Postpartum NSAIDS and Maternal Hypertension

Study Overview
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Brief Summary
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Previous studies have suggested that NSAID use causes an increase in blood pressure. Further, blood pressure elevation has been noted in women with pregnancy related hypertensive disease during the postpartum period. NSAIDs remain part of standard postpartum care in women with hypertensive disease. The objective of this study is to determine whether postpartum standard care withholding NSAID use is associated with a clinically significant reduction in postpartum hypertension in women with pregnancy induced hypertension. The investigators hypothesize that women with pregnancy induced hypertensive disease will be half as likely to have blood pressure elevation of 150/100 mmHg in the first 24 hours postpartum. This study is an open label randomized trial of women with antepartum hypertension. Women will be randomized to receive standard postpartum care or standard postpartum care without NSAIDs. Blood pressure measurements and patient outcomes will be recorded. The study period will begin at the time of delivery and will end at the time of hospital discharge.

Detailed Description
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The objective of this study is to determine whether the withholding of NSAID use is associated with a clinically significant decrease in postpartum hypertension in women with antepartum hypertension. The investigators are interested in whether the use of NSAIDs elevates blood pressure to greater than or equal to 150/100 mmHg (by either systolic or diastolic parameters) more frequently in hypertensive women. The investigators hypothesize that among participants with hypertensive disease associated with pregnancy, those who have NSAIDs withheld from standard postpartum care (experimental arm) will be half as likely to have an increase of blood pressure of 150/100 mmHg in the first 24 hours postpartum compared to participants receiving standard care that includes NSAIDs (control arm). This trial is a randomized, open label study investigating the effect of NSAID use on blood pressure during the immediate postpartum period in women with chronic hypertension (cHTN) or pregnancy induced hypertension (PIH). The experimental group in this study will be women randomized to withholding NSAIDs during the study period, as women with hypertension routinely receive NSAIDs postpartum. Women with a diagnosis of pregnancy induced hypertension [gestational hypertension (gHTN), preeclampsia, superimposed preeclampsia, ] or cHTN will be enrolled antepartum and will be separated into two groups by the route of delivery: vaginal vs. cesarean delivery. Participants in the control arm will be assigned to receive standard care, which includes NSAIDs (ketorolac, ibuprofen) and participants in the experimental arm will be assigned to receive standard care with NSAIDs withheld in the postpartum period for the duration of hospitalization. The intervention period will last approximately 2-4 days and will conclude at the time of hospital discharge. Blood pressure measurements will be obtained and recorded routinely in the postpartum period until hospital discharge. More frequent measurements may be performed in the event of severe blood pressure elevations at the discretion of the provider and treating clinical team. Complete Blood Count (CBC) on postpartum Day 1 will be performed as part of standard care. Additional laboratory evaluations will be performed at the discretion of the provider. In addition to blood pressure measurement, pain scale scores will be recorded daily using a Numeric Pain Scale Score. Initiation of anti-hypertensive medication, severe hypertension (BP 160/110 mmHg), treatment with magnesium sulfate and adverse maternal outcomes (cerebrovascular accident, congestive heart failure, pulmonary edema, eclamptic seizure, death) will be documented and abstracted from the medical record. A power calculation to estimate the appropriate number of subjects needed to detect a difference of 30% in the primary outcome, with an alpha level of 0.05 and 80% power demonstrates that approximately 100 subjects per group (50 in the experimental group and 50 in the control group) will be needed for each delivery route tested (vaginal and cesarean).

Official Title
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Effect of Non-steroidal Anti-inflammatory Use on Blood Pressure in Women With Hypertensive Disorders of Pregnancy: A Randomized Open Label Trial

Conditions
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Preeclampsia, Gestational Hypertension, Superimposed Preeclampsia, Chronic Hypertension in Obstetric Context

Intervention / Treatment
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* Drug: Ibuprofen 600 mg
* Other: Standard Postpartum Care without NSAIDs


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Women 18 years or older delivering at LAC/USC Hospital Delivery occurring at or after 20 weeks gestation Diagnosis of antenatal hypertensive disorder: gestational hypertension, preeclampsia without severe features, preeclampsia with severe features, superimposed preeclampsia, eclampsia, chronic hypertension Exclusion Criteria: HELLP Syndrome Renal dysfunction (Serum Creatinine >1.1 in current pregnancy) Known liver disease Low platelet count (<50,000 during hospital admission) Known sensitivity or allergy to ibuprofen or acetaminophen Use of therapeutic doses of anticoagulation Postpartum hemorrhage requiring blood transfusion Neonate with platelet disorder or thrombocytopenia in breastfeeding mother

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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Female

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Standard Postpartum Care<br>Subjects will receive NSAIDs (e.g. ibuprofen, ketorolac) for routine postpartum pain management. | Drug: Ibuprofen 600 mg<br>* Standard postpartum care (including administration of NSAIDs)<br>* Other names: Standard Postpartum Care;|
| Active Comparator: Standard Postpartum Care without NSAIDs<br>Subjects will receive standard postpartum care without NSAID administration for pain management. Acetaminophen or narcotics will be substituted for ibuprofen as indicated by provider. | Other: Standard Postpartum Care without NSAIDs<br>* NSAID administration will be withheld from this group.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Proportion of participants with blood pressure elevation | Incidence of Systolic Blood Pressure of 150 mmHg or Diastolic Blood Pressure of 100 mmHg or above | 24 hours postpartum | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Proportion of participants with blood pressure elevation | Incidence of Systolic Blood Pressure of 150 mmHg or Diastolic Blood Pressure of 100 mmHg or above | 48, 72 and 96 hours postpartum | 
| Number of participants with eclamptic Seizure | Documented occurrence of new onset generalized tonic-clonic seizure(s) or coma in a woman with preeclampsia | Through study completion, up to 6 weeks postpartum | 
| Number of participants with stroke | New onset neurologic deficit associated with neuroimaging (CT scan or MRI) evidence of brain infarction or bleeding | Through study completion, up to 6 weeks postpartum | 
| Initiation of anti-hypertensive medication | Provider documentation of initiation of anti-hypertensive medication (e.g. nifedipine, labetalol) | Randomization through hospital discharge, an average of 3-7 days | 
| Pain numerical rating scale (NRS) score | Numerical pain scale score 0-10; 0= no pain and 10=worst possible pain; total score reported | Randomization through hospital discharge, measured daily, an average of 3-7 days | 
| Number of participants with renal failure | Creatinine >1.1 or doubled | Through study completion, up to 6 weeks postpartum | 
| Number of participants with pulmonary edema | Evidence of lung infiltrates on chest radiograph or CT scan | Through study completion, up to 6 weeks postpartum | 
| Number of participants who die |  | From the date of randomization through date of death from any cause, assessed up to 6 weeks postpartum | 
| Length of hospital stay | Number of days from delivery to hospital discharge | Through hospital discharge, an average of 3-7 days |