Postpartum management of hypertension

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f894 (Published 25 February 2013)
Cite this as: BMJ 2013;346:f894

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  1. Kate Bramham, clinical research fellow1,
  2. Catherine Nelson-Piercy, professor of obstetric medicine2,
  3. Morris J Brown, professor of clinical pharmacology3,
  4. Lucy C Chappell, clinical senior lecturer in maternal and fetal medicine4
  1. 1Maternal Medicine/Nephrology, Women’s Health Academic Centre, King’s College, London, UK
  2. 2Guy’s and St Thomas’ NHS Foundation Trust, London, UK
  3. 3Clinical Pharmacology Unit, University of Cambridge, Cambridge, UK
  4. 4Women’s Health Academic Centre, King’s College, St Thomas’ Hospital, London SE1 7EH, UK
  1. Correspondence to: L C Chappell lucy.chappell{at}kcl.ac.uk

Summary points

  • The most common cause of postpartum hypertension is high blood pressure (from gestational hypertension or pre-eclampsia) that persists after delivery

  • Suggested first line antihypertensive drugs that are safe in breastfeeding mothers include labetalol, nifedipine, and enalapril

  • Refer women with persistent hypertension or proteinuria six weeks after delivery to a specialist

  • Inform women with recent hypertensive disorders of pregnancy of the risk of recurrence in a future pregnancy

  • Women with pre-eclampsia have a 3.7-fold increased risk of future hypertension, 2.2-fold risk of ischaemic heart disease, and 1.8-fold risk of stroke

Hypertension in the postpartum period affects several groups of women, including those with previous chronic hypertension, gestational hypertension, pre-eclampsia, and eclampsia. In addition, pre-eclampsia may present for the first time in the postnatal period. Although the underlying causes and clinical presentation of these types of hypertension vary, patients can be investigated and treated in a similar manner. This review covers management of postpartum hypertension and its future consequences. Hypertension affects 6-10% of pregnancies,1 but few studies have reported the incidence of postpartum hypertension. This review is relevant to general practitioners, obstetricians, and specialists in secondary care who may see women with postpartum hypertension.

Sources and selection criteria

We searched PubMed (June 2012) for relevant articles on postpartum management of hypertension, pre-eclampsia, and eclampsia. The MeSH terms for the search included “postpartum”, “hypertension”, “pre-eclampsia”, and “eclampsia”, in addition to keyword variations. We obtained information from prospective randomised clinical trials, cohort studies, case series, systematic reviews, and meta-analyses. We also searched national and international guidelines for those including advice on postpartum management of hypertension and kidney disease.

What are the normal blood pressure changes during pregnancy and postpartum?

Generalised systemic vasodilation occurs during pregnancy; despite a 40-50% increase in cardiac output, mean arterial pressure drops by about 10 mm Hg to reach its lowest value by mid-pregnancy.2 During the last trimester, blood pressure gradually increases to …

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