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Furosemide Fails to Reduce Risk of Dangerous de novo Postpartum Hypertension: New Research
Close monitoring for dnPPHTN during the first 2 weeks post-delivery is highly recommended for women determined to be at high risk for the hypertensive disorder of pregnancy.
Evidence is insufficient to conclude that furosemide reduces the risk of de novo postpartum hypertension (dnPPHTN), according to findings published online in the American Journal of Obstetrics & Gynecology.1
Investigators from maternal-fetal medicine departments at UC San Diego and Columbia University Irving Medical Center in New York reported that among women judged at high risk for for dnPPHTN but with no significant antenatal diagnosis the average mean arterial pressure (MAP) did not significantly differ in the 24 hours before hospital discharge or initiation of antihypertensive medication between the furosemide- and placebo-treated groups, at 88.9±7.4 mm Hg for the former and 86.8±7.1 mm Hg in the latter, an absolute difference of 2.1 mm Hg (95% CI 1.2 to 5.3), according to the study.1
Approximately 10% of study participants across the treatment and placebo groups did develop dnPPHTN. However, dnPPHTN rates did not differ significantly between groups more did the rates of antihypertensive therapy initiation and severe maternal morbidity (SMM), eg, eclampsia, stroke, pulmonary edema, and death.
According to the study findings, participants in the furosemide group had a higher median percentage of elevated BP at discharge, at 4% compared with 0% in the placebo group. There was no difference in the rates between the groups when measured at 2 to 6 weeks postpartum, nor did other secondary maternal outcomes differ between groups.1
Hypertensive Disorders of Pregnancy
Hypertensive disorders of pregnancy (HDP) are a leading cause of maternal death, with 70% of mortalities linked to hypertension occurring post-delivery.2 Among women who develop postpartum eclampsia, the authors cite evidence indicating that 33% to 69% of those people were normotensive antepartum.3 Nonetheless, dnPPHTN, defined as elevated blood pressure (BP) after delivery in normotensive birthing people, remains as "understudied phenomenon," with few studies having explored risk factors and none examining pharmacologic and monitoring strategies for the population at high risk, first author Ukachi Emeruwa, MD, MPH, assistant professor of obstetrics, gynecology, and reproductive sciences at UC San Diego Health, and colleagues wrote.1
Historical data have shown that post-delivery use of loop diuretics decreases postpartum systolic BP, speeds normalization of BP, and reduces need for use of postpartum antihypertensive therapy, according to the authors. The bicoastal team designed the current clinical trial to assess the efficacy of furosemide to prevent dnPPHTN among pregnant people at high-risk for the clinical entity.1
Study Details
Recruitment for the randomized triple masked placebo controlled trial began in October 2021 and was completed in April 2022. Final enrollment number 82 postpartum participants in the Columbia University Irving Medical Center Labor and Delivery Unit with no antenatal diagnosis of chronic hypertension or HDP and identified at high risk for dnPPHTN based on a prespecified risk factor algorithm using American College of Obstetricians and Gynecologists criteria. Participants were randomly assigned to receive either 20-mg oral furosemide (Lasix) once per day for 5 days or matching placebo. Treatment began within 8 hours following delivery.1
Participants in both groups performed home monitoring of BP twice daily for 6 weeks after delivery.
The primary outcome of interest was MAP averaged over the 24 hours before discharge or 24 hours before antihypertensive initiation. Among the secondary outcomes the researchers evaluated rates of dnPPHTN and preeclampsia, percentage of elevated BPs, rates of hypertension-related SMM, and frequency of emergency department visits and readmission. A median 5 doses of the study drug were completed and adverse events were rare, according to the study.1
"Although our algorithm was able to identify individuals at high risk for the development of dnPPHTN, we were not able to identify an effective preventative intervention," investigators wrote. the findings, they said, underscore that the underlying pathophysiology of dnPPHTN remains poorly understood.
They added that the incidence of dnPPHTN and its association with SMM warrant ongoing research. In addition, their findings suggest that close monitoring and follow-up within the first 2 weeks after delivery are essential in groups identified at high risk given the occurrence of the "rare but severe morbidity" was limited to that period of the study. "Monitoring in the subsequent 4 weeks can potentially be decreased with appropriate precautions," they concluded.1
