Postpartum Hypertension, Guideline for Management (322)

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General points

There is a physiological rise in blood pressure in the postnatal period, often reaching a peak at day 3-6 postnatal
BP should be measured at least daily for the first 2 days after birth
BP should be measured at least once between day 3 and 5 after birth
Systolic blood pressure is an important risk factor for stroke
Severe hypertension (≥160/110 mmHg) must be treated
BP persistently ≥150/100 mmHg should be treated
Eclamptic seizures can occur in the postnatal period, but are less likely after the third postnatal day. When they do occur this is frequently associated with prodromal signs and symptoms (commonly headache or visual disturbance), although not necessarily hypertension
Avoid methyldopa in the postnatal period due to its association with postnatal depression
Nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided in the presence of hypertension that is difficult to control, oliguria or impaired renal function

There are 3 groups of women with postpartum hypertension

Ante-natal Pregnancy Induced Hypertension (PIH) or pre-eclampsia (PET)
Known chronic hypertension
‘De novo’ hypertension

Irrespective of cause

BP ≥160/110 mmHg or MAP >125 requires treatment

Severe hypertension in previously normotensive women is an obstetric emergency. If the patient is clinically stable oral agents can be used in the first instance. Rarely, the clinical situation will merit IV therapy in the postnatal period-as per the severe pre-eclampsia guideline

BP ≥150/100 mmHg commence regular antihypertensives

** In cases of chronic hypertension the response to blood pressure readings should be tailored to the individual case. In women with chronic hypertension, pre-dating their pregnancy, they have reset their cerebral auto-regulation mechanism and will not be at as great a risk of CVA from a systolic reading of 160mmHg compared to a previously normotensive women

Treatment

1^st line

Offer Enalapril to treat hypertension with appropriate monitoring of maternal renal function (including serum K+)

2^nd Line

If BP not controlled with single medicine, consider a combination of Nifedipine (or Amlodipine) and Enalapril

If this combination is not tolerated or is ineffective, consider either

3^rd Line

Adding Atenolol or Labetalol (preferred if breast feeding) to the combination treatment or
Swapping 1 of the medicines already being used for Atenolol or Labetalol (preferred if breast feeding)

Women of Black African or African-Caribbean origin

Monotherapy with ACE inhibitors or B blockers is less effective in this patient group. Therefore, consider the following as first line agents:

Nifedipine
Amlodipine if the woman has previously used this to successfully control her BP

Postnatal hypertension drugs and dosage table

Important points to note:

When treating women in the postnatal period use medicines that are once daily if possible
Where possible, avoid using diuretics or angiotensin receptor blockers to treat hypertension in women who are breastfeeding or expressing
In breastfeeding, antihypertensives can pass into breast milk. However, most medicines only lead to low levels in breast milk, therefore the amounts taken in by babies are very small and would be unlikely to have any clinical effect. The exception is atenolol and it is preferable to use an alternative agent in women who are breastfeeding
ACE inhibitors can be used in breastfeeding women – enalapril is the drug of choice. In the context of severe preterm delivery discussion with the neonatal team may be appropriate
When discharged home, advise women who are breastfeeding and taking antihypertensive medication to monitor their baby for drowsiness, lethargy, pallor, cold peripheries or poor feeding

Treatment aims

Maintain BP <150/100 , ideally <140/90 mmHg in the postnatal period
For patients with end-organ damage (e.g. renal disease or diabetes) aim for target BP ≤ 130/80 mmHg
For patients with chronic hypertension aim for target BP ≤ 135/85 mmHg
Outpatient BP monitoring should be arranged e.g. Community Midwife, DCU or GP
BP <130/80 mmHg-reduce medication (see appendix 1)
BP <120/70 mmHg - stop medication

On discharge from hospital

Inform own consultant of any patient being discharged on antihypertensive medication.
Women with chronic hypertension, or hypertension secondary to other medical conditions, will have a care plan defined by their obstetric/medical team.
For women with PIH / PET:
- Outpatient monitoring should be arranged - Community Midwife or GP.
- Alternatively, home BP monitoring via DCU can be requested.
- The care plan for home BP monitoring, to be documented by medical staff in BadgerNet, should include frequency of BP recordings; target BP and thresholds for stopping treatment and indications for referral to secondary care for BP review.
- The Postnatal Discharge Letter for Women with Hypertension in Pregnancy should be completed and information sent to GP
On discharge, the case notes of any woman whose pregnancy has been complicated by hypertension should be sent to the relevant consultant to decide if the woman requires consultant postnatal review at 6-8 weeks postpartum. If this is not felt to be required the woman should be reviewed by her GP at 6-8 weeks postpartum.
Women who have had PIH / PET and remain on antihypertensive medications 2 weeks after transfer to community care should have a GP/medical review.
Women who have had PIH / PET and remain on treatment at 12 weeks postpartum, should have a specialist medical assessment of their hypertension.

Postnatal management - in hospital (flowchart)

Postnatal hypertension management in hospital - flowchart

Postnatal management - in the Community (flowchart)

Postnatal hypertension management in the community - flowchart

Appendix 1: Suggested regime for reducing antihypertensive medication

Suggested regime for reducing antihypertensive medication

Appendix 2: Post Natal Discharge Letter for Women with Hypertension in Pregnancy

Post Natal Discharge Letter for Women with Hypertension in Pregnancy (pdf)

Last reviewed: 27/02/2024

Next review date: 08/02/2029

Author(s): Claire McCormack.

Version: 3

Co-Author(s): Janet Brennand.

Approved By: Maternity Clinical Governance Group

Document Id: 322

References

NICE. Hypertension in pregnancy: diagnosis and management. [NG133] June 2019

Smith M et al. Management of postpartum hypertension. The Obstetrician & Gynaecologist 2013; 15:45-50

Handbook of Obstetric Medicine 5^th Edition, Nelson-Piercy