Postpartum diuretic administration and hospital readmission: a systematic review and meta-analysis

Objective: We aimed to determine if postpartum administration of loop diuretic therapy among patients at risk of or diagnosed with a hypertensive disorder of pregnancy impacts the rate of hospital readmission compared to typical care. Data sources: This study was a systematic review and meta-analysis of randomized controlled trials (RCTs). A research librarian performed a database search using a combination of standardized terms and keywords related to postpartum hypertension and loop diuretics from database inception until February 2025. This study was registered in PROSPERO (registration number CRD42024546708). Study eligibility criteria: RCTs that compared outcomes between administration of loop diuretic therapy and routine care among postpartum patients at risk of or diagnosed with a hypertensive disorder of pregnancy were included. Inclusion criteria and diagnosis of hypertensive disorder of pregnancy were defined per each trial's protocol. Nonrandomized trials, quasi-randomized trials, and animal models were excluded. All titles and abstracts obtained through the search were independently assessed by two reviewers using the screening tool in Covidence, and full-text articles were reviewed. A total of 10 articles met inclusion criteria and were included in the systematic review and meta-analysis. Study appraisal and synthesis methods: Two independent investigators independently abstracted data using a standardized template created in Covidence. The primary outcome was the rate of hospital readmission. Secondary maternal outcomes included readmission for hypertension, mean postpartum blood pressure, and severe maternal morbidity. The risk of bias in each study was assessed using the guidelines outlined in the Cochrane Handbook for Systematic Reviews of Interventions. Heterogeneity was measured using Higgins I². Meta-analysis was performed in Review Manager 5.4.1 to produce summary treatment effects in terms of relative risk (RR) or mean difference with 95% confidence intervals (CIs). Results: Ten RCTs, including 1401 patients, were included in the meta-analysis. The rate of hospital readmission, reported in 3 studies, did not differ between administration of loop diuretic therapy and routine care (RR=2.00; 95% CI, 0.71–5.67). The rate of readmission for hypertension also did not differ between groups (3 studies, RR=0.69; 95% CI, 0.35–1.36). Additional antihypertensive requirements were lower in patients who received diuretics (6 studies, RR=0.47; 95% CI, 0.26–0.85). There were no differences in any other secondary maternal outcomes, including discharge on antihypertensives (8 studies, RR=1.00; 95% CI, 0.91–1.11), hospital length of stay (6 studies, mean difference=0.15; 95% CI, –0.18 to 0.48), or severe maternal morbidity. Conclusion: There is insufficient evidence to support routine prophylactic administration of loop diuretic therapy in the postpartum period to prevent hospital readmission associated with hypertensive disorders of pregnancy. Additional antihypertensive requirements were lower with diuretic use. Additional large trials are needed.