How do you classify hypertension that develops postpartum in a patient with a history of pre-eclampsia, now requiring medication, specifically Labeltal (hydrochlorothiazide)?

From the Guidelines

Postpartum hypertension following pre-eclampsia is classified as persistent postpartum hypertension, which requires ongoing management even after delivery. When a patient who had pre-eclampsia during pregnancy continues to have elevated blood pressure postpartum requiring medication like labetalol, this indicates that the hypertensive condition has not resolved with delivery as expected.

Key Points to Consider

• Labetalol is an appropriate first-line agent for this condition as it's a combined alpha and beta-blocker that effectively lowers blood pressure with minimal side effects for breastfeeding mothers 1.
• The management typically involves monitoring blood pressure for at least 72 hours postpartum, and if hypertension persists beyond 12 weeks, it should be reclassified as chronic hypertension.
• For patients requiring ongoing treatment, blood pressure should be maintained below 150/100 mmHg, with a goal of transitioning off medications when possible.
• This persistent hypertension occurs because the vascular and endothelial damage from pre-eclampsia may take weeks to months to fully resolve, and some patients may have had underlying chronic hypertension that was undiagnosed before pregnancy or may have developed new-onset chronic hypertension.

Treatment Considerations

• First-line agents for the treatment of postpartum hypertension regardless of breastfeeding status include nifedipine, amlodipine, enalapril, and labetalol 1.
• Alternative agents include diuretics, which could help early postpartum BP recovery after HDP, but may affect breastmilk production at higher doses.
• It is reasonable to adopt heart failure guidelines and treat hypertension with combination therapy that includes a β-blocker and angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker, considering lactation preferences.

Important Recommendations

• All patients of childbearing potential with or at risk for cardiovascular disease will need counseling on and a documented plan for contraception, especially when initiating medications with potential teratogenicity 1.
• Patients should be closely monitored for potential complications, including stroke and eclampsia, and transferred to the ICU if necessary, based on factors such as need for respiratory support, abnormal EKG findings, or need for pressor support 1.

From the Research

Classification of Hypertension after Postpartum and Pre-eclampsia

• Hypertension that occurs after postpartum and had pre-eclampsia can be classified based on the severity of the blood pressure and the presence of other symptoms or complications.
• According to the study 2, postpartum hypertension 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.
• 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) 2.

Diagnosis and Management

• The diagnosis of postpartum preeclampsia should be considered in women with new-onset hypertension 48 hours to 6 weeks after delivery 3.
• The management of postpartum hypertension includes the use of antihypertensive agents, such as labetalol, hydralazine, and nifedipine, to reduce blood pressure and prevent complications 2, 4.
• The choice of antihypertensive agent may depend on the severity of the hypertension and the presence of other symptoms or complications, such as headache or visual disturbances 3.
• Amlodipine has been shown to be non-inferior to nifedipine ER for the management of postpartum hypertension, with similar rates of side effects and medication discontinuation 5.

Treatment Options

• Oral antihypertensive therapy, such as nifedipine, labetalol, and methyldopa, can be effective for treating severe hypertension in pregnancy and postpartum 6.
• The use of oral antihypertensive agents can be ideal for busy and resource-constrained settings, where parenteral antihypertensives may not be available or practical 6.
• Labetalol and nifedipine are also effective for acute management of severe hypertension, although nifedipine may work the fastest 2.