Dr darweish postpartum hypertensin

• Head of Obs/ Gyn department…Damietta General Hospital.
• MOH….Egypt
Dr. Mostafa Darweish
Dr. Mostafa Darweish 1

• Postnatal hypertension:
• DOI: 10.1111/j.1744-4667.2012.00144.x…The Obstetrician & Gynaecologist
• http://onlinetog.org.....2013;15:45–50 Review

• DOI: 10.1111/j.1744-4667.2012.00095.x 2012;14:99–105
• The Obstetrician & Gynaecologist (TOG)…http://onlinetog.org...Review
• New-onset hypertension in pregnancy: a review of the long-term maternal
effects

• Why …Postnatal Clinical Guidelines ??
• Early detection and management of postpartum
hypertension.
• To prevent complications of severe hypertension/pre-eclampsia,
e.g. cerebral haemorrhage, eclampsia……
• It is important to remember that preeclampsia- including
preeclampsia with severe system organ involvement and seizures
– can first develop – in the postpartum period.
• Early hospital discharge is the current practice in the USA.
• This mandates that health care providers need to have
management and referral guidelines.
A n t e n ata l D i s o r d e r s f o r t h e ‘M R C O G’ and B e y o n d ..Second Edition- © Cambridge University Press

• Why …Postnatal Clinical Guidelines ??
• In the current climate of early postnatal discharge both hospital
and community teams need to have referral and management
guidelines in place.
• The 6-week postnatal visit
• It has recently been reported that up to 13% of women initially
thought to have a diagnosis of pre-eclampsia or pregnancy-
induced hypertension will have underlying disease not suspected
antenatally.
RCOG..Tog,.

• Definitions and Diagnostic Criteria for Hypertensive Disorders of
Pregnancy.
• Hypertension:
• Gestational hypertension.
• Chronic (Pre-existing) hypertension.
• Superimposed preeclampsia:
• Preeclampsia.
• HELLP Syndrome
• Eclampsia.
• Postpartum Hypertension.

• — Hypertension:
• Generally, hypertension is defined as systolic BP ≥ 140 mmHg or diastolic BP
≥90 mmHg recorded on two occasions at least 4 hours apart.
• NB. Severe hypertension: If systolic BP is ≥160 mmHg or diastolic BP is ≥110
mmHg, confirmation within 15 to 30 minutes is sufficient
• [Confirm using a short time interval (e.g., minutes) to facilitate timely antihypertensive
therapy]
• Chronic (pre-existing) hypertension =hypertension antedates (prior to) pregnancy or
develops before the 20th
week of pregnancy or continuing more than 12 weeks
postpartum.
• It can be primary (primary hypertension, formerly called "essential hypertension") or
secondary to a variety of medical disorders
©2017,UpToDate®

• The puerperium
• The term puerperium refers to the period of about 6-8 weeks
following delivery during which the changes produced by
pregnancy regress.
• Blood pressure changes.
• Postpartum course of:
Gestational hypertension.
Pre-eclampsia.
HELLP Syndrome.
Eclampsia.

• BP in the puerperium
• BP may be significantly higher in the immediate
postpartum period than antepartum or intrapartum.
• This may be due to:
• Mobilization of extracellular fluid after delivery.
• Administration of a large volume of saline solution
(to women who have had a cesarean delivery or neuraxial anesthesia for
labor).
• Loss of the pregnancy associated vasodilation after delivery.
• Administration of NSADs.
• Administration of Ergot derivatives (Methergin®,…).
©2018,UpToDate®

• Blood pressure in the puerperium
• Following uncomplicated pregnancy most
women will experience increased BP during the
postpartum period such that systolic and
diastolic measurements are increased by an
average of 6 mmHg and 4 mmHg, respectively,
over the first 4 days.
• Furthermore, following uncomplicated pregnancy, up to 12% of
patients will have a recorded diastolic pressure greater than 100
mmHg in the first few days after delivery.
RCOG, TOG

• Gestational hypertension in the puerperium:—
• Most women with gestational hypertension
become normotensive within the first
postpartum week.
• HOWEVER, Retrospective studies suggest that 50–85% of women
with gestational hypertension will have a normal blood pressure
by 2 weeks post-delivery.
• By definition, all should be normotensive by the
12th
postpartum week, otherwise they are given
the diagnosis of chronic hypertension, which
occurs in about 15% of cases .
©2017,UpToDate®

• Pre-eclampsia in the puerperium
• Delivery of the placenta always results in
complete resolution of the maternal signs and
symptoms of the disease, with some symptoms
disappearing in a matter of hours (e.g.,
headache), while others may take weeks or
months (e.g., proteinuria).
• Vasoconstriction and endothelial dysfunction also
typically resolve over a few days, resulting in
mobilization of third-space fluid and diuresis.
©2017,UpToDate®

• Hypertension
• Retrospective studies suggest that 50–85% of women
with pre-eclampsia will have a normal blood pressure
by 2 weeks post-delivery.
• Hypertension may worsen during the first, and
occasionally the second, postpartum week, but
normalizes in most women within four weeks
postpartum.
• Rarely, hypertension persists beyond three months (12
weeks).

• Proteinuria:
• Studies of continuing proteinuria following
pregnancy complicated by pre-eclampsia have
varying results
• Proteinuria usually begins to improve within a
few days; however, in women with several
grams of protein excretion, complete resolution
may take weeks to months.

• Postpartum Preeclampsia —
• The initial diagnosis of preeclampsia may be
postpartum.
• Signs of preeclampsia can appear anytime during the
last half of pregnancy (after 20 weeks of pregnancy) or
in the first few days postpartum, and typically resolve
within few days after delivery.
©2018,UpToDate®

• HELLP syndrome POSTPARTUM COURSE —
• Although HELLP syndrome is mostly a third-trimester
condition, in 30% of cases it is first expressed or
progresses postpartum.
• Laboratory values may initially worsen following
delivery.
• An upward trend (increasing) in platelet count and a
downward trend (decreasing) in LDH concentration
should be seen by the 4th
postpartum day in the absence
of complications.
©2017,UpToDate®

• HELLP syndrome POSTPARTUM COURSE —
• Recovery can be delayed in women with
particularly severe disease, such as those with
DIC, platelet count less than 20,000 cells/microL,
renal dysfunction, or ascites.
• These women are at risk of developing
pulmonary edema and renal failure .

©2017,UpToDate®

• Eclampsia in the puerperium:
• Timing and frequency of eclampsia
• Antepartum (38 to 55%),
• Intrapartum (13 to 36%),
• Postpartum eclampsia:
• EARLY postpartum eclampsia [eclamptic seizures
developing less than or equal to 48 hours
postpartum] ,..
• Late postpartum eclampsia (i.e., eclamptic
seizures developing greater than 48 hours, but
less than four weeks postpartum) .
©2015,UpToDate®

• Aetiology of hypertension in the postpartum
• Pre-existing hypertension (i.e. present before delivery):
• This may be chronic hypertension, gestational
hypertension or preeclampsia/eclampsia.
• New-onset hypertension arising for the first time
in the postpartum period
• Transient hypertension secondary to pain, anxiety,
medications (e.g. ergometrine, nonsteroidals),
excess fluid administration and/or postpartum
fluid shifts.

• Women at risk of postnatal hypertension:
• The largest group of women with
postpartum hypertension are those who
have developed hypertension in the
antenatal period, however, hypertension
can occur de novo following delivery.
RCOG, TOG,2013

• Pre-eclampsia and gestational hypertension are
the most common causes of postpartum
hypertension.
• Factors associated with persistent hypertension
include longer duration of antihypertensive
treatment in pregnancy, high maximum blood
pressures (> 160/100 mmHg), higher BMI and
preterm pre-eclampsia.

• Women at risk of postnatal hypertension: Table 1.
• -
RCOG, TOG,2013

• New-onset postpartum hypertension
• Hypertension diagnosed for the first time in women with
normotensive gestations within 2 weeks after delivery. The
incidence of new-onset postpartum hypertension is unknown.
• There is no reliable method of early detection.
• For Diagnosis (early detection) of postpartum hypertension:
>>>>> NICE guidelines

• Diagnosis of New-onset hypertension:
• Measuring BP within 6 hours of delivery for all
uncomplicated pregnancies and on day 5
postpartum.
• Diagnosis :Apply definition of hypertension….
• Hypertension > 150/90 mmHg requires
antihypertensive therapy.
NICE guidelines.

• Management of ongoing postnatal hypertension:
• 1-Patients with ‘chronic’ hypertension.
• 2-Women without chronic hypertension
[Hypertension arising during pregnancy or in the
peurperium].
Tog

• Management of ongoing postnatal hypertension:
• Women without chronic hypertension
include:
• Gestational hypertension.
• Preeclampsia/Eclampsia.
• New onset postpartrum hypertension [diagnosed
for the first time in the postpartum period].
RCOG..Tog.

• Management of ongoing postnatal hypertension.
• 1-Patients with existing (chronic) hypertension:
• In situations where hypertension predates
pregnancy (chronic) switch to the pre-pregnancy
dose of the patient’s usual agent/s.
• Women who were previously using diuretics
should consider an alternative while they are
breastfeeding.
• NB. It is advisable to stop methyldopa following
because of its association with depression.
Tog,.

• [=Hypertension arising during pregnancy or in the
peurperium].
• Gestational Hypertension
• Preeclampsia/eclampsia.
• New onset postpartrum hypertension.
Tog,2013.

• In patients who were normotensive before
pregnancy, one of the most difficult problems is
deciding which women should have
antihypertensives prescribed following delivery.
Tog

• Women without chronic hypertension
• it might be suggested that women who have required
‘antihypertensives’ in the antenatal period, women who
have been delivered before 37 weeks of gestation
because of hypertension and women who have had
severe hypertension are most likely to benefit.

• Treatment of postpartum hypertension
• Women without chronic hypertension: —
• Antihypertensive agents may be required
temporarily postpartum if hypertension is
severe.
• Oral medications similar to those used in the
nonpregnant population may be used.
©2018,UpToDate®

• Treatment …
• Women without chronic hypertension: -
• A suggested regimen of starting treatment in the
early postnatal period might be ‘labetalol’
(providing there is no history of asthma) with
second and third-line agents of calcium
antagonist and an ACE inhibitor (such as
enalapril).
Tog

• Antihypertensive agents
Tog,2013.

• Treatment …
• Brief furosemide therapy (20 mg orally once or
twice per day for five days) may facilitate return
to normotension in women with severe, but not
mild, preeclampsia, particularly those with
significant edema.
©2017,UpToDate®

• Treatment …
• Acute episodes of hypertension in the postnatal
period should be managed in the same manner
as antenatal or intrapartum episodes.
• The agents of choice are:
• Labetalol (oral or intravenous).
• Nifedipine (oral) or
• Hydralazine (IV) : NB. its use as a first-line drug has been
questioned.
Tog

• Treatment of Postpartum hypertension
• If prepregnancy BP was normal, and if BP is
controlled, it is reasonable to stop the
antihypertensive agent after three weeks
and monitor BP to assess whether further
treatment is indicated.
©2018,UpToDate®

• Women without chronic hypertension:
• Follow-up after discharge:
• Once discharged, ‘BP’ should measured on
alternate days for the first 2 weeks.
• Refer for medical review if two measurements
>150/ 100 mmHg are obtained.
• Hospital review will be required if patients report
symptoms of pre-eclampsia or if ‘BP’ is >160/100
mmHg.
RCOG…Tog.

• At 2 weeks: medication should be reduced when
BP is measured at “130–140/80–90” mmHg.
• NB. Most women who commence postnatal
antihypertensives will require treatment for at
least 2 weeks and some women, particularly
women with early onset or severe disease may
need to continue beyond 6 weeks.
RCOG…Tog.

• If medication is required beyond 6 weeks
then further medical review should be
arranged to investigate the possibility of an
underlying cause.
RCOG…Tog.

• The 6-week postnatal visit
• Establish the diagnosis.
• Counselling ….
Recurrence rate
Prophylaxis during a future pregnancy
Advise: lifestyle changes
ACOG.. January..2019.

• The 6-week postnatal visit is an opportunity to
establish the diagnosis and to discuss implications
for future pregnancies.
• All women who have had a diagnosis of pre-
eclampsia should have their BP measured and the
urine tested for proteinuria.
ACOG.. January..2019.

• The 6-week postnatal visit ….COUNSELLING:
• Recurrence rate
[i.e. the risk of pre-eclampsia in a subsequent pregnancy]:
• Severe, early onset pre-eclampsia has a
recurrence rate up to 40% in future pregnancies
(although generally the onset of problems is 2–3 weeks
later and it is less severe than in the first pregnancy).
• Women who present with milder disease, nearer
to term have a risk of recurrence nearer to 10%.
ACOG.. January..2019

• Women at increased risk should be
offered low-dose aspirin and increased
BP surveillance during a future
pregnancy.
Tog
ACOG.. January..2019

• Risk factors of preeclampsia.
ACOG,
January 2019

• Clinical Risk Factors and Aspirin Use.
• Risk factors of preeclampsia
• HIGH RISK
• Recommendation: Recommend low-dose aspirin if the
patient has one or more of these high-risk factors.
ACOG, January 2019

• Clinical Risk Factors and Aspirin Use.
• Risk factors of preeclampsia
• Moderate RISK
• *Recommendation: Consider low-dose aspirin if the patient has more than
one of these moderate-risk factors.
ACOG, January 2019

• Clinical Risk Factors and Aspirin Use
• Clinical Recommendations
• Low-dose (81 mg/day) aspirin for
preeclampsia prophylaxis, should be
initiated between 12 weeks and 28 weeks
of gestation (optimally before 16 weeks of
gestation) and continuing until delivery.

• Finally, it is increasingly recognised that pre-
eclampsia is a risk factor for developing
cardiovascular disease in later life and patients
should be made aware of this so that they have
the opportunity make lifestyle choices to
minimise their risk.
• Simple lifestyle changes may help reduce these
risks.
Tog,2013

Senior Consultant …Obs/Gyn.
• Egypt..MOH..
• Head of Obs/ Gyn department…Damietta General Hospital.
Dr. Mostafa Darweish
Dr. Mostafa Darweish 51

Dr darweish postpartum hypertensin

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