3. CEMD in Malaysia 2006-2008
In 2006-2008, HDP represented 15.4% of total
numbers of maternal death- the 4th main cause
in Malaysia after obstetric embolism, PPH and
other medical non HDP conditions
There were 396 maternal deaths reported 2006 -
2008 ; 61 cases (15.4%) were directly related to
complications of Hypertensive Disorders in
Pregnancy (HDP)
The average incidence of HDP deaths /year - 20
cases and the trend was not declining over the last
4. Inadequate treatment of systolic
hypertension was a recurring theme
The majority of these deaths were seen
among mothers whose age was >30; with
the minority groups Iban and Orang Asli
being the commonest ethnic groups
5. Definitions
For the purposes of this presentation, the following definitions apply:
Chronic hypertension is hypertension that is
present at booking / < 20 weeks or if the
woman is already taking antihypertensive
medication when referred to maternity services.
It can be primary / secondary in aetiology
Eclampsia is a convulsive condition associated
with pre-eclampsia
HELLP syndrome is haemolysis, elevated liver
enzymes and low platelet count
Gestational hypertension is new hypertension
presenting >20 weeks without significant
proteinuria
6. Significant proteinuria - if the urinary
protein:creatinine ratio (uPCR) is >30 mg/mmol
or a validated 24-hour urine collection result
shows >300 mg protein. ( Test done following a
result of urine albumin >/= 1+)
Pre-eclampsia is new hypertension presenting
after 20 weeks with significant proteinuria
Severe pre-eclampsia is pre-eclampsia with
severe hypertension &/ with symptoms, &/
biochemical &/ haematological impairment
7. Classification of Hypertension
NICE Guideline - Guideline Development Group (GDG)
Mild hypertension
– SBP140–149 mmHg, DBP 90–99 mmHg.
Moderate hypertension
– SBP150–159 mmHg, DBP100–109 mmHg.
Severe hypertension
– SBP>/= 160 mmHg, DBP >/=110 mmHg.
* Treatment of moderate HPT prevents severe HPT and its complications
8. Postpartum Hypertension
Hypertension should be recognised & effectively
treated to :
prevent severe hypertension
avoid unnecessary delays in discharge
Poorly managed postpartum hypertension place
women at risk of significant complications
Appropriate treatment of
postnatal hypertension is
essential to prevent maternal
morbidity and mortality from
cerebral haemorrhage
9. This presentation seeks to…
• Describe the normal postpartum changes
in BP
• Consider which patients should be >
closely monitored & treated
• Consider the evidence for different
antihypertensive agents & the ass.
implications for the mother & baby
10. Normal Physiology
Following uncomplicated pregnancy over the first
4 days.1 in the postpartum period
SBP ↑ average 6 mmHg
DBP ↑ average 4 mmHg
Up to 12% of patients will have a recorded DBP >
100 mmHg
This is dt the resolution of the CVS adaptations to
pregnancy, ie.
mobilisation of fluid accumulated in the extra vascular
space during pregnancy
11. Immediate postpartum
→ tendency of an increase in BP
UTERUS
CONTRACTED BLOOD RETURNS TO
SYSTEMIC
CIRCULATION
↑ VENOUS
RETURN ↑CARDIAC
OUTPUT
↑BP
12. Pathophysiology
1/3 of women who have had PIH or Pre-
eclampsia (PE) will be sustaining HPT in the
postnatal period
Commonly they are normotensive in the early
postpartum period, possibly dt depleted
intravascular volumes following labour
There is also a group who is acknowledged to
hv HPT occuring de novo following delivery
13. Women particularly at risk of postnatal
hypertension are shown in Table 1
_____________
________________
________________________
___________________
14. In severe PE/Eclampsia
Delivery ≠ End of the problem
Severe PE/E can develop during post partum
period
44% of eclampsia occur postpartum
(has been reported up to 4 weeks)
Initial BP may fall following delivery but usually
rise again around 24h post partum
Incidence of severe PE/E fall after the 4th day
postpartum
15. Pre-eclampsia
The potential complications of PE in the
postpartum period are largely similar to those
in the antenatal period (except for fetal
complications)
There is increasing recognition that
severe systolic HPT (>160 mmHg)
↑MAPs
should prompt urgent
treatment to prevent
cerebral
haemorrhage.7
16. Evidence
Incidence of complications among patients with
PE:
Matthys et al.2 described the outcomes of 151
women readmitted in the postnatal period (up
to day 24) who received a diagnosis of PE
The incidence of complications was high:
16% eclampsia
9% pulmonary oedema
one maternal death
17. Similarly, Chames et al.5 :
29 women presenting with postpartum eclampsia,
almost all reported ≥ 1 prodromal symptom
23 (79%) patients had seizures after 48 hours
18. Lubarsky et al.6 reported a series of 334 cases
of eclampsia
16% of seizures - in the postnatal period
( > ½ of these later than 48 hours following
delivery).
19. Together, these data emphasise:
the need for prolonged vigilance in the
postpartum period
The importance of investigating reported
symptoms in such women
In the current climate of early postnatal
discharge, both hospital and community
teams need to have referral and
management guidelines in place
20. Consideration of
antihypertensive agents
The ideal antihypertensive agent to be used in
the postnatal period should
reliably and effectively control BP without diurnal
peaks and troughs
have minimal maternal side effects
be safe for breastfeeding infants
be effective with once-daily dosing to maximise
compliance
21. Due to the paucity of data, it is difficult to recommend
one antihypertensive agent over another9
In the absence of such data the clinician should be
aware of the pros and cons of available agents (Tables 2
and 3)
22.
23. 1. β-blockers
The most common agents used are labetalol
and atenolol
β 2 receptors- effect on peripheral vasodilation
β 1 receptors in cardiac tissue modulate the
sympathetic response
Renal receptors mediate changes in renin
synthesis-This modest decrement in renin
synthesis may contribute to the overall
antihypertensive effect in some patients
24. β -blockers may exacerbate & should be
avoided
asthma
cardiac failure
Individuals who describe respiratory symptoms
after commencing a β -blocker (symptoms may
not be apparent for several days) should be
changed to an alternative agent
25. Atenolol
Advantage – OD dosing
↑compliance in women who find multiple
dosing regimens difficult
The high lipid solubility of the drug means that
it is concentrated in breast milk and concerns
have previously been raised about transfer to
the neonate
26. However, only a single case of neonatal β -
blockade has been reported despite extensive
use of the drug in breastfeeding women
The risks in routine clinical practice are
therefore minimal
27. 2. Calcium channel blockers
Inhibits Ca2+ influx into vascular myocytes
thereby inhibiting vasoconstriction and reducing
vascular resistance
Minimal effects on cardiac conduction and HR ;
but may be ass. with > headache than β –blockers
There is minimal excretion into breast milk10
Nifedipine - the most commonly prescribed CCB ;
dosage- 10-20mg TDS
A 2nd-line alternative is Amlodipine 5–10 mg OD
28. 3. Methyldopa
The most common antihypertensive agent
used in the antenatal period is methyldopa-
because of its well established safety record
with regard to fetal toxicity 11
Centrally acting α-adrenergic agonist- brings
about reduced systemic vascular resistance via
↓ sympathetic vascular tone
29. Whilst methyldopa remains a safe option for
treatment of hypertension in the postnatal
period, particularly in women who have had
good antenatal control with the agent, most
authorities advise that it should be
discontinued because of its maternal side-
effects, in particular:
Sedation
postural hypotension
postnatal depression 12
30. 4. Angiotensin converting
enzyme (ACE) inhibitors
ACE inhibitors (such as Enalapril) - commonly
used outside of pregnancy to treat hypertension,
particularly that ass. with renal disease and
proteinuria
Inhibit angiotensin converting enzyme (ACE)
→ decrease production of angiotensin II (AII)
reducing AII mediated vasoconstriction
Ass. with adverse fetal outcomes when used in
the antenatal period ; but there are reassuring
data concerning their safety in breastfeeding
31. Enalapril can be prescribed as a BD dose of
5–20 mg
+ :generally well tolerated
- : can experience profound hypotension.
Association with renal impairment:-
CAUTION: recent deterioration of renal function.
32. 5. Diuretics
Diuretics - rarely used as antihypertensive agents
in the postnatal period; except- pulmonary
oedema
Postnatal women are > susceptible to postural
hypotension
Breastfeeding women may experience excessive
thirst
The associated volume contraction may interfere
33. Treatment of acute episodes of
hypertension
Acute episodes of hypertension in the
postnatal period should be managed in the
same manner as antenatal / intrapartum
episodes
The agents of choice are:
labetalol (oral or intravenous)
nifedipine (oral) or
hydralazine (intravenous)
34. Labetalol-
Advantage - an oral dose can be given before
intravenous access is established
Further intravenous doses can be given if
required
Hydralazine-
effective ; although its use as a first-line drug has
been questioned12
> commonly causes precipitous drops in BP
and the associated symptoms are unpleasant
for women (;although the concerns about
placental perfusion are no longer relevant)
35. Management of ongoing
postnatal
hypertension1. Patients with existing hypertension
It is advisable to stop methyldopa following delivery and
switch to the prepregnancy dose of her usual agent/s
Where newer drugs have been prescribed and mothers
are wishing to breastfeed, pharmaceutical advice
should be sought before delivery
All of the antihypertensive drug groups have
examples of preparations where there is reassuring
experience with breastfeeding
Women who were previously using diuretics should
consider an alternative while they are breastfeeding
36. Figure 1. (a) Algorithm for the management of postnatal
hypertension in women with chronic hypertension.
37. 2. Hypertension arising during pregnancy or in
the puerperium
In patients who were normotensive before
pregnancy, one of the most difficult problems
is deciding which women should have
antihypertensives prescribed following delivery
Women who are most likely to benefit from
antihypertensisves prescribed following
delivery:
required antihypertensives in the antenatal period
been delivered < 37 weeks of gestation because of
hypertension
had severe hypertension
38. The perceived advantages of starting treatment in the
early postnatal period are :
episodes of severe hypertension will be reduced
discharge to the community will not be delayed
unnecessarily
Balanced against this
possibility of unnecessary treatment
SE of medication
A suggested regimen 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)
39. Figure 1.(b) Algorithm for the management of postnatal
hypertension in women without chronic hypertension
40. 3. De novo hypertension
Not clear what thresholds should be used to
instigate treatment in women with de novo
hypertension in the postnatal period having
previously been normotensive
Current NICE postnatal guidance13
recommends medical review:
DBP>90 mmHg ,ass. w any symptoms of PE
OR
Diastolic hypertension sustained >4 hours
41. No systolic thresholds are suggested but
extrapolation from the subsequent
hypertension guidelines :
SBP >150 mmHg → PE should be excluded
Newly presenting patients should have a
history and examination taken to exclude IE
and have Ix that include:
FBC
BUSE/Creat
LFT
42. Inpatient management of
ongoing postnatal hypertension
ALL women should be closely monitored with
regular recordings of BP and fluid balance
(regardless whether antihypertensive agents
prescribed immediately following delivery)
Modified obstetric early warning system
(MOEWS) charts should be used to facilitate
the monitoring of these women in wards
43. A validation study of the CEMACH recommended modified early obstetric warning
system (MEOWS)*
Anaesthesia
Volume 67, Issue 1, pages 12-18, 9 NOV 2011 DOI: 10.1111/j.1365-2044.2011.06896.x
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2044.2011.06896.x/full#fa1
44.
45.
46. The frequency of measuring haematological and
biochemical indices will need to be tailored to
individual patients
(A minimum of OD testing may be required initially in
cases where there is concern about
thrombocytopenia or renal compromise)
Thereafter frequent sampling - unlikely to change
management in the absence of other clinical triggers
Furthermore, unnecessary concern may arise if
normal patterns of resolution are not appreciated (for
example, ALT reaches peak serum levels 5 days
postnatally in normal pregnancy15 )
47. NICE guidance16 recommends :
platelet count
transaminases
serum creatinine
Up to 44% of eclamptic fits occur in the postnatal
period (usually within the first 48 hours following
delivery,17) women with PE should be encouraged to
delay discharge until day 3
BP at the time of discharge should be <150/100 mmHg
Crucial that the community team receive adequate
and prompt documentation regarding the inpatient
management and the plans for follow-up
Checked 48–72 hours after birth/
Step down from Level 2 care, and
Thereafter only repeated if abnormal or
clinically indicated
48. Discharge criteria
For mild HDP – no earlier than 24-48 hrs
Severe PE/E – no earlier than day 5
DBP has settled <100 mmHg
On single/no antihypertensive drug
NO end-organ dysfunction
Patient:
understands the disease & its complications
compliant to medication
accessible to a health center
49. Notification of birth
The importance of continuing post-natal care
either at the hospital or health center cannot
be overemphasized
To facilitate this, notification of birth to the
nearest peripheral health center is vital
Phone
Fax
Report by family members/next of kin to nearest
clinic
50. Follow-up at the Community
Local experience and facilities will dictate if this
review should be by the GP / the hospital
maternity assessment unit/ Daycare unit
Hospital review will be required if patients
report symptoms of PE / if BP >160/100 mmHg
Most women who commence postnatal
antihypertensives will require treatment for ≥ 2
weeks
Some women, esp. with early onset /severe
disease may need to continue > 6 weeks18
51. Management at the
Community
EOD follow-up either at the health centre /
home visit by the community
midwife/nursing/paramedical staff :
BP
urine for albumin
signs and symptoms of PE
The patient has to be seen and examined by a
doctor either in the hospital / at health centre
fortnightly until 6 weeks post-natal period
52. Elements to be monitored Frequency of
review by nurse
Frequency of
review by
doctor
•Blood Pressure
•Urine for protein (if B/P >
140/90 mmHg)
•Signs and symptoms of severe
HDP and pre-eclampsia
•Signs and symptoms of Deep
Vein Thrombosis
(Post-natal mothers with history
of HDP have a higher risk of
developing DVT, as a
complication of advocating long
rest during antenatal period)
Every
Other
Day
(EOD)
Two weekly
53. Medication should be reduced when BPs ranged
130–140/80–90 mmHg
Refer for medical review:
>150/ 100mmHg - 2x measurements are obtained
>20 minutes apart
remains on medication at 2 weeks
Further medical review
If medication is required > 6 weeks - to Ix the
possibility of an underlying cause
It has been reported - up to 13% of women initially
thought to have a diagnosis of PE or PIH will have
underlying disease not suspected antenatally19
54. Criteria for referral
Referral to hospital to be considered, if:
- BP > 140/100 mmHg with proteinuria and/ or
- Signs and symptoms of Impending Eclampsia
- Hypertension and proteinuria persist > 6 weeks
postpartum.
55. 6 weeks post partum
The 6-week postnatal visit –
establish the diagnosis (PIH/PE/Essential HPT)
discuss implications for future pregnancies
All women who have had a diagnosis of PE
should have:
BP measured
urine tested for proteinuria
56. Counseling on the importance of contraception
and choice with reference to WHO medical
eligibility criteria (WHO MEC)
Advise to have an early booking and regular
antenatal care in the next pregnancy
If hypertension and proteinuria persists >6
weeks postpartum, the mother should be
referred to a physician
57. It is important to ascertain whether that renal
impairment detected in hypertensive
pregnancies is indeed attributable to PE20
Renal biopsies taken in the postpartum period
in 176 women who had been diagnosed in
pregnancy as having renal complications of
pre-eclampsia established
an alternative diagnosis in 1/3 of cases overall;
and this was ↑ to almost 2/3 in multiparous patients
58. Recurrence of Pre-eclampsia
The risk of pre-eclampsia in a subsequent
pregnancy depends on the presentation in the
index pregnancy
Severe, early onset pre-eclampsia -
recurrence rate up to 40% in future
pregnancies21,22
generally the onset of problems is 2–3 weeks
later
< severe than in the 1st pregnancy23
Milder disease, nearer to term - risk of
59. Future pregnancy/ risk
Women at increased risk should be offered in
a future pregnancy
low-dose aspirin
increased BP surveillance
Finally….CVD
It is increasingly recognised that PE is a risk
factor for developing cardiovascular disease in
later life
Patients should be made aware of this -
opportunity to make lifestyle choices to minimise
