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Hypertension in pregnancy - Management
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How should I follow up a woman with chronic hypertension postpartum?

  • Measure blood pressure:
    • Daily for the first 2 days after birth.
    • At least once between day 3 and day 5 after birth.
    • As clinically indicated if the woman's antihypertensive treatment is changed after birth.
  • Aim to keep blood pressure lower than 140/90 mmHg.
  • For the first 2 weeks after the birth:
    • Continue the antihypertensive treatment used during pregnancy, unless the woman is taking methyldopa.
    • If she is taking methyldopa, this should be stopped 2 days after the birth, as it may increase the risk of depression. Antihypertensive treatment that the woman took before planning a pregnancy should be restarted unless there are contraindications to a particular drug because the woman is breastfeeding or is planning further pregnancies.
  • Review antihypertensive treatment.
    • Review long-term antihypertensive treatment 2 weeks after the birth.
      • Consider restarting the woman's pre-pregnancy hypertensive treatment unless there are contraindications to a particular drug because she is breastfeeding or planning further pregnancies.
      • Target blood pressures will be those used in the long-term treatment of hypertension. For more information, see the CKS topic on Hypertension - not diabetic, or for women with diabetes, see the CKS topic on Diabetes type 2.
    • Ensure that future antihypertensive treatment and monitoring is discussed in primary care 6–8 weeks after the birth at her postnatal review.
Basis for recommendation

Monitoring and control of blood pressure after the birth

  • These recommendations are based on the expert opinion of the National Institute for Health and Clinical Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2010].
    • NICE identified no evidence about the frequency of postnatal observations or investigations.
    • Its recommendations are, therefore, based on the knowledge that blood pressure peaks between 3–5 days after birth, and that it is sensible to monitor blood pressure if changes are made to treatment.

Choice of antihypertensive drug

  • NICE identified no evidence about the choice of antihypertensive treatment postpartum. As there is no evidence for any particular antihypertensive, NICE considered that antenatal antihypertensive treatment should continue in the post-natal period unless methyldopa has been used (because of the risk of depression with methyldopa) [National Collaborating Centre for Women's and Children's Health, 2010].

Stopping methyldopa

  • NICE is aware of a Medicines and Healthcare products Regulatory Agency (MHRA) report that considers methyldopa to be the drug of choice during pregnancy and breastfeeding [MHRA, 2009]. The MHRA states that methyldopa may not be suitable for some women. However, NICE considers that this drug should not be used during the post-natal period, as women are already at risk of depression, and if possible, it should be stopped and the antihypertensive treatment that the woman was taking before her pregnancy be restarted.

Review of antihypertensive treatment

How should I follow up a woman with gestational hypertension postpartum?

The following is a summary of secondary care management recommended by the National Institute for Health and Clinical Excellence (NICE).

  • Most women will be followed up by the maternity unit until their blood pressure has returned to normal or until the woman has been referred to a specialist for a medical review should her blood pressure remain elevated. The woman should be given a care plan by the hospital detailing:
    • Who will provide follow-up care, including medical review if needed.
    • Frequency of blood pressure monitoring.
    • Thresholds for reducing or stopping treatment.
    • Indications for referral to primary care for blood pressure review.
    • Self-monitoring for symptoms of pre-eclampsia.
  • The woman should have her blood pressure measured:
    • Daily for the first 2 days after birth.
    • At least once between day 3 and day 5 after birth.
    • As clinically indicated if antihypertensive treatment is changed after birth.
  • If the woman has not taken any antihypertensive treatment during pregnancy:
    • Aim to keep her blood pressure lower than 140/90 mmHg.
    • Antihypertensive treatment will be started if blood pressure rises above 149/99 mmHg.
  • If antihypertensive treatment has been used during the antenatal period:
    • The same treatment will be continued, unless the woman has been taking methyldopa which should be stopped 2 days postpartum because of the risk of depression.
    • If blood pressure falls below 140/90 mmHg, reducing antihypertensive treatment will be considered.
    • Antihypertensive treatment will be reduced or stopped if the woman's blood pressure falls below 130/80 mmHg.
  • If the woman has gestational hypertension she should be offered a medical review either in the community or at the hospital:
    • If she remains on antihypertensive treatment 2 weeks after transfer to community care.
    • At her post-natal review 6–8 weeks after the birth.
      • Women who still need antihypertensive medication at the time of this review should be offered a specialist assessment of their hypertension.
Basis for recommendation

Monitoring and review by a specialist

Monitoring and control of blood pressure postpartum

  • These recommendations are expert opinion from NICE [National Collaborating Centre for Women's and Children's Health, 2010].
    • NICE identified no evidence about the frequency of postnatal observations or investigations.
    • Its recommendations are therefore based on the knowledge that blood pressure peaks between 3–5 days after birth and that it is sensible to monitor blood pressure if changes are made to treatment.

Choice of antihypertensive drug

  • NICE identified only one small randomized controlled trial that compared timolol with methyldopa, and therefore concluded that there is no evidence for any particular antihypertensive. NICE recommends that antenatal antihypertensive treatment should continue in the postnatal period unless methyldopa has been used.

Stopping methyldopa

  • NICE is aware of a Medicines and Healthcare products Regulatory Agency (MHRA) report that considers methyldopa to be the drug of choice during pregnancy and breastfeeding [MHRA, 2009]. The MHRA states that methyldopa may not be suitable for some women. However NICE considers that this drug should not be used during the post-natal period, as women are already at risk of depression, and if possible, it should be stopped.

Advice on review and referral

  • These recommendations are expert opinion from NICE [National Collaborating Centre for Women's and Children's Health, 2010]. NICE also considers that all women with gestational hypertension should have a review of their blood pressure at the post-natal review 6–8 weeks after the birth. Who carries out this review will depend on local circumstances and expertise, and NICE were not prescriptive about this. However NICE recommend that if the woman still requires antihypertensive treatment 6–8 weeks after the birth, then she should be offered a specialist assessment.

How should I follow up a woman with pre-eclampsia postpartum?

The following is a summary of secondary care management recommended by the National Institute for Health and Clinical Excellence (NICE).

  • The woman should not be discharged home until she has no symptoms of pre-eclampsia, her blood pressure is 149/99 mmHg or lower, and her blood tests are improving.
  • All women should be given a care plan that includes information about:
    • Who will provide follow-up care, including medical review if needed.
    • Frequency of blood pressure monitoring.
    • Thresholds for reducing or stopping treatment.
    • Indications for referral to primary care for blood pressure review.
    • Self-monitoring for symptoms of pre-eclampsia.
  • Women with pre-eclampsia who did not take antihypertensive treatment and have given birth and who have been discharged home will have:
    • Their blood pressure measured:
      • At least once between day 3 and day 5 after birth.
      • On alternate days until their blood pressure normalizes, if their blood pressure was abnormal between day 3 and day 5.
    • If blood tests are stable or improving but not in the normal range they will be repeated as clinically indicated.
    • The aim is to keep blood pressure lower than 140/90 mmHg.
    • Antihypertensive treatment will be started if blood pressure is 150/100 mmHg or higher.
  • Symptoms of pre-eclampsia, such as severe headache and epigastric pain, will be asked about each time blood pressure is measured.
  • Women with pre-eclampsia who took antihypertensive treatment and have given birth will have:
    • Their blood pressure measured every 1–2 days for up to 2 weeks after transfer to primary care until the woman is off treatment and has no hypertension.
      • If blood tests are stable or improving but not in the normal range, they will be repeated as clinically indicated.
      • The antihypertensive treatment used during the pregnancy will be continued, unless the woman has been taking methyldopa, which should be stopped 2 days postpartum because of the risk of depression. Antihypertensive treatment that the woman took before planning a pregnancy will be restarted unless there are contraindications to a particular drug because the woman is breastfeeding or is planning further pregnancies.
      • A reduction in antihypertensive treatment will be considered if their blood pressure falls below 140/90 mmHg.
      • Antihypertensive treatment will be reduced if their blood pressure falls below 130/80 mmHg.
    • Symptoms of pre-eclampsia, such as severe headache and epigastric pain, will be asked about each time blood pressure is measured.
  • Women with pre-eclampsia will be offered a medical review either in the community or at the hospital:
    • If they remain on antihypertensive treatment 2 weeks after transfer to community care.
    • At their post-natal review 6–8 weeks after the birth.
      • Women who still need antihypertensive medication at the time of this review should be offered a specialist assessment of their hypertension.
      • Perform dipstick testing of the urine. Women with 1+ proteinuria or more but normal blood pressure should be reviewed 3 months postpartum to assess kidney function and to consider referral to a renal specialist.
Basis for recommendation

Monitoring and review by a specialist

Monitoring and investigations postpartum

  • These recommendations are expert opinion from NICE [National Collaborating Centre for Women's and Children's Health, 2010].
    • NICE identified no evidence about investigations and treatment and, therefore, recommends that the investigations and observations relevant to the antenatal period also applied to the post-natal period, taking into account that blood pressure peaks between 3–5 days after birth.
    • Women may develop pre-eclampsia after birth and NICE recommends that symptoms of pre-eclampsia be enquired about at each assessment.

Choice of antihypertensive drug

  • NICE found a lack of good-quality evidence about choice of drug and whether antihypertensive treatment should be given routinely to women with pre-eclampsia. It therefore recommends that antihypertensive treatment used during the pregnancy should be continued, unless this was methyldopa.

Stopping methyldopa

  • NICE is aware of a Medicines and Healthcare products Regulatory Agency (MHRA) report that considers methyldopa to be the drug of choice during pregnancy and breastfeeding [MHRA, 2009]. The MHRA states that methyldopa may not be suitable for some women. However NICE considers that this drug should not be used during the postnatal period, as women are already at risk of depression, and if possible, it should be stopped.

Advice on review and referral

  • These recommendations are based on expert opinion from NICE [National Collaborating Centre for Women's and Children's Health, 2010]. NICE also considers that all women with pre-eclampsia should have a review of their blood pressure at the postnatal review 6–8 weeks after the birth. Who carries out this review will depend on local circumstances and expertise, and NICE were not prescriptive about this. However, NICE recommends specialist referral for women with persistent hypertension or proteinuria or both.

How do I manage a woman with postpartum pre-eclampsia or eclampsia?

  • Consider the possibility of imminent pre-eclampsia/eclampsia in a woman up to 4 weeks postpartum (even if she has not had previous hypertension or pre-eclampsia) if she develops any of the following:
    • Severe headaches (increasing frequency unrelieved by regular analgesics).
    • Vision problems, such as blurred vision, flashing lights, double vision, or floating spots.
    • Persistent new epigastric pain or pain in the right upper quadrant.
    • Vomiting.
    • Hypertension.
    • Proteinuria.
    • Breathlessness due to pulmonary oedema.
    • Sudden swelling of the face, hands, or feet.
  • Consider the possibility of eclampsia in any woman who has a seizure within 4 weeks of delivery.
  • All women with suspected postpartum pre-eclampsia or eclampsia should be admitted to hospital for immediate assessment.
Basis for recommendation

Importance of considering the possibility of pre-eclampsia/eclampsia even if the woman has not had antepartum or intrapartum pre-eclampsia

  • Pre-eclampsia and eclampsia may both present for the first time after delivery [Mathew et al, 2003; Duley et al, 2006].
  • In a study of 23 women with late postpartum eclampsia, only five had been previously diagnosed with pre-eclampsia [Chames et al, 2002].
  • A prospective descriptive study of every case of eclampsia in the UK in 1992 found that 44% of cases occurred postpartum [Douglas and Redman, 1994].

Possibility of presenting up to 4 weeks after delivery

  • A multicentre, retrospective analysis of data involving 89 women with eclampsia found that 29 women had postpartum eclampsia and 23 (79%) of these women had late-onset eclampsia (developing more than 48 hours after delivery) [Chames et al, 2002].
  • In a multicentre, retrospective analysis of 3988 women diagnosed with pre-eclampsia, 229 (5.7%) were diagnosed during the postpartum period [Matthys et al, 2004]. Of these, 151 women were studied and 29 (16%) developed eclampsia. The average time from delivery to readmission was 7 days and ranged from 1 day to 24 days.

Importance of considering the possibility of eclampsia in any woman who has a seizure within 4 weeks of delivery

  • Symptoms and signs of pre-eclampsia usually precede eclampsia, but not always, which can make diagnosis difficult.
  • Case studies of three women report eclampsia developing without preceding hypertension or proteinuria [Dziewas et al, 2002].

Importance of considering pre-eclampsia if the woman develops a headache, vision symptoms, abdominal pain, or typical symptoms

  • In a multicentre, retrospective analysis of data involving 89 women with eclampsia, 29 women had postpartum eclampsia, and 21 of these had at least one prodromal symptom that heralded the onset of eclampsia: 20 women had headache, 10 women had vision changes, 5 women had nausea or vomiting, and 2 women had epigastric pain [Chames et al, 2002].
  • Case studies have shown that acute severe headache, vision disturbances, and gastrointestinal symptoms may herald impending eclampsia [Veltkamp et al, 2000; Dziewas et al, 2002; Mathew et al, 2003; Graeber et al, 2005; Munjuluri et al, 2005].
  • A case-control study of 53 women admitted in the postpartum period found that headache, a blind spot, cortical blindness, malaise, nausea, and vomiting were more likely to occur in women with postpartum severe pre-eclampsia or eclampsia than in women with intrapartum pre-eclampsia [Atterbury et al, 1998].

Immediate referral to hospital

  • This is accepted good clinical practice.

Which antihypertensive drugs can be used during breastfeeding?

  • The following are considered to be safe during breastfeeding:
    • Labetalol
    • Nifedipine
    • Enalapril
    • Captopril
    • Atenolol
    • Metoprolol
    • Methyldopa
  • Do not prescribe the following:
    • Angiotensin-converting enzyme inhibitors, other than captopril and enalapril.
    • Angiotensin-II receptor antagonists.
    • Amlodipine.
Basis for recommendation
  • The National Institute for Health and Clinical Excellence (NICE) reviewed the available evidence on use of antihypertensive drugs in breastfeeding women [National Collaborating Centre for Women's and Children's Health, 2010]. The studies identified measured non-clinical endpoints, such as secretion of the drug in the mother's milk or detection of the drug in the infant's plasma. No studies were found on whether antihypertensive drugs taken while breastfeeding had adverse effects on the infants.

Use of labetalol, nifedipine, and methyldopa

  • NICE concluded that:
    • The drugs mostly likely to be used by breastfeeding women seem to be suitable: labetalol, nifedipine, and methyldopa.
    • However, NICE does not recommend the use of methyldopa in the postnatal period due to the risk of depression. This view conflicts with advice from the Medicines and Healthcare products Regulatory Agency (MHRA), which recommends methyldopa as the drug of choice during breastfeeding [MHRA, 2009].

Use of atenolol and metoprolol

    • NICE commented that there are no known adverse effects.

Use of angiotensin-converting enzyme (ACE) inhibitors

  • There is conflicting advice about the use of ACE inhibitors:
    • NICE recommends that if ACE inhibitors are needed, then captopril or enalapril should be used because of the quality and quantity of associated safety data.
    • However, the MHRA recommends that ACE inhibitors should not be used by breastfeeding mothers in the first few weeks after delivery. This is because, although amounts of the drug transferred to the infant by breastfeeding are unlikely to be clinically relevant, data are insufficient to exclude the possibility of profound hypotension in the infant. The MHRA considers that pre-term infants may be at particular risk. The MHRA suggests that the use of captopril, enalapril, or quinapril may be considered in older infants who are being breastfed.

Use of angiotensin-II receptor antagonists (AIIRAs)

  • Both NICE and the MHRA agree that AIIRAs should not be used as there are no data on their use and their effects on breastfeeding infants.

Use of amlodipine

  • NICE found insufficient evidence of safety and, therefore, does not recommend the use of amlodipine.

Use of diuretics

  • NICE make no statement regarding the use of diuretics for treating hypertension in a woman who is breastfeeding.
  • Although the amount of bendroflumethiazide excreted in breast milk is too small to be harmful, care is needed that the diuresis does not cause dehydration, leading to inhibition of breastfeeding. However, this is less likely if a low dose of 2.5 mg daily is used [LactMed, 2007].

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