Grand Rounds

Labetalol or Nifedipine for Chronic Hypertension in Pregnancy?

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

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

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)

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

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