Severe Persistent Hypertension Research Articles

447 Factors associated with persistent severe hypertension in patients with preeclampsia

447 Factors associated with persistent severe hypertension in patients with preeclampsia

Randomized Controlled Trial of Labetalol Versus Hydralazine, for Severe Hypertension in Obstetric Patients, at Tertiary Care Hospital of Karachi

Background: Blood pressure ≥160/110 mm Hg, is indication for urgent drug therapy in obstetric women, to prevent complications and deaths. There is limited data for comparison of Labetalol to Hydralazine in emergent treatment of severe pregnancy related hypertension. Methods: Randomized controlled trial, analyzed 184 women with severe hypertension at ≥28 weeks of pregnancy or within 72 hours after delivery, from October 2012 to September 2014. Ninety-two patients in each group received intravenous Labetalol or Hydralazine boluses, repeated every 10 or 20 minutes respectively (maximum 5 boluses). Outcome measures comprised blood pressure reduction <160/110 mm Hg, mean arterial pressure, severe persistent hypertension, number of boluses, maternal hypotension, tachycardia, adverse effect on fetal heart, still birth and neonatal bradycardia. Data was collected on a semi -structured proforma and analyzed through SPSS version 20. Numeric outcome measures were compared by Mann Whitney U test or independent sample t test according to normality distribution. Qualitative measures were compared by Chi square or Fisher’s exact test. Level of significance was <0.05 Results: There was no significant difference in reduction of systolic, diastolic blood pressure and severe persistent hypertension, between Labetalol and Hydralazine (p>0.05). Tachycardia, palpitation, headache, were significantly higher (p <0.05) in Hydralazine group. Adverse effects on fetal heart were not statistically significant. Numbers of boluses were significantly lower in labetalol group. Conclusion: Labetalol is equal to hydralazine in reducing severe pregnancy related hypertension. Maternal side effect profile of Labetalol is better, and it achieves blood pressure control with reduced boluses. Keywords: Pregnancy-induced hypertension, Hypertensive crisis, Labetalol, Hydralazine, Pregnancy, Preeclampsia, Antihypertensive agent.

Timely treatment of severe hypertension and risk of severe maternal morbidity at an urban hospital

Hypertensive disorders of pregnancy have been identified as a leading contributor to severe maternal morbidity and mortality. Pregnant persons with hypertensive disorders who develop severe hypertension at delivery admission have been shown to experience higher rates of severe maternal morbidity relative to those without severe hypertension. Current guidelines recommend prompt treatment of severe hypertension given known associated maternal and fetal risks; however, only 1 previous study has described an association between timeliness of antihypertensive therapy and risk of severe maternal morbidity. This study aimed to characterize how development of severe intrapartum hypertension and its timely treatment affect the risk of severe maternal morbidity. We conducted a population cohort study of deliveries with and without hypertensive disorders of pregnancy at a single urban hospital between 2016 and 2018. Among deliveries of persons with hypertensive disorders of pregnancy, we identified those with persistent severe hypertension (defined as blood pressure ≥160/105 mm Hg sustained over ≥15 minutes) and further classified individuals with severe hypertension as having received timely (within 60 minutes) or delayed treatment. Severe maternal morbidity was identified using a composite measure developed by the Centers for Disease Control and Prevention. We calculated overall and indicator-specific rates of severe maternal morbidity for 4 categories of deliveries: without hypertensive disorder of pregnancy, with hypertensive disorder of pregnancy without severe hypertension, with severe hypertension and timely treatment, and with severe hypertension and delayed treatment. We assessed the association between hypertensive disorder of pregnancy, severe hypertension, timeliness of treatment, and severe maternal morbidity using multivariable robust Poisson regression, adjusting for demographic and clinical characteristics. Of 3723 delivery hospitalizations within the study time frame, 32.3% (1204/3723) were complicated by presence of a hypertensive disorder without severe hypertension and 5.7% (211/3723) by presence of a hypertensive disorder with severe hypertension. Among those with severe hypertension, 48.8% (103/211) received timely treatment. Compared with deliveries not complicated by a hypertensive disorder, severe maternal morbidity risk was increased for hypertensive disorder of pregnancy without severe hypertension (124.4/1000 vs 52.0/1000; adjusted risk ratio, 1.84; 95% confidence interval, 1.41-2.40), severe hypertension with timely treatment (233.0/1000; adjusted risk ratio, 3.81; 95% confidence interval, 2.45-5.92), and severe hypertension with delayed treatment (305.6/1000; adjusted risk ratio, 5.38; 95% confidence interval, 3.75-7.73). Patients with hypertensive disorders of pregnancy are at an elevated risk of severe maternal morbidity, and development of severe hypertension further increases this risk. Timely antihypertensive treatment is associated with lower risk of severe maternal morbidity among those with severe hypertension. These findings emphasize the importance of provider education and quality improvement efforts aimed at expediting treatment of severe hypertension.

Nonadherence to treatment protocol for severe hypertension in pregnancy

Hypertensive disorders of pregnancy are one of the leading causes of maternal mortality and severe morbidity. The American College of Obstetricians and Gynecologists recommends treatment of persistent severe hypertension because this has been shown to improve overall outcomes. Treatment remains inconsistent and may be influenced by patient-level sociodemographic and clinical characteristics. This study aimed to identify which factors are associated with nonadherence to an institutional protocol for the treatment of severe hypertension in pregnancy. Retrospective cohort study of patients who had persistent severe hypertension (≥2 systolic blood pressures ≥160 mm Hg and/or diastolic blood pressures >110 mm Hg between 15 and 60 minutes apart) during their delivery hospitalization in 3 hospitals within an integrated health system from February 1, 2018 to March 1, 2020. Adherence to an institutional protocol was defined as receiving antihypertensive medication within 1 hour of a second severe blood pressure measurement. Demographic information, medical comorbidities, and delivery hospitalization characteristics were compared between women who received treatment based on institutional protocol and those who did not. Patient zone improvement plan codes were linked to neighborhood-level data from the US Census Bureau's American Community Survey to extract socioeconomic characteristics. A multivariable logistic regression was performed to evaluate factors associated with delayed treatment while adjusting for potential confounders. Of the 996 patients included, 449 (45%) received treatment within 60 minutes and 547 (55%) did not. Having an elevated, nonsevere range blood pressure (adjusted odds ratio, 0.55; 95% confidence interval, 0.38-0.79) or a severe range blood pressure (adjusted odds ratio, 0.25; 95% confidence interval, 0.16-0.38) on admission, persistent severe hypertension ≥1 hour before or after delivery (adjusted odds ratio, 0.27; 95% confidence interval, 0.27-0.45), and chronic hypertension (adjusted odds ratio, 0.58; 95% confidence interval, 0.37-0.93) were associated with timely treatment. Hospital site (adjusted odds ratio, 1.97; 95% confidence interval, 1.18-3.28) and increasing gestational age (adjusted odds ratio, 1.14; 95% confidence interval, 1.07-1.21) were associated with nonadherence to treatment protocol. A subanalysis evaluating treatment in 344 (35%) patients who had a nonelevated blood pressure on admission showed that White race, persistent severe hypertension within 1 hour of delivery, increasing gestational age, body mass index, twin gestation, preferred language other than English or Spanish, and a higher neighborhood unemployment rate were associated with nonadherence to treatment protocol. Several factors were associated with nonadherence to an institutional protocol for treatment of persistent severe hypertension. Provider bias may impact whether treatment is executed or not. Awareness of these risk factors may improve timely administration of antihypertensive medication in pregnant and postpartum patients.

Factors associated with appropriate treatment of acute-onset severe obstetrical hypertension

The American College of Obstetricians and Gynecologists recommends that pregnant patients receive expeditious treatment with first-line antihypertensive agents within 1 hour of confirmed severe hypertension to reduce the risk for maternal stroke. However, it is unknown how often this guideline is followed and what factors influence a patient's likelihood of receiving guideline-concordant care. We aimed to identify factors associated with receiving guideline-concordant treatment for an obstetrical hypertensive emergency. We present a case-control study of all pregnant and postpartum patients who had persistent severe hypertension (≥2 systolic blood pressures ≥160 mm Hg or diastolic blood pressure ≥110 mm Hg, or both within 1 hour of each other) during their delivery hospitalization at a tertiary hospital from October 1, 2013, to August 31, 2020. Data were extracted from the hospital electronic medical records using standard definitions and billing and diagnosis codes. We defined receipt of the recommended treatment as administration of a first-line antihypertensive agent (intravenous labetalol, intravenous hydralazine, or immediate-release oral nifedipine) within 60 minutes of the first or second severe-range blood pressure measurement during their delivery hospitalization. Delayed treatment was defined as the administration of a first-line agent >60 minutes after the second elevated blood pressure measurement. Patients were considered untreated if a first-line agent was never administered. Maternal sociodemographic, clinical and pregnancy factors, and time and day of the week of the hypertensive emergency were compared among patients who received the recommended treatment, those who received delayed treatment, and those who were untreated. Bivariate analyses were performed, and multinomial and multivariable logistic regression models were used to adjust for potential confounders. Of the 39,918 deliveries in the cohort, 1987 (5.0%) were complicated by severe, persistent obstetrical hypertension. Of these patients, 532 (26.8%) received the recommended treatment, 356 (17.9%) received delayed treatment, and 1099 (55.3%) did not receive any first-line antihypertensive therapy. The multinomial regression models that were used to compare these 3 groups indicated that patients who received the recommended treatment were more likely to be Black (adjusted odds ratio, 1.85; 95% confidence interval, 1.36-2.51), Hispanic (adjusted odds ratio, 1.77; 95% confidence interval, 1.28-2.52), or pregnant and at <37 weeks of gestation (adjusted odds ratio, 6.65; 95% confidence interval, 5.08-8.72). Treatment was less likely if the severe obstetrical hypertension emergency occurred overnight (7:00 PM to 6:59 AM) (adjusted odds ratio, 0.79; 95% confidence interval, 0.64-0.97) or during the postpartum period (adjusted odds ratio, 0.66; 95% confidence interval, 0.51-0.86). Approximately half of obstetrical patients with at least 2 documented severely elevated blood pressure measurements did not receive the recommended antihypertensive treatment. Of those who did receive treatment, about 40% had delayed treatment. Black and Hispanic race and preterm gestation were associated with an increased likelihood of receiving the recommended treatment when compared with White race and term pregnancies. Patients whose severe obstetrical hypertension emergency occurred overnight and those who were postpartum were less likely to receive any first-line antihypertensive treatment. Overall, patients without sociodemographic and clinical risk factors for severe obstetrical hypertension or other pregnancy complications were less likely to be treated. However, treatment improved significantly over time with the implementation of targeted quality measures and specific institutional policies based on the American College of Obstetricians and Gynecologists' latest severe obstetrical hypertension management guidelines.

Atypical Moyamoya Disease Associated with Midaortic Syndrome

AbstractWe report a case of a 4-year-old boy who presented with moyamoya disease associated with midaortic syndrome. He had been treated for severe persistent hypertension until he suffered multiple episodes of seizure and cerebral ischemic attack. Cerebral angiography showed bilateral terminal internal carotid artery stenosis. Angiographic survey showed severe stenosis of abdominal aorta and bilateral proximal renal arteries. This is a very rare report of moyamoya disease with midaortic syndrome.

506 Factors associated with appropriate treatment of obstetric hypertensive emergency

We aimed to identify factors associated with receiving recommended treatment for obstetric hypertensive emergency. We present a retrospective case-control study of all women who had persistent severe hypertension (≥2 systolic blood pressures (BP) ≥160 mm Hg and/or diastolic BP ≥110 mm Hg within 1 hour of each other) during their delivery hospitalization at a tertiary hospital from 1/2013 to 9/2020. Data were extracted from hospital electronic medical records using standard definitions and billing and diagnosis codes. We defined recommended treatment as administration of intravenous labetalol or hydralazine, or oral immediate-release nifedipine any time after the first or second severe-range BP during their delivery hospitalization. Maternal age, race/ethnicity, marital status, insurance type, pre-pregnancy BMI, smoking status, parity, singleton versus multiple gestation, diabetes (pre-existing or gestational), hypertensive disorders of pregnancy (HDP), time of day (7am-6pm versus 7pm-6am) and day of week (weekday versus weekend) of hypertensive emergencies were compared between women who received recommended treatment and those who never received recommended treatment. Adjusted odds ratios (aOR) and 95% CI were calculated using multivariable regression analysis. Of 39,919 women, 2114 (5.3%) met inclusion criteria. 950 (44.9%) women received recommended treatment, while 1,164 (55%) did not. In the multivariate model, treated women were more likely than untreated women to be Black (aOR 1.51, 95% CI 1.17 – 1.95), have HDP (aOR 6.13, 95% CI 5.02 – 7.49) or have diabetes (aOR 1.45, 95% CI 1.43-1.85). Treatment was less likely if hypertensive emergency occurred overnight (aOR 0.70, 95% CI 0.57-0.86)(Table). Black race, HDP, diabetes, and daytime occurrence were associated with increased likelihood of receiving recommended treatment for obstetric hypertensive emergency. Severe hypertension overnight was associated with a 30% lower odds of receiving treatment, and could serve as a target for measures aimed at improving treatment and reducing maternal morbidity.

Adrenal Mass Causing Secondary Hypertension

BackgroundMost hypertensive patients have essential (primary) hypertension; only 5% to 10% have a secondary cause. Two clinical characteristics suggestive of secondary hypertension are early onset (< 30 years of age) and severe hypertension (>180/110 mm Hg). When faced with these findings, clinicians should consider a secondary cause of hypertension. Case ReportA 22-year-old woman being evaluated for asthma exacerbation in the emergency department was noted to have severe persistent hypertension. Additional evaluation revealed severe hypokalemia, metabolic alkalosis, and hypernatremia. The patient was admitted to the hospital for blood pressure management, electrolyte replacement, and further evaluation of presumed hyperaldosteronism. Diagnostic imaging revealed a large adrenal mass. Surgical resection was performed, leading to a diagnosis of hyperaldosteronism caused by adrenal carcinoma. Why Should an Emergency Physician Be Aware of This?Secondary hypertension is far less common than essential hypertension; however, considering the large volume of patients seen in emergency departments, it is likely that some will have secondary hypertension. Emergency physicians should be aware of the clinical characteristics that suggest secondary hypertension so that the appropriate diagnostic and treatment pathways can be pursued.

Oral nifedipine or intravenous labetalol for severe hypertension?

The systematic review by Shekhar et al. adds to both the relevant Cochrane review [Duley et al. Cochrane Database Syst Rev 2013;31(7):CD001449] and other recent reviews of oral antihypertensive therapy (Firoz et al. BJOG 2014;121:1210–8; Shi et al. Int J Cardiol 2015;178:162–4), by including two abstracts from conferences in India and three new trials, and clarifying data excluded from the Cochrane review. Shekhar et al. provide evidence that oral nifedipine is more effective than intravenous labetalol based on the results of seven trials and 363 women with severe hypertension, due to pre-existing or gestational hypertension, or pre-eclampsia. Five of the seven trials were assessed as being at low risk of bias. Oral nifedipine (usually tablets) was associated with less persistent (severe) hypertension [6/182, 3.3% (nifedipine) versus 15/181, 8.3% (labetalol); relative risk (RR) 0.42, 95% confidence interval (95% CI) 0.18–0.96; seven trials, 363 women] that was defined in various ways, all clinically relevant: a blood pressure persistently > 150–160/100 mmHg or failure to achieve either a 25% reduction in blood pressure (despite maximal doses of drug) or an absolute blood pressure of ≤ 150/95 mmHg within an hour. Although the authors report that the results were no longer significant (and there was also notable heterogeneity) when risk difference was then used as the summary statistic, the latter is not usually recommended because it is unlikely to give consistent estimates of treatment effect. Alternatively, one could conclude that there is a 5.0% reduction in the incidence of persistent severe hypertension with nifedipine versus intravenous labetalol. Of additional interest is the adverse-effect profile seen in the included trials. Although there are fears that nifedipine is associated with more maternal and, potentially, more perinatal adverse effects compared with other antihypertensive agents used for severe hypertension, this was not borne out in Shekhar et al.'s systematic review. Nifedipine was associated with fewer maternal adverse effects of headache, nausea, vomiting, or palpitations [19/106 (nifedipine) versus 32/101 (labetalol); RR 0.57, 95% CI 0.35–0.94; three trials, 207 women]. The incidence of hypotension was very low, with only one documented occurrence in a woman who received nifedipine [1/176 (nifedipine) versus 0/167 (labetalol)]. Also, nifedipine was not associated with more stillbirths [13/166 (nifedipine) versus 18/157 (labetalol); RR 0.66, 95% CI 0.13–1.27; five trials, 323 women] and was associated with fewer neonatal deaths [3/116 (nifedipine) versus 10/105 (labetalol); RR 0.27, 95% CI 0.09–0.87; four trials, 221 women], although gestational age at delivery was not reported by any of the trials. This review provides further evidence that nifedipine (tablets or capsules swallowed whole) is a reasonable antihypertensive for treatment of severe pregnancy hypertension, regardless of the underlying hypertensive disorder of pregnancy. This is good news for the global obstetric community, as nifedipine is widely available for treatment of preterm birth, in both high- and low-and-middle-income countries. Units providing maternity care are encouraged to reconsider the use of nifedipine as an antihypertensive of choice for pregnant women with severe hypertension. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Ketanserin versus dihydralazine for the treatment of severe hypertension in early-onset preeclampsia: a double blind randomized controlled trial

ObjectiveDetermine the definitive position of ketanserin and dihydralazine for treatment of severe hypertension in pregnancy. Study designA single centre double blind randomized controlled trial was performed at the obstetrical tertiary high care unit of the University Medical Centre in Rotterdam, the Netherlands. Women with severe hypertension in pregnancy (diastolic blood pressure (DBP)≥110mmHg), and significant proteinuria (≥300mg/24h), and gestational age≤32 weeks were eligible for the study. All patients (n=30) received two infusions (double dummy technique): one contained the active ingredient (ketanserin or dihydralazine), the other was used for placebo. Nicardipine was used as rescue medication. The main outcome measures were persistent severe hypertension (DBP>100mmHg>120min) despite maximum dosage of study medication and prolongation of pregnancy. ResultsDihydralazine was significantly more effective in lowering blood pressure than ketanserin. No significant difference in prolongation of pregnancy was seen between the two groups. After 30 inclusions, the study was stopped because of the high rate of persistent hypertension using ketanserin and the high rate of maternal side effects using dihydralazine and the apparent succesful use of the rescue drug nicardipine. ConclusionsOur results do not support the use of either dihydralazine or ketanserin for the treatment of severe hypertension in pregnancy. Future research is needed to compare nicardipine with other antihypertensive drugs currently in use for treatment of severe hypertension in pregnancy.

228-POS

Objectives We outline a case of a woman with lupus (SLE) and antiphospholipid syndrome (APLA) at 26 weeks’ gestation who develops a complex multiorgan condition with a broad differential. Methods Case report. Results A 34 year old woman, G1P0, presented at 26 weeks gestation with a 5 day history of epigastric pain and emesis. She has a history of lupus anticoagulant (LAC), anticardiolipin (ACL) and anti-dsDNA (ADD) positive SLE and APLA syndrome diagnosed at age 13 with multiple small cerebral infarcts. She was treated with ASA, warfarin and plaquenil; the latter two stopped by age 25, with no recurrent thrombosis. Her pregnancy was conceived through IVF. She continued on ASA and LWMH for prophylactic anticoagulation. Upon presentation, she was hypertensive (pressures >160/100) with thrombocytopenic at 47 × 109/L, creatinine rise from 40 to 93 μmol/L, high uric acid level at 518 μmol/L, and AST and ALT at 74 and 64 U/L respectively peaking in the 4800 s. HIT and SRA were negative, blood films showed schistocytes, positive DAT and C3/C4 levels were low at 0.7 and 0.06 g/L respectively. The patient was diagnosed with preeclampsia and HELLP syndrome. Immediate cesarean section was performed without delivery or hemostatic complications. Placental histology was consistent with preeclampsia. Postpartum, she had persistent severe hypertension with CT confirmed multiorgan infarcts. Anemia and thrombocytopenia also persisted (platelet nadir 4 × 109/L), complement levels remained low and creatinine peak at 485 μmol/L. ADAMTS13 level was 43%. The differential diagnosis included TTP, atypical HUS or SLE progression. High dose steroids, PLEX, dialysis and eculizumab were utilized with minimal response. A trial of vincristine and rituximab was initiated. Conclusions SLE and APLA predispose women to increased pregnancy related complications, including preeclampsia, however the pathogenesis is not well understood. This complex case highlights numerous challenges and addresses the utility of new targeted therapeutic interventions. Disclosures A.E. Lin: None. N. Shehata: None. H. Reich: None. D. Barth: None. C. Laskin: None. S. Lapinsky: None. S. Gandhi: None.

The effect of nitroglycerin infusion versus hydralazine infusion as antihypertensive therapy in acute management of patients with severe pre-eclampsia

Background Severe pre-eclampsia (PE) is a potentially life-threatening multisystem disease that requires urgent management. Delivery of the fetus is the definitive treatment for PE. However, effective and safe control of severe hypertension is the most important aspect of critical care management. This study aimed to compare the effectiveness and safety profile of hydralazine infusion versus nitroglycerin infusion as antihypertensive therapy in the acute management of patients with severe PE. Patients and methods A total of 180 patients with severe PE admitted to Ain Shams Obstetric ICU to stabilize blood pressure before delivery were randomly assigned to one of two equal groups: group H and group N. Group H received hydralazine infusion (1 mg/ml) and group N received nitroglycerin infusion (1 mg/ml). The infusion rate (5 ml/h) was adjusted to maintain systolic blood pressure at 130-140 mmHg and diastolic blood pressure at 80-100 mmHg. Results As regards hemodynamic parameters, the time to achieve blood pressure control was significantly shorter in the N group compared with the H group. However, the number of cases of severe persistent hypertension and the number of attacks of hypotension were comparable between the two groups. Maternal side effects and fetal and neonatal complications were comparable between the two groups, except for maternal headache and tachycardia, which were significantly higher in the H group compared with the N group. Concerning the mode of delivery, the rate of cesarean section delivery was significantly higher than the rate of vaginal delivery in both groups. Meanwhile, the rate of cesarean section after induction of labor was significantly higher in the N group compared with the H group. Conclusion Nitroglycerin could be a good alternative option for the acute management of patients with severe PE. It is an effective antihypertensive with minimal side effects.

316: Emergent therapy using either labetalol or hydralazine for acute-onset persistent severe hypertension in recommended dosages does not achieve an optimal hemodynamic profile

316: Emergent therapy using either labetalol or hydralazine for acute-onset persistent severe hypertension in recommended dosages does not achieve an optimal hemodynamic profile

A randomised comparison of hydralazine and mini‐bolus diazoxide for hypertensive emergencies in pregnancy: The PIVOT trial

Diazoxide is one of few available agents for treatment of hypertensive emergencies in pregnancy. From previous studies, there is a question concerning safety after moderate-dose administration caused episodes of hypotension. Rapid control of severe hypertension is necessary to reduce maternal morbidity, for example, stroke and placental abruption. This study was designed to compare the efficacy of mini-bolus diazoxide with intravenous (i.v.) hydralazine. A randomised controlled trial. Tertiary referral maternity hospital, Royal Prince Alfred Women and Babies, Sydney Australia. Antenatal and postnatal women with severe hypertension. One hundred and twenty-four hypertensive women were randomised to either i.v. hydralazine (5 mg doses) or mini-bolus diazoxide (15 mg doses). Achievement of target blood pressure reduction; secondary measures included requirement for Caesarean section because of fetal deterioration as determined by non-reassuring cardiotocograph (CTG). Reduction in systolic and diastolic blood pressure was 34 min for hydralazine and 19 min for diazoxide (P < 0.001). There were no episodes of hypotension after diazoxide and one after hydralazine (after epidural). Episodes of persistent severe hypertension were more common with hydralazine (38%) than with diazoxide (16%), P < 0.01. The Caesarean section rate for no-reassuring CTG was no different between the two groups. Neonatal outcomes were similar. Diazoxide and hydralazine are safe and effective antihypertensives, showing a controlled and comparable blood pressure reduction in women with hypertensive emergencies in pregnancy. The mini-bolus doses of 15 mg of diazoxide did not precipitate maternal hypotension as previously described and reduces episodes of persistent severe hypertension.

Management of Severe Hypertension in the Postpartum Period with Intravenous Hydralazine or Labetalol: A Randomized Clinical Trial

Objective: To compare the safety and efficacy of intravenous labetalol and intravenous hydralazine for acutely lowering blood pressure in the puerperium. Design: Randomized clinical trial. Setting: Critical care unit of gynecology and obstetrics department in the Complejo hospitalario “Dr. AAM” de la Caja de Seguro Social in Panama. Population: Eighty-two women with severe hypertension during the postpartum period. Methods: Patients were randomized to receive hydralazine (5 mg as a slow bolus dose given intravenously, and repeated every 20 minutes to a maximum of five doses) or labetalol (20 mg in an intravenous bolus dose followed by 40 mg if not effective within 20 minutes, followed by 80 mg every 20 minutes to a maximum dose of 300 mg). The primary endpoint was the successful lowering of blood pressure. Secondary endpoints were maternal complications and side-effects. Results: Forty-two women were enrolled in the hydralazine group and 40 in the labetalol group. Women were similar with respect to characteristics at randomization. No significant differences were observed for persistent severe hypertension or maternal side-effects. There was only one case of persistent severe hypertension in the labetalol group. There were no maternal deaths in any of the women studied. Conclusions: This randomized clinical trial shows that intravenous hydralazine and intravenous labetalol are effective and safe in the management of severe hypertension in the postpartum period.

Severe Hypertension in Pregnancy: Hydralazine or Labetalol. A Randomized Clinical Trial

Hypertensive disease complicates up to one in 5 pregnancies and is a major risk factor for fetal illness and death-particularly the marked hypertension associated with preeclampsia. Hydralazine long has been the preferred drug for treating severe hypertension in this setting, but side effects are common and may mimic worsening preeclampsia. Intravenous labetalol, another option for treating acute hypertension in pregnancy, causes fewer side effects. There is, however, concern about neonatal bradycardia. This study compared the 2 drugs in 200 pregnant women with severe hypertension, defined as a systolic blood pressure of at least 160 mm Hg and/or a diastolic pressure of at least 110 mm Hg while not on antihypertensive therapy. Participants were randomized to receive either hydralazine (5 mg as a slow intravenous bolus dose repeated at 20-minute intervals up to 5 doses) or labetalol (20 mg as an intravenous bolus dose followed by 40 mg if not effective within 20 minutes and than 80 mg every 20 minutes up to a maximum of 300 mg). Women in the 2 treatment groups were similar in maternal and gestational ages, hypertensive disorder, parity, baseline blood pressure, and urinary protein. In 12% of participants, the baseline diastolic blood pressure was 115 mm Hg or higher at the time of randomization. Palpitations and maternal tachycardia were significantly more frequent in patients given hydralazine, but there were no significant group differences in maternal hypertension or persistent severe hypertension. Two hydralazine-treated women had overshoot hypotension. Neonatal hypotension and bradycardia were significantly more frequent in the labetalol group (10.6% vs 1.9%; P = .008), however, they did not result in prolonged neonatal intensive care unit admission or neonatal death. There were 2 neonatal deaths in each group; 3 of the 4 deaths were associated with delivery at or before 28 weeks gestation. None of the mothers died. Both hydralazine and labetalol, given intravenously, are appropriate drugs for use in treating pregnant women who are severely hypertensive.

Severe hypertension in pregnancy: Hydralazine or labetalol: A randomized clinical trial

Objective The objective was to compare the safety and efficacy of intravenous labetalol and intravenous hydralazine for acutely lowering blood pressure in pregnancy. Study design Two hundred women with severe hypertension in pregnancy were randomized to receive hydralazine (5 mg as a slow bolus dose given intravenously, and repeated every 20 min up to a maximum of five doses) or labetalol (20-mg intravenous bolus dose followed by 40 mg if not effective within 20 min, followed by 80 mg every 20 min up to a maximum dose of 300 mg). The primary end point was successful lowering of blood pressure and maternal hypotension. Results Women were similar with respect to characteristics at randomization. No significant differences were observed for maternal hypotension or persistent severe hypertension; only two patients in the hydralazine group presented with hypotension. Palpitations ( p = 0.01) and maternal tachycardia ( p = 0.05) occurred significantly more often in patients treated with hydralazine. The main neonatal outcomes were very similar per group; however, hypotension and bradycardia were significantly more frequent in the labetalol group. There were two neonatal deaths per antihypertensive drug group. Conclusions This randomized clinical trial shows that labetalol and hydralazine fulfill the criteria required for an antihypertensive drug to treat severe hypertension in pregnancy.

Hydralazine for treatment of severe hypertension in pregnancy: meta-analysis

Objective To review outcomes in randomised controlled trials comparing hydralazine against other antihypertensives for severe hypertension in pregnancy.Study design Meta-analysis of randomised controlled trials (published between 1966 and September 2002)...

SIR 2003 Film Panel Case 4: Neurofibromatosis

An 11-year-old boy presented with persistent severe hypertension while on several antihypertensive medications. At 4 years of age he underwent resection of a subaortic stenosis. He is somewhat developmentally delayed. He denies headaches, visual disturbances, and abdominal or back pain.

Liddle's syndrome, an underrecognized entity: A report of four cases, including the first report in black individuals

Liddle's syndrome, a rare cause of hypokalemic hypertension, is characterized by a renal tubular sodium channel defect resulting in excessive sodium absorption and concomitant potassium wasting. In this disorder, although the clinical manifestations resemble primary aldosteronism, serum and urine aldosterone are suppressed. The syndrome is transmitted in an autosomal dominant pattern. It has been reported previously in white and oriental populations but not in the black individuals. We identified four patients (two of whom are black) in our nephrology clinic, with severe hypokalemic hypertension not correctly diagnosed for several years. All patients underwent an extensive work-up for secondary hypertension because of persistent severe hypertension (average blood pressure, 210 130 mm Hg) despite high-dose multi-drug therapy. Primary aldosteronism was excluded because of low serum aldosterone. Cushing's syndrome, pheochromocytoma, renal artery stenosis, and enzymatic deficiencies of cortisol synthesis (11β-hydroxylase, 17α-hydroxylase, 5β-reductase, and 11β-hydroxysteroid dehydrogenase) were ruled out with extensive endocrine and radiologic studies. Once the diagnosis of Liddle's syndrome was suspected, all patients were treated with either triamterene or ameloride, with resolution of hypokalemia and correction of hypertension occurring within 5 to 7 days. Our findings suggest that Liddle's syndrome can occur in the black population. Although the actual incidence of this syndrome remains unknown, it may be significantly more common than we are led to believe since it is inherited in a Mendelian pattern. Whether there is a subset of low-renin, salt-sensitive black hypertensive patients who have the same or similar sodium channel defect remains to be elucidated.