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Grand Rounds

Labetalol or Nifedipine for Chronic Hypertension in Pregnancy?

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BACKGROUND AND PURPOSE:

  • Chronic hypertension in pregnancy is approximately 3% and rising due to obesity epidemic and increasing maternal age
  • In nonpregnant setting, ethnicity helps to determine first line antihypertensive medication
    • For example, calcium channel blockers are first line in those with African/Caribbean family origin
  • RCT data on antihypertensive medications for women with chronic hypertension in pregnancy is limited
  • Webster et al. (Hypertension, 2017) sought to compare labetalol and nifedipine for chronic hypertension in pregnancy, additionally assessing the impact of ethnicity on treatment efficacy

METHODS:

  • PANDA study (Pregnancy and Chronic Hypertension: Nifedipine Versus Labetalol as Antihypertensive Treatment)
  • Randomized Controlled Trial (RCT)
  • Pregnant women with chronic hypertension were enrolled at 4 UK centers
  • Eligibility criteria
    • Prenatal diagnosis of chronic hypertension (treated or untreated) or blood pressure (BP) readings ≥140 mm Hg systolic or ≥ 90 mm Hg diastolic before 20 weeks’ gestation, requiring antihypertensive treatment before 27w6d
  • Open-label first-line antihypertensive treatment was randomly assigned
    • Labetalol (200-1800 mg/d)
    • Nifedipine-modified release (20-80 mg/d)
  • Outcomes were maximum blood pressure, mean blood pressure, and central aortic pressure

RESULTS:

  • 56 women were randomized to labetalol and 58 to nifedipine
  • Both medications were effective in controlling BP
    • Mean BP: labetalol 134/84 mm Hg versus nifedipine 134/85 mm Hg
    • No difference in days out of target range (≥160 mm Hg systolic, ≥150 mm Hg systolic, and <80 mm Hg diastolic)
  • There was a mean 7.4 mm Hg decrease (-0.4 to -14.4 mm Hg) in central aortic pressure in the nifedipine arm but not seen in peripheral BP measurements
  • No difference in treatment effect was observed in black women, but a mean 4 mm Hg reduction (-6.6 to -0.8 mm Hg; p= 0.015) in brachial diastolic blood pressure was observed with labetalol compared with nifedipine in non-black women
  • Secondary maternal and perinatal outcomes
    • More women receiving nifedipine developed superimposed preeclampsia but difference was not significant
    • 6 women (11%) in each group developed superimposed preeclampsia < 34 weeks
    • No difference noted in requirement for additional oral antihypertensive agents
    • A greater proportion of nifedipine group (14% versus 4%) required IV antihypertensive agents
    • Rates of induction of labor and cesarean section were comparable as were median gestation at delivery and adverse maternal outcomes (11% labetalol vs 14% nifedipine)

CONCLUSION:

  • First head-to-head RCT trial comparing labetalol to nifedipine for chronic hypertension in pregnancy, and results show both maximum and mean BP were comparable
  • Study was not sufficiently powered to make conclusions regarding secondary perinatal and maternal outcomes
  • In non-white women, labetalol has a greater effect in reducing diastolic BP but more research needed to determine whether this finding is of any clinical significance

Learn More – Primary Sources:

Labetalol Versus Nifedipine as Antihypertensive Treatment for Chronic Hypertension in Pregnancy: A Randomized Controlled Trial

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Related ObG Topics:

ACOG Guidance: Emergency Treatment for Severe Hypertension in Pregnancy
Diagnosing Preeclampsia – Key Definitions and ACOG Guidelines
Eclampsia and Role of Magnesium Sulfate
HYPITAT-II: Immediate Delivery or Expectant Management for Non-Severe Hypertension at 34 – 37 weeks?

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