Postpartum management of the hypertensive disorders of pregnancy

Objective : To assess the effectiveness and safety of management strategies for postpartum hypertension. Data sources : We searched the Cochrane Pregnancy and Childbirth’s Trials Register in collaboration with their Information Specialist, on 20/October/2022. As the Pregnancy and Childbirth Review Group closed (2023), we updated our literature search on 17/September/2024, using a strategy developed with an information specialist from the Royal College of Physicians, United Kingdom. Study eligibility criteria: We included randomised controlled trials (RCTs) assessing any intervention (pharmacological, surgical, or models of care) used to reduce maternal blood pressure (BP) in participants with postpartum hypertension. Study appraisal and synthesis methods: Search results were screened independently by two authors, with any disagreement resolved by consensus. Data were extracted independently, onto a Cochrane-based bespoke form which included Cochrane’s Trustworthiness Screening Tool. Random-effects meta-analysis was performed in RevMan. Results : Of 538 studies identified, 39 were included. Evidence was low/very low certainty. There were no safety concerns. In seven trials (n=1113 participants) of diuretics (primarily furosemide) vs. placebo/no therapy, BP control was better, due to trials administering antihypertensives to both groups. In three trials (n=96) of antihypertensive vs. placebo, data were insufficient to inform effectiveness. In eight trials (n=749) of antihypertensive (4 types) vs. another (2 types) for non-severe hypertension, additional antihypertensive need was similar in comparisons with either nifedipine or methyldopa, but greater when amlodipine or enalapril were compared with nifedipine. In eight trials (n=403) of antihypertensive vs. another for severe hypertension, BP was lower with diltiazem (vs. nifedipine). In four trials (n=668) of uterine curettage vs. usual care, small improvements in some laboratory parameters were of unclear clinical importance. In nine trials (n=1263) of models of postnatal care (usually BP self-monitoring/management, N=6) vs. usual care, BP was lower eight months postpartum following BP self-monitoring/management or lifestyle change. Conclusions : Diuretics cannot be recommended as monotherapy. There is little to guide choice of antihypertensive. Of greatest relevance to current practice is whether enalapril and amlodipine are as effective as nifedipine, and the role of BP self-measurement/management and lifestyle change in preventing longer-term cardiovascular outcomes.