Type A, Race, Anger, Forgiveness, Plus Stroke, HRT, and Hydralazine - The Bad, the Good, and the To-Be-Avoided

November 14, 2003

In This Article

Hydralazine Challenged as First-Line Treatment of Severe Hypertension in Pregnancy

In many countries, including the United States and Canada, the United Kingdom, and Australia and New Zealand, the antihypertensive of first choice for control of severe pressure in pregnancy has been hydralazine, despite side effects that mimic symptoms of deteriorating preeclampsia. Now, however, Canadian researchers report that the results of a meta-analysis of randomized, controlled trials of the treatment of severe hypertension in pregnancy do not support this recommendation.[18]

Laura A Magee, MD (University of British Columbia, Vancouver) and colleagues in Vancouver and Toronto analyzed perinatal, maternal, and neonatal outcomes in 21 trials (893 women) of short-acting antihypertensive agents in pregnant women with moderate to severe hypertension (mean baseline DBP 100-109 mm Hg or ≥ 110 mm Hg, respectively). The trials were published between 1996 and September 2002. Eight compared hydralazine with nifedipine, 5 with labetalol, 4 ketanserin, 2 urapidil, 1 each with epoprostenol and isradipine. Data were abstracted by 2 independent reviewers and entered into Cochrane review manager software (RevMan, Oxford, UK) for quantitative analysis. Risk difference (absolute effect) was also calculated.

The researchers found that hydralazine was associated with some poorer maternal and perinatal outcomes than other antihypertensives. Hydralazine was associated with a trend toward less persistent severe hypertension than labetalol (relative risk 0.29, 2 trials) but more persistent severe hypertension than nifedipine or isradipine (1.41, 4 trials). Compared with the other antihypertensives, hydralazine was also associated with more maternal hypotension, more placental abruption, more cesarean sections, more maternal oliguria, more maternal side effects, and more adverse effects on fetal heart rate. In the trials that reported perinatal outcomes, hydralazine was associated with more low Apgar scores at 1 minute and a trend toward an increase in stillbirth compared with the other antihypertensives.

Dr. Magee and colleagues conclude that their results "support the use of antihypertensive agents other than hydralazine for the acute management of severe hypertension in pregnancy." As alternatives to hydralazine, they suggest short-acting nifedipine (sublingual or orally administered), parenteral labetalol, or ketanserin. They point out that nifedipine has the clinical advantage of being able to be given as required by midwives or nurses in the absence of a physician.


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