Subscribe to RSS
Postpartum NSAID Use and Adverse Outcomes among Women with Hypertensive Disorders of Pregnancy: A Systematic Review and Meta-analysisFunding This study is supported by grant funding from Friends of Prentice (SP0051562) through Northwestern University.
Objective This study was aimed to perform a systematic review and meta-analysis of the association between postpartum nonsteroidal anti-inflammatory drug (NSAID) use among women with hypertensive disorders of pregnancy (HDP) and risks of adverse postpartum outcomes.
Study Design Studies were eligible if they included women who had been diagnosed with HDP and were postpartum, reported exposure to NSAIDs, were written in English, and were published between January 2000 and November 2019. Assessment of bias was performed using the Newcastle–Ottawa scale for observational studies or the Cochrane Collaborative tool for randomized trials. The primary outcome was maternal blood pressure ≥ 150 mm Hg systolic and/or 100 mm Hg diastolic. Secondary outcomes were persistent blood pressures ≥ 160 mm Hg systolic and/or 110 mm Hg diastolic, mean arterial pressure (MAP), initiation or up-titration of antihypertensive medication, length of hospital stay, rehospitalization for blood pressure control, and postpartum opioid use. A random-effect meta-analysis was performed using RevMan, with a p-value < 0.05 used to indicate statistical significance (PROSPERO CRD no.: 42019127043).
Results Among 7,395 abstracts identified, seven studies (four randomized and three cohort studies, n = 777 patients) met inclusion criteria. All cohort analyses exhibited low levels of bias, while two randomized controlled trials exhibited a high risk of bias in blinding and inclusion criteria. There was no association between NSAID use and blood pressures ≥ 150 mm Hg systolic and/or 100 mm Hg diastolic (risk ratio [RR]: 1.21, 95% confidence interval [CI]: 0.89–1.64). Conversely, NSAID use was associated with a statistically significant, but clinically insignificant, increase in length of postpartum stay (0.21 days, 95% CI: 0.05–0.38). No other secondary outcomes were significantly different between groups.
Conclusion Postpartum NSAID use among women with HDP was not associated with maternal hypertension exacerbation. These findings support the recent American College of Obstetricians and Gynecologists' guideline change, wherein preeclampsia is no longer a contraindication to postpartum NSAID use.
Postpartum (PP) NSAID use does not worsen hypertension in preeclampsia.
PP NSAID use is associated with a longer, though clinically insignificant, length of stay.
Our findings support ACOG's recommendations for PP NSAID use.
Keywordspreeclampsia - hypertensive disorders of pregnancy - NSAIDs - nonsteroidal anti-inflammatory drugs - postpartum
This study was presented as an abstract at the Society for Maternal-Fetal Medicine's 40th Annual Pregnancy Meeting, February 3–8, 2020, Grapevine, TX.
Received: 13 March 2020
Accepted: 08 May 2020
18 July 2020 (online)
© 2020. Thieme. All rights reserved.
Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA
- 1 Mol BWJ, Roberts CT, Thangaratinam S, Magee LA, de Groot CJM, Hofmeyr GJ. Pre-eclampsia. Lancet 2016; 387 (10022): 999-1011
- 2 MacDorman MF, Declercq E, Thoma ME. Trends in maternal mortality by sociodemographic characteristics and cause of death in 27 states and the District of Columbia. Obstet Gynecol 2017; 129 (05) 811-818
- 3 American College of Obstetricians and Gynecologists (ACOG). Hypertension In Pregnancy. Accessed May 23, 2020 at: http://www.spog.org.pe/web/phocadownloadpap/HypertensioninPregnancy.pdf
- 4 Zlatnik MG, Buhimschi I, Chwalisz K, Liao QP, Saade GR, Garfield RE. The effect of indomethacin and prostacyclin agonists on blood pressure in a rat model of preeclampsia. Am J Obstet Gynecol 1999; 180 (05) 1191-1195
- 5 Makris A, Thornton C, Hennessy A. Postpartum hypertension and nonsteroidal analgesia. Am J Obstet Gynecol 2004; 190 (02) 577-578
- 6 Schoenfeld A, Freedman S, Hod M, Ovadia Y. Antagonism of antihypertensive drug therapy in pregnancy by indomethacin?. Am J Obstet Gynecol 1989; 161 (05) 1204-1205
- 7 Deussen AR, Ashwood P, Martis R. Analgesia for relief of pain due to uterine cramping/involution after birth. Cochrane Database Syst Rev 2011; (05) CD004908
- 8 Wuytack F, Smith V, Cleary BJ. Oral non-steroidal anti-inflammatory drugs (single dose) for perineal pain in the early postpartum period. Cochrane Database Syst Rev 2016; 7: CD011352
- 9 American College of Obstetricians and Gynecologists (ACOG). ACOG practice bulletin no. 202: gestational hypertension and preeclampsia. Obstet Gynecol 2019; 133 (01) e1-e25
- 10 American College of Obstetricians and Gynecologists (ACOG). ACOG practice bulletin no. 203: chronic hypertension in pregnancy. Obstet Gynecol 2019; 133 (01) e26-e50
- 11 Deeks JJ, Dinnes J, D'Amico R. et al; International Stroke Trial Collaborative Group, European Carotid Surgery Trial Collaborative Group. Evaluating non-randomised intervention studies. Health Technol Assess 2003; 7 (27) iii-x , 1–173
- 12 Cochrane Handbook for Systematic Reviews of Interventions: Cochrane Collaboration; 2011
- 13 Cornell JE, Mulrow CD, Localio R. et al. Random-effects meta-analysis of inconsistent effects: a time for change. Ann Intern Med 2014; 160 (04) 267-270
- 14 Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ 2003; 327 (7414): 557-560
- 15 Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ 1997; 315 (7109): 629-634
- 16 Moher D, Liberati A, Tetzlaff J, Altman DG. PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 2009; 339: b2535
- 17 Stroup DF, Berlin JA, Morton SC. et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA 2000; 283 (15) 2008-2012
- 18 Anastasio HB, Campbell LE, Buermeyer A. et al. Nonsteroidal anti-inflammatory drug administration and postpartum blood pressure in women with hypertensive disorders of pregnancy. Obstet Gynecol 2018; 132 (06) 1471-1476
- 19 Blue NR, Murray-Krezan C, Drake-Lavelle S. et al. Effect of ibuprofen vs acetaminophen on postpartum hypertension in preeclampsia with severe features: a double-masked, randomized controlled trial. Am J Obstet Gynecol 2018; 218 (06) 616.e1-616.e8
- 20 Vigil-De Gracia P, Solis V, Ortega N. Ibuprofen versus acetaminophen as a post-partum analgesic for women with severe pre-eclampsia: randomized clinical study. J Matern Fetal Neonatal Med 2017; 30 (11) 1279-1282
- 21 Viteri OA, England JA, Alrais MA. et al. Association of nonsteroidal anti-inflammatory drugs and postpartum hypertension in women with preeclampsia with severe features. Obstet Gynecol 2017; 130 (04) 830-835
- 22 Wasden SW, Ragsdale ES, Chasen ST, Skupski DW. Impact of non-steroidal anti-inflammatory drugs on hypertensive disorders of pregnancy. Pregnancy Hypertens 2014; 4 (04) 259-263
- 23 Penfield CA, McNulty JA, Oakes MC, Nageotte MP. Ibuprofen and postpartum blood pressure in women with hypertensive disorders of pregnancy: a randomized controlled trial. Obstet Gynecol 2019; 134 (06) 1219-1226
- 24 Triebwasser JE, Hesson A, Langen ES. A randomized-controlled trial to assess the effect of ibuprofen on postpartum blood pressure in women with hypertensive disorders of pregnancy. Pregnancy Hypertens 2019; 18: 117-121
- 25 Bellos I, Pergialiotis V, Antsaklis A, Loutradis D, Daskalakis G. Safety of non-steroidal anti-inflammatory drugs in the postpartum period among women with hypertensive disorders of pregnancy: a meta-analysis. Ultrasound Obstet Gynecol 2020; 56 (03) 329-339
- 26 Ioannidis JP, Patsopoulos NA, Rothstein HR. Reasons or excuses for avoiding meta-analysis in forest plots. BMJ 2008; 336 (7658): 1413-1415