Transcript Postpartum Hypertension - Family Medicine Resident

Postpartum Hypertension
Lin-Fan Wang MD
5/4/09
PGY-1 OB/GYN Rotation
Family and Social Medicine
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.
• 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 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 cont
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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
• 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
• 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
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Essential HTN
Persistent Antenatal GHTN or PEC
De novo HTN
Pre-eclampsia/HELLP
Renal disease
Pheochromocytoma
Primary hyperaldosteronism
Incidence of Late PP PEC
Year
Country
PEC (n)
Late PP PEC (%)
1994
UK
383
5
1998
Colombia
164
12
2000
U.S.
399
17
2002
U.S.
89
26
2003
Singapore
62
3
Risk Factors
• Recurrence of HTN postpartum
• Preterm delivery
• Multips with higher uric acid levels or BUN
• Preeclampsia (vs. GHTN)
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
• 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
• 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, Bblockers with high protein binding (e.g., oxprenolol),
ACEIs, some dihydropyridine CCBs
• ? MgSO4 in patients with PEC
Case
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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
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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.