Preeclampsia: Antihypertensives Reducing Stroke Risk

Ricki Lewis, PhD

February 12, 2018

Use of antihypertensives among women with preeclampsia increased from 2006 to 2015, as incidence of stroke decreased, according to findings published online February 5 and in the March issue of Obstetrics and Gynecology.

Antihypertensive medications can lower the risk for fatal hypertension-related intracranial hemorrhage in pregnant women. The American College of Obstetricians and Gynecologists recommends giving antihypertensives for preeclampsia in women with sustained 160 mm Hg systolic or 110 mm Hg diastolic blood pressure, including intravenous labetalol or hydralazine or oral nifedipine.

"What our data show is that physicians are really incorporating this evidence into practice. In a broad range of clinical settings, use of antihypertensives is increasing," said principle investigator Alexander Friedman, MD, MPH, from Columbia University, New York City, in a podcast the journal provided.

To evaluate the role of antihypertensives in combating preeclampsia-related stroke, Kirsten L. Cleary, MD, and colleagues from Columbia University conducted a retrospective cohort analysis of use of nifedipine, hydralazine, and oral and intravenous labetalol for hospital deliveries complicated by preeclampsia from 2006 through the first quarter of 2015. They also evaluated stroke risk.

The information came from the Perspective database, which monitors 15% of all inpatient hospital stays annually in the United States. "The database is used across medical specialties to look at drug and device administration," Friedman said.

Of 239,454 women evaluated, 126,595 had mild preeclampsia, 31,628 had superimposed preeclampsia (chronic hypertension), and 81,231 had severe preeclampsia. Of all the women, 105,409 received an antihypertensive.

Use of the drugs increased overall during the study period, although prescription rates varied among hospitals. In 2006, 37.8% of women received any antihypertensive compared with 49.4% in 2015. Specifically, use of oral labetalol increased from 20.3% to 31.4%, intravenous labetalol from 13.3% to 21.4%, hydralazine from 12.8% to 16.9%, and nifedipine from 15.0% to 18.2%. Use of more than one drug increased from 16.5% to 25.8%.

Simultaneously, stroke risk declined during the same period. For severe preeclampsia, the risk decreased from 13.5 per 10,000 deliveries in 2006 to 2008 (n=27) to 9.7 in 2009 to 2011 (n=25) to 6.0 in 2012 to 2014 (n=20; P = .02).

Providers preferentially prescribed intravenous and oral labetalol, which Friedman called "a good first choice" in medication.

During the period investigated, the proportion of patients with severe or superimposed preeclampsia increased compared with mild preeclampsia: severe preeclampsia accounted for 36.9% of cases in 2015 compared with 30.9% of cases in 2006.

The investigators conclude that from 2006 to the beginning of 2015, use of several antihypertensives increased as the rate of maternal stroke decreased. Overall, the findings indicate increased attention to the problem. "Although misclassification between severe and mild preeclampsia is a potential concern, increased use of antihypertensive agents for women with mild preeclampsia may represent health care providers treating more lower range BPs more frequently, particularly with oral agents before discharge," they write. Friedman calls the approach "low-hanging fruit" — an easy intervention with great potential benefit.

Limitations of the study include reliance on administrative records that do not include data on individual hospital practices, lack of information on vital signs before drug administration, no data on types of stroke, no information on risk factors such as obesity, and inability to causally connect antihypertensive use to decreased maternal stroke.

The investigators have disclosed no relevant financial relationships.

Obstet Gynecol. 2018;131:441-450. Abstract

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