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Postpartum Hypertension

Postpartum Hypertension. Lin-Fan Wang MD 5/4/09 PGY-1 OB/GYN Rotation Family and Social Medicine. Case. HPI : 29yo G 6 P 2133 PPD #9 s/p NSVD, induced at 34 5 GA for SiPEC presented to clinic with “I need BP medicine”. H/o CHTN prior to last pregnancy

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Postpartum Hypertension

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  1. Postpartum Hypertension Lin-Fan Wang MD 5/4/09 PGY-1 OB/GYN Rotation Family and Social Medicine

  2. Case • HPI: 29yo G6P2133 PPD #9 s/p NSVD, induced at 345GA for SiPEC presented to clinic with “I need BP medicine”. • H/o CHTN prior to last pregnancy • HCTZ for CHTN d/c’ed during pregnancy • No h/o PEC or GHTN with prior pregnancies • BPs 94-147/57-78 until 34wk

  3. Case cont. • Admitted for BP check & collection of 24hr urine • Criteria for SPEC met by severe range BP, 300+ protein in 24hr urine collection, and persistent maternal headache • Pt given hydralazine 10mg IV x1, MgSO4 x24hr

  4. Case cont. • PPD #1-2: BP in nl-mild range. Pt was asymptomatic, adequate UOP. • Pt given HCTZ 25mg PO x1 on PPD #2 • Pt d/c’ed on PPD #2 without anti-HTN meds

  5. Case cont • Pt denies HA/vision changes/N/V/abd pain • Nervous about having a premature baby • BP in clinic 150-160s/110s • Exam benign • PEC labs sent

  6. Postpartum Blood Pressure • Few published studies • Studies of non-hypertensive women • Rise in BP over PPD #1-5 • BP peak on PPD #3-6 • 10% had diastolic BP >100 mmHg • Study of women with antenatal PEC • Initial decrease then hypertensive levels PPD #3-6 • 50% had BP >150/100 on PPD #5 • Study of women with GHTN & PEC • GHTN: nl BP PPD #6 • PEC: nl BP PPD #16

  7. Pathophysiology • Mobilization of extravascular fluid to intravascular space • Excretion of urinary sodium has been observed on PPD #3-5 • De novo postpartum HTN may be due to lower ANP levels vs. lack of decrease in angiotensin I levels

  8. Differential Diagnosis • Essential HTN • Persistent Antenatal GHTN or PEC • De novo HTN • Pre-eclampsia/HELLP • Renal disease • Pheochromocytoma • Primary hyperaldosteronism

  9. Incidence of Late PP PEC

  10. Risk Factors • Recurrence of HTN postpartum • Preterm delivery • Multips with higher uric acid levels or BUN • Preeclampsia (vs. GHTN)

  11. Morbidity & Mortality • Death • ~10% of maternal deaths in UK due to a hypertensive disorder of pregnancy occurred postpartum • 1/15 deaths attributed to severe hypertension that developed only postpartum in women with antenatal pre-eclampsia • Other complications of severe PP HTN include stroke and eclampsia

  12. Prophylaxis • Should women with antenatal hypertension receive antihypertensive medication postpartum to prevent transient severe maternal postpartum hypertension or to decrease length of hospital stay? • Insufficient data based on a Cochrane review of the literature

  13. Treatment • General consensus for treatment of severe hypertension • Prevent acute maternal vascular complications, i.e. stroke • No consensus for mild-moderate postpartum hypertension • Limited evidence to support safety of antihypertensives for breastfeeding • Observational studies recommend methyldopa, B-blockers with high protein binding (e.g., oxprenolol), ACEIs, some dihydropyridine CCBs • ? MgSO4 in patients with PEC

  14. Case • Lab results: AST/ALT 41/71, uric acid 8.8 • Pt called to go to Weiler ED • Pt went to Monte instead • BP 150/100 --> 148/90, urine protein -, AST/ALT 25/58, uric acid 9.1 • Pt signed out AMA prior to GYN consult • Pt saw PMD for baby visit few days later, doing well

  15. References • Tan L-K, de Swiet M. The management of postpartum hypertension. BJOG 2002;109:733-6. • Sibai BM, Stella CL. Diagnosis and management of atypical preeclampsia-eclampsia. AJOG 2009;200:481.e1-7. • Magee L, Sadeghi S. Prevention and treatment of postpartum hypertension. Cochrane Database of Systematic Reviews 2005, Issue 1.:CD004351. DOI:10.1002/14651858.CD004351.pub2. • Matthys LA, Coppage KH, Lambers DS, et al. Delayed postpartum preeclampsia: An experience of 151 cases. AJOG. 2004;190:1464-6 • Arterbury JL, Groome LJ, Hoff C, et al. Clinical presentation of women readmitted with postpartum severe preeclampsia or eclampsia. JOGNN. 1997;27:134-41.

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