertensive therapy Antihypertensive therapy (any route), placebo or no treatment Primary outcome: Achievement of target blood pressure occurring within 24 hours of treatment Secondary outcomes: Maternal and perinatal outcomes Systematic review of randomised controlled trials Oral antihypertensives, in particular nifedipine, are effective for managing severe high blood pressure in pregnancy with no increased in adverse maternal or fetal outcomes
Research literacy The Cochrane Risk of Bias Assessment Tool The authors of this systematic review succinctly summarised the risks of bias of the included study using the Cochrane Collaboration’s Tool for Assessing Risks of Bias (The Cochrane Collaboration: http://bit.ly/1p3yH0G). The tool includes six domains: sequence generation, allocation concealment, blinding, completeness of outcome data, selective outcome reporting and other potential threats to validity.
Feedback on the study Oral antihypertensives are effective The study has shown that oral medications are effective for managing severe hypertension in pregnancy with no significant differences in adverse effects in mothers and babies. Most included trials compared oral nifedipine (8–10 mg) with other parenteral agents. The number of subjects included in the trials evaluating the effectiveness of oral labetalol and methyldopa were small; their benefits are less clearly shown.
Is achievement of target blood pressure sufficient to treat pregnancy-induced hypertension and pre-eclampsia? The primary outcome evaluated whether the use of oral antihypertensives could achieve target blood pressure within 24 hours of treatment. However, effective blood pressure management is merely a surrogate outcome of pre-eclampsia and pregnancy-induced hypertension. Moreover, some of the complications of pre-eclampsia, including seizures (eclampsia), can occur without the usual hypertension or proteinuria (Am J Obstet Gynecol 2009;200:481.e1–7). It is important to recognise the other components of managing severe hypertension in pregnancy, including eclampsia prevention, thromboprophylaxis and expediting delivery.
Implications on the management of pre-eclampsia in resource-poor settings Pregnancy-induced hypertensive disorder remains a major cause of significant maternal morbidity and mortality worldwide. The equivalent effectiveness of oral antihypertensives shown is particularly important in settings where skilled medical personnel and equipment to administer parenteral medications are scarce.
Take home messages Oral antihypertensives, in particular nifedipine, are as effective and safe as parenteral antihypertensives for managing severe high blood pressure in pregnancy. The findings may be particularly relevant in resource-poor settings.
Acknowledgements We are grateful for all contributions to this journal club. A transcript and a list of contributors can be viewed at http://bit.ly/1lTgzMm. The Altmetric summary of this journal club paper can be viewed at: http://bit.ly/1oo3ZAf. EYL Leung Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, UK About #BlueJC: Regular #BlueJC starts on the last Wednesday of each month (except December). For an introduction to #BlueJC, please refer to BJOG 2013;120:657–60. Further information is available on www.BJOG.org. Follow @BlueJCHost on Twitter to receive updates of #BlueJC news. Queries should be sent to [email protected] or @BlueJCHost.
ª 2014 Royal College of Obstetricians and Gynaecologists
147
Copyright of BJOG: An International Journal of Obstetrics & Gynaecology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
A report from #BlueJC: Should we use oral or parenteral medications for severe hypertension in pregnancy? Paper discussed: Firoz T, Magee L, MacDonell K, Payne B, Gordon R, Vidler M, von Dadelszen P; the Community Level Interventions for Pre-eclampsia (CLIP) Working Group. Oral antihypertensive therapy for severe hypertension in pregnancy and postpartum: a systematic review. BJOG 2014;121:1210–20. Location: Twitter. Number of participants 22. Date of journal club: 27 August 2014. Number of tweets 86. Paper summary: Participants Intervention Comparison Outcomes Study design Findings
Severe hypertension (systolic blood pressure ≥ 160 mmHg/diastolic blood pressure ≥ 110 mmHg) in any hypertensive disorders in pregnancy Oral antihypertensive therapy Antihypertensive therapy (any route), placebo or no treatment Primary outcome: Achievement of target blood pressure occurring within 24 hours of treatment Secondary outcomes: Maternal and perinatal outcomes Systematic review of randomised controlled trials Oral antihypertensives, in particular nifedipine, are effective for managing severe high blood pressure in pregnancy with no increased in adverse maternal or fetal outcomes
Research literacy The Cochrane Risk of Bias Assessment Tool The authors of this systematic review succinctly summarised the risks of bias of the included study using the Cochrane Collaboration’s Tool for Assessing Risks of Bias (The Cochrane Collaboration: http://bit.ly/1p3yH0G). The tool includes six domains: sequence generation, allocation concealment, blinding, completeness of outcome data, selective outcome reporting and other potential threats to validity.
Feedback on the study Oral antihypertensives are effective The study has shown that oral medications are effective for managing severe hypertension in pregnancy with no significant differences in adverse effects in mothers and babies. Most included trials compared oral nifedipine (8–10 mg) with other parenteral agents. The number of subjects included in the trials evaluating the effectiveness of oral labetalol and methyldopa were small; their benefits are less clearly shown.
Is achievement of target blood pressure sufficient to treat pregnancy-induced hypertension and pre-eclampsia? The primary outcome evaluated whether the use of oral antihypertensives could achieve target blood pressure within 24 hours of treatment. However, effective blood pressure management is merely a surrogate outcome of pre-eclampsia and pregnancy-induced hypertension. Moreover, some of the complications of pre-eclampsia, including seizures (eclampsia), can occur without the usual hypertension or proteinuria (Am J Obstet Gynecol 2009;200:481.e1–7). It is important to recognise the other components of managing severe hypertension in pregnancy, including eclampsia prevention, thromboprophylaxis and expediting delivery.
Implications on the management of pre-eclampsia in resource-poor settings Pregnancy-induced hypertensive disorder remains a major cause of significant maternal morbidity and mortality worldwide. The equivalent effectiveness of oral antihypertensives shown is particularly important in settings where skilled medical personnel and equipment to administer parenteral medications are scarce.
Take home messages Oral antihypertensives, in particular nifedipine, are as effective and safe as parenteral antihypertensives for managing severe high blood pressure in pregnancy. The findings may be particularly relevant in resource-poor settings.
Acknowledgements We are grateful for all contributions to this journal club. A transcript and a list of contributors can be viewed at http://bit.ly/1lTgzMm. The Altmetric summary of this journal club paper can be viewed at: http://bit.ly/1oo3ZAf. EYL Leung Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, UK About #BlueJC: Regular #BlueJC starts on the last Wednesday of each month (except December). For an introduction to #BlueJC, please refer to BJOG 2013;120:657–60. Further information is available on www.BJOG.org. Follow @BlueJCHost on Twitter to receive updates of #BlueJC news. Queries should be sent to [email protected] or @BlueJCHost.
ª 2014 Royal College of Obstetricians and Gynaecologists
147
Copyright of BJOG: An International Journal of Obstetrics & Gynaecology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
