From the Guidelines
Postpartum hypertension following preeclampsia or eclampsia requires immediate and vigilant management to prevent severe complications, including stroke and eclampsia, with blood pressure monitoring and treatment tailored to the severity of hypertension, as recommended by the most recent guidelines 1. The management of postpartum hypertension involves careful monitoring of blood pressure, with checks within 72 hours of discharge and again 7-10 days postpartum.
- For severe hypertension (≥160/110 mmHg), immediate treatment with labetalol or oral nifedipine is recommended, as these are considered first-line treatments for hypertensive emergencies during pregnancy 1.
- For non-severe hypertension (≥150/100 mmHg), oral medications like labetalol, nifedipine, or methyldopa are appropriate, with treatment continuing until blood pressure has been normal for at least 48 hours, with gradual tapering thereafter. Key considerations in the management of postpartum hypertension include:
- Monitoring of blood pressure at least every 4 hours while awake in the early postpartum period, with antihypertensives administered antenatally continued and consideration given to restarting them after delivery 1.
- Avoidance of NSAIDs in women with preeclampsia, especially in the setting of AKI, and use of alternative pain relief 1.
- Education of patients about symptoms requiring immediate attention, including severe headache, visual changes, chest pain, or shortness of breath. The pathophysiology of postpartum hypertension involves persistent endothelial dysfunction and inflammatory responses that can continue beyond delivery, with women having increased long-term cardiovascular risks and requiring counseling about future pregnancy risks and the importance of cardiovascular health monitoring 1.
From the Research
Postpartum Hypertension Subsequent to Preeclampsia/Eclampsia
- Postpartum hypertension can be related to persistence of gestational hypertension, preeclampsia, or preexisting chronic hypertension, or it could develop de novo postpartum secondary to other causes 2.
- The differential diagnosis of postpartum hypertension-preeclampsia is extensive, and varies from benign (mild gestational or essential hypertension) to life-threatening such as severe preeclampsia-eclampsia, pheochromocytoma, and cerebrovascular accidents 2.
- Evaluation and management of postpartum hypertension-preeclampsia should be performed in a stepwise fashion and may require a multidisciplinary approach that considers predelivery risk factors, time of onset, associated signs/symptoms, and results of selective laboratory and imaging findings 2.
Diagnosis and Management
- Hypertension complicating pregnancy, including postpartum, is defined as systolic blood pressure 140 mm Hg or greater and/or diastolic blood pressure 90 mm Hg or greater on 2 or more occasions at least 4 hours apart 3.
- Severe hypertension is defined as systolic blood pressure 160 mm Hg or greater and/or diastolic blood pressure 110 mm Hg or greater on 2 or more occasions repeated at a short interval (minutes) 3.
- For treatment of severe postpartum hypertension, antihypertensive agents such as labetalol, hydralazine, and nifedipine can be used 3, 4, 5, 6.
- Oral antihypertensive agents, including nifedipine, labetalol, and methyldopa, are suitable options for treatment of severe hypertension in pregnancy and postpartum 5, 6.
Treatment Options
- Nifedipine, labetalol, and methyldopa are viable initial options for treating severe hypertension in low-resource settings 6.
- Nifedipine retard use resulted in a greater frequency of primary outcome attainment than labetalol or methyldopa use 6.
- The choice of antihypertensive agent should be based on a clinician's familiarity with the drug 4.