Hemodynamics‐guided treatment of hypertensive disorders of pregnancy: systematic review and meta‐analysis

Objective: To determine whether antihypertensive therapy guided by maternal hemodynamic assessment improves maternal and perinatal outcomes in women with hypertensive disorders of pregnancy (HDP) compared with standard care based on blood-pressure thresholds. Methods: This was a systematic review and meta-analysis of randomized and non-randomized comparative studies comparing hemodynamics-guided management vs standard antihypertensive care in women with HDP. PubMed/MEDLINE and The Cochrane Library were searched from inception until 15 June 2025 for eligible studies. Outcome data were extracted for pre-eclampsia/eclampsia, HELLP syndrome, severe hypertension, fetal growth restriction, placental abruption, preterm birth and perinatal death. The composite adverse outcome included all abovementioned outcomes. The risk of bias was assessed using the Risk Of Bias In Non-Randomized Studies of Interventions tool, the revised Cochrane Risk-of-Bias tool and the Newcastle-Ottawa scale. Certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Odds ratios (OR) were pooled using random-effects models, with heterogeneity quantified by I2. Leave-one-out analyses were performed to investigate sensitivity to outliers. Results: The literature search retrieved six studies, including one randomized controlled trial, four non-randomized comparative studies and one multicenter prospective cohort study. Depending on the outcome analyzed, 418-614 patients were included in the intervention group and 617-731 patients in the control group. Compared with standard care, hemodynamics-guided therapy reduced the odds of pre-eclampsia/eclampsia by 53% (OR, 0.47 (95% CI, 0.33-0.65); I2 = 0%), severe hypertension by 61% (OR, 0.39 (95% CI, 0.18-0.88); I2 = 31%), fetal growth restriction by 46% (OR, 0.54 (95% CI, 0.38-0.76); I2 = 0%) and preterm birth by 60% (OR, 0.40 (95% CI, 0.16-0.99); I2 = 80%). The OR for the composite adverse outcome was 0.27 (95% CI, 0.21-0.36) (I2 = 0%). The overall certainty of evidence according to the GRADE framework was low to very low. Conclusions: Hemodynamics-guided antihypertensive management of women with HDP was associated with reductions in several adverse maternal and perinatal outcomes compared with standard care. Given the predominance of non-randomized study designs, measurement heterogeneity and risk of residual confounding, these associations should be interpreted as hypothesis-generating and require confirmation in adequately powered randomized controlled trials.