NSAIDs OK for Pain After Birth in Gestational Hypertension

Kristin Jenkins

November 22, 2018

The use of nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief after delivery does not lead to an increase in blood pressure among women with hypertensive disorders of pregnancy, results from a retrospective cohort study indicate.

The study, led by Hannah B. Anastasio, MD, of the Division of Maternal-Fetal Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, was published in the December issue of Obstetrics & Gynecology.

The analysis of 276 women with hypertensive disorders of pregnancy, which affects around 10% of pregnant women, showed that postpartum use of NSAIDs was not associated with a significant change in mean arterial pressure compared with no NSAID administration (20.7 versus 21.8 mmHg; mean difference, 1.10 mmHg).

There was also no difference in the need to start or increase the dose of antihypertensive agents or to rehospitalize new mothers for hypertensive disorder.

The findings therefore challenge current recommendations to avoid use of NSAIDs in women with hypertensive disorders of pregnancy, say the authors.

Challenges 2013 ACOG Guidance to Avoid NSAID Use

The authors note that gestational disorders of pregnancy include gestational hypertension, preeclampsia, eclampsia, hemolysis, elevated liver enzymes, low platelet count syndrome, chronic hypertension, and superimposed preeclampsia.

"Our data suggest that administration of NSAIDs postpartum to women with hypertensive disorders of pregnancy is not associated with worsening hypertension and may be associated with less consumption of opioid pain medications during the inpatient postpartum course," they write.

Anastasio and colleagues point out that in 2013 the American College of Obstetricians and Gynecologists (ACOG) made a recommendation against use of NSAIDs in women with hypertensive disorders of pregnancy persisting for longer than 24 hours after delivery. 

At that time, the Task Force on Hypertension in Pregnancy suggested that NSAIDs contributed to increased blood pressure in these women.

"These findings lead us to question the recommendation against use of NSAIDs postpartum in women with hypertensive disorders of pregnancy," say Anastasio and colleagues.

"Larger studies, or meta-analysis of existing studies, may shed further light on rare adverse outcomes, which individual studies to date have been underpowered to evaluate."

The authors suggest that if clinicians did not have to avoid NSAIDs — "the mainstay" of postpartum analgesia — they would no longer have to resort to alternatives such as acetaminophen (Tylenol, Johnson & Johnson), opioids, gabapentin (Neurontin, Pfizer), or the lidocaine transdermal patch (Lidoderm, Endo Health Solutions).

"Increasing the use of opioid pain medication is particularly problematic in light of the present opioid use disorder epidemic," they explain.

"Evaluating the safety of NSAID administration for postpartum women with hypertensive disorders is therefore important."

Study Findings

For the current study, data from 276 women with hypertensive disorders of pregnancy who delivered at Thomas Jefferson University Hospital between January 2008 and May 2015 were collected from patient charts and electronic medical records.

Data were analyzed according to whether or not NSAIDs had been given postpartum. The final dataset included 147 NSAID-exposed women and 129 who had not been exposed, matched chronologically by date of admission.

The investigators also performed post hoc subgroup analyses by mode of delivery and in women with and without chronic hypertension.

The cohorts had similar demographic and medical characteristics, although patients who did not receive NSAIDs were six times more likely to have pre-existing renal disease than those who received NSAIDs (12% vs 2%; P < .01).

In women who received NSAIDs, 35% were on antihypertensive medication antepartum compared with 22% of women who did not (P = .01).

As per standard postsurgical protocol at the tertiary care institution, patients who had a cesarean section were managed with intravenous patient-controlled opioid analgesia on the day of delivery. On postoperative day 1, they were transitioned to the same oral analgesia regimen offered as a set order to postpartum patients.

Mild-to-moderate pain was managed with the NSAID ibuprofen (Advil, Pfizer), and opioid medication (oxycodone-acetaminophen) (Percocet, Endo Pharmaceuticals) was reserved for severe pain.

Decisions about dose and frequency were shared between patients and their nurses.

In addition to the finding of no differences in mean arterial pressure between patients who did and did not receive NSAIDs, there were no differences in systolic or diastolic blood pressure change, maximum systolic or diastolic blood pressure, or rate of initiation or dose escalation of antihypertensives.

In addition to ibuprofen, oxycodone, or hydromorphone, 45% of patients overall received adjunctive pain medication, primarily acetaminophen.

No differences were observed between the cohorts in any of the blood pressure or cumulative opioid use outcomes when patients were stratified by route of delivery, presence of chronic hypertension, or other adverse postpartum events. The latter included acute renal insufficiency, need for blood transfusion, and hospital readmission for a hypertensive disorder within 30 days of discharge.

The authors note, however, that the study was not powered to detect changes in these secondary outcomes.

The authors have reported no relevant financial relationships.

Obstet Gynecol. 2018;132:1471-1476. Abstract

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