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x 2013;15:4550
The Obstetrician & Gynaecologist
Review
http://onlinetog.org
Please cite this paper as: Smith M, Waugh J, Nelson-Piercy C. Management of postpartum hypertension. The Obstetrician & Gynaecologist 2013;15:4550.
Chronic treatment
Labetalol 100 bd200 mg qds Asthma, cardiac failure, bradycardia, 2nd or Postural hypotension, headache, urinary
Atenolol 25100 mg daily 3rd degree AV block hesitancy, fatigue
Nifedipine (SR) 1040 mg bd Advanced aortic stenosis Headache, tachycardia, palpitations, ushing
Amlodipine 510 mg od
Enalapril 520 mg bd Avoid in AKI Hypotension, cough, renal impairment
Acute treatment
Hydralazine 510 mg IV or IM repeated Severe tachycardia, high output cardiac failure Headache, ushing, anxiety, arrhythmias
if necessary
Labetalol 20 mg IV repeated if necessary As chronic treatment As chronic treatment
at 20 min intervals
Nifedipine 10 mg sublingual repeated if Care to avoid profound hypotension when As chronic treatment
necessary at 20 min intervals used alongside magnesium sulphate
AKI = acute kidney injury; AV = atrioventricular; bd = twice daily; IM = intramuscular; IV = intravenous; od = once daily; qds = four-times daily;
SR = sustained release
Restart prepregnancy
medicaon
Aim to keep
BP <140/90
Discharge to community:
communicate plans to GP and CMW
>160/110, >150/100,
asymptomac symptoms of
pre-eclampsia
(b)
Figure 1. (a) Algorithm for the management of postnatal hypertension in women with chronic hypertension. (b) Algorithm for the management
of postnatal hypertension in women without chronic hypertension
have antihypertensives prescribed following delivery. From count, transaminases and serum creatinine are checked
Table 1, it might be suggested that women who have required 4872 hours after birth, or step down from Level 2 care, and
antihypertensives in the antenatal period, women who have only repeated thereafter if abnormal or clinically indicated.
been delivered before 37 weeks of gestation because of Given that up to 44% of eclamptic fits occur in the
hypertension and women who have had severe hypertension postnatal period, usually within the first 48 hours following
are most likely to benefit. The perceived advantages of delivery,17 women with pre-eclampsia should be encouraged
starting treatment in the early postnatal period are that to delay discharge until day 3. Blood pressure at the time of
episodes of severe hypertension will be reduced and discharge discharge should be <150/100 mmHg. It is crucial that
to the community will not be delayed unnecessarily. Balanced the community team receive adequate and prompt
against this is the possibility of unnecessary treatment and documentation regarding the inpatient management and
side effects of medication. A suggested regimen might be the plans for follow-up.
labetalol (providing there is no history of asthma) with
second and third-line agents of calcium antagonist and an Follow-up
ACE inhibitor (such as enalapril). Once discharged, the community midwife should measure
The recently published NICE guidance for postpartum blood pressure on alternate days for the first 2 weeks and
care indicates that blood pressure should be measured within refer for medical review if two measurements >150/
6 hours of delivery. Furthermore, at the first postnatal 100 mmHg are obtained more than 20 minutes apart.
contact, all women should be made aware of the symptoms of Local experience and facilities will dictate if this review
pre-eclampsia (headaches within 72 hours of delivery should be by the GP or the hospital maternity assessment
accompanied by visual disturbance, or nausea or vomiting) unit. Hospital review will be required if patients report
along with the need to urgently contact an appropriate symptoms of pre-eclampsia or if blood pressure (BP) is
health professional. >160/100 mmHg. Most women who commence postnatal
It is not clear what thresholds should be used to instigate antihypertensives will require treatment for at least 2 weeks
treatment in women who present with de novo hypertension and some women, particularly women with early onset or
in the postnatal period having previously been normotensive. severe disease may need to continue beyond 6 weeks.18
Current NICE postnatal guidance13 recommends medical Medication should be reduced when BP is measured at
review if the diastolic pressure is >90 mmHg and is 130140/8090 mmHg and medical review sought if the
associated with any symptoms of pre-eclampsia or if this patient remains on medication at 2 weeks. If medication is
level of diastolic hypertension is sustained over 4 hours. No required beyond 6 weeks then further medical review should
systolic thresholds are suggested but extrapolation from the be arranged to investigate the possibility of an underlying
subsequent hypertension guidelines would indicate that pre- cause. It has recently been reported that up to 13% of women
eclampsia should be excluded when systolic pressure is initially thought to have a diagnosis of pre-eclampsia or
>150 mmHg. Newly presenting patients should have a pregnancy-induced hypertension will have underlying disease
history and examination taken to exclude impending not suspected antenatally.19
eclampsia and have full blood count, electrolytes and liver The 6-week postnatal visit is an opportunity to establish
function checked. the diagnosis and to discuss implications for future
Regardless of whether antihypertensive agents are pregnancies. All women who have had a diagnosis of
prescribed immediately following delivery, all women pre-eclampsia should have their blood pressure measured and
should be closely monitored with regular recordings made the urine tested for proteinuria. The importance of ensuring
of blood pressure and fluid balance. It is anticipated that the that renal impairment detected in hypertensive pregnancies is
introduction of modified obstetric early warning system indeed attributable to pre-eclampsia has been highlighted
(MOEWS) charts might facilitate the detection of women by Fischer et al.20 Renal biopsies taken in the postpartum period
who require further medical review.14 The frequency of in 176 women who had been diagnosed in pregnancy as
measuring haematological and biochemical indices will need having renal complications of pre-eclampsia established an
to be tailored to individual patients. A minimum of once- alternative diagnosis in a third of cases overall, and this was
daily testing may be required initially in cases where there is increased to almost two thirds in multiparous patients.
concern about thrombocytopenia or renal compromise, The risk of pre-eclampsia in a subsequent pregnancy
thereafter frequent sampling is unlikely to change depends on the presentation in the index pregnancy. Severe,
management in the absence of other clinical triggers. early onset pre-eclampsia has a recurrence rate up to 40% in
Furthermore, unnecessary concern may arise if normal future pregnancies21,22 although generally the onset of
patterns of resolution are not appreciated, if, for example, problems is 23 weeks later and it is less severe than in the
ALT reaches peak serum levels 5 days postnatally in normal first pregnancy.23 Women who present with milder disease,
pregnancy.15 NICE guidance16 recommends that the platelet nearer to term have a risk of recurrence nearer to 10%.
Women at increased risk should be offered low-dose aspirin 9 Magee L, Sadeghi S. Prevention and treatment of postpartum
hypertension. Cochrane Database Syst Rev 2005;(1):CD004351.
and increased blood pressure surveillance during a future
10 Beardmore KS, Morris JM, Gallery EDM. Excretion of antihypertensive
pregnancy. Future research should establish the role, if any, medication into human breast milk: a systematic review. Hypertens
of second trimester uterine artery Doppler assessment. Pregnancy 2002;21:8595.
Finally, it is increasingly recognised that pre-eclampsia is a 11 Redman CW, Beilin LJ, Bonnar J. Treatment of hypertension in
pregnancy with methyldopa: blood pressure control and side effects.
risk factor for developing cardiovascular disease in later life
Br J Obstet Gynaecol 1977;84:41926.
and patients should be made aware of this so that they have 12 Magee LA, Cham C, Waterman EJ, Ohlsson A, von Dadelszen P.
the opportunity make lifestyle choices to minimise their risk. Hydralazine for treatment of severe hypertension in pregnancy: meta-
analysis. BMJ 2003;327:95560.
13 National Institute for Health and Clinical Excellence. Routine Postnatal
Conflict of interest Care of Women and their Babies. London: NICE; 2006.
None declared. 14 Lewis G. The Condential Enquiry into Maternal and Child Health
(CEMACH). Saving Mothers Lives: Reviewing Maternal Deaths to
Make Motherhood Safer - 20032005. The Seventh Report on
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