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Three Part Question

[With pregnant females in a hypertensive emergency], would [oral nifedipine be better than intravenous labetalol] at [stabilizing the blood pressure in the pre-hospital setting]?

Clinical Scenario

38-year-old female, 30 weeks of gestation with her 3rd child, had 1 miscarriage a year ago due to pre-eclampsia. At her last doctor's visit, she was placed on medication to keep her blood pressure under control. The patient is staying 4 hours away from the closest rural hospital. The patient was educated on hypertension and instructed to keep track of her blood pressure daily. The patient called one night and stated that she ran out of her blood pressure medications two days ago, and her blood pressure reading has been increasing since this morning and is now reading 170/116. The closest airport is 10 minutes away from her, and the flight time is 1 hour. The aircraft was activated immediately. Would oral nifedipine be better than labetalol in stabilizing this patient pre-hospital?

Search Strategy

Web of Science
(ALL = pregnant woman AND hypertensive emergency AND oral Nifedipine OR IV labetalol ) AND (LIST==("Labetalol vs Nifedipine"))
PubMed
(preeclampsia) AND (Oral nifedipine) OR (intravenous labetalol) AND (hypertensive emergencies)
Keywords used: pregnant woman, hypertensive emergency, oral nifedipine, or IV labetalol.

A total of 101 articles were obtained from the PubMed and Web of Science databases. These articles were thoroughly examined, and five papers were selected for the purpose of addressing this specific subject. Four studies were randomized controlled trials published from 1999 to 2017. The fifth paper, published in 2023, was a systematic review and meta-analysis.

Search Outcome

Based on the available data, pregnant individuals experiencing hypertensive emergencies can be efficiently treated by controlling their blood pressure using either oral Nifedipine or IV Labetalol. These treatments have minimal negative effects on both the mother and the fetuses in the short term. Oral nifedipine may be favored since it is easy to administer, rapidly lowers blood pressure, and promotes increased urine output.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Dey R, Mukhopadhyay A, Biswas SC, et al. 2017 Kolkata	150 patients between 34-41 gestational age with a blood pressure greater or equal to 160/110	prospective, interventional, randomized control trial	56% in Labetalol group was stabilized with 2 doses. 61.33% in the Nifedipine group was stabilized with 2 doses		hospital-based trial
1. Kumari VR, Saraswathi K, Srilaxmi A. 2016 Hyderabab	200 women with a blood pressure greater than or equal to 160/110mmHg	A randomized control trial	Time to stabilize blood pressure in labetalol group = 36.61±5.2 min and nifedipine group 34.77±4.8 min. Doses need to stabilize group 3doses of labetalol and 2 doses of nifedipine. 14% in each group needed crossover treatment.		In-hospital study. No follow-up is done.
Vermillion ST, Scardo JA, Newman RB, et al 1999 Charleston, South Carolina	50 peripartum patients with blood pressure greater or equal to 170/105 mmHg	Double-blind randomized control trial	Blood pressure goal was achieved faster with nifedipine (mean ± SD, 25 ± 13.6 minutes) than labetalol (43.6 ± 25.4 minutes; P = .002) No Crossover treatment needed. Better urine output in the nifedipine dosing (99 ± 99 mL) com Pared with labetalol (44.8 ± 19.1 mL)		Small number of patients (50). No previous studies have been done to compare results. Both groups received magnesium sulfate infusions at the time of enrollment.

Comment(s)

Based on the available data, pregnant individuals experiencing hypertensive emergencies can be efficiently treated by controlling their blood pressure using either oral Nifedipine or IV Labetalol. These treatments have minimal negative effects on both the mother and the fetuses in the short term. Oral nifedipine may be preferred since it is easy to administer, rapidly lowers blood pressure, and promotes increased urine output.

Clinical Bottom Line

There is ample evidence indicating that nifedipine is as effective as labetalol in treating hypertensive emergencies in pregnant women. Some studies have shown that nifedipine achieves the desired blood pressure levels faster than labetalol, with fewer side effects. However, there is no definitive conclusion on which drug should be the first choice for hypertensive emergencies. These studies still recommend that the decision of which drug to use should be left to the medical practitioner's discretion.

References

1. Dey R, Mukhopadhyay A, Biswas SC, et al. Intravenous labetalol versus oral nifedipine for acute blood pressure control in severe pregnancy-induced hypertension-a randomized trial J. Evolution Med. Dent. Sci./eISSN- 2278-4802, pISSN- 2278-4748/ Vol. 6/ Issue 92/ Dec. 04, 2017 DOI: 10.14260/jemds/2017/1426
2. 1. Kumari VR, Saraswathi K, Srilaxmi A. Oral nifedipine versus intravenous labetalol for control of blood pressure in severe preeclampsia. J. Evolution Med. Dent. Sci. 2016;5(20):994-997, DOI: 10.14260/jemds/2016/231 2016;5(20):994-997, DOI: 10.14260/jemds/2016/231
3. Vermillion ST, Scardo JA, Newman RB, et al A randomized, double-blind trail of oral nifedipine and intravenous labetalol in hypertensive emergencies of pregnancy AJOG Volume 181, Issue 4, October 1999, Pages 858-861
4. Raheem I, Saaid R, Omar S, Tan P. Oral nifedipine versus intravenous labetalol for acute blood pressure control in hypertensive emergencies of pregnancy BJOG 2012;119:78–85.
5. Lin Lia†, Wenxia Xieb, Hao Xuaand Lei Cao Oral nifedipine versus intravenous labetalol for hypertensive emergencies during pregnancy: a systematic review and meta-analysis Published by Informa UK Limited, trading as Taylor & Francis Group 2023, VOL. 36, NO. 2, 2235057