Hypertensive Disorders in Pregnancy (HDP) represented 15.4% of total numbers of maternal death- the 4th main cause after obstetric embolism, PPH and other medical non HDP conditions

1. Dr Chan Joe Mee
O&G Department, SGH
Postpartum Hypertension –
a challenge even after childbirth

2. Postpartum Hypertension ??
Chronic
HPT
Preeclampsia Gestational HPT
de novo HPT

3. CEMD in Malaysia 2006-2008
 HDP represented 15.4% of total numbers of
maternal death- the 4th main cause after
obstetric embolism, PPH and other medical non
HDP conditions
 396 maternal deaths ;
 61 cases (15.4%) were DIRECTLY related to
complications of Hypertensive Disorders in
Pregnancy (HDP)
 Average incidence of HDP deaths /year - 20
cases

4.  Inadequate treatment of systolic
hypertension was a recurring theme
 The majority of these deaths were seen
among mothers whose age was >30; with
the minority groups Iban and Orang Asli
being the commonest ethnic groups

5. Definitions
For the purposes of this presentation, the following definitions apply (ISSHP
2000):
 Chronic hypertension is hypertension that is
present at booking / < 20 weeks or if the
woman is already taking antihypertensive
medication when referred to maternity services.
It can be primary / secondary in aetiology
 Eclampsia is a convulsive condition associated
with pre-eclampsia
 HELLP syndrome is haemolysis, elevated liver
enzymes and low platelet count
 Gestational hypertension is new hypertension
presenting >20 weeks without significant
proteinuria

6.  Significant proteinuria - if the urinary
protein:creatinine ratio (uPCR) is >30 mg/mmol
or a validated 24-hour urine collection result
shows >300 mg protein. ( Test done following a
result of urine albumin >/= 1+)
 Pre-eclampsia is new hypertension presenting
after 20 weeks with significant proteinuria
 Severe pre-eclampsia is pre-eclampsia with
severe hypertension &/ with symptoms, &/
biochemical &/ haematological impairment

7. Classification of Hypertension
NICE Guideline - Guideline Development Group (GDG)
 Mild hypertension
– SBP140–149 mmHg, DBP 90–99 mmHg.
 Moderate hypertension
– SBP150–159 mmHg, DBP100–109 mmHg.
 Severe hypertension
– SBP>/= 160 mmHg, DBP >/=110 mmHg.
* Treatment of moderate HPT prevents severe HPT and its complications

8. International Society for the Study of
Hypertension in Pregnancy / ISSHP 2014-
Revised Classification
 The revised classification for hypertensive
disorders in pregnancy is as follows:
1. Chronic hypertension.
2. Gestational hypertension.
3. Pre-eclampsia – de novo or superimposed on
chronic
hypertension.
4. White coat hypertension.

9. Pre-eclampsia

10. White Coat
Hypertension

11. Postpartum Hypertension
 Hypertension should be recognised & effectively
treated to :
 prevent severe hypertension
 avoid unnecessary delays in discharge
 Poorly managed postpartum hypertension place
women at risk of significant complications
 Appropriate treatment of
postnatal hypertension is
essential to prevent maternal
morbidity and mortality from
cerebral haemorrhage

12. This presentation seeks to…
• Describe the normal postpartum changes
in BP
• Consider which patients should be >
closely monitored & treated
• Consider the evidence for different
antihypertensive agents & the ass.
implications for the mother & baby

13. Normal Physiology
 Following uncomplicated pregnancy over the first
4 days in the postpartum period
 SBP ↑ average 6 mmHg
 DBP ↑ average 4 mmHg
 Up to 12% of patients will have a recorded DBP >
100 mmHg
 This is dt the resolution of the CVS adaptations to
pregnancy, ie.
 mobilisation of fluid accumulated in the extra vascular
space during pregnancy

14. Immediate postpartum
→ tendency of an increase in BP
UTERUS
CONTRACTED BLOOD RETURNS TO
SYSTEMIC
CIRCULATION
↑ VENOUS
RETURN ↑CARDIAC
OUTPUT
↑BP

15. Pathophysiology
 1/3 of women who have had PIH or Pre-
eclampsia (PET) will be sustaining HPT in the
postnatal period
 Commonly they are normotensive in the early
postpartum period, possibly dt depleted
intravascular volumes following labour
 There is also a group who is acknowledged to
hv HPT occuring de novo following delivery

16. Women particularly at risk of postnatal
hypertension - Table 1
_____________
________________
________________________
___________________

17. In severe PE/Eclampsia
Delivery ≠ End of the problem
 Severe PE/E can develop during post partum
period
 44% of eclampsia occur postpartum
(has been reported up to 4 weeks)
 Initial BP may fall following delivery but usually
rise again around 24h post partum
 Incidence of severe PE/E fall after the 4th day
postpartum

18. Pre-eclampsia
 The potential complications of PE in the
postpartum period are largely similar to those
in the antenatal period (except for fetal
complications)
 There is increasing recognition that
 severe systolic HPT (>160 mmHg)
 ↑MAPs
should prompt urgent
treatment to prevent
cerebral
haemorrhage.7

19. Evidence
Incidence of complications among patients with
PET:
 Matthys et al. (AJOG 2004)described the
outcomes of 151 women readmitted in the
postnatal period (up to day 24) who received
a diagnosis of PET
 The incidence of complications was high:
 16% eclampsia
 9% pulmonary oedema
 one maternal death

20.  Similarly, Chames et al. (AJOG 2002) :
 29 women presenting with postpartum
eclampsia, almost all reported ≥ 1 prodromal
symptom
 23 (79%) patients had seizures after 48 hours
 Study conducted from March 1996 through Feb
2001

21.  Lubarsky et al. reported a series of 334 cases
of eclampsia
 16% of seizures - in the postnatal period
( > ½ of these later than 48 hours following
delivery).

22.  Emphasis of these data :
 the need for prolonged vigilance in the
postpartum period
 The importance of investigating reported
symptoms in such women
 In the current climate of early postnatal
discharge, both hospital and community
teams need to have referral and
management guidelines in place

23. Consideration of
antihypertensive agents
 The ideal antihypertensive agent to be used
in the postnatal period should
 reliably and effectively control BP without
diurnal peaks and troughs
 have minimal maternal side effects
 be safe for breastfeeding infants
 be effective with once-daily dosing to maximise
compliance

24.  Due to the paucity of data, it is difficult to recommend
one antihypertensive agent over another9
 In the absence of such data the clinician should be
aware of the pros and cons of available agents

26. 1. β-blockers
 The most common agents used are labetalol
and atenolol
 β 2 receptors- effect on peripheral vasodilation
 β 1 receptors in cardiac tissue modulate the
sympathetic response
 Renal receptors mediate changes in renin
synthesis-This modest decrement in renin
synthesis may contribute to the overall
antihypertensive effect in some patients

27.  β -blockers may exacerbate & should be
avoided
 asthma
 cardiac failure
 Individuals who describe respiratory symptoms
after commencing a β -blocker (symptoms may
not be apparent for several days) should be
changed to an alternative agent

28. Atenolol
 Advantage – OD dosing (25-100mg OD)
 ↑compliance in women who find multiple
dosing regimens difficult
 The high lipid solubility of the drug means
that it is concentrated in breast milk and
concerns have previously been raised about
transfer to the neonate

29.  However, only a single case of neonatal β -
blockade has been reported despite extensive
use of the drug in breastfeeding women
 The risks in routine clinical practice are
therefore minimal

30. 2. Calcium channel blockers
 Inhibits Ca2+ influx into vascular myocytes
thereby inhibiting vasoconstriction and
reducing vascular resistance
 Minimal effects on cardiac conduction and HR ;
but may be ass. with > headache than β –blockers
 There is minimal excretion into breast milk10
 Nifedipine - the most commonly prescribed CCB ;
dosage- 10-20mg TDS
 A 2nd-line alternative is Amlodipine 5–10 mg OD

31. 3. Methyldopa
 The most common antihypertensive agent
used in the antenatal period is methyldopa-
because of its well established safety record
with regard to fetal toxicity
 Centrally acting α-adrenergic agonist- brings
about reduced systemic vascular resistance
via ↓ sympathetic vascular tone

32.  Whilst methyldopa remains a safe option for
treatment of hypertension in the postnatal
period, particularly in women who have had
good antenatal control with the agent, most
authorities advise that it should be
discontinued because of its maternal side-
effects, in particular:
 Sedation
 postural hypotension
 postnatal depression

33. 4. Angiotensin converting
enzyme (ACE) inhibitors
 ACE inhibitors (such as Enalapril) - commonly
used outside of pregnancy to treat hypertension,
particularly that ass. with renal disease and
proteinuria
 Inhibit angiotensin converting enzyme (ACE)
→ decrease production of angiotensin II (AII)
reducing AII mediated vasoconstriction
 Ass. with adverse fetal outcomes when used in
the antenatal period ; but there are reassuring
data concerning their safety in breastfeeding

34.  Enalapril can be prescribed as a BD dose of
5–20 mg
 + :generally well tolerated
 - : can experience profound hypotension.
 Association with renal impairment:-
 CAUTION: recent deterioration of renal function.

35. 5. Diuretics
 Diuretics - rarely used as antihypertensive agents
in the postnatal period; except- pulmonary
oedema
 Postnatal women are > susceptible to postural
hypotension
 Breastfeeding women may experience excessive
thirst
 The associated volume contraction may interfere

36. Treatment of acute episodes of
hypertension
 Acute episodes of hypertension in the
postnatal period should be managed in the
same manner as antenatal / intrapartum
episodes
 The agents of choice are:
 labetalol (oral or intravenous)
 nifedipine (oral) or
 hydralazine (intravenous)

37.  Labetalol-
 Advantage - an oral dose can be given before
intravenous access is established
 Further intravenous doses can be given if
required
 Hydralazine-
 effective ; although its use as a first-line drug has
been questioned
 > commonly causes precipitous drops in BP
and the associated symptoms are unpleasant
for women (;although the concerns about
placental perfusion are no longer relevant)

38. Management of ongoing
postnatal
hypertension1. Patients with existing hypertension
 It is advisable to stop methyldopa following delivery and
switch to the prepregnancy dose of her usual agent/s
 Where newer drugs have been prescribed and mothers
are wishing to breastfeed, pharmaceutical advice
should be sought before delivery
 All of the antihypertensive drug groups have
examples of preparations where there is reassuring
experience with breastfeeding
 Women who were previously using diuretics should
consider an alternative while they are breastfeeding

39. Figure 1. (a) Algorithm for the management of postnatal
hypertension in women with chronic hypertension.

40. 2. Hypertension arising during pregnancy or
in the puerperium
 In patients who were normotensive before
pregnancy, one of the most difficult problems
is deciding which women should have
antihypertensives prescribed following delivery
 Women who are most likely to benefit from
antihypertensisves prescribed following
delivery:
 required antihypertensives in the antenatal period
 been delivered < 37 weeks of gestation because of
hypertension

41.  The perceived advantages of starting treatment in
the early postnatal period are :
 episodes of severe hypertension will be reduced
 discharge to the community will not be delayed
unnecessarily
 Balanced against this
 possibility of unnecessary treatment
 SE of medication
 A suggested regimen might be
 labetalol (providing there is no history of asthma) , with
 second and third-line agents of calcium antagonist and
an ACE inhibitor (such as enalapril)

42. Figure 1.(b) Algorithm for the management of postnatal
hypertension in women without chronic hypertension

43. 3. De novo hypertension
 Not clear what thresholds should be used to
instigate treatment in women with de novo
hypertension in the postnatal period having
previously been normotensive
 Current NICE postnatal guidance recommends
medical review:
 DBP>90 mmHg ,ass. w any symptoms of PET
OR
 Diastolic hypertension sustained >4 hours

44.  No systolic thresholds are suggested but
extrapolation from the subsequent
hypertension guidelines :
 SBP >150 mmHg → PET should be excluded
 Newly presenting patients should have a
history and examination taken to exclude IE
and have Ix that include:
 FBC
 BUSE/Creat
 LFT

45. Inpatient management of
ongoing postnatal hypertension
 ALL women should be closely monitored with
regular recordings of BP and fluid balance
(regardless whether antihypertensive agents
prescribed immediately following delivery)
 Modified obstetric early warning system
(MOEWS) charts should be used to facilitate
the monitoring of these women in wards

46. A validation study of the CEMACH recommended modified early obstetric warning
system (MEOWS)*
Anaesthesia
Volume 67, Issue 1, pages 12-18, 9 NOV 2011 DOI: 10.1111/j.1365-2044.2011.06896.x
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2044.2011.06896.x/full#fa1

49. Frequency of PET profile
 The frequency of measuring haematological and
biochemical indices will need to be tailored to
individual patients
(A minimum of OD testing may be required initially in
cases where there is concern about
thrombocytopenia or renal compromise)
 Thereafter frequent sampling - unlikely to change
management in the absence of other clinical triggers
 Furthermore, unnecessary concern may arise if
normal patterns of resolution are not appreciated (for
example, ALT reaches peak serum levels 5 days
postnatally in normal pregnancy15 )

50. NICE guidance16 recommends :
 platelet count
 transaminases
 serum creatinine
 Up to 44% of eclamptic fits occur in the postnatal
period (usually within the first 48 hours following
delivery,17) women with PET should be encouraged to
delay discharge until day 3
 BP at the time of discharge should be <150/100 mmHg
 Crucial that the community team receive adequate
and prompt documentation regarding the inpatient
management and the plans for follow-up
Checked 48–72 hours after birth/
Step down from Level 2 care, and
Thereafter only repeated if abnormal or
clinically indicated

51. Discharge criteria
 De novo HPT (non-proteinuric) – >6 hrs: Discharge if
BP <150/90 (EOD BP- expect going down to
<140/90mmHg)
 For mild HDP – no earlier than 24-48 hrs
 Severe PE/E – no earlier than day 3
 DBP has settled <100 mmHg
 On single/no antihypertensive drug
 NO end-organ dysfunction
 Patient:
 understands the disease & its complications
 compliant to medication
 accessible to a health center

52. Notification of birth
 The importance of continuing post-natal care
either at the hospital or health center cannot
be overemphasized
 To facilitate this, notification of birth to the
nearest peripheral health center is vital
 Phone
 Fax
 Report by family members/next of kin to nearest
clinic

53. Follow-up at the Community
 Local experience and facilities will dictate if this
review should be by the GP / the hospital
maternity assessment unit/ Daycare unit
 Hospital review will be required if patients
report symptoms of PET / if BP >160/100
mmHg
 Most women who commence postnatal
antihypertensives will require treatment for ≥ 2
weeks
 Some women, esp. with early onset /severe
disease may need to continue > 6 weeks18

54. Management at the
Community
 EOD follow-up either at the health centre /
home visit by the community
midwife/nursing/paramedical staff :
 BP
 urine for albumin
 signs and symptoms of PET
 The patient has to be seen and examined by a
doctor either in the hospital / at health centre
fortnightly until 6 weeks post-natal period

55. Elements to be monitored Frequency of
review by nurse
Frequency of
review by
doctor
•Blood Pressure
•Urine for protein (if B/P >
140/90 mmHg)
•Signs and symptoms of severe
HDP and pre-eclampsia
•Signs and symptoms of Deep
Vein Thrombosis
(Post-natal mothers with history
of HDP have a higher risk of
developing DVT, as a
complication of advocating long
rest during antenatal period)
Every
Other
Day
(EOD)
Two weekly

56.  Medication should be reduced when BPs
ranged 130–140/80–90 mmHg
 Refer for medical review:
 >150/ 100mmHg - 2x measurements are
obtained >20 minutes apart
 Further medical review
 If medication is required > 6 weeks - to Ix the
possibility of an underlying cause
 It has been reported - up to 13% of women
initially thought to have a diagnosis of PET or
PIH will have underlying disease not
suspected antenatally

57. 6 weeks post partum
 The 6-week postnatal visit –
 establish the diagnosis (PIH/PET/Essential HPT)
 discuss implications for future pregnancies
 Advise to have an early booking (LDA+CaCO3) and
regular antenatal care in the next pregnancy
 Counseling on the importance of
contraception and choice with reference to
WHO medical eligibility criteria (WHO MEC)

58.  If hypertension and proteinuria persists >6
weeks postpartum, the mother should be referred to
a physician
 It is important to ascertain whether that renal
impairment detected in hypertensive
pregnancies is indeed attributable to PET
 Renal biopsies taken in the postpartum period in 176
women who had been diagnosed in pregnancy as
having renal complications of pre-eclampsia
established →
 an alternative diagnosis in 1/3 of cases overall; and this
was ↑ to almost 2/3 in multiparous patients

59. Recurrence of Pre-eclampsia
 The risk of pre-eclampsia in a subsequent
pregnancy depends on the presentation in the
index pregnancy
 Severe, early onset pre-eclampsia -
recurrence rate up to 40% in future
pregnancies
 generally the onset of problems is 2–3 weeks
later
 < severe than in the 1st pregnancy
 Milder disease, nearer to term - risk of

60. Future pregnancy/ risk
 Women at increased risk should be offered in
a future pregnancy
 low-dose aspirin
 increased BP surveillance
 Finally….CVD
 It is increasingly recognised that PET is a risk
factor for developing cardiovascular disease in
later life
 Patients should be made aware of this -
opportunity to make lifestyle choices to minimise

61. THANK YOU
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