Postpartum HypertensionPostpartum Hypertension

Lin-Fan Wang MD

5/4/09

PGY-1 OB/GYN Rotation

Family and Social Medicine

CaseCase

• 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/c’ed during pregnancy

• No h/o PEC or GHTN with prior pregnancies

• BPs 94-147/57-78 until 34wk

Case cont.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

Case cont.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/c’ed on PPD #2 without anti-HTN meds

Case contCase 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

Postpartum Blood PressurePostpartum 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 >100 mmHg

• Study of women with antenatal PEC• Initial decrease then hypertensive levels PPD #3-6• 50% had BP >150/100 on PPD #5

• Study of women with GHTN & PEC• GHTN: nl BP PPD #6• PEC: nl BP PPD #16

PathophysiologyPathophysiology

• 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

Differential DiagnosisDifferential Diagnosis

• Essential HTN

• Persistent Antenatal GHTN or PEC

• De novo HTN

• Pre-eclampsia/HELLP

• Renal disease

• Pheochromocytoma

• Primary hyperaldosteronism

Incidence of Late PP PECIncidence 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

Risk FactorsRisk Factors

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

Morbidity & MortalityMorbidity & 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

ProphylaxisProphylaxis

• 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

TreatmentTreatment

• 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

CaseCase

• 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 --> 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

ReferencesReferences

1. Tan L-K, de Swiet M. The management of postpartum hypertension. BJOG 2002;109:733-6.

2. Sibai BM, Stella CL. Diagnosis and management of atypical preeclampsia-eclampsia. AJOG 2009;200:481.e1-7.

3. Magee L, Sadeghi S. Prevention and treatment of postpartum hypertension. Cochrane Database of Systematic Reviews 2005, Issue 1.:CD004351. DOI:10.1002/14651858.CD004351.pub2.

4. Matthys LA, Coppage KH, Lambers DS, et al. Delayed postpartum preeclampsia: An experience of 151 cases. AJOG. 2004;190:1464-6

5. Arterbury JL, Groome LJ, Hoff C, et al. Clinical presentation of women readmitted with postpartum severe preeclampsia or eclampsia. JOGNN. 1997;27:134-41.