Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Athens University Medical School, National and Kapodistrian University of Athens, Athens, Greece.
Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Athens University Medical School, National and Kapodistrian University of Athens, Athens, Greece.
Am J Obstet Gynecol. 2020 Oct;223(4):525-537. doi: 10.1016/j.ajog.2020.03.016. Epub 2020 Mar 19.
Chronic hypertension is associated with adverse perinatal outcomes, although the optimal treatment is unclear. The aim of this network metaanalysis was to simultaneously compare the efficacy and safety of antihypertensive agents in pregnant women with chronic hypertension.
Medline, Scopus, CENTRAL, Web of Science, Clinicaltrials.gov, and Google Scholar databases were searched systematically from inception to December 15, 2019. Both randomized controlled trials and cohort studies were held eligible if they reported the effects of antihypertensive agents on perinatal outcomes among women with chronic hypertension.
The primary outcomes were preeclampsia and small-for-gestational-age risk. A frequentist network metaanalytic random-effects model was fitted. The main analysis was based on randomized controlled trials. The credibility of evidence was assessed by taking into account within-study bias, across-studies bias, indirectness, imprecision, heterogeneity, and incoherence.
Twenty-two studies (14 randomized controlled trials and 8 cohorts) were included, comprising 4464 women. Pooling of randomized controlled trials indicated that no agent significantly affected the incidence of preeclampsia. Atenolol was associated with significantly higher risk of small-for-gestational age compared with placebo (odds ratio, 26.00; 95% confidence interval, 2.61-259.29) and is ranked as the worst treatment (P-score=.98). The incidence of severe hypertension was significantly lower when nifedipine (odds ratio, 0.27; 95% confidence interval, 0.14-0.55), methyldopa (odds ratio, 0.31; 95% confidence interval, 0.17-0.56), ketanserin (odds ratio, 0.29; 95% confidence interval, 0.09-0.90), and pindolol (odds ratio, 0.17; 95% confidence interval, 0.05-0.55) were administered compared with no drug intake. The highest probability scores were calculated for furosemide (P-score=.86), amlodipine (P-score=.82), and placebo (P-score=.82). The use of nifedipine and methyldopa were associated with significantly lower placental abruption rates (odds ratio, 0.29 [95% confidence interval, 0.15-0.58] and 0.23 [95% confidence interval, 0.11-0.46], respectively). No significant differences were estimated for cesarean delivery, perinatal death, preterm birth, and gestational age at delivery.
Atenolol was associated with a significantly increased risk for small-for-gestational-age infants. The incidence of severe hypertension was significantly lower when nifedipine and methyldopa were administered, although preeclampsia risk was similar among antihypertensive agents. Future large-scale trials should provide guidance about the choice of antihypertensive treatment and the goal blood pressure during pregnancy.
慢性高血压与不良围产期结局相关，尽管最佳治疗方法尚不清楚。本网络荟萃分析的目的是同时比较慢性高血压孕妇中降压药物的疗效和安全性。
从成立到 2019 年 12 月 15 日，系统地检索了 Medline、Scopus、CENTRAL、Web of Science、Clinicaltrials.gov 和 Google Scholar 数据库。如果报告了降压药物对慢性高血压妇女围产期结局的影响，则将随机对照试验和队列研究都纳入合格研究。
主要结局是子痫前期和胎儿生长受限的风险。采用固定效应模型进行频率网络荟萃分析。主要分析基于随机对照试验。通过考虑研究内偏倚、研究间偏倚、间接性、不精确性、异质性、不连贯性，评估证据的可信度。
纳入了 22 项研究（14 项随机对照试验和 8 项队列研究），共纳入 4464 名女性。随机对照试验的荟萃分析表明，没有一种药物显著影响子痫前期的发生率。与安慰剂相比，阿替洛尔与胎儿生长受限的风险显著增加（比值比，26.00；95%置信区间，2.61-259.29），被评为最差治疗（P 评分=.98）。与未用药相比，硝苯地平（比值比，0.27；95%置信区间，0.14-0.55）、甲巯丙脯酸（比值比，0.31；95%置信区间，0.17-0.56）、酮色林（比值比，0.29；95%置信区间，0.09-0.90）和普萘洛尔（比值比，0.17；95%置信区间，0.05-0.55）的使用显著降低了重度高血压的发生率。呋塞米（P 评分=.86）、氨氯地平（P 评分=.82）和安慰剂（P 评分=.82）的最高概率评分。硝苯地平和甲巯丙脯酸的使用与胎盘早剥发生率显著降低相关（比值比，0.29 [95%置信区间，0.15-0.58]和 0.23 [95%置信区间，0.11-0.46]）。在剖宫产、围产儿死亡、早产和分娩时的胎龄方面，没有估计到显著差异。
阿替洛尔与胎儿生长受限的风险显著增加有关。与其他降压药物相比，硝苯地平和甲巯丙脯酸的使用显著降低了重度高血压的发生率，尽管子痫前期的风险在降压药物中相似。未来的大规模试验应提供有关降压治疗选择和妊娠期目标血压的指导。
