What are the stages of hypertension in the postpartum period?

Stages of Hypertension in the Postpartum Period

Hypertension in the postpartum period is diagnosed when systolic blood pressure is ≥140 mmHg and/or diastolic blood pressure is ≥90 mmHg, measured on at least two separate occasions or at least 15 minutes apart in cases of severe hypertension. 1

Classification of Postpartum Hypertension

Based on Severity:

1. Normal Blood Pressure: <120/80 mmHg
2. Elevated Blood Pressure: 120-129/<80 mmHg
3. Stage 1 Hypertension: 130-139/80-89 mmHg
4. Stage 2 Hypertension: 140-159/90-109 mmHg
5. Severe Hypertension (Hypertensive Emergency): ≥160/110 mmHg

Based on Etiology:

1. Continuation of Pregnancy-Related Hypertension:

   • Persistent gestational hypertension
   • Persistent preeclampsia (should resolve within 6-12 weeks postpartum)
   • Pre-existing chronic hypertension (usually persists >6 weeks postpartum)

2. De Novo Postpartum Hypertension:

   • Postpartum preeclampsia (new onset after delivery)
   • New-onset essential hypertension

3. Iatrogenic Causes:

   • Medication-induced (NSAIDs, ergot derivatives for postpartum hemorrhage, ephedrine)

4. Secondary Causes:

   • Renal disease
   • Endocrine disorders
   • Anxiety-related hypertension 1

Important Clinical Considerations

Blood Pressure Patterns

• Blood pressure typically rises after delivery, peaking around 3-5 days postpartum 2
• Women who were normotensive during pregnancy may develop hypertension in the first postnatal week 2
• Maximum blood pressure during labor and delivery admission can predict readmission risk 3

Monitoring Recommendations

• Monitor blood pressure at least every 4-6 hours during the first 3 days postpartum 2
• Home blood pressure monitoring is recommended for women with hypertensive disorders 2
• All women with hypertensive disorders should be reviewed at 3 months postpartum 2

Treatment Thresholds

• Severe hypertension (≥160/110 mmHg): Treat immediately as a medical emergency within 30-60 minutes 2, 4
• Stage 2 hypertension (140-159/90-109 mmHg): Start long-acting antihypertensive medication 2
• Target blood pressure reduction: Decrease mean blood pressure by 15-25% with a target of 140-150/90-100 mmHg 2, 4

Clinical Implications and Risks

• 10% of maternal deaths due to hypertensive disorders occur in the postpartum period 1
• Complications of severe postpartum hypertension include stroke and eclampsia 1, 2
• Higher blood pressure at discharge is associated with increased risk of readmission within 6 weeks 3
• Women with blood pressures ≥160/110 mmHg at discharge are almost 3 times more likely to be readmitted than those with normal blood pressure 3

Management Considerations

• First-line medications for severe hypertension: IV labetalol, oral nifedipine, or IV hydralazine 2
• Medications safe for breastfeeding: labetalol, nifedipine, enalapril, and metoprolol 1, 2
• Avoid methyldopa postpartum due to risk of postnatal depression 2
• Consider magnesium sulfate for prevention of eclampsia in women with severe hypertension 2
• Do not give magnesium sulfate concomitantly with calcium channel blockers due to risk of hypotension 1, 2

Long-term Follow-up

• Annual medical review is advised lifelong for women with a history of hypertensive disorders of pregnancy 2
• Peripartum screening combining clinical and echocardiographic features can help identify women at risk of chronic hypertension 5
• Lifestyle modifications including weight management and regular exercise are recommended 2

Understanding and properly managing the stages of postpartum hypertension is critical for reducing maternal morbidity and mortality, particularly given the significant risk of complications that can occur after delivery.