Physicians treat postpartum pain with nonsteroidal anti-inflammatory drugs (NSAIDs) or other pain relievers such as opioids. Increasing concerns about narcotic dependence, however, have driven physicians to increasingly prescribe NSAIDs over opioids, even to women with preeclampsia. New data suggest this is the right decision.
Researchers have found that women with preeclampsia and severe features before delivery who used NSAIDs did not have an increased rate of persistent postpartum hypertension relative to similar women who did not use NSAIDs. The findings have led the researchers to suggest NSAIDs are safer than opioids, even for this vulnerable group of women.
College Task Force Recommendations
The 2013 Task Force for Hypertension in Pregnancy developed by the American College of Obstetricians and Gynecologists recommended avoiding NSAIDs in postpartum women with hypertension persisting more than 24 hours after delivery. The current study is the first to evaluate the association between NSAIDs and blood pressure (BP) in a College Task Force–defined population of hypertensive puerperal women with preeclampsia and severe features before delivery.
Oscar A. Vieri, MD, a maternal-fetal medicine fellow at the University of Texas Health Science Center at Houston, and colleagues published their results online September 7 in Obstetrics & Gynecology.
The retrospective study included 399 puerperal women with antenatal preeclampsia. The majority (75%) of women in the cohort received NSAIDs (either ibuprofen or ketorolac) despite current task force guidelines.
Overall, 81% of women in the cohort remained hypertensive for 24 hours after delivery. When the researchers performed a multivariable logistic regression, they found that the likelihood of reaching a blood pressure of 150 mm Hg systolic or 100 mm Hg diastolic (or both) on two occasions at least 4 hours apart was similar between those who received NSAIDs and those who did not (70% vs 73%; adjusted odds ratio [OR], 1.1; 95% confidence interval [CI], 0.6 – 2.0).
Moreover, the rates of other adverse outcomes did not differ significantly between those who received NSAIDs and those who did not: pulmonary edema (3% vs 10%; OR, 4.4; 95% CI, 1.5 – 13.1), renal dysfunction (5% vs 8%; OR, 1.7; 95% CI, 0.6 – 4.8), eclampsia (1% vs 0%; P = .34), or intensive care unit admission (3% vs 8%; OR, 2.4: 95% CI, 0.8 – 7.1).
Resolving the Science
In 2004, physicians first raised the concerns about the safety of NSAIDs in a case series of six women who were exposed to indomethacin or ibuprofen after delivery who then went on to experience hypertensive crises. The concern was exacerbated by a recent open-label randomized clinical trial of ibuprofen compared with acetaminophen that found that women with vaginal delivery with preeclampsia who were exposed to ibuprofen were significantly more likely to experience elevated blood pressure 24 to 96 hours postpartum compared with those who received acetaminophen.
However, the authors of the current study note that the previous clinical trial likely had ascertainment bias because it excluded women who delivered by caesarean. They also explain in their discussion that although their results contradict the findings of the two studies mentioned here, the results are consistent with data published in 2014.
“Our results are in line with those by Wasden et al who performed a retrospective chart review of 223 women who received magnesium sulfate for seizure prophylaxis as a surrogate marker for preeclampsia with severe features and compared them based on their exposure to NSAIDs,” write Dr Vieri and colleagues. “No significant differences were noted in the average mean arterial pressure between the study groups. Similarly, treatment with NSAIDs was not significantly associated with initiation or dose increases of antihypertensive medication postpartum, prolonged hospital stay, or adverse events related to hypertension including hospital readmission for BP control or central nervous system symptoms, eclampsia, pulmonary edema, or intensive care unit admission.”
The authors conclude, “It is our opinion that, given the relative safety of NSAIDs over opioids in nursing women and because of increasing concerns regarding narcotic dependence, an adequately powered randomized clinical trial is warranted to answer this clinical question before recommendations forfeiting NSAIDs use in this population are made.”
The authors have disclosed no relevant financial relationships.
Obstet Gynecol. Published online September 7, 2017.
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