- 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
[CG] Hypertension, postpartum : management
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Treatment Options: - initially choose 1 drug from the most appropriate class
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Box 1 |
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Drug Class |
Drug |
Dose |
Contraindications |
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Beta blocker* |
Labetalol |
200mg tds to |
Asthma, cardiac failure, bradycardia, heart block.
|
|
Or Atenolol |
50-100mg daily |
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|
Calcium channel blocker |
Nifedipine SR |
10-40mg bd |
Severe aortic stenosis |
|
Or Amlodipine |
5-10mg daily |
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|
ACE inhibitor |
Enalapril |
5-20mg daily |
Acute renal injury |
|
Captopril |
12.5-25mg |
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* - 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.
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.
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.
