Treatment of acute-onset hypertension in pregnancy: A network meta-analysis of randomized controlled trials comparing anti-hypertensives and route of administration

Adithya D Bhat; Paige M Keasler; Lavanya Kolluru; Michael M Dombrowski; Arvind Palanisamy; Preet Mohinder Singh

doi:10.1016/j.preghy.2023.10.005

Treatment of acute-onset hypertension in pregnancy: A network meta-analysis of randomized controlled trials comparing anti-hypertensives and route of administration

Pregnancy Hypertens. 2023 Dec:34:74-82. doi: 10.1016/j.preghy.2023.10.005. Epub 2023 Oct 17.

Authors

Adithya D Bhat¹, Paige M Keasler², Lavanya Kolluru³, Michael M Dombrowski⁴, Arvind Palanisamy¹, Preet Mohinder Singh⁵

Affiliations

¹ Department of Anesthesiology, Washington University School of Medicine in St. Louis, MO, USA.
² Department of Anesthesiology, Washington University School of Medicine in St. Louis, MO, USA; Department of Anesthesiology, University of Washington Medical Center, WA, USA.
³ University of Missouri-Kansas City School of Medicine, MO, USA.
⁴ Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, MO, USA.
⁵ Department of Anesthesiology, Washington University School of Medicine in St. Louis, MO, USA. Electronic address: singh.p@wustl.edu.

PMID: 37857042
DOI: 10.1016/j.preghy.2023.10.005

Abstract

Background: Consensus on the relative efficacy of available antihypertensive agents used in pregnancy is lacking.

Objective: To compare treatment success with antihypertensives and categorize by route of administration.

Search strategy: MEDLINE, Embase, PubMed, Web of Science, Scopus, CINAHL, and clinicaltrials.gov were searched without date restriction.

Data collection: Peer-reviewed randomized controlled trials (RCTs) comparing pharmacologic agents used to treat hypertension in parturients were included. Evaluated treatment groups included IV-labetalol (BBIV), IV-hydralazine (DIV), oral-nifedipine (CCBPO), sublingual nifedipine (CCBSL), IV-calcium channel blocker (nonspecific)(CCBIV), IV-nitroglycerine (NTG), epoprostenol infusion (PRO), IV-ketanserin (5HT2B), IV-diazoxide (BZO), oral-nifedipine + methyldopa (CCBAG), oral-methyl-dopa (AAG), and oral prazosin (ABPO).

Analysis: Seventy-four studies (8324 patients) were eligible post PRISMA guidelines screening. Results were pooled using a Bayesian-approach for success of treatment (study defined target blood pressure), time to achieve target pressure, and neonatal intensive-care admissions.

Results: Treatment success (primary outcome, 55 trials with 5518 patients) was analyzed. Surface under the cumulative ranking curve (SUCRA) was categorized for 13 drugs, CCBPO (0.84) followed by CCBSL (0.78) were most likely to be effective in achieving target blood pressure. After sub-grouping by presence/absence of preeclampsia, CCB-PO ranked highest for both [(0.82) vs. (0.77), respectively]. Serotonin antagonists (0.99) and nitroglycerin (0.88) ranked highest for time to target pressure. NICU admissions were lowest for alpha-2 agonists (0.89), followed by BB PO (0.82) and hydralazine IV (0.49).

Conclusion: Oral calcium-channel blockers ranked highest for treatment success. Ketanserin achieved target blood pressure fastest, warranting additional research. The results should be interpreted with caution as SUCRA values may not indicate whether the differences between interventions have clinically meaningful effect sizes.

Keywords: Antihypertensives; Hypertension; Network meta-analysis.

Publication types

Meta-Analysis
Review

MeSH terms

Antihypertensive Agents
Calcium Channel Blockers / therapeutic use
Female
Humans
Hydralazine / therapeutic use
Hypertension* / drug therapy
Infant, Newborn
Ketanserin / therapeutic use
Methyldopa
Network Meta-Analysis
Nifedipine / therapeutic use
Pre-Eclampsia* / drug therapy
Pregnancy
Randomized Controlled Trials as Topic

Substances

Antihypertensive Agents
Calcium Channel Blockers
Hydralazine
Ketanserin
Methyldopa
Nifedipine