Management of Hypertension in Pregnancy and Postpartum
The management of hypertension in pregnancy and postpartum requires close monitoring and appropriate medication selection, with home blood pressure monitoring programs showing improved outcomes for both normal and elevated blood pressure in the postpartum period. 1
Classification of Hypertensive Disorders in Pregnancy
- Chronic hypertension: Hypertension known before pregnancy or present in the first 20 weeks
- Gestational hypertension: New onset hypertension after 20 weeks without proteinuria
- Preeclampsia: New onset hypertension after 20 weeks with proteinuria or end-organ dysfunction
- Chronic hypertension with superimposed preeclampsia 1, 2
Management During Pregnancy
Blood Pressure Targets
- For non-severe hypertension (140-159/90-109 mmHg): Target 110-140/85 mmHg 2
- For severe hypertension (≥160/110 mmHg): Immediate treatment required to prevent maternal stroke 2
First-line Medications During Pregnancy
- Labetalol: 200-800 mg divided twice daily or more frequently
- Methyldopa: Considered safest based on long-term follow-up studies
- Nifedipine XR: 30-60 mg once daily 2
Contraindicated Medications
- ACE inhibitors, ARBs, direct renin inhibitors (fetal toxicity)
- Sodium nitroprusside (risk of fetal cyanide poisoning)
- Atenolol (risk of intrauterine growth restriction) 2
Management of Severe Acute Hypertension
Immediate Treatment Options
- Labetalol (IV): 20 mg IV bolus, then 40 mg after 10 minutes, followed by 80 mg every 10 minutes for 2 additional doses (maximum 220 mg)
- Hydralazine (IV): 5 mg IV bolus, then 10 mg every 20-30 minutes (maximum 25 mg)
- Nifedipine (PO): 10 mg orally, repeated every 20 minutes (maximum 30 mg) 2
Postpartum Management
For Normal Blood Pressure Postpartum
- Monitor BP at least once within 72 hours and again within 10 days of delivery 1
- Home BP monitoring recommended for all women with history of hypertensive disorders in pregnancy
- BP should be checked daily or twice daily in the first week after discharge 1
- Transition to primary care or cardiology for long-term follow-up 1, 2
For Elevated Blood Pressure Postpartum
- For severe hypertension (≥160/110 mmHg): Immediate IV antihypertensive therapy (preferably labetalol) 2, 3
- For mild-moderate hypertension (140-159/90-109 mmHg): Start oral antihypertensives 2
- Preferred medications:
Home Blood Pressure Monitoring Protocol
- Check BP twice daily for 10 days after discharge 1
- Alternative protocol: BP monitoring 5 days a week in first week, with decreasing frequency over 6 weeks 1
- Beyond 6 weeks: Consider decreasing to twice weekly for up to 1 year postpartum 1
- Report readings ≥140/90 mmHg to healthcare provider 6
- Minimum of 12 BP readings within a 30-day period recommended for clinical management 1
Long-term Follow-up
- Annual cardiovascular risk assessments recommended lifelong for women with history of hypertensive disorders in pregnancy 1, 2
- Aim to achieve pre-pregnancy weight by 12 months postpartum 1
- Adopt healthy lifestyle including regular exercise and balanced diet 1, 2
- Limit interpregnancy weight gain through healthy lifestyle 1
Special Considerations
- Avoid concomitant administration of magnesium sulfate with calcium channel blockers due to risk of synergistic hypotension 2
- When transitioning from IV to oral therapy, ensure adequate overlap to maintain BP control 3
- Home BP monitors should be checked for accuracy against a sphygmomanometer 2
Postpartum Hypertension Clinics
- Emerging as innovative solutions for enhanced management of postpartum hypertension 1
- Can be led by a single specialty or as part of multidisciplinary cardio-obstetrics program 1
- Provide opportunity for screening and management of cardiovascular risk factors 1
- Serve as bridge to longitudinal care 1
By following these evidence-based recommendations, clinicians can effectively manage hypertension during pregnancy and postpartum, reducing maternal morbidity and mortality while improving long-term cardiovascular outcomes.