Monitoring
STOP TREATMENT
Hypertension in Pregnancy_Follow Up
If pre-pregnancy BP
was normal or unknown, taper or stop antihypertensive when BP is consistently
<140/90 mmHg. For patients with hypertensive disorders of pregnancy, the BP should be checked within 7-10 days postpartum, supplemented by home BP
monitoring. Monitor the BP at 1- to 2-week intervals
followed by 3- to 6-month intervals for 1 year. Postpartum individuals with
prior pregnancy-associated hypertension whose BP normalizes and who no longer
require antihypertensive therapy should have their BP checked at least once a
year. Start treatment if hypertension recurs postpartum.
Complications
POSTPARTUM HYPERTENSION
In the early postpartum period, BP
measurement and medication titration should be individualized and patient
centered. Postpartum hypertension occurs most often in women with antenatal
hypertensive disorders but may also arise de novo after delivery.
Measure BP within 6 hours of delivery then within 3-7 days postpartum and
recheck no later than 7-14 days postpartum to evaluate for delayed postpartum
preeclampsia. BP monitoring and medication adjustment should continue up to 6
weeks postpartum or until BP stabilizes. BP is measured at least annually in
postpartum women with a history of pregnancy-associated hypertension in whom BP
elevations resolve and antihypertensive medications are discontinued. Resolution of high BP is usually more rapid in patients with
gestational hypertension. Delayed resolution
(>12 weeks) may occur in patients who suffered preeclampsia and
especially in those who had a longer duration of preeclampsia and greater renal
impairment. The greatest risk of occurrence of postpartum eclampsia is within
the first 48 hours.
Potential Complications
Women with
hypertension in pregnancy are at increased long-term risk of chronic
hypertension, chronic kidney disease, and cardiovascular disease (CVD), and
those with hypertension that persists postpartum may develop complications (eg
encephalopathy, heart failure, pulmonary edema, and renal failure postpartum).
Delayed postpartum preeclampsia (new-onset preeclampsia occurring 48 hours to 6
weeks postpartum) carries substantial maternal risks, including severe
hypertension with need for readmission, eclampsia, and stroke. Regular BP
measurements, urine analyses, and CVD risk assessment should at least be
performed 6-12 weeks, 6 months, and 12 months postpartum, then annually.
Treatment
Magnesium sulfate may be continued 12-24 hours after delivery or longer to prevent postpartum eclampsia. Continue oral antihypertensive treatment given antepartum in severe postpartum hypertension to keep BP below 160/110 mmHg and in non-severe postpartum hypertension if with comorbidities. For uncomplicated postpartum hypertension (first 6 weeks after delivery), use Labetalol or Nifedipine; Metoprolol may be used if Labetalol is unavailable. For acute, severe postpartum hypertension, Labetalol, Nifedipine and Hydralazine may be used. Antihypertensive treatment may be reduced if BP falls <130/80 mmHg. For untreated women with gestational hypertension or preeclampsia, antihypertensive therapy may be started postpartum if BP is ≥150/100 mmHg.
Treatment of Hypertension During Lactation
Breastfeeding is encouraged, as the amounts of antihypertensive agents taken in by the infants are very small and unlikely to cause any clinical effect. Patients should monitor their infants for poor feeding, pallor, drowsiness, lethargy, or cold peripheries.
Mild Hypertension
For mothers who want to breastfeed for a few months, they may withhold medications with close monitoring of the BP and reinstate treatment after discontinuation of lactation.
Severe Hypertension
Consider reducing the dose of antihypertensive with close observance of the mother and infant or using antihypertensive agents with once-daily dosing. If a beta-blocker is indicated, Labetalol is preferred; may also prefer long-acting calcium antagonists. Enalapril may also be considered with monitoring of maternal renal function and serum potassium. If combination therapy is indicated, consider Amlodipine with Enalapril; consider either adding or switching one of the agents for Labetalol if this combination is ineffective or not tolerated.
The following agents should be avoided: Angiotensin receptor blockers (ARBs); Acebutolol, Atenolol, Metoprolol, Nadolol, Propranolol and Nifedipine concentrate in breast milk; diuretics decrease milk volume and suppress lactation; and though Methyldopa may be used during breastfeeding, it is recommended to avoid it in the postnatal period (stopped within 2 days after delivery) due to the risk of postpartum depression.