Postnatal Hypertension

Who can refer:

• GP
• Community midwife

Who to refer:

Consider the possibility of pre-eclampsia or eclampsia in the postnatal period if a woman develops any of the following:

• Severe headaches, increasing frequency, unrelieved by analgesia
• Visual problems
• Persistent new epigastric or RUQ pain
• Vomiting
• Hypertension >140/90
• Proteinuria
• Sudden onset SOB due to pulmonary oedema
• Sudden swelling of hands, face or feet
• Seizure within 4 weeks of birth

If concerns about pre-eclampsia or very high BP (160/110mHg) – urgent referral to Obstetric Triage Assessment at Royal Infirmary (0131 242 2657) or labour ward at St John’s Hospital (01506 524125), or contact the Obstetric Registrar On Call via Switchboard at Royal Infirmary / St John’s Hospital.

How to refer:

For emergencies and urgent care, patients can come without calling.

However, if possible, the patient should phone for advice first. There is a midwife who is available 24/7:

Royal Infirmary of Edinburgh 0131 242 2657

St John’s Hospital 01506 524125

For women with existing hypertension

Suggested monitoring

• Daily for the first 2 days after birth, once between days 3-4, then as clinically indicated

thereafter, usually every other day for 2 weeks. This can be completed by the community midwives.

Suggested treatment

• Continue antihypertensives
• Methyldopa should have been stopped after birth
• Restart antihypertensive treatment from before pregnancy unless breast feeding
• Medical review at 6-8 weeks

For women with gestational hypertension

Suggested monitoring

• Daily for the first 2 days after birth, once between days 3-4, then as clinically indicated

thereafter. This can be completed by the community midwives.

Suggested treatment

• For women discharged on antihypertensives – continue medications, monitor BP as above and reduce doses as required
• Duration will usually be similar to duration of antenatal treatment but may be longer
• Medical review 2 weeks after transfer to community care and at 6-8 weeks
• Target BP is 140/90
• If gestational hypertension not on treatment, consider initiation of treatment if BP >140/90, Review at 6 weeks if gestational hypertension not on treatment

Postnatal hypertension

Blood pressure peaks days 3-6 postnatal and BP should be checked postnatally to identify late pre-eclampsia. This can be completed by the community midwives.

Suggested monitoring

• Daily for the first 2 days after birth, once between days 3-4, then as clinically indicated thereafter.

Suggested treatment

• Aim <140/90. If BP >140/90 – consider commencing antihypertensive – see table below if breastfeeding
• If not breastfeeding postnatally – manage as per NICE guideline for hypertension in adults.
• If BP >160/110 or symptomatic – refer to Obs Triage for urgent assessment

Ongoing Follow Up

• All patients should have a repeat urine dipstick for protein at 6 weeks, if not resolved please send urine PCR and for further review at 3 months. If ongoing proteinuria or abnormal renal function consider referral to renal physician as appropriate
• If hypertensive and <40 – for investigation for secondary cause as per guidelines
• If hypertensive and >40 – for management as new adult essential hypertension
• Women with pregnancy induced hypertension in the long term have high rates of chronic hypertension, cardiovascular disease and thromboembolism.
• Consider using ASSIGN or QRISK in women over 30 who have had hypertension during pregnancy, even if resolved following delivery.
• Life style changes – Smoking cessation, weight management, low salt diet and regular exercise encouraged.

Antenatal Hypertension medication recommendations used in NHS Lothian

Drug	Place in Therapy	Starting dose	Max Dose	Contraindication	Breastfeeding
Labetalol	1st line	100mg BD	600mg QDS	Asthma	Yes – only small amounts in breast milk
Nifedipine (Coracten SR)	2nd line	10mg MR BD	40mg MR BD		Yes – amount too small to be harmful, manufacturer suggests avoid but widely used without reports neonatal effect
Methyldopa	2nd line	250mg BD	1g TDS	Depression	Yes
Hydralazine	2nd line	25mg TDS	75mg QDS		Yes

Postnatal hypertension medication recommendation if breastfeeding – if not breastfeeding as per Adult Hypertension guidelines

Drug	Place in Therapy	Starting dose	Max Dose	Contraindication	Breastfeeding
Enalapril	1st line – requires K and renal function monitoring	5mg OD	40mg OD		Yes – low concentrations excreted, probably too small to be harmful
Nifedipine (Coracten SR)	2nd line	10mg MR BD	40mg MR BD		Yes – amount too small to be harmful, manufacturer suggests avoid but widely used without reports neonatal effect
Labetalol	3rd line	100mg BD	600mg QDS	Asthma	Yes – only small amounts in breast milk

NICE guideline 133: Hypertension in Pregnancy- Diagnosis and Management – 25^th June 2019

Overview | Hypertension in pregnancy: diagnosis and management | Guidance | NICE