1. ORAL ANTIHYPERTENSIVE THERAPY FOR SEVERE HYPERTENSION IN PREGNANCY AND POSTPARTUM: A SYSTEMATIC REVIEW Tabassum FirozLaura Magee Karen MacDonellBeth Payne Rebecca GordonMarianne Vidler Peter von Dadelszen The Community Level Interventions for Pre-Eclampsia (CLIP) Working Group

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3. Severe Pregnancy Hypertension Defined as systolic BP ≥160 mmHg and/or diastolic BP ≥ 110 mmHg Immediate treatment recommended It is appropriate to lower severely elevated BP over hours, by oral or parenteral anti- hypertensive therapy

4. Severe Pregnancy Hypertension Objective: To determine the effectiveness of oral antihypertensive therapy for treatment of severe pregnancy or postpartum hypertension

5. Description of Research ParticipantsPoorly controlled hypertension secondary to any hypertensive disorder of in pregnancy InterventionSingle oral antihypertensive therapy ComparisonAntihypertensive therapy (any route), placebo, or no treatment OutcomesMaternal: End-organ complications, mode of delivery, adverse pregnancy outcome Perinatal: Apgar scores (1 and 5 min), admission to a neonatal intensive care unit (NICU), perinatal mortaility

6. Flow chart of the study 465 records for consideration 22 records screened in detail 19 full- text articles assessed for eligibility 16 trials included EXCLUDED 1 not randomised 1 enrolled women with non-severe hypertension1 2 abstracts not obtained 1 abstract did not clarify route of antihypertensive administration 443 records excluded

7. Oral antihypertensives used 12 RCTs compared oral nifedipine (5-10mg, 12 trials, 724 women) with another agent, usually: – IV hydralazine (5-20mg, 7 trials, 350 women) – IV labetalol (20mg, 2 trials, 100 women) Nifedipine was administered as a: – Capsule (8 trials) 4 by puncture/biting, 1 by swallowing whole – Tablet (3 trials; one compared with capsule), or – The formulation was unclear (2 trials)

8. Oral antihypertensives used Nifedipine achieved treatment success in most pregnant women (84-100%) – Similar to Hydralazine [RR 1.07, 95% CI 0.98, 1.17], or Labetalol [RR 1.02, 95% CI 0.95, 1.09] Nifedipine (1 postpartum RCT) compared favourably with IV hydralazine – Need for additional antihypertensive therapy [5% vs. 28%; RR 0.18, 95% CI 0.02, 1.40; 38 women]

9. Nifedipine & hypotension

11. Summary and Conclusion The oral antihypertensive agent for which there is the most evidence is nifedipine (10mg) Labetalol (100 mg) and methyldopa (250 mg) are reasonable options, based on limited data Choice of agent will depend on a woman’s current antihypertensive therapy, co-morbidities and setting in which medication is administered.