Postpartum Hypertension

1
Postpartum Hypertension

• Lin-Fan Wang MD
• 5/4/09
• PGY-1 OB/GYN Rotation
• Family and Social Medicine

2
Case

• HPI 29yo G6P2133 PPD 9 s/p NSVD, induced at
  345GA for SiPEC presented to clinic with I need
  BP medicine.
• H/o CHTN prior to last pregnancy
• HCTZ for CHTN d/ced during pregnancy
• No h/o PEC or GHTN with prior pregnancies
• BPs 94-147/57-78 until 34wk

3
Case cont.

• Admitted for BP check collection of 24hr urine
• Criteria for SPEC met by severe range BP, 300
  protein in 24hr urine collection, and persistent
  maternal headache
• Pt given hydralazine 10mg IV x1, MgSO4 x24hr

4
Case cont.

• PPD 1-2 BP in nl-mild range. Pt was
  asymptomatic, adequate UOP.
• Pt given HCTZ 25mg PO x1 on PPD 2
• Pt d/ced on PPD 2 without anti-HTN meds

5
Case cont

• Pt denies HA/vision changes/N/V/abd pain
• Nervous about having a premature baby
• BP in clinic 150-160s/110s
• Exam benign
• PEC labs sent

6
Postpartum Blood Pressure

• Few published studies
• Studies of non-hypertensive women
• Rise in BP over PPD 1-5
• BP peak on PPD 3-6
• 10 had diastolic BP gt100 mmHg
• Study of women with antenatal PEC
• Initial decrease then hypertensive levels PPD
  3-6
• 50 had BP gt150/100 on PPD 5
• Study of women with GHTN PEC
• GHTN nl BP PPD 6
• PEC nl BP PPD 16

7
Pathophysiology

• Mobilization of extravascular fluid to
  intravascular space
• Excretion of urinary sodium has been observed on
  PPD 3-5
• De novo postpartum HTN may be due to lower ANP
  levels vs. lack of decrease in angiotensin I
  levels

8
Differential Diagnosis

• Essential HTN
• Persistent Antenatal GHTN or PEC
• De novo HTN
• Pre-eclampsia/HELLP
• Renal disease
• Pheochromocytoma
• Primary hyperaldosteronism

9
Incidence of Late PP PEC
Year Country PEC (n) Late PP PEC ()
1994 UK 383 5
1998 Colombia 164 12
2000 U.S. 399 17
2002 U.S. 89 26
2003 Singapore 62 3
10
Risk Factors

• Recurrence of HTN postpartum
• Preterm delivery
• Multips with higher uric acid levels or BUN
• Preeclampsia (vs. GHTN)

11
Morbidity Mortality

• Death
• 10 of maternal deaths in UK due to a
  hypertensive disorder of pregnancy occurred
  postpartum
• 1/15 deaths attributed to severe hypertension
  that developed only postpartum in women with
  antenatal pre-eclampsia
• Other complications of severe PP HTN include
  stroke and eclampsia

12
Prophylaxis

• Should women with antenatal hypertension receive
  antihypertensive medication postpartum to prevent
  transient severe maternal postpartum hypertension
  or to decrease length of hospital stay?
• Insufficient data based on a Cochrane review of
  the literature

13
Treatment

• General consensus for treatment of severe
  hypertension
• Prevent acute maternal vascular complications,
  i.e. stroke
• No consensus for mild-moderate postpartum
  hypertension
• Limited evidence to support safety of
  antihypertensives for breastfeeding
• Observational studies recommend methyldopa,
  B-blockers with high protein binding (e.g.,
  oxprenolol), ACEIs, some dihydropyridine CCBs
• ? MgSO4 in patients with PEC

14
Case

• Lab results AST/ALT 41/71, uric acid 8.8
• Pt called to go to Weiler ED
• Pt went to Monte instead
• BP 150/100 --gt 148/90, urine protein -, AST/ALT
  25/58, uric acid 9.1
• Pt signed out AMA prior to GYN consult
• Pt saw PMD for baby visit few days later, doing
  well

15
References

• Tan L-K, de Swiet M. The management of postpartum
  hypertension. BJOG 2002109733-6.
• Sibai BM, Stella CL. Diagnosis and management of
  atypical preeclampsia-eclampsia. AJOG
  2009200481.e1-7.
• Magee L, Sadeghi S. Prevention and treatment of
  postpartum hypertension. Cochrane Database of
  Systematic Reviews 2005, Issue 1.CD004351.
  DOI10.1002/14651858.CD004351.pub2.
• Matthys LA, Coppage KH, Lambers DS, et al.
  Delayed postpartum preeclampsia An experience of
  151 cases. AJOG. 20041901464-6
• Arterbury JL, Groome LJ, Hoff C, et al. Clinical
  presentation of women readmitted with postpartum
  severe preeclampsia or eclampsia. JOGNN.
  199727134-41.