Efficacy of Pharmacological Agents for Management of Post-partum Hypertension: A Network Meta-analysis

Efficacy of Pharmacological Agents for Management of Post-partum Hypertension: A Network Meta-analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Efficacy of Pharmacological Agents for Management of Post-partum Hypertension: A Network Meta-analysis ALOK SINGH, Madhusudan Prasad Singh, Pushpawati Thakur, Sameer U Khasbage, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7523179/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Postpartum hypertension is a frequent cause of maternal morbidity and mortality and may occur as persistence of pregnancy-related hypertension or as new onset after delivery. Despite the burden, there is no consensus on the most effective antihypertensive drug regimen for the postpartum period. Pharmacological strategies vary widely, and treatment decisions are often extrapolated from antenatal studies rather than dedicated postpartum trials. Objectives The objective of this study was to compare the effectiveness and safety of pharmacological agents for management of postpartum hypertension. Study Design We performed a systematic review and Bayesian network meta-analysis of randomized controlled trials enrolling women with postpartum hypertension treated with systemic antihypertensive drugs. MEDLINE and Embase were searched through July 2025. Eligible trials compared active agents or placebo/usual care and reported blood pressure outcomes. Primary outcomes were time to achieve blood pressure control (hours) and proportion of women achieving blood pressure control within seven days postpartum. Treatment ranking was evaluated using surface under the cumulative ranking probability curves. Results Thirteen randomized controlled trials including 1625 women were identified. For time to blood pressure control, amlodipine and nifedipine ranked highest. Compared with labetalol, amlodipine reduced time to control by -5.85 hours (95% CI, -21.3 to 11.4) and nifedipine by -5.11 hours (95% CI, -17.9 to 9.71). Rankings indicated amlodipine were most effective for rapid control, followed by labetalol.For the proportion achieving control within seven days, labetalol ranked highest, with a probability near 100%. Compared with labetalol, 60 risk ratios for blood pressure control were 61 1.01 (95% CI, 0.55–1.75) for nifedipine, 1.03 (95% CI, 0.49–2.16) for hydralazine, and 1.31 (95% CI, 0.46–3.49) for hydrochlorothiazide–lisinopril. SUCRA values ranked labetalol highest, followed by nifedipine, hydralazine, and hydrochlorothiazide–lisinopril. Conclusions Calcium channel blockers appear most effective for rapid reduction of blood pressure after childbirth, while labetalol is most reliable for sustained control within the first postpartum week. These findings provide a comparative framework for treatment selection and emphasize the need for larger, rigorously designed postpartum hypertension trials. Amlodipine Antihypertensive therapy Blood pressure control Labetalol Maternal outcomes Nifedipine Postpartum hypertension Network meta-analysis Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Postpartum hypertension (PPHTN), defined as elevated blood pressure occurring or persisting within six weeks after childbirth, represents a significant cardiovascular complication in the puerperium. Hypertensive disorders of pregnancy (HDP), which include gestational hypertension and preeclampsia, complicate approximately 10% of pregnancies globally and 13–15% in the United States. [1,2] Recent data indicate an upward trend in HDP-related hospitalizations, rising from 13.3% to 15.9% between 2017 and 2019. [3] PPHTN encompasses both the persistence of HDP beyond delivery and de novo onset of hypertension in the postpartum period, the latter affecting up to 8% of women within the first week following childbirth.[4] Importantly, nearly 60% of maternal deaths occur within one year postpartum, with HDP being a major contributor. [5] The pathophysiology of PPHTN involves complex transitions in cardiovascular and hormonal systems during the shift from pregnancy to the non-pregnant state, including intravascular volume redistribution and autonomic fluctuations. Women with a history of HDP are at increased risk of chronic hypertension, coronary artery disease, and stroke, underscoring the need for optimal acute management strategies to improve both short- and long-term outcomes. [6] The condition disproportionately affects certain populations, with the highest prevalence observed among women aged 35-44 years (18.0%) and those identifying as Black (20.9%) or American Indian and Alaska Native (16.4%).[3] Pharmacological management of PPHTN varies widely across clinical settings. Commonly used antihypertensive agents include labetalol (a combined a- and ß-blocker), nifedipine (a calcium channel blocker), hydralazine (a direct vasodilator), and methyldopa (a central a-2 agonist). [7,8] Of these, labetalol and methyldopa are often preferred due to their favorable safety profiles in breastfeeding women. [9] While several randomized controlled trials (RCTs) have compared these agents, robust comparative data specific to the postpartum population remain limited. A pivotal trial comparing nifedipine retard, labetalol, and methyldopa in pregnancy showed all three as effective first-line options. [10] However, systematic reviews have noted that oral labetalol and methyldopa may only be effective in about 50% of pregnant women, emphasizing the need for further evaluation. [11] Several RCTs have focused specifically on PPHTN, including comparisons between oral nifedipine and oral labetalol. [12] Early network meta-analyses (NMAs) of antihypertensive drugs in pregnancy suggested that nifedipine 114 at various doses was more effective than intravenous labetalol. [13] Other NMAs and trial sequential analyses have reported that agents like glyceryl trinitrate and labetalol are associated with fewer maternal adverse effects compared to hydralazine. [14] Nevertheless, the existing evidence is fragmented, with inconsistent methodologies, heterogeneity in outcome definitions, and limited data specific to the postpartum setting. Given these limitations, clinicians often lack clear, evidence-based guidance on selecting the most appropriate antihypertensive agent in the postpartum period. The postpartum setting introduces unique therapeutic considerations, such as breastfeeding safety, rapid physiological shifts, and the need for prompt blood pressure control. Existing reviews acknowledge the absence of a standardized stepwise pharmacologic strategy for PPHTN. [12] Moreover, treatment decisions can significantly impact maternal outcomes, including hospital readmission rates. [15] Amid increasing emphasis on maternal safety and standardized care pathways, the demand for reliable comparative effectiveness data is urgent. Therefore, this systematic review and network meta-analysis aim to synthesize the best available evidence from randomized controlled trials to evaluate the comparative effectiveness and safety of antihypertensive agents used in PPHTN. By integrating both direct and indirect comparisons, this analysis seeks to support evidence-based clinical decision-making and improve maternal outcomes during this critical phase of care. Methods Data Sources and Searches This systematic review and network meta-analysis followed the PRISMA extension for Network Meta-Analyses (PRISMA-NMA) reporting guideline. [16] Methodological procedures were guided by the Cochrane Handbook for Systematic Reviews of Interventions, Version 6.4. [17] MEDLINE and Embase were searched from inception to July 2025, without language restrictions. Reference lists of relevant reviews and eligible articles were screened to identify additional studies. The protocol was prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO) prior to data collection and analysis. [PROSPERO Registration Number: CRD420251104693] Search strategy is available as supplementary file (S1). Study Selection Eligible studies were randomized clinical trials (RCTs) enrolling women with postpartum hypertension treated with any systemic pharmacological antihypertensive agents. Comparators included other active antihypertensive drugs or placebo/standard care. Trials were required to report at least one prespecified outcome. Nonrandomized studies, antenatal hypertension trials without postpartum data, assessed only non-pharmacological interventions, and those lacking extractable outcome measures were excluded. Two reviewers independently screened all titles, abstracts, and full texts, with disagreements resolved by consensus. Data Extraction and Quality Assessment Three investigators (AS, MPS, RY) independently extracted data on study design, population characteristics, interventions, and outcomes using a standardized form. Risk of bias was assessed with the Cochrane Risk of Bias 2.0 tool. [18] Discrepancies were resolved by discussion or by consultation with a third reviewer (SK). Outcomes The primary outcomes were (1) time from delivery to attainment of blood pressure control (measured in hours) and (2) the proportion of women achieving blood pressure control within seven days postpartum. Definitions for blood pressure control were accepted as per each individual trial, commonly systolic <140 mmHg and diastolic <90mmHg. The outcomes were finalized by two authors (PT, AS). Statistical Analysis A Bayesian random-effects network meta-analysis was performed by the Meta Insight platform (University of Leicester, UK) which uses gemtc package and network plot was created to show connections among numerous drugs evaluated. [19] Posterior distributions for treatment effect were synthesized by non-informative prior distributions by using Markov Chain Monte Carlo (MCMC) simulations. MCMC convergence has been assessed for each endpoint and presented along with results. Brooks- Gelman diagnostics tool was used to assess convergence. To assess transitivity, the distribution of potential effect modifiers was reviewed across all comparisons. Model convergence was assessed by visual inspection of trace plots and posterior distributions. Consistency between direct and indirect evidence was evaluated using design-by-treatment interaction models and node-splitting approaches. [20] SUCRA (Surface Under the Cumulative Ranking Curve) values were also calculated to complement ranking assessments. Treatments were ranked using cumulative probability, which represent the mean probability of each intervention being superior to others. [21] For outcomes with =10 contributing trials, comparison-adjusted funnel plots were constructed to evaluate small-study effects and potential publication bias. [22,23] Treatment effects were expressed as mean differences (MDs) with 95% confidence intervals (C.I.) for continuous outcomes and risk ratios (RRs) with 95% C.I. for binary outcomes. A two-tailed P value <.05 was considered statistically significant for all comparisons. Results Characteristics of Included Studies Sixteen randomized controlled trials (2005–2025) enrolling a total of 1,625 postpartum women with hypertensive disorders were included (Table 1) (Figure 1). Studies were conducted in Brazil, India, the United States, Mexico, Pakistan, and Turkey, with sample sizes ranging from 42 to 384 participants. All participants were female, with mean ages spanning early 20s to late 30s. A wide range of antihypertensive interventions was assessed: labetalol, nifedipine (immediate/extended release), amlodipine, enalapril, methyldopa/alpha-methyldopa, 196 hydralazine, clonidine, diltiazem, furosemide (alone or in combination), and hydrochlorothiazide/lisinopril. Comparators most frequently included nifedipine, captopril, placebo, amlodipine, labetalol, and enalapril. Follow-up durations ranged from 24 hours (acute BP control studies) to 6 weeks postpartum, with primary outcomes encompassing time to achieve blood pressure (BP) control, proportion of women with BP control at 7 days, need for additional antihypertensives, hospital length of stay, maternal complications (e.g., pulmonary edema, HELLP syndrome, eclampsia), readmission, and breastfeeding-related outcomes. Two primary evidence networks were formed for the NMA: 1. Time to achieve BP control (hours): labetalol, nifedipine, amlodipine, and enalapril. 2. Proportion achieving BP control within 7 days: labetalol, nifedipine, hydralazine, and HCTZ/lisinopril combination. Risk of Bias Risk of bias was assessed using the ROB-2 tool (Figure 2). Low risk or some concerns: Several trials (e.g., Gupta 2023, Sharma 2017, Perdigao 2021, Pratt 2025, Cursino 2025, Vigil-de Gracia 2007, Noronha 2017) demonstrated relatively low bias, with minor issues mainly in deviations from interventions. High risk: Other trials (e.g., Ainuddin 2019, Bartal 2023, Marques 2025, Sayin 2005, Hernandez 2020, Yoselevsky 2023) were judged high risk, primarily due to unclear or inadequate randomisation processes and missing outcome data. Domains most affected: Randomisation (D1) and missing data (D3) were the most frequent sources of high risk. Outcome measurement (D4) and selective reporting (D5) were generally low risk. Overall, the evidence base consists of a mix of rigorously conducted recent RCTs and older or smaller studies with methodological limitations, necessitating cautious interpretation of treatment rankings. Node-splitting and consistency checks indicated no significant disagreement between direct and indirect evidence (p > 0.05), supporting the use of the consistency model. Network Meta-analysis 1. Time to Achieve Blood Pressure Control A total of four antihypertensive agents—labetalol, nifedipine, amlodipine, and enalapril— were evaluated across the included randomized controlled trials for the outcome of time (in hours) to achieve postpartum blood pressure control. Labetalol was the most frequently studied agent and served as the reference for analysis. MCMC Convergence Assessment The Bayesian random-effects network meta-analysis demonstrated robust convergence across all parameters. Convergence diagnostics showed excellent performance: shrink factors (R-hat) approached 1.0 (<1.05) by approximately 5,000 iterations for all treatment comparisons (d.Nifedipine.Amlodipine, d.Nifedipine.Enalapril, d.Nifedipine.Labetalol) and the between study heterogeneity parameter (sd.d). Trace plots confirmed good chain mixing and stationarity across all four MCMC chains (20,000 iterations each after 5,000 burn-in iterations, number of chains 4), ensuring reliable posterior estimates. Pairwise and Network Meta-analysis The Bayesian random-effects network meta-analysis with confirmed convergence revealed that, compared with labetalol (reference): Amlodipine: MD -5.85 hours (95% C.I.: -21.3, 11.4) - associated with shorter time to BP control Nifedipine: MD -5.11 hours (95% C.I.: -17.9, 9.71) - associated with shorter time to BP control Enalapril: MD +23.7 hours (95% C.I.: -9.25, 57.3) - associated with longer time to BP control All Pairwise Comparisons The comprehensive treatment comparison matrix revealed: Amlodipine vs. Nifedipine: MD 0.84 hours (95% C.I.: -15.9, 17.6) - minimal difference Enalapril vs. Amlodipine: MD 29.3 hours (95% C.I.: -5.13, 63.7) - enalapril slower Enalapril vs. Nifedipine: MD 28.6 hours (95% C.I.: -2.31, 59.3) - enalapril slower Treatment Ranking (Figure 3A,3B,3C) Surface Under the Cumulative Ranking (SUCRA) analysis indicated a clear hierarchy for speed of BP control: 1. Amlodipine (SUCRA = 79.7%): Most likely to achieve fastest BP control 2. Nifedipine (SUCRA = 75.2%): Second most effective for rapid BP control 3. Labetalol (SUCRA = 40.3%): Intermediate effectiveness 4. Enalapril (SUCRA = 4.8%): Slowest to achieve BP control Consistency Assessment (supplementary file S2) Node-splitting analysis and consistency plots showed good agreement between direct and indirect evidence across all comparisons (p-values > 0.05), supporting the validity of the consistency model assumptions. 2. Proportion of Women Achieving Blood Pressure Control Within Seven Days Postpartum A total of four antihypertensive agents—labetalol, nifedipine, hydralazine, and HCTZ/lisinopril combination—were evaluated across the included randomized controlled trials for the binary outcome of achieving postpartum blood pressure control within seven days. Based on the network structure, labetalol served as the reference treatment for the analysis. MCMC Convergence Assessment The Bayesian random-effects network meta-analysis demonstrated robust convergence across all parameters. Convergence diagnostics showed excellent performance: shrink factors (R-hat) approached 1.0 (<1.05) by approximately 5,000 iterations for all treatment comparisons (d.Labetalol.Hydralazine, d.Labetalol.Nifedipine, d.Labetalol.HCTZ_Lisinopril) and the between-study heterogeneity parameter (sd.d). Trace plots confirmed good chain mixing and stationarity across all four MCMC chains (20,000 iterations each after 5,000 burn-in iterations, chain 04), ensuring reliable posterior estimates. (supplementary file S3) Pairwise and Network Meta-analysis The Bayesian random-effects network meta-analysis with confirmed convergence revealed that compared with labetalol (reference), all alternative treatments showed numerically higher risk ratios, indicating potentially lower effectiveness: HCTZ/Lisinopril combination: RR 1.31 (95% C.I.: 0.460, 3.49) Hydralazine: RR 1.03 (95% C.I.: 0.494, 2.16) Nifedipine: RR 1.01 (95% C.I.: 0.547, 1.75) All Pairwise Comparisons The comprehensive treatment comparison matrix revealed that: Nifedipine vs. Hydralazine: RR 0.99 (95% C.I.: 0.57, 1.83) HCTZ/Lisinopril vs. Hydralazine: RR 1.28 (95% C.I.: 0.35, 4.32) HCTZ/Lisinopril vs. Nifedipine: RR 1.29 (95% C.I.: 0.56, 2.99) Treatment Ranking (Figure 4A,4B,4C) Surface Under the Cumulative Ranking (SUCRA) analysis indicated a clear hierarchy in the probability of achieving blood pressure control within seven days: 1. Labetalol (SUCRA ˜ 100%): Consistently ranked as the most effective treatment 2. Nifedipine (SUCRA ˜ 60%): Second most likely to achieve BP control 3. Hydralazine (SUCRA ˜ 35%): Intermediate effectiveness 4. HCTZ/Lisinopril (SUCRA ˜ 5%): Lowest probability of achieving BP control within seven days Overall Evidence Synthesis and Implications Taken together, the evidence suggests that amlodipine and nifedipine are most promising for rapid BP control, whereas labetalol is the most reliable for sustained control within seven days. Enalapril and HCTZ/lisinopril combinations appear less effective. Although credible intervals remain wide due to the limited sample sizes and number of trials, the convergence diagnostics, low-to-moderate heterogeneity, and network consistency support the robustness of these findings. Importantly, these results should be interpreted as probabilistic rankings rather than definitive treatment effects, and they highlight the urgent need for larger, rigorously designed postpartum hypertension trials to establish a clear treatment hierarchy. Discussion In this network meta-analysis of randomized controlled trials evaluating pharmacological management of postpartum hypertension, we identified clinically meaningful differences in treatment performance depending on the outcome of interest. For rapid blood pressure control, calcium channel blockers (CCBs)—particularly amlodipine and nifedipine—ranked highest, achieving blood pressure reduction approximately 5–6 hours earlier than labetalol. This finding is consistent with the HIPPO randomized controlled trial, which demonstrated that amlodipine achieved sustained blood pressure control a mean of 7.2 hours earlier than oral labetalol in postpartum women with hypertension. [29] Similarly, a trial comparing extended-release nifedipine with oral labetalol reported shorter time to achieve BP targets with nifedipine (˜30.4 h vs. 35.6 h). [36] Mechanistically, these observations are biologically plausible. CCBs act directly on vascular smooth muscle, blocking L-type calcium channels to produce rapid vasodilation and an immediate fall in systemic vascular resistance. This explains their superior performance in acute stabilization and the faster speed of BP recovery noted in both our network analysis and individual RCTs. [40] In contrast, enalapril—a prototypical angiotensin-converting enzyme (ACE) inhibitor—exerts its antihypertensive effect by suppressing the renin–angiotensin– remodeling. This indirect mechanism results in slower onset of BP reduction. The PICk-UP feasibility trial demonstrated that enalapril improved postnatal cardiac structure and diastolic function after preterm preeclampsia, highlighting benefits for medium- to long-term cardiovascular outcomes rather than immediate postpartum BP lowering. [41] For the proportion of women achieving blood pressure control within seven days postpartum, our analysis ranked labetalol as the most effective treatment, with nifedipine and hydralazine showing intermediate performance. This aligns with previous clinical observations where labetalol, due to its combined a- and ß-adrenergic blockade, provides steady control without large fluctuations in hemodynamics. [42] By contrast, ACE inhibitor–based regimens such as hydrochlorothiazide–lisinopril combinations were consistently less effective in short term postpartum BP control, reinforcing their limited role in the immediate postpartum setting. Our findings are in agreement with recent comparative effectiveness studies. A multicenter non-inferiority RCT reported that amlodipine was comparable to nifedipine extended-release in postpartum hypertension, though differences emerged in tolerability and discontinuation rates. [26] Observational studies further suggest that nifedipine may be associated with fewer readmissions for hypertensive complications compared with labetalol, particularly in North American cohorts. [43-46] Together with our NMA, these results support the preferential use of CCBs for rapid stabilization, while reserving labetalol for reliable longer-term control across the first postpartum week. Despite consistent trends, caution is warranted in interpretation. Many trials were underpowered, varied in their definitions of blood pressure control, and used heterogeneous dosing regimens. Moreover, few studies assessed maternal and neonatal safety in a standardized fashion, limiting firm conclusions regarding comparative safety. Enalapril, for example, is considered safe during lactation, with minimal drug transfer into breast milk, yet its slow onset diminishes its utility for urgent postpartum hypertension control. Clinical implications. Our findings suggest a goal-directed therapeutic strategy: For rapid stabilization, CCBs such as nifedipine or amlodipine are most effective. For steady, reliable control over the first week, labetalol may be more appropriate. ACE inhibitors (e.g., enalapril) and ACE inhibitor–diuretic combinations may have a role in longer-term cardiovascular remodeling but are less effective for immediate postpartum BP reduction. The evidence base remains limited, with wide credible intervals reflecting small sample sizes and heterogeneous designs. Larger, multicenter RCTs with harmonized BP endpoints and standardized safety reporting are urgently needed to confirm treatment hierarchies, evaluate combination therapies, and clarify maternal and neonatal safety profiles across diverse populations. This network meta-analysis provides a comprehensive synthesis of pharmacologic strategies for postpartum hypertension. CCBs appear most effective for rapid BP control due to their direct vasodilatory action, labetalol is superior for sustained control, and enalapril may be best suited for longer-term cardiovascular remodeling rather than acute stabilization. Until adequately powered trials are available, clinical decision-making should remain individualized, balancing pharmacologic properties, therapeutic goals, breastfeeding considerations, and local availability. Conclusion In this first network meta-analysis of pharmacological treatments for postpartum hypertension, calcium channel blockers (amlodipine and nifedipine) ranked highest for rapid blood pressure reduction, whereas labetalol was most effective for sustained control within seven days. Enalapril and hydrochlorothiazide–lisinopril combinations consistently ranked lowest across outcomes. Although these findings provide a comparative framework for treatment selection, wide credible intervals and variable study quality underscore the need for larger, rigorously conducted randomized trials. Together, the results suggest that treatment choice may be guided by the clinical objective—rapid stabilization or sustained control—while further research is needed to confirm these hierarchies and strengthen the evidence base for postpartum hypertension management. References American College of Obstetricians and Gynecologists (2022) Hypertension in pregnancy: diagnosis, blood pressure goals, and pharmacotherapy. Hypertension 79(2):e21 e41 Giorgione V, Ridder A, Kalafat E et al (2021) Incidence of postpartum hypertension within 2 years of a pregnancy complicated by pre-eclampsia: a systematic review and meta-analysis. BJOG 128(3):495–503 Kilpatrick SJ, Abreo A, Gould J et al (2022) Hypertensive disorders in pregnancy and mortality at delivery hospitalization — United States, 2017–2019. MMWR Morb Mortal Wkly Rep 71(17):585–591 Bernstein JA, Bello NA, Hsu CD et al (2022) De novo postpartum hypertension: incidence and risk factors at a safety-net hospital. Hypertension 79(11):2534–2543 Bello NA, Zhou H, Cheetham TC et al (2024) Hypertension in pregnancy and postpartum: current standards and opportunities to improve care. Circulation 150(20):1545 Garovic VD, Dechend R, Easterling T, et al. Hypertension in pregnancy: diagnosis, blood pressure goals, and pharmacotherapy: a scientific statement from the American Heart Association. Hypertension. 2022;79(2):e21-e41. Duhig KE, Vandermolen B, Shennan A. Recent advances in the diagnosis and management of pre-eclampsia. F1000Res. 2018;7:242. ACOG Practice Bulletin No. 202: Gestational hypertension and preeclampsia. Obstet Gynecol. 2019;133(1):e1-e25. Podymow T, August P. Postpartum course of gestational hypertension and preeclampsia. Hypertens Pregnancy. 2010;29(3):294–300. Duan L, Ng A, Chen W, et al. Oral antihypertensive regimens (nifedipine retard, labetalol, and methyldopa) for management of severe hypertension in pregnancy: an open-label, randomised controlled trial. Lancet. 2019;394(10203):1011–1021. Duley L, Meher S, Jones L. Drugs for treatment of very high blood pressure during pregnancy. Cochrane Database Syst Rev. 2013;(7):CD001449. Naqash F, Arshad A, Iram S, et al. Oral labetalol versus oral nifedipine for the management of postpartum hypertension: a randomized control trial. Pak J Med Sci. 2019;35(4):1055–1060. Liu Y, Li G, Zhang W. Different dosage regimens of nifedipine, labetalol, and hydralazine for the treatment of severe hypertension during pregnancy: a network meta analysis of randomized controlled trials. Pregnancy Hypertens. 2022;28:123–132. Zeng L, Tian XT, Zhang L, et al. Drugs for treating severe hypertension in pregnancy: a network meta-analysis and trial sequential analysis of randomized clinical trials.Br J Clin Pharmacol. 2018;84(9):1908–1921. Lovgren T, Caine V, Miller P, et al. Impact of labetalol versus nifedipine treatment on readmission risk in postpartum hypertension: a randomized controlled trial. Pregnancy. 2025;5(1):e70005. Hutton B, Salanti G, Caldwell DM, et al. The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations. Ann Intern Med. 2015;162(11):777–784. Higgins JPT, Thomas J, Chandler J, et al. Cochrane Handbook for Systematic Reviews of Interventions version 6.4 (updated August 2023). Cochrane; 2023. Sterne JAC, Savović J, Page MJ, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366:l4898. Owen, RK, Bradbury, N, Xin, Y, Cooper, N, Sutton, A. MetaInsight: An interactive web-based tool for analyzing, interrogating, and visualizing network meta-analyses using R-shiny and netmeta. Res Syn Meth. 2019; 10: 569–581. Dias S, Welton NJ, Caldwell DM, Ades AE. Checking consistency in mixed treatment comparison meta-analysis. Stat Med. 2010;29(7–8):932–944. Nevill CR, Cooper NJ, Sutton AJ. A multifaceted graphical display, including treatment ranking, was developed to aid interpretation of network meta-analysis. J Clin Epidemiol. 2023;157:83–91. Chaimani A, Higgins JP, Mavridis D, Spyridonos P, Salanti G. Graphical tools for network meta-analysis in STATA. PLoS One. 2013;8(10):e76654. Higgins JPT, Thomas J, Chandler J, et al, eds. Cochrane Handbook for Systematic Reviews of Interventions. Version 6.3 (updated February 2022). Cochrane; 2022. Marques RMCP, Maia SB, Araújo ATV, et al. Management of hypertension in the early postpartum: A randomized controlled trial. Pregnancy Hypertens. 2025;39:101195. doi:10.1016/j.preghy.2025.101195 Cursino T, Katz L, Coutinho I, et al. Postpartum furosemide for accelerating recovery in patients with preeclampsia: a randomized placebo-controlled trial. Am J Obstet Gynecol MFM. 2025;7(5):101614. doi:10.1016/j.ajogmf.2025.101614 Pratt K, Lordo R, Self S, Carlson L. Amlodipine versus nifedipine ER for the management of postpartum hypertension: a noninferiority randomized controlled trial. Am J Obstet Gynecol MFM . 2025;7(1):101575. doi:10.1016/j.ajogmf.2024.101575 Emeruwa UN, Azad H, Ona S, et al. Lasix for the prevention of de novo postpartum hypertension: a randomized placebo-controlled trial (LAPP Trial). Am J Obstet Gynecol . 2025;232(1):125.e1-125.e21. doi:10.1016/j.ajog.2024.04.016 Yoselevsky EM, Seely EW, Celi AC, Robinson JN, McElrath TF. A randomized controlled trial comparing the efficacy of nifedipine and enalapril in the postpartum period. Am J Obstet Gynecol MFM. 2023;5(12):101178. doi:10.1016/j.ajogmf.2023.101178 Gupta A, Nayak D, Sharma J, Keepanasseril A. Comparing the efficacy of oral labetalol with oral amlodipine in achieving blood pressure control in women with postpartum hypertension: randomized controlled trial (HIPPO study-Hypertension In Pregnancy & Postpartum Oral-antihypertensive therapy). J Hum Hypertens. 2023;37(12):1056–1062. doi:10.1038/s41371-023-00841-x Fishel Bartal M, Blackwell SC, Pedroza C, et al. Oral combined hydrochlorothiazide and lisinopril vs nifedipine for postpartum hypertension: a comparative-effectiveness pilot randomized controlled trial. Am J Obstet Gynecol . 2023;228(5):571.e1-571.e10. doi:10.1016/j.ajog.2023.01.015 Suganya T, Vijayalakshmi A, Saravanan S, Aarthikarasi R. Comparative study between oral labetalol vs oral labetalol with oral frusemide in control of blood pressure among postpartum mothers with severe pre-eclampsia. Int J Pharm Clin Res. 2024;16(2):119- Lopes Perdigao J, Lewey J, Hirshberg A, et al. Furosemide for Accelerated Recovery of Blood Pressure Postpartum in women with a hypertensive disorder of pregnancy: A Randomized Controlled Trial. Hypertension . 2021;77(5):1517–1524. doi:10.1161/HYPERTENSIONAHA.120.16133 Arias-Hernández G, Vargas-De-León C, Calzada-482 Mendoza CC, Ocharan-Hernández ME. Efficacy of Diltiazem for the Control of Blood Pressure in Puerperal Patients with Severe Preeclampsia: A Randomized, Single-Blind, Controlled Trial. Int J Hypertens. 2020;2020:5347918. Published 2020 Jul 23. doi:10.1155/2020/5347918 Ainuddin J, Javed F, Kazi S. Oral labetalol versus oral nifedipine for the management of postpartum hypertension a randomized control trial. Pak J Med Sci. 2019;35(5):1428–1433. doi:10.12669/pjms.35.5.812 Veena P, Perivela L, Raghavan SS. Furosemide in postpartum management of severe preeclampsia: A randomized controlled trial. Hypertens Pregnancy. 2017;36(1):84–89. doi:10.1080/10641955.2016.1239735 Sharma KJ, Greene N, Kilpatrick SJ. Oral labetalol compared to oral nifedipine for postpartum hypertension: A randomized controlled trial. Hypertens Pregnancy. 2017;36(1):44–47. doi:10.1080/10641955.2016.1231317 Noronha Neto C C, Maia SSB, Katz L, Coutinho IC, Souza AR, Amorim MM (2017) Clonidine versus Captopril for Severe Postpartum Hypertension: A Randomized Controlled Trial. PLoS ONE 12(1): e0168124. https://doi.org/10.1371/journal.pone.0168124 Vigil-De Gracia P, Ruiz E, López JC, de Jaramillo IA, Vega-Maleck JC, Pinzón J. Management of severe hypertension in the postpartum period with intravenous hydralazine or labetalol: a randomized clinical trial. Hypertens Pregnancy. 2007;26(2):163–171. doi:10.1080/10641950701204430 Sayin NC, Altundag G, Varol FG. Efficacy of alpha-methyldopa and nifedipine in the treatment of postpartum hypertension. J Turk Ger Gynecol Assoc. 2005;6(2):118–122. Easterling T, Mundle S, Bracken H, et al. Oral antihypertensive regimens (nifedipine retard, labetalol, and methyldopa) for management of severe hypertension in pregnancy: an open-label, randomised controlled trial. Lancet. 2019;394(10203):1011- doi:10.1016/S0140-6736(19)31282-6 Ormesher L, Higson S, Luckie M, et al. Postnatal Enalapril to Improve Cardiovascular Function Following Preterm Preeclampsia (PICk-UP):: A Randomized Double-Blind Placebo-Controlled Feasibility Trial. Hypertension. 2020;76(6):1828–1837. doi:10.1161/HYPERTENSIONAHA.120.15875 Magee LA, von Dadelszen P, Rey E, et al. Less-tight versus tight control of hypertension in pregnancy. N Engl J Med. 2015;372(5):407–417. doi:10.1056/NEJMoa1404595 Lovgren T, Connealy B, Yao R, Dahlke JD. Postpartum management of hypertension and effect on readmission rates. Am J Obstet Gynecol MFM . 2022;4(1):100517. doi:10.1016/j.ajogmf.2021.100517 Do SC, Leonard SA, Kan P, Panelli DM, Girsen AI, Lyell DJ, El-Sayed YY, et al. Postpartum readmission for hypertension after discharge on labetalol or nifedipine. Obstet Gynecol . 2022;140(4):591–598. doi:10.1097/AOG.0000000000004937 Lovgren T, Connealy B, Yao R, Dahlke JD. Postpartum medical management of hypertension and risk of readmission for hypertensive complications. J Hypertens . 2023;41(2):351–355. doi:10.1097/HJH.0000000000003382 Mitro SD, Hedderson M, Xu F, Forquer H, Baker JM, Kuzniewicz MW, Greenberg M. Risk of postpartum readmission after hypertensive disorder of pregnancy and variation by discharge antihypertensive medication prescription. Am J Obstet Gynecol . 2024;231(4):456.e1-456.e13. doi:10.1016/j.ajog.2024.01.015 Tables Table 1. Study Characteristics Study Authors/ Year Age Sex Country/ Race Sample size Intervention Comparator Follow-up duration Outcomes Marques R/2025 Methyldopa : 30.0 ± 7.2 Captopril: 30.4 ± 7.3 Females Brazil 172 Active 1: Captopril: 75 mg/day (25 mg tablet every 8 h). Active 2: Methyldopa : 750 mg/day (250 mg tablet every 8 h) ---- 15 days Blood pressure control during first 48 hours postpartum, blood pressure spike, % requiring treatment Escalation , % requiring treatment de-escalation, Edinburgh Postnatal Depression Scale at Day 15, frequency of side effects Cursino T/2025 Furosemide: 23.0±6.9 Placebo: 23.6±6.3 Females Brazil 118 Furosemide (40 mg/d orally for 5 days) Placebo Length of stay in the hospital Mean SBP & DBP during hospitalization, frequency of severe hypertensive episodes, Number of antihypertensives at discharge, Time until BP Control, Time from intervention to hospital discharge, Frequency of side effects, frequency of maternal complications. Pratt K/2025 Amlodipine: 27.9±6.8 nifedipine ER: 27.8±5.9 Females United States of America 175 Active 1: amlodipine 2.5 mg/day Active 2: nifedipine ER 30 mg/day ---- 6 weeks Time from delivery until hospital discharge, acute antihypertensive treatment, discharge dose, need for additional long-acting antihypertensives, side effects, medication discontinuation, breastfeeding outcomes, and readmission rate within 6 weeks postpartum. Emeruwa UN/2025 Furosemide: 35.0 (30.8-39.2) Placebo : 37.0 (34.0e-9.0) Females United States of America 80 once-daily 20-mg oral furosemide Placebo 6 weeks Average MAP over 24 hours before discharge, rate of preeclampsia, % of elevated BP, rate of MgSO4 administration, time to hospital discharge, rates of initiation of antihypertensives, rates of hypertension-related SMM, mean frequency of triage or emergency department presentations and read- mission, breastfeeding continuation rates, and neonatal outcomes Yoselevsky EM/2023 Nifedipine: 33.2 (6.4) Enalapril: 32.4 (6.7) Females United States of America 94 Active 1: enalapril 10 mg /day Active 2: nifedipine ER 30 mg/day ----- 6 weeks prolonged hospitalization, unplanned clinic visit, a triage visit, hospital readmission after starting the study agent, time to sustained BP control, need for additional antihypertensives, time to discharge from the hospital, BP at the initial clinic visit after discharge, creatinine levels at follow-up visits, continued need for antihypertensive up to 6 weeks postpartum, side effects, patient reported compliance. Gupta A/2023 Labetalol: 27.8 ± 5.4 Amlodipine: 27.4 ± 5.5 Females India 130 Active 1: Oral Labetalol ( 100mg BD) Active 2: Oral Amlodipine (2.5 mg BD) - Length of hospital stay time taken to achieve BP control, dose to achieve control of hypertension, side effects of each drug. Bartal MF/2023 combined hydrochlorothiazide and lisinopril : 30.0 (28.03± 3.5) Nifedipine: 33.00 (27.03± 6.3) Females United States of America 67 Active 1: combined hydrochlorothiazide (12.5 mg/day) and lisinopril (10 mg/day) Active 2: Nifedipine(30mg/day) --- 6 weeks average BP over days 7 to 10 after delivery, severe maternal morbidity up to 6 weeks after delivery, severe BP requiring intravenous medications, post- partum hospital length of stay, sBP and dBP during the first clinic visit, medication compliance at 7 to 10 days after delivery and during the postpartum period, and adverse events. Suganya T/2023 Labetalol : 25.9 (5.41) Labetalol And Furosemide: 26.48 (4.89) Females India 60 Labetalol And Furosemide (40 mg OD) Labetalol 14 days Systolic BP reduction, need for additional antihypertensive, morbidity , Hospital stay. Perdigao JL/2021 Furosemide: 27 (22–32) placebo : 27 (23–33) Females United States of America 384 oral furosemide 20mg placebo 6 weeks prevalence of persistent hypertension 7-days postpartum, days required to achieve resolution of hypertension,% of postpartum severe BP, need for additional antihypertensive medications postpartum, postpartum readmissions or emergency visits, postpartum length of stay, pulmonary edema and severe maternal morbidity, adverse effects, neonatal ICU admission, self-reported breastfeeding issues Arias-Hernandez/2020 Diltiazem: 21.6 (6.8) Nifedipine: 23.2 (6.2) Females Mexico 42 Active 1: diltiazem (60 mg) TDS Active 2: nifedipine (10 mg) TDS ---- 48 hours SBP , DBP and HR, number of hypertension and hypo- tension episodes and ICU length of stay. Ainuddin J/2019 Labetalol: 26.7 ± 1.9 Nifedipine: 25.9 ± 1.8 Females Pakistan 124 Active 1: Labetalol 100 mg Q1D Active 2: nifedipine LA 30mg/day ---- 72 hours time to achieve BP control, sustained BP control, need of additional antihypertensive medications, length of hospital stay , drug related side effects. Veena P/2017 Nifedipine and furosemide: 36.0 ± 3.0 Nifedipine: 36.1 ± 3.0 Females India 100 Nifedipine(10 mg) and furosemide(20 mg) Nifedipine(10 mg) 2 weeks reduction in SBP & DBP, reduction in MAP, dose of nifedipine required for control of BP, requirement of additional antihypertensive drugs, number of days of hospital stay after delivery, and anti- hypertensive requirement at discharge. Sharma KJ/2017 Labetalol : 34.0 (7.4) Nifedipine ER: 33.3 (6.4) Females United States of America 50 Active 1: Labetalol 200 mg PO BID escalating to 800 mg PO BID Active 2: Nifedipine ER 30 mg PO daily escalating to 90 mg PO daily ---- 6 weeks time to achieve BP control, postpartum length of stay, the need for increased dosing, need for additional IV and oral antihypertensive medication, side effects Noronha Neto C/2017 Clonidine: 28.9 (6.7) Captopril: 28.8 (6.7) Females Brazil 88 Active 1: oral clonidine (0.1 mg) Active 2: oral captopril (25 mg) ----- Length of hospital stay frequency of very high BP episodes, daily mean SBP and DBP levels, number of days with very high BP episodes, number of days until BP was controlled, percentage reduction in SBP, % reduction in DBP, number of doses used to control BP, need to add another hypertensive agent, number of antihypertensives added, need for sodium nitroprusside, maternal complications, adverse effects, number of days in obstetric ICU and death. Vigil-De Gracia/2007 Hydralazine: 29.9 ± 5.9 Labetalol: 31.3 ± 5.5 Females United States of America 82 Active 1: hydralazine (5 mg slow bolus given intravenously, and repeated every 20 minutes to a maximum of 5 doses) Active 2: labetalol (20 mg intravenous bolus dose followed by 40 mg if not effective within 20 minutes, followed by 80 mg every 20 minutes to a maximum dose of 300 mg) ---- 24 hours lowering of BP, uncontrolled BP, need for additional antihypertensive therapy, doses of antihypertensive, eclampsia, HELLP syndrome, pulmonary edema, oliguria, DIC, hypertensive encephalopathy, maternal heart rate ≥ 100 beats/min, maternal side-effects Sayin N/2005 alpha-methyldopa: 28.1±5.9 nifedipine: 27.1±5.9 Females Turkey 83 Active 1 : alpha-methyldopa (750 mg/d) Active 2: nifedipine (40 mg/d) ---- Time taken to achieve normotension Monotherapy success rates, dual or triple therapy required, lab parameters, Medication needed after 7 days. Supplementary Files Supplementary files S1-S3 are not available with this version. Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7523179","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":509448988,"identity":"10e939dd-0ae2-49b9-9794-5953811abec3","order_by":0,"name":"ALOK 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06:01:56","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":true,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":true},"doi":"10.21203/rs.3.rs-7523179/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7523179/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":90813414,"identity":"9027f068-5dca-4f9b-a981-d248c1131f5d","added_by":"auto","created_at":"2025-09-08 12:30:38","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":5713,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-7523179/v1/5abbcff95e6f93ac26672b2c.png"},{"id":90813417,"identity":"5ab577eb-8278-4799-83ac-15806a3956ac","added_by":"auto","created_at":"2025-09-08 12:30:39","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":154475,"visible":true,"origin":"","legend":"\u003cp\u003eRisk of bias was assessed using the \u003cstrong\u003eROB-2 tool.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-7523179/v1/f05883c44853bd9f9c1bd724.png"},{"id":90813416,"identity":"42f8afa3-3d53-4162-85f0-43efc7c933df","added_by":"auto","created_at":"2025-09-08 12:30:39","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":288413,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-7523179/v1/871ba695cfb0789e718dc5bb.png"},{"id":90814067,"identity":"288d412d-43a5-4a20-9de2-b69fc8bd005d","added_by":"auto","created_at":"2025-09-08 12:38:39","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":227277,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-7523179/v1/51dea7efdc54cf7c7f1b72dc.png"},{"id":90814459,"identity":"5638e225-00e9-49a5-a3ee-e6d1fe0983d7","added_by":"auto","created_at":"2025-09-08 12:46:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1244007,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7523179/v1/13cca2ae-a8d4-4175-9e64-d1b1087514b7.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eEfficacy of Pharmacological Agents for Management of Post-partum Hypertension: A Network Meta-analysis\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePostpartum hypertension (PPHTN), defined as elevated blood pressure occurring or persisting within six weeks after childbirth, represents a significant cardiovascular complication in the puerperium. Hypertensive disorders of pregnancy (HDP), which include gestational hypertension and preeclampsia, complicate approximately 10% of pregnancies globally and 13\u0026ndash;15% in the United States. [1,2] Recent data indicate an upward trend in HDP-related hospitalizations, rising from 13.3% to 15.9% between 2017 and 2019. [3] PPHTN encompasses both the persistence of HDP beyond delivery and de novo onset of hypertension in the postpartum period, the latter affecting up to 8% of women within the first week following childbirth.[4] Importantly, nearly 60% of maternal deaths occur within one year postpartum, with HDP being a major contributor. [5] The pathophysiology of PPHTN involves complex transitions in cardiovascular and hormonal \u0026nbsp;systems during the shift from pregnancy to the non-pregnant state, including intravascular volume redistribution and autonomic fluctuations. Women with a history of HDP are at \u0026nbsp;increased risk of chronic hypertension, coronary artery disease, and stroke, underscoring the \u0026nbsp;need for optimal acute management strategies to improve both short- and long-term outcomes. [6] The condition disproportionately affects certain populations, with the highest prevalence observed among women aged 35-44 years (18.0%) and those identifying as Black (20.9%) or American Indian and Alaska Native (16.4%).[3] Pharmacological management of PPHTN varies widely across clinical settings. Commonly used antihypertensive agents include labetalol (a combined a- and \u0026szlig;-blocker), nifedipine (a calcium channel blocker), hydralazine (a direct vasodilator), and methyldopa (a central a-2 agonist). [7,8] Of these, labetalol and methyldopa are often preferred due to their favorable \u0026nbsp;safety profiles in breastfeeding women. [9] While several randomized controlled trials (RCTs) have compared these agents, robust comparative data specific to the postpartum population remain limited. A pivotal trial comparing nifedipine retard, labetalol, and methyldopa in pregnancy showed all three as effective first-line options. [10] However, systematic reviews have noted that oral labetalol and methyldopa may only be effective in about 50% of pregnant women, emphasizing the need for further evaluation. [11]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSeveral RCTs have focused specifically on PPHTN, including comparisons between oral nifedipine and oral labetalol. [12] Early network meta-analyses (NMAs) of antihypertensive drugs in pregnancy suggested that nifedipine 114 at various doses was more effective than intravenous labetalol. [13] Other NMAs and trial sequential analyses have reported that agents \u0026nbsp;like glyceryl trinitrate and labetalol are associated with fewer maternal adverse effects \u0026nbsp;compared to hydralazine. [14] Nevertheless, the existing evidence is fragmented, with \u0026nbsp;inconsistent methodologies, heterogeneity in outcome definitions, and limited data specific to \u0026nbsp;the postpartum setting. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGiven these limitations, clinicians often lack clear, evidence-based guidance on selecting the \u0026nbsp;most appropriate antihypertensive agent in the postpartum period. The postpartum setting \u0026nbsp;introduces unique therapeutic considerations, such as breastfeeding safety, rapid physiological \u0026nbsp;shifts, and the need for prompt blood pressure control. Existing reviews acknowledge the \u0026nbsp;absence of a standardized stepwise pharmacologic strategy for PPHTN. [12] Moreover, \u0026nbsp;treatment decisions can significantly impact maternal outcomes, including hospital \u0026nbsp;readmission rates. [15] Amid increasing emphasis on maternal safety and standardized care pathways, the demand for reliable comparative effectiveness data is urgent.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTherefore, this systematic review and network meta-analysis aim to synthesize the best available evidence from randomized controlled trials to evaluate the comparative effectiveness and safety of antihypertensive agents used in PPHTN. By integrating both direct and indirect comparisons, this analysis seeks to support evidence-based clinical decision-making and improve maternal outcomes during this critical phase of care.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eData Sources and Searches\u003c/p\u003e\n\u003cp\u003eThis systematic review and network meta-analysis followed the PRISMA extension for \u0026nbsp;Network Meta-Analyses (PRISMA-NMA) reporting guideline. [16] Methodological procedures were guided by the Cochrane Handbook for Systematic Reviews of Interventions, Version 6.4. [17] MEDLINE and Embase were searched from inception to July 2025, without language restrictions. Reference lists of relevant reviews and eligible articles were screened to identify additional studies. The protocol was prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO) prior to data collection and analysis. [PROSPERO Registration Number: CRD420251104693] Search strategy is available as supplementary file (S1).\u003c/p\u003e\n\u003cp\u003eStudy Selection\u003c/p\u003e\n\u003cp\u003eEligible studies were randomized clinical trials (RCTs) enrolling women with postpartum hypertension treated with any systemic pharmacological antihypertensive agents. Comparators included other active antihypertensive drugs or placebo/standard care. Trials were required to report at least one prespecified outcome. Nonrandomized studies, antenatal hypertension trials without postpartum data, assessed only non-pharmacological interventions, and those lacking extractable outcome measures were excluded. Two reviewers independently screened all titles, abstracts, and full texts, with disagreements resolved by consensus.\u003c/p\u003e\n\u003cp\u003eData Extraction and Quality Assessment\u003c/p\u003e\n\u003cp\u003eThree investigators (AS, MPS, RY) independently extracted data on study design, population characteristics, interventions, and outcomes using a standardized form. Risk of bias was assessed with the Cochrane Risk of Bias 2.0 tool. [18] Discrepancies were resolved by discussion or by consultation with a third reviewer (SK).\u003c/p\u003e\n\u003cp\u003eOutcomes\u003c/p\u003e\n\u003cp\u003eThe primary outcomes were (1) time from delivery to attainment of blood pressure control (measured in hours) and (2) the proportion of women achieving blood pressure control within seven days postpartum. Definitions for blood pressure control were accepted as per each individual trial, commonly systolic \u0026lt;140 mmHg and diastolic \u0026lt;90mmHg. The outcomes were finalized by two authors (PT, AS).\u003c/p\u003e\n\u003cp\u003eStatistical Analysis\u003c/p\u003e\n\u003cp\u003eA Bayesian random-effects network meta-analysis was performed by the Meta Insight platform (University of Leicester, UK) which uses gemtc package and network plot was created to show connections among numerous drugs evaluated. [19] Posterior distributions for treatment effect were synthesized by non-informative prior distributions by using Markov Chain Monte Carlo (MCMC) simulations. MCMC convergence has been assessed for each endpoint and presented along with results. Brooks- Gelman diagnostics tool was used to assess convergence. To assess transitivity, the distribution of potential effect modifiers was reviewed across all comparisons. Model convergence was assessed by visual inspection of trace plots and posterior distributions. Consistency between direct and indirect evidence was evaluated \u0026nbsp;using design-by-treatment interaction models and node-splitting approaches. [20] SUCRA \u0026nbsp;(Surface Under the Cumulative Ranking Curve) values were also calculated to complement ranking assessments. Treatments were ranked using cumulative probability, which represent the mean probability of each intervention being superior to others. [21] For outcomes with =10 contributing trials, comparison-adjusted funnel plots were constructed to evaluate small-study effects and potential publication bias. [22,23] Treatment effects were expressed as mean differences (MDs) with 95% confidence intervals (C.I.) for continuous outcomes and risk ratios (RRs) with 95% C.I. for binary outcomes. A two-tailed P value \u0026lt;.05 was considered statistically significant for all comparisons.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eCharacteristics of Included Studies\u003c/p\u003e\n\u003cp\u003eSixteen randomized controlled trials (2005\u0026ndash;2025) enrolling a total of 1,625 postpartum women with hypertensive disorders were included (Table 1) (Figure 1). Studies were conducted in Brazil, India, the United States, Mexico, Pakistan, and Turkey, with sample sizes ranging from 42 to 384 participants. All participants were female, with mean ages spanning early 20s to late 30s. A wide range of antihypertensive interventions was assessed: labetalol, nifedipine (immediate/extended release), amlodipine, enalapril, methyldopa/alpha-methyldopa, 196 hydralazine, clonidine, diltiazem, furosemide (alone or in combination), and hydrochlorothiazide/lisinopril. Comparators most frequently included nifedipine, captopril, placebo, amlodipine, labetalol, and enalapril.\u003c/p\u003e\n\u003cp\u003eFollow-up durations ranged from 24 hours (acute BP control studies) to 6 weeks postpartum, with primary outcomes encompassing time to achieve blood pressure (BP) control, proportion of women with BP control at 7 days, need for additional antihypertensives, hospital length of stay, maternal complications (e.g., pulmonary edema, HELLP syndrome, eclampsia), readmission, and breastfeeding-related outcomes.\u003c/p\u003e\n\u003cp\u003eTwo primary evidence networks were formed for the NMA:\u003c/p\u003e\n\u003cp\u003e1. Time to achieve BP control (hours): labetalol, nifedipine, amlodipine, and enalapril.\u003c/p\u003e\n\u003cp\u003e2. Proportion achieving BP control within 7 days: labetalol, nifedipine, hydralazine, and HCTZ/lisinopril combination.\u003c/p\u003e\n\u003cp\u003eRisk of Bias\u003c/p\u003e\n\u003cp\u003eRisk of bias was assessed using the ROB-2 tool (Figure 2).\u003c/p\u003e\n\u003cp\u003eLow risk or some concerns: Several trials (e.g., Gupta 2023, Sharma 2017, Perdigao 2021, Pratt 2025, Cursino 2025, Vigil-de Gracia 2007, Noronha 2017) demonstrated relatively low bias, with minor issues mainly in deviations from interventions.\u003c/p\u003e\n\u003cp\u003eHigh risk: Other trials (e.g., Ainuddin 2019, Bartal 2023, Marques 2025, Sayin 2005, Hernandez 2020, Yoselevsky 2023) were judged high risk, primarily due to unclear or inadequate randomisation processes and missing outcome data.\u003c/p\u003e\n\u003cp\u003eDomains most affected: Randomisation (D1) and missing data (D3) were the most frequent sources of high risk. Outcome measurement (D4) and selective reporting (D5) were generally low risk.\u003c/p\u003e\n\u003cp\u003eOverall, the evidence base consists of a mix of rigorously conducted recent RCTs and older or smaller studies with methodological limitations, necessitating cautious interpretation of treatment rankings. Node-splitting and consistency checks indicated no significant disagreement between direct and indirect evidence (p \u0026gt; 0.05), supporting the use of the consistency model.\u003c/p\u003e\n\u003cp\u003eNetwork Meta-analysis\u003c/p\u003e\n\u003cp\u003e1. Time to Achieve Blood Pressure Control\u003c/p\u003e\n\u003cp\u003eA total of four antihypertensive agents\u0026mdash;labetalol, nifedipine, amlodipine, and enalapril\u0026mdash; were evaluated across the included randomized controlled trials for the outcome of time (in hours) to achieve postpartum blood pressure control. Labetalol was the most frequently studied agent and served as the reference for analysis.\u003c/p\u003e\n\u003cp\u003eMCMC Convergence Assessment\u003c/p\u003e\n\u003cp\u003eThe Bayesian random-effects network meta-analysis demonstrated robust convergence across all parameters. Convergence diagnostics showed excellent performance: shrink factors (R-hat) approached 1.0 (\u0026lt;1.05) by approximately 5,000 \u0026nbsp;iterations for all treatment comparisons \u0026nbsp;(d.Nifedipine.Amlodipine, d.Nifedipine.Enalapril, d.Nifedipine.Labetalol) and the between study heterogeneity parameter (sd.d). Trace plots confirmed good chain mixing and stationarity across all four MCMC chains (20,000 iterations each after 5,000 burn-in iterations, number of chains 4), ensuring reliable posterior estimates.\u003c/p\u003e\n\u003cp\u003ePairwise and Network Meta-analysis\u003c/p\u003e\n\u003cp\u003eThe Bayesian random-effects network meta-analysis with confirmed convergence revealed that, compared with labetalol (reference):\u003c/p\u003e\n\u003cp\u003eAmlodipine: MD -5.85 hours (95% C.I.: -21.3, 11.4) - associated with shorter time to BP control\u003c/p\u003e\n\u003cp\u003eNifedipine: MD -5.11 hours (95% C.I.: -17.9, 9.71) - associated with shorter time to BP control\u003c/p\u003e\n\u003cp\u003eEnalapril: MD +23.7 hours (95% C.I.: -9.25, 57.3) - associated with longer time to BP control\u003c/p\u003e\n\u003cp\u003eAll Pairwise Comparisons\u003c/p\u003e\n\u003cp\u003eThe comprehensive treatment comparison matrix revealed:\u003c/p\u003e\n\u003cp\u003eAmlodipine vs. Nifedipine: MD 0.84 hours (95% C.I.: -15.9, 17.6) - minimal difference\u003c/p\u003e\n\u003cp\u003eEnalapril vs. Amlodipine: MD 29.3 hours (95% C.I.: -5.13, 63.7) - enalapril slower\u003c/p\u003e\n\u003cp\u003eEnalapril vs. Nifedipine: MD 28.6 hours (95% C.I.: -2.31, 59.3) - enalapril slower\u003c/p\u003e\n\u003cp\u003eTreatment Ranking (Figure 3A,3B,3C)\u003c/p\u003e\n\u003cp\u003eSurface Under the Cumulative Ranking (SUCRA) analysis indicated a clear hierarchy for speed of BP control:\u003c/p\u003e\n\u003cp\u003e1. Amlodipine (SUCRA = 79.7%): Most likely to achieve fastest BP control\u003c/p\u003e\n\u003cp\u003e2. Nifedipine (SUCRA = 75.2%): Second most effective for rapid BP control\u003c/p\u003e\n\u003cp\u003e3. Labetalol (SUCRA = 40.3%): Intermediate effectiveness\u003c/p\u003e\n\u003cp\u003e4. Enalapril (SUCRA = 4.8%): Slowest to achieve BP control\u003c/p\u003e\n\u003cp\u003eConsistency Assessment (supplementary file S2)\u003c/p\u003e\n\u003cp\u003eNode-splitting analysis and consistency plots showed good agreement between direct and indirect evidence across all comparisons (p-values \u0026gt; 0.05), supporting the validity of the consistency model assumptions.\u003c/p\u003e\n\u003cp\u003e2. Proportion of Women Achieving Blood Pressure Control Within Seven Days Postpartum\u003c/p\u003e\n\u003cp\u003eA total of four antihypertensive agents\u0026mdash;labetalol, nifedipine, hydralazine, and HCTZ/lisinopril combination\u0026mdash;were evaluated across the included randomized controlled trials for the binary outcome of achieving postpartum blood pressure control within seven days. Based on the network structure, labetalol served as the reference treatment for the analysis.\u003c/p\u003e\n\u003cp\u003eMCMC Convergence Assessment\u003c/p\u003e\n\u003cp\u003eThe Bayesian random-effects network meta-analysis demonstrated robust convergence across all parameters. Convergence diagnostics showed excellent performance: shrink factors (R-hat) approached 1.0 (\u0026lt;1.05) by approximately 5,000 iterations for all treatment comparisons \u0026nbsp;(d.Labetalol.Hydralazine, d.Labetalol.Nifedipine, d.Labetalol.HCTZ_Lisinopril) and the between-study heterogeneity parameter (sd.d). Trace plots confirmed good chain mixing and stationarity across all four MCMC chains (20,000 iterations each after 5,000 burn-in iterations, chain 04), ensuring reliable posterior estimates. (supplementary file S3)\u003c/p\u003e\n\u003cp\u003ePairwise and Network Meta-analysis\u003c/p\u003e\n\u003cp\u003eThe Bayesian random-effects network meta-analysis with confirmed convergence revealed that compared with labetalol (reference), all alternative treatments showed numerically higher risk ratios, indicating potentially lower effectiveness:\u003c/p\u003e\n\u003cp\u003eHCTZ/Lisinopril combination: RR 1.31 (95% C.I.: 0.460, 3.49)\u003c/p\u003e\n\u003cp\u003eHydralazine: RR 1.03 (95% C.I.: 0.494, 2.16)\u003c/p\u003e\n\u003cp\u003eNifedipine: RR 1.01 (95% C.I.: 0.547, 1.75)\u003c/p\u003e\n\u003cp\u003eAll Pairwise Comparisons\u003c/p\u003e\n\u003cp\u003eThe comprehensive treatment comparison matrix revealed that:\u003c/p\u003e\n\u003cp\u003eNifedipine vs. Hydralazine: RR 0.99 (95% C.I.: 0.57, 1.83)\u003c/p\u003e\n\u003cp\u003eHCTZ/Lisinopril vs. Hydralazine: RR 1.28 (95% C.I.: 0.35, 4.32)\u003c/p\u003e\n\u003cp\u003eHCTZ/Lisinopril vs. Nifedipine: RR 1.29 (95% C.I.: 0.56, 2.99)\u003c/p\u003e\n\u003cp\u003eTreatment Ranking (Figure 4A,4B,4C)\u003c/p\u003e\n\u003cp\u003eSurface Under the Cumulative Ranking (SUCRA) analysis indicated a clear hierarchy in the probability of achieving blood pressure control within seven days:\u003c/p\u003e\n\u003cp\u003e1. Labetalol (SUCRA \u0026tilde; 100%): Consistently ranked as the most effective treatment\u003c/p\u003e\n\u003cp\u003e2. Nifedipine (SUCRA \u0026tilde; 60%): Second most likely to achieve BP control\u003c/p\u003e\n\u003cp\u003e3. Hydralazine (SUCRA \u0026tilde; 35%): Intermediate effectiveness\u003c/p\u003e\n\u003cp\u003e4. HCTZ/Lisinopril (SUCRA \u0026tilde; 5%): Lowest probability of achieving BP control within seven days\u003c/p\u003e\n\u003cp\u003eOverall Evidence Synthesis and Implications\u003c/p\u003e\n\u003cp\u003eTaken together, the evidence suggests that amlodipine and nifedipine are most promising for rapid BP control, whereas labetalol is the most reliable for sustained control within seven days. Enalapril and HCTZ/lisinopril combinations appear less effective. Although credible intervals remain wide due to the limited sample sizes and number of trials, the convergence diagnostics, low-to-moderate heterogeneity, and network consistency support the robustness of these findings. Importantly, these results should be interpreted as probabilistic rankings rather than definitive treatment effects, and they highlight the urgent need for larger, rigorously designed postpartum hypertension trials to establish a clear treatment hierarchy.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this network meta-analysis of randomized controlled trials evaluating pharmacological management of postpartum hypertension, we identified clinically meaningful differences in treatment performance depending on the outcome of interest. For rapid blood pressure control, calcium channel blockers (CCBs)\u0026mdash;particularly amlodipine and nifedipine\u0026mdash;ranked highest, achieving blood pressure reduction approximately 5\u0026ndash;6 hours earlier than labetalol. This finding is consistent with the HIPPO randomized controlled trial, which demonstrated that amlodipine achieved sustained blood pressure control a mean of 7.2 hours earlier than oral labetalol in postpartum women with hypertension. [29] Similarly, a trial comparing extended-release nifedipine with oral labetalol reported shorter time to achieve BP targets with nifedipine (\u0026tilde;30.4 h vs. 35.6 h). [36]\u003c/p\u003e\n\u003cp\u003eMechanistically, these observations are biologically plausible. CCBs act directly on vascular smooth muscle, blocking L-type calcium channels to produce rapid vasodilation and an immediate fall in systemic vascular resistance. This explains their superior performance in acute stabilization and the faster speed of BP recovery noted in both our network analysis and individual RCTs. [40] In contrast, enalapril\u0026mdash;a prototypical angiotensin-converting enzyme (ACE) inhibitor\u0026mdash;exerts its antihypertensive effect by suppressing the renin\u0026ndash;angiotensin\u0026ndash; remodeling. This indirect mechanism results in slower onset of BP reduction. The PICk-UP feasibility trial demonstrated that enalapril improved postnatal cardiac structure and diastolic function after preterm preeclampsia, highlighting benefits for medium- to long-term cardiovascular outcomes rather than immediate postpartum BP lowering. [41]\u003c/p\u003e\n\u003cp\u003eFor the proportion of women achieving blood pressure control within seven days postpartum, our analysis ranked labetalol as the most effective treatment, with nifedipine and hydralazine showing intermediate performance. This aligns with previous clinical observations where labetalol, due to its combined a- and \u0026szlig;-adrenergic blockade, provides steady control without large fluctuations in hemodynamics. [42] By contrast, ACE inhibitor\u0026ndash;based regimens such as hydrochlorothiazide\u0026ndash;lisinopril combinations were consistently less effective in short term postpartum BP control, reinforcing their limited role in the immediate postpartum setting. Our findings are in agreement with recent comparative effectiveness studies. A multicenter non-inferiority RCT reported that amlodipine was comparable to nifedipine extended-release in postpartum hypertension, though differences emerged in tolerability and discontinuation rates. [26] Observational studies further suggest that nifedipine may be associated with fewer readmissions for hypertensive complications compared with labetalol, particularly in North American cohorts. [43-46] Together with our NMA, these results support the preferential use of CCBs for rapid stabilization, while reserving labetalol for reliable longer-term control across the first postpartum week.\u003c/p\u003e\n\u003cp\u003eDespite consistent trends, caution is warranted in interpretation. Many trials were underpowered, varied in their definitions of blood pressure control, and used heterogeneous dosing regimens. Moreover, few studies assessed maternal and neonatal safety in a standardized fashion, limiting firm conclusions regarding comparative safety. Enalapril, for example, is considered safe during lactation, with minimal drug transfer into breast milk, yet its slow onset diminishes its utility for urgent postpartum hypertension control.\u003c/p\u003e\n\u003cp\u003eClinical implications. Our findings suggest a goal-directed therapeutic strategy:\u003c/p\u003e\n\u003cp\u003eFor rapid stabilization, CCBs such as nifedipine or amlodipine are most effective.\u003c/p\u003e\n\u003cp\u003eFor steady, reliable control over the first week, labetalol may be more appropriate.\u003c/p\u003e\n\u003cp\u003eACE inhibitors (e.g., enalapril) and ACE inhibitor\u0026ndash;diuretic combinations may have a role in longer-term cardiovascular remodeling but are less effective for immediate postpartum BP reduction.\u003c/p\u003e\n\u003cp\u003eThe evidence base remains limited, with wide credible intervals reflecting small sample sizes and heterogeneous designs. Larger, multicenter RCTs with harmonized BP endpoints and standardized safety reporting are urgently needed to confirm treatment hierarchies, evaluate combination therapies, and clarify maternal and neonatal safety profiles across diverse populations. This network meta-analysis provides a comprehensive synthesis of pharmacologic strategies for postpartum hypertension. CCBs appear most effective for rapid BP control due to their direct vasodilatory action, labetalol is superior for sustained control, and enalapril may be best suited for longer-term cardiovascular remodeling rather than acute stabilization. Until adequately powered trials are available, clinical decision-making should remain individualized, balancing pharmacologic properties, therapeutic goals, breastfeeding considerations, and local availability.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this first network meta-analysis of pharmacological treatments for postpartum hypertension, calcium channel blockers (amlodipine and nifedipine) ranked highest for rapid blood pressure reduction, whereas labetalol was most effective for sustained control within seven days. Enalapril and hydrochlorothiazide\u0026ndash;lisinopril combinations consistently ranked lowest across outcomes. Although these findings provide a comparative framework for treatment selection, wide credible intervals and variable study quality underscore the need for larger, rigorously conducted randomized trials. Together, the results suggest that treatment choice may be guided by the clinical objective\u0026mdash;rapid stabilization or sustained control\u0026mdash;while further research is needed to confirm these hierarchies and strengthen the evidence base for postpartum hypertension management.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eAmerican College of Obstetricians and Gynecologists (2022) Hypertension in pregnancy: diagnosis, blood pressure goals, and pharmacotherapy. Hypertension 79(2):e21 e41\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eGiorgione V, Ridder A, Kalafat E et al (2021) Incidence of postpartum hypertension within 2 years of a pregnancy complicated by pre-eclampsia: a systematic review and meta-analysis. BJOG 128(3):495\u0026ndash;503\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eKilpatrick SJ, Abreo A, Gould J et al (2022) Hypertensive disorders in pregnancy and mortality at delivery hospitalization \u0026mdash; United States, 2017\u0026ndash;2019. MMWR Morb Mortal Wkly Rep 71(17):585\u0026ndash;591\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eBernstein JA, Bello NA, Hsu CD et al (2022) De novo postpartum hypertension: incidence and risk factors at a safety-net hospital. Hypertension 79(11):2534\u0026ndash;2543\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eBello NA, Zhou H, Cheetham TC et al (2024) Hypertension in pregnancy and postpartum: current standards and opportunities to improve care. Circulation 150(20):1545\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eGarovic VD, Dechend R, Easterling T, et al. Hypertension in pregnancy: diagnosis, blood pressure goals, and pharmacotherapy: a scientific statement from the American Heart Association. Hypertension. 2022;79(2):e21-e41.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eDuhig KE, Vandermolen B, Shennan A. Recent advances in the diagnosis and management of pre-eclampsia. F1000Res. 2018;7:242.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eACOG Practice Bulletin No. 202: Gestational hypertension and preeclampsia. Obstet Gynecol. 2019;133(1):e1-e25.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003ePodymow T, August P. Postpartum course of gestational hypertension and preeclampsia. Hypertens Pregnancy. 2010;29(3):294\u0026ndash;300.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eDuan L, Ng A, Chen W, et al. Oral antihypertensive regimens (nifedipine retard, labetalol, and methyldopa) for management of severe hypertension in pregnancy: an open-label, randomised controlled trial. Lancet. 2019;394(10203):1011\u0026ndash;1021.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eDuley L, Meher S, Jones L. Drugs for treatment of very high blood pressure during pregnancy. Cochrane Database Syst Rev. 2013;(7):CD001449.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eNaqash F, Arshad A, Iram S, et al. Oral labetalol versus oral nifedipine for the management of postpartum hypertension: a randomized control trial. Pak J Med Sci. 2019;35(4):1055\u0026ndash;1060.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLiu Y, Li G, Zhang W. Different dosage regimens of nifedipine, labetalol, and hydralazine for the treatment of severe hypertension during pregnancy: a network meta analysis of randomized controlled trials. Pregnancy Hypertens. 2022;28:123\u0026ndash;132.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eZeng L, Tian XT, Zhang L, et al. Drugs for treating severe hypertension in pregnancy: a network meta-analysis and trial sequential analysis of randomized clinical trials.Br J Clin Pharmacol. 2018;84(9):1908\u0026ndash;1921.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLovgren T, Caine V, Miller P, et al. Impact of labetalol versus nifedipine treatment on readmission risk in postpartum hypertension: a randomized controlled trial. Pregnancy. 2025;5(1):e70005.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eHutton B, Salanti G, Caldwell DM, et al. The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations. Ann Intern Med. 2015;162(11):777\u0026ndash;784.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eHiggins JPT, Thomas J, Chandler J, et al. Cochrane Handbook for Systematic Reviews of Interventions version 6.4 (updated August 2023). Cochrane; 2023.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSterne JAC, Savović J, Page MJ, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366:l4898.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eOwen, RK, Bradbury, N, Xin, Y, Cooper, N, Sutton, A. MetaInsight: An interactive web-based tool for analyzing, interrogating, and visualizing network meta-analyses using R-shiny and netmeta. Res Syn Meth. 2019; 10: 569\u0026ndash;581.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eDias S, Welton NJ, Caldwell DM, Ades AE. Checking consistency in mixed treatment comparison meta-analysis. Stat Med. 2010;29(7\u0026ndash;8):932\u0026ndash;944.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eNevill CR, Cooper NJ, Sutton AJ. A multifaceted graphical display, including treatment ranking, was developed to aid interpretation of network meta-analysis. J Clin Epidemiol. 2023;157:83\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eChaimani A, Higgins JP, Mavridis D, Spyridonos P, Salanti G. Graphical tools for network meta-analysis in STATA. PLoS One. 2013;8(10):e76654.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eHiggins JPT, Thomas J, Chandler J, et al, eds. Cochrane Handbook for Systematic Reviews of Interventions. Version 6.3 (updated February 2022). Cochrane; 2022.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMarques RMCP, Maia SB, Ara\u0026uacute;jo ATV, et al. Management of hypertension in the early postpartum: A randomized controlled trial. Pregnancy Hypertens. 2025;39:101195. doi:10.1016/j.preghy.2025.101195\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eCursino T, Katz L, Coutinho I, et al. Postpartum furosemide for accelerating recovery in patients with preeclampsia: a randomized placebo-controlled trial. Am J Obstet Gynecol MFM. 2025;7(5):101614. doi:10.1016/j.ajogmf.2025.101614\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003ePratt K, Lordo R, Self S, Carlson L. Amlodipine versus nifedipine ER for the management of postpartum hypertension: a noninferiority randomized controlled trial. \u003cem\u003eAm J Obstet Gynecol MFM\u003c/em\u003e. 2025;7(1):101575. doi:10.1016/j.ajogmf.2024.101575\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eEmeruwa UN, Azad H, Ona S, et al. Lasix for the prevention of de novo postpartum hypertension: a randomized placebo-controlled trial (LAPP Trial). \u003cem\u003eAm J Obstet Gynecol\u003c/em\u003e. 2025;232(1):125.e1-125.e21. doi:10.1016/j.ajog.2024.04.016\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eYoselevsky EM, Seely EW, Celi AC, Robinson JN, McElrath TF. A randomized controlled trial comparing the efficacy of nifedipine and enalapril in the postpartum period. Am J Obstet Gynecol MFM. 2023;5(12):101178. doi:10.1016/j.ajogmf.2023.101178\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eGupta A, Nayak D, Sharma J, Keepanasseril A. Comparing the efficacy of oral labetalol with oral amlodipine in achieving blood pressure control in women with postpartum hypertension: randomized controlled trial (HIPPO study-Hypertension In Pregnancy \u0026amp; Postpartum Oral-antihypertensive therapy). J Hum Hypertens. 2023;37(12):1056\u0026ndash;1062. doi:10.1038/s41371-023-00841-x\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eFishel Bartal M, Blackwell SC, Pedroza C, et al. Oral combined hydrochlorothiazide and lisinopril vs nifedipine for postpartum hypertension: a comparative-effectiveness pilot randomized controlled trial. \u003cem\u003eAm J Obstet Gynecol\u003c/em\u003e. 2023;228(5):571.e1-571.e10. doi:10.1016/j.ajog.2023.01.015\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSuganya T, Vijayalakshmi A, Saravanan S, Aarthikarasi R. Comparative study between oral labetalol vs oral labetalol with oral frusemide in control of blood pressure among postpartum mothers with severe pre-eclampsia. Int J Pharm Clin Res. 2024;16(2):119-\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLopes Perdigao J, Lewey J, Hirshberg A, et al. Furosemide for Accelerated Recovery of Blood Pressure Postpartum in women with a hypertensive disorder of pregnancy: A Randomized Controlled Trial. \u003cem\u003eHypertension\u003c/em\u003e. 2021;77(5):1517\u0026ndash;1524. doi:10.1161/HYPERTENSIONAHA.120.16133\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eArias-Hern\u0026aacute;ndez G, Vargas-De-Le\u0026oacute;n C, Calzada-482 Mendoza CC, Ocharan-Hern\u0026aacute;ndez ME. Efficacy of Diltiazem for the Control of Blood Pressure in Puerperal Patients with Severe Preeclampsia: A Randomized, Single-Blind, Controlled Trial. Int J Hypertens. 2020;2020:5347918. Published 2020 Jul 23. doi:10.1155/2020/5347918\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eAinuddin J, Javed F, Kazi S. Oral labetalol versus oral nifedipine for the management of postpartum hypertension a randomized control trial. Pak J Med Sci. 2019;35(5):1428\u0026ndash;1433. doi:10.12669/pjms.35.5.812\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eVeena P, Perivela L, Raghavan SS. Furosemide in postpartum management of severe preeclampsia: A randomized controlled trial. Hypertens Pregnancy. 2017;36(1):84\u0026ndash;89. doi:10.1080/10641955.2016.1239735\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSharma KJ, Greene N, Kilpatrick SJ. Oral labetalol compared to oral nifedipine for postpartum hypertension: A randomized controlled trial. Hypertens Pregnancy. 2017;36(1):44\u0026ndash;47. doi:10.1080/10641955.2016.1231317\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eNoronha Neto C C, Maia SSB, Katz L, Coutinho IC, Souza AR, Amorim MM (2017) Clonidine versus Captopril for Severe Postpartum Hypertension: A Randomized Controlled Trial. PLoS ONE 12(1): e0168124. https://doi.org/10.1371/journal.pone.0168124\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eVigil-De Gracia P, Ruiz E, L\u0026oacute;pez JC, de Jaramillo IA, Vega-Maleck JC, Pinz\u0026oacute;n J. Management of severe hypertension in the postpartum period with intravenous hydralazine or labetalol: a randomized clinical trial. Hypertens Pregnancy. 2007;26(2):163\u0026ndash;171. doi:10.1080/10641950701204430\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSayin NC, Altundag G, Varol FG. Efficacy of alpha-methyldopa and nifedipine in the treatment of postpartum hypertension. J Turk Ger Gynecol Assoc. 2005;6(2):118\u0026ndash;122.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eEasterling T, Mundle S, Bracken H, et al. Oral antihypertensive regimens (nifedipine retard, labetalol, and methyldopa) for management of severe hypertension in pregnancy: an open-label, randomised controlled trial. Lancet. 2019;394(10203):1011-\u003c/span\u003e\u003cspan\u003edoi:10.1016/S0140-6736(19)31282-6\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eOrmesher L, Higson S, Luckie M, et al. Postnatal Enalapril to Improve Cardiovascular Function Following Preterm Preeclampsia (PICk-UP):: A Randomized Double-Blind Placebo-Controlled Feasibility Trial. Hypertension. 2020;76(6):1828\u0026ndash;1837. doi:10.1161/HYPERTENSIONAHA.120.15875\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMagee LA, von Dadelszen P, Rey E, et al. Less-tight versus tight control of hypertension in pregnancy. N Engl J Med. 2015;372(5):407\u0026ndash;417. doi:10.1056/NEJMoa1404595\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLovgren T, Connealy B, Yao R, Dahlke JD. Postpartum management of hypertension and effect on readmission rates. \u003cem\u003eAm J Obstet Gynecol MFM\u003c/em\u003e. 2022;4(1):100517. doi:10.1016/j.ajogmf.2021.100517\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eDo SC, Leonard SA, Kan P, Panelli DM, Girsen AI, Lyell DJ, El-Sayed YY, et al. Postpartum readmission for hypertension after discharge on labetalol or nifedipine. \u003cem\u003eObstet Gynecol\u003c/em\u003e. 2022;140(4):591\u0026ndash;598. doi:10.1097/AOG.0000000000004937\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLovgren T, Connealy B, Yao R, Dahlke JD. Postpartum medical management of hypertension and risk of readmission for hypertensive complications. \u003cem\u003eJ Hypertens\u003c/em\u003e. 2023;41(2):351\u0026ndash;355. doi:10.1097/HJH.0000000000003382\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMitro SD, Hedderson M, Xu F, Forquer H, Baker JM, Kuzniewicz MW, Greenberg M. Risk of postpartum readmission after hypertensive disorder of pregnancy and variation by discharge antihypertensive medication prescription. \u003cem\u003eAm J Obstet Gynecol\u003c/em\u003e. 2024;231(4):456.e1-456.e13. doi:10.1016/j.ajog.2024.01.015\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e \u003cstrong\u003eStudy Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"964\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy Authors/ Year\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCountry/ Race\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSample size\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntervention\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eComparator\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFollow-up duration\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMarques R/2025\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMethyldopa : 30.0 \u0026plusmn; 7.2\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eCaptopril:\u0026nbsp;30.4 \u0026plusmn; 7.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemales\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBrazil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e172\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eActive 1:\u003c/strong\u003e Captopril: 75 mg/day (25 mg tablet every 8 h).\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eActive 2:\u0026nbsp;\u003c/strong\u003eMethyldopa : 750 mg/day (250 mg tablet every 8 h)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e----\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15 days\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBlood pressure control during first 48 hours postpartum, blood\u003c/p\u003e\n \u003cp\u003epressure spike, \u0026nbsp; \u0026nbsp; % requiring treatment Escalation , % requiring treatment de-escalation, \u0026nbsp;Edinburgh Postnatal Depression Scale at Day 15, frequency of\u003c/p\u003e\n \u003cp\u003eside effects\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCursino T/2025\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFurosemide: 23.0\u0026plusmn;6.9\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePlacebo: 23.6\u0026plusmn;6.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemales\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBrazil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e118\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFurosemide (40 mg/d orally for 5 days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePlacebo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLength of stay in the hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMean SBP \u0026amp; DBP during hospitalization, frequency of severe hypertensive episodes,\u003c/p\u003e\n \u003cp\u003eNumber of antihypertensives at discharge, Time until BP Control, Time from intervention to hospital discharge, Frequency of side effects, frequency of maternal complications.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePratt K/2025\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAmlodipine: 27.9\u0026plusmn;6.8\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003enifedipine ER: 27.8\u0026plusmn;5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemales\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUnited States of America\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e175\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eActive 1:\u0026nbsp;\u003c/strong\u003eamlodipine 2.5 mg/day\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eActive 2:\u0026nbsp;\u003c/strong\u003enifedipine ER\u003c/p\u003e\n \u003cp\u003e30 mg/day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e----\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTime from delivery until hospital discharge,\u0026nbsp;acute\u003c/p\u003e\n \u003cp\u003eantihypertensive treatment, discharge\u003c/p\u003e\n \u003cp\u003edose, need for additional long-acting\u003c/p\u003e\n \u003cp\u003eantihypertensives, side effects, medication discontinuation, breastfeeding outcomes, and readmission rate within 6 weeks postpartum.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEmeruwa UN/2025\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFurosemide: 35.0 (30.8-39.2)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePlacebo : 37.0 (34.0e-9.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemales\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUnited States of America\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eonce-daily 20-mg oral\u003c/p\u003e\n \u003cp\u003efurosemide\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePlacebo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAverage MAP over 24 hours before discharge, rate of preeclampsia, % of elevated BP, rate of MgSO4 administration, time to hospital discharge, rates of initiation\u003c/p\u003e\n \u003cp\u003eof antihypertensives, rates of\u003c/p\u003e\n \u003cp\u003ehypertension-related SMM, \u0026nbsp;mean\u003c/p\u003e\n \u003cp\u003efrequency of triage or emergency\u003c/p\u003e\n \u003cp\u003edepartment presentations and read-\u003c/p\u003e\n \u003cp\u003emission, breastfeeding continuation\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003erates, and neonatal outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYoselevsky EM/2023\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNifedipine:\u003c/p\u003e\n \u003cp\u003e33.2 (6.4)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eEnalapril:\u0026nbsp;32.4 (6.7)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemales\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUnited States of America\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eActive 1:\u0026nbsp;\u003c/strong\u003eenalapril 10 mg /day\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eActive 2:\u003c/strong\u003e nifedipine ER 30 mg/day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-----\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eprolonged hospitalization,\u0026nbsp;unplanned clinic visit, a triage visit, hospital readmission after\u003c/p\u003e\n \u003cp\u003estarting the study agent, time to sustained BP control,\u0026nbsp;need for additional antihypertensives,\u003c/p\u003e\n \u003cp\u003etime to discharge from the hospital,\u003c/p\u003e\n \u003cp\u003eBP at the initial clinic visit\u003c/p\u003e\n \u003cp\u003eafter discharge, creatinine levels at\u003c/p\u003e\n \u003cp\u003efollow-up visits, continued\u003c/p\u003e\n \u003cp\u003eneed for antihypertensive up to 6 weeks\u003c/p\u003e\n \u003cp\u003epostpartum, side effects, patient\u003c/p\u003e\n \u003cp\u003ereported compliance.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGupta A/2023\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLabetalol:\u0026nbsp;27.8 \u0026plusmn; 5.4\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAmlodipine:\u003c/p\u003e\n \u003cp\u003e27.4 \u0026plusmn; 5.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemales\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIndia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e130\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eActive 1:\u0026nbsp;\u003c/strong\u003eOral Labetalol ( 100mg BD)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eActive 2:\u0026nbsp;\u003c/strong\u003eOral Amlodipine (2.5 mg BD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLength of hospital stay\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003etime taken to achieve BP control,\u0026nbsp;dose to achieve control\u003c/p\u003e\n \u003cp\u003eof hypertension,\u0026nbsp;side effects of each drug.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBartal MF/2023\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ecombined hydrochlorothiazide \u0026nbsp;and\u003c/p\u003e\n \u003cp\u003elisinopril : 30.0 (28.03\u0026plusmn; 3.5)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNifedipine: 33.00 (27.03\u0026plusmn; 6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemales\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUnited States of America\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eActive 1:\u0026nbsp;\u003c/strong\u003ecombined hydrochlorothiazide\u0026nbsp;(12.5 mg/day) and\u003c/p\u003e\n \u003cp\u003elisinopril (10 mg/day)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eActive 2:\u0026nbsp;\u003c/strong\u003eNifedipine(30mg/day)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eaverage BP\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eover days 7 to 10 after delivery, severe\u003c/p\u003e\n \u003cp\u003ematernal morbidity up to 6 weeks after\u003c/p\u003e\n \u003cp\u003edelivery,\u0026nbsp;severe BP\u0026nbsp;requiring intravenous\u003c/p\u003e\n \u003cp\u003emedications,\u0026nbsp;post-\u003c/p\u003e\n \u003cp\u003epartum hospital length of stay, sBP and\u003c/p\u003e\n \u003cp\u003edBP during the first clinic visit, medication compliance at 7 to 10 days after\u003c/p\u003e\n \u003cp\u003edelivery and during the postpartum\u003c/p\u003e\n \u003cp\u003eperiod, and adverse events.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSuganya T/2023\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLabetalol :\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e25.9 (5.41)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLabetalol And\u003c/p\u003e\n \u003cp\u003eFurosemide: 26.48 (4.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemales\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIndia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLabetalol And\u003c/p\u003e\n \u003cp\u003eFurosemide (40 mg OD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLabetalol\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSystolic BP reduction, need for additional antihypertensive, morbidity , Hospital stay.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePerdigao JL/2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFurosemide:\u0026nbsp;27 (22\u0026ndash;32)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eplacebo : 27 (23\u0026ndash;33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemales\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUnited States of America\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e384\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eoral furosemide 20mg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eplacebo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eprevalence of persistent hypertension 7-days postpartum, days required to achieve resolution of\u003c/p\u003e\n \u003cp\u003ehypertension,% of postpartum severe BP, need for additional antihypertensive medications postpartum,\u0026nbsp;postpartum readmissions or emergency visits, postpartum length of stay, pulmonary edema and severe maternal morbidity,\u0026nbsp;adverse effects,\u0026nbsp;neonatal ICU admission, self-reported\u003c/p\u003e\n \u003cp\u003ebreastfeeding issues\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eArias-Hernandez/2020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDiltiazem: 21.6 (6.8)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNifedipine: 23.2 (6.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemales\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMexico\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eActive 1:\u0026nbsp;\u003c/strong\u003ediltiazem\u003c/p\u003e\n \u003cp\u003e(60 mg) TDS\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eActive 2:\u0026nbsp;\u003c/strong\u003enifedipine (10 mg) TDS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e----\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e48 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSBP , DBP and HR, number of hypertension and hypo-\u003c/p\u003e\n \u003cp\u003etension episodes and ICU length of stay.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAinuddin J/2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLabetalol: 26.7 \u0026plusmn; 1.9\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNifedipine: 25.9 \u0026plusmn; 1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemales\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePakistan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e124\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eActive 1:\u0026nbsp;\u003c/strong\u003eLabetalol 100 mg Q1D\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eActive 2:\u0026nbsp;\u003c/strong\u003enifedipine LA 30mg/day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e----\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e72 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003etime to achieve BP\u0026nbsp;\u003c/p\u003e\n \u003cp\u003econtrol,\u0026nbsp;sustained BP\u003c/p\u003e\n \u003cp\u003econtrol,\u0026nbsp;need of additional\u003c/p\u003e\n \u003cp\u003eantihypertensive medications, length of hospital\u003c/p\u003e\n \u003cp\u003estay , drug related side effects.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eVeena P/2017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNifedipine and furosemide:\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e36.0 \u0026plusmn; 3.0\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNifedipine: 36.1 \u0026plusmn; 3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemales\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIndia\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNifedipine(10 mg) and furosemide(20 mg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNifedipine(10 mg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;2 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ereduction in SBP \u0026amp; DBP, reduction in MAP, dose of nifedipine required for control of BP, requirement of additional antihypertensive drugs,\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003enumber of days of hospital stay after delivery, and anti-\u003c/p\u003e\n \u003cp\u003ehypertensive requirement at discharge.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSharma KJ/2017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLabetalol : 34.0 (7.4)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNifedipine ER: 33.3 (6.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemales\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUnited States of America\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eActive 1:\u0026nbsp;\u003c/strong\u003eLabetalol 200 mg PO BID escalating to 800 mg PO BID\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eActive 2:\u0026nbsp;\u003c/strong\u003eNifedipine ER 30 mg PO daily escalating to 90 mg PO daily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e----\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003etime to achieve BP control, postpartum length of stay, the need for increased dosing, need for additional IV and oral \u0026nbsp;antihypertensive medication,\u003c/p\u003e\n \u003cp\u003eside effects\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNoronha Neto C/2017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eClonidine: 28.9 (6.7)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eCaptopril:\u0026nbsp;28.8 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemales\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBrazil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eActive 1:\u0026nbsp;\u003c/strong\u003eoral clonidine (0.1 mg)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eActive 2:\u003c/strong\u003e oral captopril (25 mg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-----\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLength of hospital stay\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003efrequency of very high BP episodes, daily mean SBP and DBP levels, number of days with\u003c/p\u003e\n \u003cp\u003every high BP episodes, number of days until BP was controlled,\u0026nbsp;percentage reduction in SBP, % reduction in DBP, number of doses used to control\u003c/p\u003e\n \u003cp\u003eBP, need to add another hypertensive agent, number\u003c/p\u003e\n \u003cp\u003eof antihypertensives added, need for sodium nitroprusside, maternal complications, adverse effects, number of days in \u0026nbsp;obstetric ICU and death.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eVigil-De Gracia/2007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHydralazine: \u0026nbsp; \u0026nbsp; 29.9 \u0026plusmn; 5.9\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLabetalol: \u0026nbsp;31.3 \u0026plusmn; 5.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemales\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUnited States of America\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eActive 1:\u0026nbsp;\u003c/strong\u003ehydralazine (5 mg slow bolus given intravenously, and repeated every 20\u003c/p\u003e\n \u003cp\u003eminutes to a maximum of 5 doses)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eActive 2:\u003c/strong\u003e labetalol (20 mg intravenous bolus\u003c/p\u003e\n \u003cp\u003edose followed by 40 mg if not effective within 20 minutes, followed by 80 mg every 20 minutes to a maximum dose of 300 mg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e----\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003elowering of BP,\u0026nbsp;uncontrolled BP, need for\u003c/p\u003e\n \u003cp\u003eadditional antihypertensive therapy, doses of antihypertensive, eclampsia,\u003c/p\u003e\n \u003cp\u003eHELLP syndrome, pulmonary edema, oliguria, DIC, hypertensive encephalopathy, maternal heart rate \u0026ge; 100 beats/min, maternal side-effects\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSayin N/2005\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ealpha-methyldopa: 28.1\u0026plusmn;5.9\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003enifedipine: 27.1\u0026plusmn;5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemales\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTurkey\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eActive 1\u003c/strong\u003e: alpha-methyldopa (750 mg/d)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eActive 2:\u0026nbsp;\u003c/strong\u003enifedipine (40 mg/d)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e----\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTime taken to achieve normotension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMonotherapy success rates, dual or triple therapy required, lab parameters, Medication needed after 7 days.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Supplementary Files","content":"\u003cp\u003eSupplementary files S1-S3 are not available with this version.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"All India Institute of Medical Sciences Raipur","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Amlodipine, Antihypertensive therapy, Blood pressure control, Labetalol, Maternal outcomes, Nifedipine, Postpartum hypertension, Network meta-analysis","lastPublishedDoi":"10.21203/rs.3.rs-7523179/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7523179/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePostpartum hypertension is a frequent cause of maternal morbidity and mortality and may occur as persistence of pregnancy-related hypertension or as new onset after delivery. Despite the burden, there is no consensus on the most effective antihypertensive drug regimen for the postpartum period. Pharmacological strategies vary widely, and treatment decisions are often extrapolated from antenatal studies rather than dedicated postpartum trials.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe objective of this study was to compare the effectiveness and safety of pharmacological agents for management of postpartum hypertension.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe performed a systematic review and Bayesian network meta-analysis of randomized controlled trials enrolling women with postpartum hypertension treated with systemic antihypertensive drugs. MEDLINE and Embase were searched through July 2025. Eligible trials compared active agents or placebo/usual care and reported blood pressure outcomes. Primary outcomes were time to achieve blood pressure control (hours) and proportion of women achieving blood pressure control within seven days postpartum. Treatment ranking was evaluated using surface under the cumulative ranking probability curves.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThirteen randomized controlled trials including 1625 women were identified. For time to blood pressure control, amlodipine and nifedipine ranked highest. Compared with labetalol, amlodipine reduced time to control by -5.85 hours (95% CI, -21.3 to 11.4) and nifedipine by -5.11 hours (95% CI, -17.9 to 9.71). Rankings indicated amlodipine were most effective for rapid control, followed by labetalol.For the proportion achieving control within seven days, labetalol ranked highest, with a probability near 100%. Compared with labetalol, 60 risk ratios for blood pressure control were 61 1.01 (95% CI, 0.55–1.75) for nifedipine, 1.03 (95% CI, 0.49–2.16) for hydralazine, and 1.31 (95% CI, 0.46–3.49) for hydrochlorothiazide–lisinopril. SUCRA values ranked labetalol \u0026nbsp;highest, followed by nifedipine, hydralazine, and hydrochlorothiazide–lisinopril.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCalcium channel blockers appear most effective for rapid reduction of blood pressure after childbirth, while labetalol is most reliable for sustained control within the first postpartum week. These findings provide a comparative framework for treatment selection and emphasize \u0026nbsp;the need for larger, rigorously designed postpartum hypertension trials.\u003c/p\u003e","manuscriptTitle":"Efficacy of Pharmacological Agents for Management of Post-partum Hypertension: A Network Meta-analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-08 12:30:34","doi":"10.21203/rs.3.rs-7523179/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"85c50b1d-4616-472b-b028-238ba85cd98f","owner":[],"postedDate":"September 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-08T12:30:34+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-08 12:30:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7523179","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7523179","identity":"rs-7523179","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}