1. Postpartum Hypertension Lin-Fan Wang MD 5/4/09 PGY-1 OB/GYN Rotation Family and Social Medicine

2. Case HPI: 29yo G 6 P 2133 PPD #9 s/p NSVD, induced at 34 5 GA 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

3. 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

4. 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

5. Case cont 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

6. 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

7. 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

8. Differential Diagnosis Essential HTN Persistent Antenatal GHTN or PEC De novo HTN Pre-eclampsia/HELLP Renal disease Pheochromocytoma Primary hyperaldosteronism

9. Incidence of Late PP PEC YearCountryPEC (n)Late PP PEC (%) 1994UK3835 1998Colombia16412 2000U.S.39917 2002U.S.8926 2003Singapore623

10. Risk Factors Recurrence of HTN postpartum Preterm delivery Multips with higher uric acid levels or BUN Preeclampsia (vs. GHTN)

11. 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

12. 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

13. 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, B- blockers with high protein binding (e.g., oxprenolol), ACEIs, some dihydropyridine CCBs ? MgSO4 in patients with PEC

14. Case 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

15. References 1.Tan L-K, de Swiet M. The management of postpartum hypertension. BJOG 2002;109:733-6. 2.Sibai BM, Stella CL. Diagnosis and management of atypical preeclampsia-eclampsia. AJOG 2009;200:481.e1-7. 3.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. 4.Matthys LA, Coppage KH, Lambers DS, et al. Delayed postpartum preeclampsia: An experience of 151 cases. AJOG. 2004;190:1464-6 5.Arterbury JL, Groome LJ, Hoff C, et al. Clinical presentation of women readmitted with postpartum severe preeclampsia or eclampsia. JOGNN. 1997;27:134-41.