Original Research ajog.

org

OBSTETRICS
Hydralazine vs nifedipine for acute hypertensive emergency
in pregnancy: a randomized controlled trial
Chanderdeep Sharma, MD (OBG), DNB (OBG); Anjali Soni, MD (OBG); Amit Gupta, MD (OBG); Ashok Verma, MD (OBG);
Suresh Verma, MD (OBG)

BACKGROUND: There is a paucity of good quality evidence regarding
the best therapeutic option for acute control of blood pressure during acute
hypertensive emergency of pregnancy.
OBJECTIVE: We sought to compare the efficacy of intravenously
administered hydralazine and oral nifedipine for acute blood pressure
control in acute hypertensive emergency of pregnancy.
STUDY DESIGN: In this double-blind, randomized, controlled trial,
pregnant women (
24 weeks period of gestation) with sustained increase
in systolic blood pressure of
160 mm Hg or diastolic blood pressure of

110 mm Hg were randomized to receive intravenous hydralazine in-
jection in doses of 5, 10, 10, and 10 mg and a placebo tablet or oral
nifedipine (10 mg tablet up to 4 doses) and intravenous saline injection
every 20 minutes until the target blood pressure of 150 mm Hg systolic
and 100 mm Hg diastolic was achieved. Crossover treatment was
administered if the initial treatment failed. The primary outcome of the
study was time necessary to achieve target blood pressure. The secondary
outcomes were the number of dosages required, adverse maternal and
neonatal effects, and perinatal outcome.
RESULTS: From December 2014 through September 2015, we
enrolled 60 patients. The median time to achieve target blood pressure
was 40 minutes in both groups (intravenous hydralazine and oral nifedi-
pine) (interquartile interval 5 and 40 minutes, respectively, P ¼ .809). The
median dose requirement in both groups was 2 (intravenous hydralazine
and oral nifedipine) (interquartile range 1 and 2 doses, respectively, P ¼
.625). Intravenous hydralazine was associated with statistically signifi-
cantly higher occurrence of vomiting (9/30 vs 2/30, respectively, P ¼
.042). No serious adverse maternal or perinatal side effects were wit-
nessed in either group.
CONCLUSION: Both intravenous hydralazine and oral nifedipine are
equally effective in lowering of blood pressure in acute hypertensive
emergency of pregnancy.
Key words: acute hypertensive emergency of pregnancy, blood
pressure, critical care, double blind, hypertension, intravenous
hydralazine, maternal morbidity, maternal mortality, oral nifedipine,
preeclampsia

Introduction Increased BP is associated with pregnant women with severe sustained

Hypertension is one of the most common
medical disorders during pregnancy.1
Hypertensive disorders of pregnancy
constitute one of the major causes of
maternal and fetal morbidity and mor-
tality worldwide.2 The American
Congress of Obstetricians and Gynecol-
ogists (ACOG) defines systolic blood
pressure (BP)
160 mm Hg or diastolic
BP
110 mm Hg as one of the severe
features of preeclampsia. BP readings
should preferably be taken on 2 occasions
with an interval of at least 4 hours be-
tween them. Nonetheless, diagnosis can
be confirmed within a shorter interval
(even minutes) to facilitate timely anti-
hypertensive therapy.
Cite this article as: Sharma C, Soni A, Gupta A, et al.
Hydralazine vs nifedipine for acute hypertensive emer-
gency in pregnancy: a randomized controlled trial. Am J
Obstet Gynecol 2017;217:687.e1-6.
0002-9378/$36.00
ª 2017 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajog.2017.08.018
increased risk of morbidity and mortality
in preeclamptic women.2 ACOG Task
Force recommends use of antihyperten-
sive therapy to lower severe hypertension
in preeclamptic women during preg-
nancy.2 Cochrane meta-analysis on drugs
for the treatment of very high BP during
pregnancy states that until better evidence
is available, the choice of antihypertensive
should depend on clinician experience and
women’s preferences.3 Commonly used
agents for acute lowering of BP in pre-
eclamptic women with severe hyperten-
sion in pregnancy are intravenous
hydralazine, intravenous labetalol, and
oral nifedipine.3,4
However, there is limited evidence with
respect to nature of drug to be used.
Cochrane meta-analysis found no signifi-
cant difference regarding efficacy between
various agents (hydralazine, labetalol, or
nifedipine). Recently there was concern
regarding use of hydralazine for acute BP
control in preeclamptic women with se-
vere hypertension.1,4 Use of intravenous
hydralazine for acute BP control in
hypertension has been implicated with
increased risk of cesarean delivery,
placental abruption, maternal overshoot
hypotension, and low Apgar scores in ne-
onates.4-6
Additionally, on detailed evaluation of
available evidence7-13 comparing hy-
dralazine with nifedipine for acute BP
control in women with severe hyper-
tension during pregnancy, it is observed
that the majority of these studies actually
used short-acting sublingual nifedi-
pine,7,8,11,13 which was withdrawn
because of concerns of excessive cardio-
vascular morbidity and mortality.4 From
1995 through 2013 a PubMed database
search for trials comparing hydralazine
and nifedipine BP control in pregnant
preeclamptic women with severe hyper-
tension using key words “severe hyper-
tension,” “pregnancy,” “nifedipine,” and
“hydralazine” revealed only 1 random-
ized controlled trial10 that had compared
nifedipine and intravenous hydralazine
for the lowering of BP during hyper-
tensive emergency in pregnancy.

DECEMBER 2017 American Journal of Obstetrics & Gynecology 687.e1

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Original Research OBSTETRICS
Hence, in the present era of evidence-
based medicine there is a paucity of
good-quality evidence on the better op-
tion between 2 commonly used agents,
ie, intravenous hydralazine and oral
nifedipine, for the control of acute BP
control in women with severe pre-
eclampsia during pregnancy.
With this objective in mind, we con-
ducted this double-blind randomized
controlled trial to evaluate which of the 2
drugseintravenous hydralazine or oral
nifedipineehas better efficacy in con-
trolling acute severe hypertension in
pregnant women with preeclampsia.
Materials and Methods
We conducted this randomized, double-
blind, controlled trial for acute lowering
of BP during hypertensive emergency of
pregnancy. The trial was conducted in
the labor ward of the Department of
Obstetrics and Gynecology of Dr
Rajendra Prasad Government Medical
College and Hospital, Tanda, India, a
tertiary care teaching and referral hos-
pital. The recruitment took place from
December 2014 through September
2015 after obtaining approval from the
institutional ethics committee. The trial
was also registered with the Trial Registry
of India (CTRI) (registration no. CTRI/
2014/12/005285).
All pregnant women with sustained
severe hypertension (defined as systolic
BP
160 mm Hg or diastolic BP
110
mm Hg on 2 separate occasions, at least
30 minutes apart) were approached for
enrollment. Women were eligible for
inclusion if they were between 18-45
years of age, they were at
24 weeks of
gestation, their heart rate was between

60 and <120 beat/min, and they had a
reassuring fetal heart rate (120-160 beat/
min, with no abnormality detected on
admission cardiotocography).
The exclusion criteria were a known
atrial-ventricular heart block or history
of heart failure, moderate to severe
bronchial asthma provoked by either
drug under study, exposure to any anti-
hypertensive medication within the past
24 hours, and nonpregnancy-related
hypertension (diagnosed cases of
chronic or secondary hypertension).
Consolidated Standards of Reporting
687.e2 American Journal of Obstetrics & Gynecology DECEMBER 2017
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FIGURE 1
CONSORT flowchart of the participants
Assessed for Eligibility
(n = 132)
ENROLLMENT
RANDOMIZED (60)
ALLOCATION
Allocated to intervention
HYDRALAZINE
(n=30)
FOLLOW UP & ANALYSIS
ANALYSED = 30
(LOST TO FOLLOW
UP;NONE)
Consolidated Standards of Reporting Trials (CONSORT) flow chart of participants.
Sharma et al. Hypertensive emergency: hydralazine vs nifedipine. Am J Obstet Gynecol 2017.
Trials (CONSORT) guidelines were
strictly followed throughout the trial.
Written informed consent was ob-
tained from the participating women.
The randomization sequence was
computer-generated in blocks of 4 or 8.
Study medications were placed in
sequentially numbered sealed envelopes.
Each envelope contained 2 packages.
One was labeled as package A and the
other was labeled as package B.
Package A contained either intrave-
nous hydralazine vials (total 10 mL as
hydralazine, 5 mg/mL) (Dralgeen;
Bharat Serums and Vaccines Ltd,
Maharashtra, India) and 4 placebo tab-
lets or intravenous saline (10 mL as
0.9%) and 4 10-mg nifedipine tablets
(Zydus Cadila, Gujarat, India).
Package B contained the opposite
regimen if treatment crossover was
required. These envelopes were opened
by an investigator, and package A was
administered first to the participant.
Oral nifedipine and placebo tablets were
ajog.org
Excluded
• Not meeting inclusion criteria(n=36)
• Declined to participate (n=46)
Allocated to intervention
NIFEDIPINE
(n=30)
ANALYSED = 30
(LOST TO FOLLOW UP;
NONE)
identical in appearance. Each tablet
contained 10 mg nifedipine or placebo.
Colorless intravenous study solution
(hydralazine or saline) was placed into a
10-mL syringe by the investigator and
was labeled as “A,” then given to the
physician (resident doctor) for intrave-
nous administration, along with 4 tablets
(nifedipine or placebo) from package A.
Intravenous study solution was admin-
istered through an intravenous line
secured as soon as the women were
enrolled in the trial. In case of crossover
to regimen B, the contents of package B
were prepared in a manner similar as
described for regimen A, and the syringe
was labeled “B.” Thus, the physician and
the participant were blinded regarding
the treatment administered. The women
rested in bed in the semirecumbent po-
sition. The physicians were instructed to
administer 1 tablet to be swallowed from
package A and to administer 1 mL
intravenously from syringe A over 1
minute as the initial treatment (ie, 5 mg
ajog.org OBSTETRICS Original Research

of intravenous hydralazine or 1 mL sa-

TABLE 1
line). After 20 minutes, if the systolic BP
Demographic characteristics of women in both groups
was >150 mm Hg or if the diastolic BP
was >100 mm Hg, the second tablet was Hydralazine, Nifedipine,
administered and 2 mL intravenous so- n ¼ 30 n ¼ 30 P value
lution from syringe A was administered a
Age, y 24.2  6.3 23.4  2.6 .163
over 1 minute (ie, 10 mg of intravenous b
Gravida 2 (1) 2 (1) .280
hydralazine or 2 mL of saline). If the
target BP was not achieved even after 1 16 22
another 20 minutes, the third tablet was 2 8 4
administered, along with intravenous 3 5 2
administration of 2 mL solution from
4 1 2
syringe A. This was repeated for 1 more
cycle of treatment if required to lower BP BMI,a kg/m2 21.8  3.2 22.5  2.8 .776
to the target range (ie, hydralazine in a
Heart rate, beat/min 78  7 86  6 .279
doses of 5 mg, 10 mg, 10 mg, and 10 mg POG, da
257  28 258  17 .856
and a flat dose of nifedipine 10 mg each
Systolic BP at enrollment, mm Hg a
177  18 168  6 .064
every 20 minutes to a maximum of 4
doses). Crossover to regimen B occurred Diastolic BP at enrollment, mm Hg a
109  11 107  8 .307
if target BP was not achieved after 4 cy- Mean arterial pressure at enrollment, 127  14 125  9 .492
cles of regimen A. Regimen B was mm Hga
administered in a fashion identical to Women with systolic BP
160 mm Hg, n 26 21 .209
that of regimen A. If the target BP was
Women with diastolic BP
110 mm Hg, n 19 18 .989
still not achieved, open-label treatment
was performed according to the prefer- Neonatal sex, n
ence of the provider. The BP was  Male 15 13 .605
measured with mercury sphygmoma-  Female 15 17
nometer as per standard recommenda-
Antenatal steroid given, n 4 3 .688
tions, using Korotkoff sound 5 for
BMI, body mass index; BP, blood pressure; POG, period of gestation.
diastolic BP. The BP was measured every a
Mean  SD; b Median (interquartile interval).
20 minutes for at least
100 minutes
Sharma et al. Hypertensive emergency: hydralazine vs nifedipine. Am J Obstet Gynecol 2017.
until the target BP of 150 mm Hg systolic
and 100 mm Hg diastolic was ach-
ieved. Once the target BP was achieved,
no further trial medication was admin- trial medication as per discretion of the mean time interval required to achieve
istered. During the course of treatment, provider. As per the standard protocol, target BP from nifedipine and hydral-
continuous electronic fetal heart moni- the delivery of the neonate was per- azine as 24.0  10 min and 34.8 
toring was performed. In the event of formed as a definite treatment for severe 18.8 min, respectively, assuming 2-sided
nonreassuring fetal or maternal status, pregnancy-induced hypertension. As per significance with a ¼ 0.05 and b ¼ 0.2,
the trial protocol was abandoned and the institutional protocol all women 28 women are required in each group.
appropriate measures such as open after admission received magnesium Statulator beta software was used to es-
antihypertensive treatment or expedited sulfate. The primary outcome measured timate the sample size (http://statulator.
delivery were instituted. If clinically sig- was time needed to achieve target sys- com/about.html). Giving due consider-
nificant maternal hypotension occurred, tolic BP of 150 mm Hg and diastolic ation for attrition and possible skewed
appropriate measures were suggested for BP of 100 mm Hg (both targets had to distributions that might require
the provider’s consideration. After be fulfilled). Secondary outcomes nonparametric testing, we randomized a
completion of the trial protocol, women included total number of antihyperten- total of 60 women (30 in each group).
were requested to complete a question- sive dosages required to achieve the The data were entered into software
naire regarding occurrence of side effects target BP (ie, systolic 150 mm Hg and (SPSS 17; IBM Corp, Armonk, NY). The
during the trial period (ie, nausea, diastolic 100 mm Hg), maternal heart analysis was based on the intention to
vomiting, headache, dizziness, urticaria, rate profile during the first 100 minutes, treat. One-sample Kolmogorov-Smir-
flushing, pruritus, nasal congestion, maternal hypotension (BP <90/60 mm nov test was used to check normal dis-
conjunctivitis, palpitations). Hg), side-effects profile, and perinatal tribution of continuous data. Student t
After successfully lowering the BP to outcome. test was used to analyze the normally
target range, further antihypertensive Sample size calculations are based on a distributed data and ordinal data were
therapy was started 2 hours after the last previous study by Rezaei et al.10 Taking analyzed by Mann-Whitney U test.

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Original Research
TABLE 2
Outcomes of randomized trial comparing intravenous hydralazine with oral
nifedipine for acute blood pressure control in pregnancy
Primary outcome
Time for BP control,a min
Secondary outcomes
No. of doses,a n
Maternal side effects
 Nausea
 Vomiting
 Overshoot hypotension
 Tachycardia (>90 beat/min)
Elective cesarean delivery, n
Induction of labor, n
Emergency cesarean delivery
Apgar score <7
 1 min
 5 min
NICU admission, n
Neonatal birthweight, g
BP, blood pressure; NICU, neonatal intensive care unit.
a
Median (interquartile interval).
Sharma et al. Hypertensive emergency: hydralazine vs nifedipine. Am J Obstet Gynecol 2017.
Categorical data sets were analyzed with
Fisher exact test. All tests were 2-sided
and P < .05 was considered significant.
Participants were analyzed on the
intention-to-treat basis.
Results
Figure 1 shows the CONSORT flow
chart of participants after enrollment.
Sixty women were enrolled into the
study, and divided into 2 groups of
30 each. Each group of 30 was random-
ized to receive either intravenous
hydralazine or oral nifedipine. As shown
in Table 1, both groups were similar with
respect to maternal age, gravidity, period
of gestation, systolic and diastolic BP at
enrollment, and use of antenatal
steroids.
Median time to achieve target BP
(defined as systolic BP <150 and dia-
stolic BP <100 mm Hg, both conditions
fulfilled) was 40 minutes in both groups
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OBSTETRICS
Hydralazine, Nifedipine,
n ¼ 30 n ¼ 30 P value
40 (5) 40 (40) .809
2 (1) 2 (2) .625
3 5 .706
9 2 .042
1 nil .998
nil 2 .491
3 2 .986
27 28 .998
6 5 .898
2 3 .640
1 2 .554
1 2 .978
2280  628 2544  514 .079
(intravenous hydralazine vs oral nifedi-
pine; interquartile interval 5 and 40
minutes, respectively, P ¼ .809). All
women in the study required a median of
2 doses for acute control of BP (intra-
venous hydralazine and oral nifedipine;
interquartile range 1 and 2 doses,
respectively, P ¼ .625) (Table 2). No
woman in the study required the cross-
over treatment. Figure 2 shows a
decrease of BP in women during the
study period. In the first 80 minutes,
100% of women achieved the target BP.
Repeated measures analysis of the vari-
ance of BP for the first 80 minutes
indicated that both systolic and diastolic
BP decreased significantly with the pas-
sage of time in both groups (Figure 2).
The Figure 3 shows the cumulative
percentage of patients who happened to
achieve the target BP in both groups over
the specified time. The mean maternal
heart rate at the beginning of the
ajog.org
treatment was 88 beat/min in the hy-
dralazine group and 86 beat/min in the
nifedipine group (P ¼ .279). The corre-
sponding values at the end of the treat-
ment were 78 and 88 beat/min in the
hydralazine and nifedipine groups,
respectively. Two women had tachy-
cardia (heart rate >90 beat/min), both in
the nifedipine group. Both of them were
managed conservatively without any
additional treatment. Repeated measures
analysis of variance of maternal heart
rate for the first 80 minutes revealed a
significant increase with time in the
nifedipine group (P < .001). However,
there was no statistically significant dif-
ference in mean heart rate of women in
the hydralazine group. As shown in
Table 2, there was no statistically signif-
icant difference in maternal or neonatal
outcomes in either group except for
maternal vomiting, which was signifi-
cantly more frequent in the hydralazine
group (hydralazine vs nifedipine 9 vs 2,
P ¼.042). There was 1 case of precipitous
decrease in maternal BP during the trial
period (although she did not meet the
initial defined criteria of hypotension, ie,
BP <90 mm Hg). This woman was in the
hydralazine group. She received a second
dose of hydralazine when she developed
significant decrease in BP (systolic
BP 110 mm Hg). She reported uneasi-
ness. Intravenous fluids were adminis-
tered and no fetal heart rate
abnormality was detected. Her BP was
normalized in 20 minutes after intrave-
nous hydration with 0.9% normal
saline. Subsequently after induction of
labor she had normal vaginal delivery of
a healthy neonate.
There was no maternal or fetal death
during the study.
Comment
In this double-blinded, randomized
controlled trial, we found intravenous
hydralazine and oral nifedipine to have
similar efficacy for acute BP control in
pregnant women with severe sustained
hypertension.
There is a paucity of literature with
respect to these 2 agents for acute
BP control in pregnant women with severe
sustained hypertension. Several studies
compared sublingual nifedipine with
ajog.org OBSTETRICS Original Research

achieved. Additionally, there is slight

FIGURE 2
variation in the target BP range in their
Profiles of systolic and diastolic blood pressure (mean – SD) during
study as they used systolic BP <150 mm
treatment
Hg and diastolic BP 90-100 mm Hg as the
HYDRALAZINE SBP target. One major drawback of the study
200
NIFEDIPINE SBP by Rezaei et al10 was that there was no
HYDRALAZINE DBP
180 NIFEDIPINE DBP
blinding of patients or treating physicians.
Blood pressure in mm of Hg

160 Not doing so is a well-known confounding

140 factor in randomized trials and, as such,
120
has been mandated as an essential crite-
100
80 rion by CONSORT guidelines
60 worldwide.14
40 Nonetheless, they reported 100% ef-
20
ficacy of both drugs for achieving target
0
0 20 40 60 80 BP within the stipulated time period and
Time taken for blood pressure control (min) this finding is similar to our observation
as no woman required crossover treat-
Profiles of mean  SD systolic blood pressure (SBP) and diastolic blood pressure (DBP) during ment in either group in our study.
treatment.
None of the women had any major side
Sharma et al. Hypertensive emergency: hydralazine vs nifedipine. Am J Obstet Gynecol 2017.
effects in our study. However, intravenous
hydralazine was statistically more signifi-
cantly associated with vomiting as
intravenous hydralazine.7,8,11,13 However, oral nifedipine had better efficacy (mean compared to oral nifedipine (P ¼ .042).
the use of sublingual nifedipine has been time required for BP control oral nifedi- We did not observe any statistically sig-
abandoned due to serious associated car- pine vs intravenous hydralazine: 24 vs 35 nificant difference with respect to
diovascular complications.4 To our minutes, P ¼ .016). This could be due to maternal or neonatal effects in either
knowledge, only 1 study by Rezaei et al10 higher dose of nifedipine used, ie, initial 10 group. There has been much controversy
compared oral nifedipine with intrave- mg dose followed by 20 mg every 20 mi- regarding the use of intravenous hydral-
nous hydralazine and they observed that nutes to a total of 5 doses or target BP azine as first-line agent due to increased
need for cesarean delivery, placental
abruption, overshoot hypotension, and
FIGURE 3 low 5-minute Apgar scores.4-6
Cumulative percentage of women who achieved target blood pressure There has been some speculation
during study period regarding safety profile of oral nifedipine
especially with respect to overshoot hy-
100 potension, synergistic effect with concur-
90 rent use of magnesium sulfate, and risk of
prolonged labor (as nifedipine has also
80
been used for tocolysis). Nonetheless,
70 these concerns have been satisfactorily
60 proven wrong by various trials15-22 and the
safety of nifedipine has been well docu-
50
Hydralazine mented as antihypertensive agent12,15,16 as
40
Nifedipine well as with respect to tocolysis17-21 or
30 synergistic action with magnesium sul-
fate.22 In our study, there was no case of
20
overshoot hypotension with use of oral
10 nifedipine. All women received magne-
0 sium sulfate and no case of neuromuscular
20 40 60 80 blockade was observed. The majority of
women required 2-4 doses of nifedipine to
(x-axis: Time taken for BP control, minutes, y-axis: Cumulative percentage of women who achieved target
achieve target BP and were exposed to
blood pressure of 150/100 mm Hg or less)
much lesser doses in comparison to what
Cumulative percentage of women who achieved target blood pressure (BP) during specified time is used for tocolysis.
period.
The questions can, however, be raised
Sharma et al. Hypertensive emergency: hydralazine vs nifedipine. Am J Obstet Gynecol 2017.
regarding different dosing schedule of

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Original Research OBSTETRICS
both intravenous hydralazine and oral
nifedipine. We preferred lower dosage of
hydralazine as initial dose (5 mg), and
subsequently it was followed by the
higher dose (10 mg), as advised by the
standard textbook by Cunningham
et al.23 Additionally, we followed the
protocol of Shekhar et al1 with respect to
the dosage of nifedipine to have a flat
dose of 10 mg, which was to be repeated
every 20 minutes thereby keeping the
dosing interval similar for 2 drugs.
Regarding the side-effect profile;
vomiting was statistically more signifi-
cantly common in hydralazine group (9
vs 2, P ¼ .042). There was 1 case of
precipitous decrease in maternal BP in
the hydralazine group and 2 cases of
tachycardia in the nifedipine group.
However, these were transient and
responded to routine maneuvers and
there was no major maternal or fetal side
effect in our study. Nonetheless, it is
prudent to mention that our study
lacked adequate power to assess the
safety profile of these drugs conclusively.
Our observation of equal efficacy of
both these agents is slightly at variance
with the observations of Rezaei et al.10
However, it does establish oral nifedi-
pine as first-line agent, which is better
tolerated as compared to intravenous
hydralazine for acute BP control in hy-
pertensive emergency of pregnancy.
Therefore, a larger, well-controlled,
adequately powered study, especially
with respect to the maternal and fetal
side effects, is the need of the hour.
Until then, we completely agree with
Shekhar et al1 that “oral nifedipine may
be preferred because of flat dosing
regimen, ease of oral administration,
wide availability, and low cost.” n Katz Z, Shoham Z. Nifedipine in the treatment of
References
1. Shekhar S, Sharma C, Thakur S, Verma S.
Oral nifedipine or intravenous labetalol for
687.e6 American Journal of Obstetrics & Gynecology DECEMBER 2017
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For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
hypertensive emergency in pregnancy: a
randomized controlled trial. Obstet Gynecol
2013;122:1057-63.
2. ACOG Task Force. Hypertension in preg-
nancy. Available at: https://www.acog.org/
w/media/Task%20Force%20and%20Work%
20Group%20Reports/public/Hypertensionin
Pregnancy.pdf. Accessed May 28, 2017.
3. Duley L, Meher S, Jones L. Drugs for treat-
ment of very high blood pressure during preg-
nancy. Cochrane Database Syst Rev 2013;7:
CD001449.
4. Magee LA, Cham C, Waterman EJ,
Ohlsson A, von Dadelszen P. Hydralazine for
treatment of severe hypertension in pregnancy:
meta-analysis. BMJ 2003;327:955-60.
5. Vink GJ, Moodley J, Philpott RH. Effect of
dihydralazine on the fetus in the treatment of
maternal hypertension. Obstet Gynecol
1980;55:519-22.
6. Vink GJ, Moodley J. The effect of low-dose
dihydralazine on the fetus in the emergency
treatment of hypertension in pregnancy. S Afr
Med J 1982;62:475-7.
7. Aali B, Nejad SS. Nifedipine or hydralazine as
a first-line agent to control hypertension in se-
vere pre-eclampsia. Acta Obstet Gynecol Scand
2002;81:25-30.
8. Walss Rodriguez RJ, Flores Padilla LM.
Management of severe pre-eclampsia/
eclampsia. Comparison between nifedipine
and hydralazine as antihypertensive drugs.
Ginecol Obstet Mex 1993;61:76-9.
9. Martins-Costa S, Ramos JG, Barros E,
Bruno RM, Costa CA. Randomized, controlled
trial of hydralazine versus nifedipine in pre-
eclamptic women with acute hypertension. Clin
Exp Hypertens 1992;B11:25-44.
10. Rezaei Z, Sharbaf FR, Pourmojieb M, et al.
Comparison of the efficacy of nifedipine and
hydralazine in hypertensive crisis in pregnancy.
Acta Med Iran 2011;49:701-6.
11. Kwawukume EY, Ghosh TS. Oral nifedipine
therapy in the management of severe pre-
eclampsia. Int J Gynaecol Obstet 1995;49:
265-9.
12. Seabe SJ, Moodley J, Becker P. Nifedipine
in acute hypertensive emergencies in preg-
nancy. S Afr Med J 1989;76:248-50.
13. Fenakel K, Fenakel G, Appelman Z, Lurie S,
severe preeclampsia. Obstet Gynecol 1991;77:
331-7.
14. Schulz KF, Altman DG, Moher D; for the
CONSORT Group. CONSORT 2010 statement:
ajog.org
updated guidelines for reporting parallel group
randomized trials. Obstet Gynecol 2010;115:
1063-70.
15. Barton JR, Hiett AK, Conover WB. The
use of nifedipine during the postpartum
period in patients with severe preeclamp-
sia. Am J Obstet Gynecol 1990;162:
788-92.
16. Scardo JA, Vermillion ST, Hogg BB,
Newman RB. Hemodynamic effects of oral
nifedipine in preeclamptic hypertensive emer-
gencies. Am J Obstet Gynecol 1996;175:
336-8.
17. Meyer W, Randall HW, Graves WL.
Nifedipine versus ritodrine for suppressing
preterm labor. J Reprod Med 1990;35:
649-53.
18. Ferguson JE, Dyson DC, Schutz T,
Stevenson DK. A comparison of tocolysis
with nifedipine or ritodrine: analysis of effi-
cacy and maternal, fetal, and neonatal
outcome. Am J Obstet Gynecol 1990;163:
105-11.
19. Bracero LA, Leikin E, Kirshenbaum N,
Tejani N. Comparison of nifedipine and ritodrine
for the treatment of preterm labor. Am J Perinatol
1991;8:365-9.
20. Kupferminc M, Lessing JB, Yaron Y,
Peyser MR. Nifedipine versus ritodrine for sup-
pression of preterm labor. Br J Obstet Gynaecol
1993;100:1090-4.
21. Papatsonis DNM, van Geijn HP, Ader HJ,
Lange FM, Bleker OP, Dekker GA. Nifedipine
and ritodrine in the management of preterm la-
bor: a randomized multicenter trial. Obstet
Gynecol 1997;90:230-4.
22. Magee LA, Miremadi S, Li J, et al. Therapy
with both magnesium sulfate and nifedipine
does not increase the risk of serious
magnesium-related maternal side effects in
women with preeclampsia. Am J Obstet Gyne-
col 2005;193:153-63.
23. Cunningham FG, Leveno KJ, Bloom SL,
et al. Williams obstetrics. 24th ed. New York, NY:
McGraw Hill; 2014:762.
Author and article information
From the Dr Rajendra Prasad Government Medical
College, Tanda (HP), India.
Received June 28, 2017; revised Aug. 12, 2017;
accepted Aug. 23, 2017.
The authors report no conflict of interest.
Corresponding author: Chanderdeep Sharma, MD
(OBG), DNB (OBG). cdsharma2006@gmail.com