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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

Postpartum Hypertension

Lin-Fan Wang MD

5/4/09

PGY-1 OB/GYN Rotation

Family and Social Medicine

slide2
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
case cont
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
case cont1
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
case cont2
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
postpartum blood pressure
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
pathophysiology
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
differential diagnosis
Differential Diagnosis
  • Essential HTN
  • Persistent Antenatal GHTN or PEC
  • De novo HTN
  • Pre-eclampsia/HELLP
  • Renal disease
  • Pheochromocytoma
  • Primary hyperaldosteronism
risk factors
Risk Factors
  • Recurrence of HTN postpartum
    • Preterm delivery
    • Multips with higher uric acid levels or BUN
    • Preeclampsia (vs. GHTN)
morbidity mortality
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
prophylaxis
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
treatment
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
slide14
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
references
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.