What are the recommendations for a 28-year-old female with postpartum hypertension, who had preeclampsia (pre-eclampsia), for primary care physician (PCP) management of hypertension (HTN)?

From the Guidelines

For a 28-year-old female with postpartum hypertension following preeclampsia, management should begin with close blood pressure monitoring for at least 72 hours postpartum and weekly for 6 weeks, with first-line antihypertensive medications including labetalol, nifedipine, or methyldopa, aiming for blood pressure goals of <150/100 mmHg initially, transitioning to <140/90 mmHg long-term, as recommended by the most recent guidelines 1. The patient's blood pressure should be monitored closely, and medication should be continued until blood pressure normalizes, typically within 6-12 weeks postpartum, with gradual tapering. Some key points to consider in management include:

• Close monitoring of blood pressure for at least 72 hours postpartum and weekly for 6 weeks
• First-line antihypertensive medications: labetalol (starting at 200-400 mg twice daily, maximum 2400 mg/day), nifedipine (extended-release 30-60 mg daily, maximum 120 mg/day), or methyldopa (250-500 mg twice daily, maximum 3 g/day)
• Blood pressure goals: <150/100 mmHg initially, transitioning to <140/90 mmHg long-term
• Medication should be continued until blood pressure normalizes, typically within 6-12 weeks postpartum, with gradual tapering
• Regular follow-up is essential, with blood pressure checks at 7-10 days and 6 weeks postpartum
• Annual blood pressure screening and lifestyle modifications (reduced sodium intake, regular exercise, weight management) are recommended to reduce the risk of developing chronic hypertension and cardiovascular disease
• Breastfeeding is still encouraged as all first-line medications are compatible with lactation, as noted in the European Heart Journal 1. It is also important to note that women with a history of preeclampsia are at increased risk of developing hypertension, stroke, and cardiovascular disease in later life, and therefore, long-term follow-up and lifestyle modifications are crucial 1.

From the Research

Postpartum Hypertension Management

The patient, a 28-year-old female with postpartum hypertension and a history of pre-eclampsia, requires careful management to prevent complications.

• The definition of hypertension in the postpartum period is a systolic blood pressure of 140 mm Hg or greater and/or diastolic blood pressure of 90 mm Hg or greater on 2 or more occasions at least 4 hours apart 2.
• Severe hypertension is defined as systolic blood pressure of 160 mm Hg or greater and/or diastolic blood pressure of 110 mm Hg or greater on 2 or more occasions repeated at a short interval (minutes) 2.
• For acute management of severe hypertension, labetalol, hydralazine, and nifedipine are effective options, with nifedipine potentially working the fastest 2.
• For persistent postpartum hypertension, a long-acting antihypertensive agent should be started, with labetalol and nifedipine being effective options 2.

Risk of Postpartum Hypertension

• Women with a history of hypertensive disorders of pregnancy, including pre-eclampsia, are at increased risk of developing postpartum hypertension 3.
• The risk of hypertension within 2 years of birth is six-fold higher in women who experienced pre-eclampsia 3.
• The augmented risk of hypertension after hypertensive disorders of pregnancy is highest in the early postpartum period, suggesting that diagnosis and targeted interventions to improve maternal cardiovascular health may need to be commenced in the immediate postpartum period 3.

Management Strategies

• A workup for secondary causes of hypertension should be pursued, especially in patients with severe or resistant hypertension, hypokalemia, abnormal creatinine, or a strong family history of renal disease 2.
• Providers must be aware of the risks associated with postpartum hypertension and educate women about the symptoms of postpartum preeclampsia 2.
• The Consensus Bundle on Severe Hypertension During Pregnancy and the Postpartum Period provides guidance to coordinate and standardize the care provided to women with severe hypertension during pregnancy and the postpartum period 4.