Pharmacologic strategies to prevent hemodynamic changes after intubation in parturient women with hypertensive disorders of pregnancy: A systematic review and network meta-analysis protocol

BACKGROUND: Hypertensive disorders of pregnancy are major health issues affecting mothers and infants. General anesthesia is inevitable for certain mothers with these conditions and they may exhibit pronounced hemodynamic instability, especially during induction and airway manipulation. The aims of this study are to combine direct and indirect comparisons of the efficacies of different medications used in attenuating reflex hemodynamic responses and generate intervention ranking by network meta-analysis (NMA). METHODS: A systematic and comprehensive search will be performed using MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar databases, beginning from their inceptions to November 2019. Only randomized clinical trials evaluating the efficacy and safety of pharmacologic interventions for preventing hemodynamic changes after intubation in parturient women with hypertensive disorders of pregnancy will be included. The primary endpoints will be maximal mean arterial pressure (MAP) and maximal heart rate after intubation. Maximal systolic arterial pressure (SAP), diastolic arterial pressure (DAP), and maternal/fetal blood gas analysis, as well as safety issues, including Apgar score at 1 minute and 5 minutes after delivery, will be also assessed. We will conduct both pairwise meta-analysis and network meta-analysis. We will use surface under the cumulative ranking curve (SUCRA) values and rankograms to present the hierarchy of pharmacologic interventions. A comparison-adjusted funnel plot will be used to assess the presence of small-study effects. The quality of the studies included will be assessed using the risk of bias tool 2.0. All statistical analyses will be performed using Stata SE, version 15.0 (StataCorp, College Station, TX). RESULTS: The results of this systematic review and NMA will be published in a peer-reviewed journal. CONCLUSION: This NMA will enable us to determine the order of effectiveness and safety of pharmacological interventions used in attenuating hemodynamic responses for mothers with hypertensive disorders of pregnancy. TRIAL REGISTRATION NUMBER: CRD42019136067.