What is the recommended management for postpartum hypertension?

Management of Postpartum Hypertension

Immediate treatment is required for severe postpartum hypertension (BP ≥160/110 mmHg lasting >15 minutes) to reduce the risk of stroke and other complications. 1, 2

Diagnosis and Classification

• Postpartum hypertension is diagnosed when systolic BP ≥140 mmHg and/or diastolic BP ≥90 mmHg, measured on at least two separate occasions or at least 15 minutes apart in severe hypertension (≥160/110 mmHg) 1
• Postpartum hypertension may result from:
  • Continuation of pre-existing hypertension
  • Gestational hypertension or preeclampsia
  • Iatrogenic causes (NSAIDs, ergot derivatives, ephedrine)
  • Anxiety 1, 2

Acute Management of Severe Hypertension

• For BP ≥160/110 mmHg, immediate antihypertensive treatment is required 1, 2
• First-line treatments include:
  • IV labetalol
  • Oral nifedipine 1, 3
• Methyldopa should NOT be used for urgent BP reduction 1, 2
• Magnesium sulfate is recommended for prevention of eclampsia and seizures but should not be given concomitantly with calcium channel blockers due to risk of synergistic hypotension 1, 2

Monitoring Protocol

• Blood pressure should be monitored at least every 4 hours while awake for at least 3 days postpartum 4, 2
• Home blood pressure monitoring is recommended after discharge 1, 5
• Laboratory tests (hemoglobin, platelets, creatinine, liver enzymes) should be repeated the day after delivery and then every other day until stable if any were abnormal before delivery 2

Maintenance Therapy for Persistent Hypertension

• Antihypertensive medications should be continued postpartum with gradual tapering rather than abrupt cessation 4
• Safe medications for breastfeeding mothers include:
  • Labetalol 1, 6
  • Nifedipine 1, 2
  • Enalapril (unless neonate is premature or has renal failure) 1, 2
  • Metoprolol 1, 2
• Amlodipine is non-inferior to nifedipine ER for postpartum hypertension treatment and has fewer discontinuations due to side effects 7
• Diuretics (furosemide, hydrochlorothiazide, spironolactone) may reduce milk production and are generally not preferred in breastfeeding women 1, 2
• Continue antihypertensive medication until BP has normalized, which may take days to several weeks postpartum 1, 2

Special Considerations

• Avoid NSAIDs for pain relief if possible, especially in women with acute kidney injury, as they may worsen hypertension 4, 2
• 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
  • Need for IV antihypertensive medication after first-line drugs have failed 1, 4

Long-term Follow-up

• All women with postpartum hypertension should be reviewed within 1 week if still requiring antihypertensives at discharge 2
• A comprehensive review at 3 months postpartum is recommended, by which time BP and laboratory tests should have normalized 4, 2
• Women with persisting hypertension under age 40 should be assessed for secondary causes of hypertension 1
• Women with history of hypertensive disorders in pregnancy have increased long-term cardiovascular risk and require annual medical review lifelong 4, 2
• Lifestyle modifications including regular exercise, healthy diet, and maintaining ideal body weight are recommended 4

Prevention Strategies

• Early identification and treatment of hypertension can prevent progression to severe complications 1, 3
• Home blood pressure monitoring programs have been shown to improve identification and management of postpartum hypertension 5
• Patient education about symptoms of postpartum preeclampsia is essential 3