Prevention and treatment of postpartum hypertension

 

Abstract

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 medical therapy is better than placebo/no treatment; and
(2) treat postpartum hypertension, by assessing whether (i) one 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 methods

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (May 2009), PubMed (2002 to May 2009), 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

Eight trials are included.

Prevention: Three trials (313 women) compared furosemide or nifedipine capsules with placebo/no therapy. For women with antenatal pre-eclampsia, postnatal furosemide is associated with a strong trend towards reduced use of antihypertensive therapy in hospital.

Treatment: For treatment of mild-moderate postpartum hypertension, three trials (189 women) compared timolol, hydralazine (po), or nifedipine (po) with methyldopa. Use of additional antihypertensive therapy did not differ between groups (risk ratio (RR) 0.69, 95% confidence interval (CI) 0.39 to 1.21; three trials), but the trials were not consistent in their effects. The drugs were well tolerated.

For treatment of severe postpartum hypertension, two trials (120 women) compared intravenous hydralazine with either sublingual nifedipine or intravenous labetalol. There were no maternal deaths or hypotension. Use of additional antihypertensive therapy did not differ between groups (RR 0.43, 95% CI 0.11 to 1.77; two trials), but the trials were not consistent in their effects.

Authors' conclusions

For women with pre-eclampsia, postnatal furosemide may decrease the need for postnatal antihypertensive therapy in hospital, but more data are needed on substantive outcomes before this practice can be recommended. There are no reliable data to guide management of women who are hypertensive postpartum. Any antihypertensive agent used should be based on a clinician's familiarity with the drug. Future studies should include data on postpartum analgesics, severe maternal hypertension, breastfeeding, hospital length of stay, and maternal satisfaction with care.

 

Plain language summary

Prevention and treatment of postpartum hypertension

Not enough evidence to know how best to treat women with hypertension after birth.

After birth, it is not uncommon for women to experience high blood pressure (hypertension), but it can have serious consequences. It can lead to stroke and, very rarely, death. It is unclear what causes hypertension after childbirth, or which women may develop the problem, although women with antenatal severe pre-eclampsia appear to be at highest risk. The review of eight trials found no reliable evidence to guide care for these women. Further research is needed, particularly as the problem occurs most commonly three to six days after birth when most women have left hospital.

 

摘要

背景

產後高血壓的預防及治療

在生產過後的3到6天，產後血壓(BP)是最高的，而此時大多數的婦女都已出院回到家。很明顯的血壓上升可能會有危險(例如會導致中風)，但是就如何預防或治療產後高血壓而言，幾乎沒有相關的資訊。

目標

對下列的項目進行醫療干預行為時，要評估相對的優點與風險：(1)預防產後高血壓，可藉由評估口服降血壓藥物療法在「例行性的」產後給藥方面，是否會優於安慰劑/不採取治療；與(2)治療產後高血壓，可藉由評估是否(i)口服降血壓藥物療法會優於安慰劑/不採用任何療法，以用於輕度中度的產後高血壓；以及(ii)某種降血壓藥物會比另外一種帶來更多的優點，以用於輕度中度或是嚴重的產後高血壓。

搜尋策略

我們搜尋了the Cochrane Pregnancy and Childbirth Group trials register(2004年三月)、MEDLINE(1966年到2003年五月)、EMBASE(1980年到2003年一月)，以及所取得的論文之參考文獻，還有個人檔案。

選擇標準

針對患有產前高血壓的婦女而言，這些試驗將某種醫療的干預行為與安慰劑/不採取任何療法之間進行了比較。針對患有產後高血壓的婦女而言，這些試驗將某種降血壓藥物與另外一種藥物或是安慰劑/不採取任何療法之間進行了比較。

資料收集與分析

我們獨立地擷取出資料，而且並沒有對於試驗的特徵或是結果採取盲法。當有可能的時候，我們針對遺失的資料而與作者們進行聯繫。

主要結論

當中共包含了6組試驗。在預防方面，有3組試驗(315名婦女；6項比較)將furosemide或是nifedipine膠囊與安慰劑/不採取任何療法進行比較。針對有關於這些處理策略之潛在的優點與風險，在結論方面並沒有足夠的資料。大多數的預後只是從1組試驗中歸納出資料。針對嚴重的母體高血壓或是哺餵母乳，並沒有試驗提出報告。在2組試驗中(106名婦女；3項比較)的治療方法，針對了治療輕度到中度的產後高血壓，將口服的timolol或hydralazine與口服的methyldopa進行比較。有1份試驗(38名婦女；1項比較)，針對治療嚴重的產後該血壓，口服的hydralazine加上舌下的nifedipine，用來與舌下的nifedipine進行比較。需要額外之降血壓療法，在各組別之間並不會不同(相對風險4.24, 95% 信賴區間0.96 to 18.84; 3份試驗, 樣本數 = 144 個婦女)，但是一共研究了3種降血壓的藥物。所有藥物的接受情況都很良好。

作者結論

對於患有產後高血壓的婦女，或是有較高的風險會得到高血壓時，沒有可信賴的資料可以用來指導如何該治療。假使有某位臨床醫師\覺得，高血壓的狀況已經嚴重到要進行治療了，所使用的藥物應該要根據他/她對於該藥物的熟悉程度。對於產後高血壓的預防與治療，未來的研究應該要涵蓋關於使用產後止痛劑，嚴重高血壓之預後、哺餵母乳、住院的時間，還有母親對於護理之滿意度等方面的資訊。

翻譯人

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

沒有足夠的證據可以證明產後對於患有高血壓的婦女的最佳治療方式。在生產之後，婦女遇上血壓升高(高血壓)的現象並不算是異常，但是這卻有可能導致嚴重的後果。高血壓可能會造成中風，罕見的情況下會造成死亡。目前還不知道是什麼原因會造成產後高血壓，或是哪些婦女身上可能會發展出這樣的問題，但在產前患有子癲前症(preeclampsia)的婦女看起來會有最高的風險。本篇試驗的回顧發現，並沒有可信賴的證據可以用來指導如何該照顧這些婦女。還需要有更進一步的研究，尤其是這樣的問題最常發生在生產過後的3到6天，而此時大多數的婦女們都已經離開醫院了。