What is the management for postpartum hypertension?

Management of Postpartum Hypertension

Postpartum hypertension requires prompt treatment with labetalol, nifedipine, or hydralazine for severe cases (BP ≥160/110 mmHg), followed by maintenance therapy with labetalol, nifedipine, or enalapril until blood pressure normalizes, along with close monitoring through home blood pressure measurements. 1, 2

Diagnosis and Classification

• Postpartum hypertension is defined as systolic BP ≥140 mmHg and/or diastolic BP ≥90 mmHg measured on at least two occasions at least 4 hours apart 3
• Severe hypertension is defined as systolic BP ≥160 mmHg and/or diastolic BP ≥110 mmHg, which requires immediate treatment 1
• Postpartum hypertension may result from:
  • Continuation of pre-existing hypertension
  • Gestational hypertension or preeclampsia
  • De novo postpartum hypertension
  • Iatrogenic causes (NSAIDs, ergot derivatives, ephedrine)
  • Anxiety 1

Acute Management of Severe Hypertension

• Severe hypertension (BP ≥160/110 mmHg) lasting >15 minutes requires immediate treatment to reduce risk of stroke and other complications 1
• First-line medications for acute severe hypertension include:
  • IV labetalol
  • Oral nifedipine (immediate release)
  • IV hydralazine 2, 4
• Treatment should be initiated within 30-60 minutes of confirmed severe hypertension 4, 5
• Methyldopa should NOT be used for urgent BP reduction 1
• If first-line agents fail despite successive appropriate doses, consult with specialists (anesthesiology, maternal-fetal medicine, or critical care) 4

Maintenance Therapy for Persistent Hypertension

• For persistent postpartum hypertension, initiate long-acting antihypertensive agents 3
• Recommended medications for breastfeeding mothers include:
  • Labetalol
  • Nifedipine
  • Enalapril
  • Metoprolol 1
• ACE inhibitors (particularly enalapril) can be used in lactating mothers unless the neonate is premature or has renal failure 1
• Diuretics (furosemide, hydrochlorothiazide, spironolactone) may reduce milk production and are generally not preferred in breastfeeding women 1
• Continue antihypertensive medication until BP has normalized, which may take days to several weeks postpartum 1

Monitoring Protocol

• Blood pressure should be monitored at least 4-6 hourly during the day for at least 3 days postpartum 1
• The American College of Obstetricians and Gynecologists (ACOG) recommends BP check within 72 hours and again within 10 days of delivery 1
• Home blood pressure monitoring (HBPM) is recommended:
  • Daily or twice daily in the first week after discharge 1, 6
  • With decreasing frequency over 6 weeks of follow-up 1
  • Some programs recommend monitoring twice weekly for up to 1 year postpartum for high-risk cases 1
• Laboratory tests (hemoglobin, platelets, creatinine, liver enzymes) should be repeated the day after delivery and then second daily until stable if any were abnormal before delivery 1

Special Considerations

• Avoid NSAIDs for pain relief if possible, especially in women with acute kidney injury, as they may worsen hypertension 1
• Magnesium sulfate is recommended for prevention of eclampsia and treatment of seizures but should not be given concomitantly with calcium channel blockers due to risk of synergistic hypotension 1
• Consider transfer to intensive care for patients with:
  • Need for respiratory support
  • Severe tachycardia (>150 bpm) or bradycardia (<40 bpm)
  • Need for pressor support or cardiovascular support
  • Severe electrolyte abnormalities 1

Long-term Follow-up

• All women with postpartum hypertension should be reviewed within 1 week if still requiring antihypertensives at discharge 1
• A comprehensive review at 3 months postpartum is recommended, by which time BP and laboratory tests should have normalized 1
• Persistent abnormalities require further investigation for secondary causes of hypertension 1, 3
• Women with history of hypertensive disorders in pregnancy have increased long-term cardiovascular risk and require lifelong follow-up 1
• Postpartum hypertension clinics with multidisciplinary care can improve outcomes and provide a bridge to longitudinal care 1