[CG] Hypertension, postpartum : management

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General points

  • There is a physiological rise in blood pressure for the first five postnatal days.
  • SYSTOLIC hypertension is an important risk factor for stroke.
  • Severe hypertension (≥ 160/110 mm Hg) must be treated.
  • BP persistently ≥150/100 mm Hg should be treated.
  • Eclampsia is less likely to present after the third postnatal day, and when it does is frequently associated with prodromal symptoms and signs, although not necessarily hypertension.
  • Methyldopa should not be prescribed / continued postpartum (it causes postnatal depression)– revert to pre-pregnancy medications or commence an agent as per box 1
  • Avoid NSAIDs in the presence of hypertension that is difficult to control, oliguria or impaired renal function

There are 3 groups of women with postpartum hypertension

  1. Antepartum PIH or pre-eclampsia
  2. Known chronic hypertension
  3. ‘De Novo’ hypertension

Irrespective of cause

BP ≥ 160/110 mm Hg, or MAP ≥ 125      TREAT. **

Severe hypertension in previously normotensive women is an obstetric emergency. If the patient is clinically stable oral agents can be used in the first instance. Rarely, the clinical situation will merit IV therapy in the postnatal period – as per severe pre-eclampsia guideline.

BP persistently ≥ 150 / 100 mm Hg commence regular antihypertensive medication

** - In cases of chronic hypertension the response to blood pressure recordings should be tailored to the individual case. Women with chronic hypertension, pre- dating pregnancy, have reset their cerebral auto-regulation mechanism and will not be at as great a risk of CVA from a systolic reading of 160 mm Hg compared to a previously normotensive woman.

Treatment options

Treatment Options: - initially choose 1 drug from the most appropriate class

Box 1

Drug Class 

Drug

Dose 

Contraindications

Beta blocker*

Labetalol

200mg tds to 
300mg qds

Asthma, cardiac failure, bradycardia, heart block. 

 

Or Atenolol

50-100mg daily 

Calcium channel blocker

Nifedipine SR

10-40mg bd

Severe aortic stenosis

Or Amlodipine 

5-10mg daily

ACE inhibitor

Enalapril 

5-20mg daily

Acute renal injury

Captopril 

12.5-25mg
bd initially to 
50-75mg bd 

* - Beta-blockers are of less benefit for black women of African or Caribbean origin – calcium channel blockers are the first line drug of choice in this group of patients.

 

Drugs and breastfeeding

The drugs discussed in Box 1 above are considered compatible with breast feeding in term healthy infants, except amlodipine for which there is currently insufficient data. 

A second drug, from a different class, should be prescribed if single agent is clearly not working. Discuss prescription of second-line agent with registrar / consultant. If a higher dose of enalapril is required, discuss with a consultant. Avoid repeated stat doses of a drug – if this is happening it needs to be prescribed on a regular basis.

If, by day 3 postpartum, BP is inadequately controlled, consultant review is required.

Treatment aims

Aim for BP of < 150/100 mm Hg.

(Remember, this is an arbitrary level, and BP readings slightly higher than this may be acceptable, particularly in women with chronic hypertension, – discuss with senior staff).

In patients with end-organ damage – eg underlying renal disease or diabetes, aim  for tighter BP control eg. ≤ 140/90 mm Hg – discuss with consultant.

If BP < 150/100 mmHg, the patient is well and progressive PET has been excluded, they can be discharged (usually on the 3rd or 4th postnatal day).

Outpatient BP monitoring should be arranged ie. Community midwife or GP.

BP˂140/90 mmHg – consider reducing medication.

BP <130/80 – reduce or stop medication

6 week postnatal review at the hospital for women with PIH/PET may be appropriate to discuss diagnosis / recurrence / longer term health implications. Consultant Obstetrician to determine this. If still hypertensive suggest GP refers to physicians for further assessment.

On discharge, the case notes of any woman whose pregnancy has been complicated by hypertension should be sent to the relevant consultant and they will decide if the woman requires a postnatal review at the hospital.

Write a care plan for women with gestational hypertension who have given birth and are being transferred to community care that includes all of the following:

  • who will provide follow-up care, including medical review if needed
  • frequency of blood pressure monitoring needed
  • thresholds for reducing or stopping treatment indications for referral to primary care for blood pressure review.

Complete 3 copies of High Blood Pressure Postnatal Care letter – give one to the woman, attach one to the handheld notes and send one to the GP.

Offer women who have had gestational hypertension and remain on antihypertensive treatment 2 weeks after transfer to community care a medical /GP review.

Offer women who have had gestational hypertension a medical review(GP) at their postnatal review (6–8 weeks after the birth).

Offer women who have had gestational hypertension and who still need antihypertensive treatment at the postnatal review (6–8 weeks after the birth) a specialist assessment of their hypertension.

Postnatal - in hospital (flowchart)

Postnatal - in the Community (flowchart)

Appendix: discharge letter

References

NICE. Hypertension in pregnancy: diagnosis and management. [CG107] August 2010, last updated January 2011.  

Smith M et al. Management of postpartum hypertension. The Obstetrician & Gynaecologist 2013; 15:45-50.

Bramham K et al. Postpartum management of hypertension. BMJ 2013; 346: f894 

 

Last reviewed: 06 September 2017

Next review: 01 June 2022

Author(s): Dr. Janet Brennand, Consultant Obstetrician QEUH

Version: 2

Co-Author(s): Other professionals consulted: Dr Ann Duncan, Consultant Obstetrician, PRM; Mrs Fiona Anderson, Specialist Clinical Pharmacist, PRM; Dr A M Mathers, Consultant Obstetrician, PRM

Approved By: Obstetric Clinical Governance Group