Postpartum hypertension (PPH) – Is it something you should worry about? Hypertensive disorders affect pregnant women during or after pregnancy and PPH is one such condition.
It is very common; however, its exact incidence in pregnant women is not known. It can be serious as it can lead to serious complications. Therefore, awareness about postpartum hypertension is necessary for all new and future mothers.
What is normal postpartum blood pressure?
The delivery of a baby is a natural process. Pain, fluid loss, and blood loss are typical. As a result, blood pressure may fall in the early postpartum period. But our bodies are built in a way that naturally brings any change or abnormality back to its normal state. And so, the body tries to compensate for this decreased blood pressure by raising it. Hence, the increase in blood pressure of the new mother comes to a maximum on the 3rd to 6th day of the postpartum period.
What is postpartum hypertension?
PPH is the increased blood pressure within 2 days to 6 weeks after delivery.
A blood pressure of more than 140/90mm Hg after delivery can be considered postpartum hypertension. However if blood pressure is more than 160/110 mm Hg, it is severe hypertension and must be taken control of immediately.
Postpartum hypertension can present as a de novo hypertension, i.e. this high blood pressure after pregnancy has presented for the first time and has never occurred before. Or, this may also happen when chronic hypertension or pregnancy-induced hypertension, which appears before or during pregnancy, fails to resolve after delivery.
Signs and symptoms of postpartum hypertension:
Raised blood pressure has the same symptoms whether it arises during pregnancy or after pregnancy, even without pregnancy. These symptoms include
- Headache (increased frequency or severity, or the kind of headache that is not relieved on medications)
- Problems in the vision (blurred vision, double images, flashes, etc)
- Pain in the upper part of the abdomen
- Nausea, retching, or vomiting
- General weakness and fatigue
- Difficulty breathing due to edema in the lungs
- Generalized swelling which may present in feet, face or hands, etc
Some of these symptoms normally coincide with symptoms that usually present in the postpartum period. Hence differentiating these features and identifying postpartum hypertension can be a challenge too.
What causes postpartum hypertension?
Postpartum hypertension can present at any point after delivery and may persist even after 6 weeks. There may be different causes for hypertension depending on how early it presents or stays.
Ø Early postpartum hypertension (within 6 weeks of the postpartum period)
There can be multiple causes of postpartum hypertension which may be related to the normal delivery process or the interventions made during the procedure.
As said earlier, delivery involves loss of blood and other body fluids, painful contractions, and delivery of the placenta. All these processes involve certain body changes which are compensated either by the body naturally or are treated by using drugs or medicines for different purposes.
For instance, non-steroidal anti-inflammatory drugs (NSAIDs) and other painkillers are used for treating pain. Loss of blood and body fluid is compensated by intravenous fluid administration using blood products or fluids, like normal saline or Ringer Lactate, etc. Other drugs are also used to maintain the tone of the blood vessels to prevent blood loss.
All these factors, be natural or interventional, may lead to a temporary and short-lived increase in blood pressure during the postpartum period (1).
Ø Late postpartum hypertension (after 6 weeks of the postpartum period)
If the blood pressure is peaking persistently despite the passage of 6 weeks after delivery, it means that there must be some secondary cause that is causing this post-partum hypertension. These may include (2):
- Renal causes (e.g. Chronic Kidney Disease, Renal artery stenosis, kidney damage due to uncontrolled or prolonged drugs intake)
- Endocrine causes (e.g. Conn’s syndrome, Cushing Syndrome, Pheochromocytoma, Thyroid disorders)
- Neurological causes (e.g. spinal cord injuries, sleep disorders) – etc
Who is at risk of developing postpartum hypertension?
Multiple risk factors have been identified that contribute to the development of postpartum hypertension. These risk factors include:
- Older age
- Pregnancy-induced hypertension (also known as gestational hypertension)
- History of raised blood pressure during or after previous pregnancies
- Twin pregnancies
- Obesity – etc
How is postpartum hypertension diagnosed?
As mentioned before, postpartum hypertension may or may not be associated with symptomatic presentation. Therefore it is important to monitor blood pressure during and after pregnancy.
Regular monitoring with the knowledge of normal blood pressure variation in the postpartum period is essential. A transient rise in blood pressure due to a normal physiological response to the natural process of delivery should be differentiated from hypertension. Therefore, strict monitoring is advised.
High blood pressure with proteins in the urine may confirm postpartum preeclampsia. But immediate proteinuria may not be present after birth.
How to manage postpartum hypertension?
It is a no-brainer that postpartum hypertension should be managed as soon as possible. Otherwise, it may lead to serious consequences. However, multiple factors need to be reviewed before starting any management of high blood pressure in the postpartum period. These factors include:
- The severity of the disease
- Risk factors of PPH
- Treatment facilities availability
- Risk of developing serious complications
- Any identified cause of postpartum hypertension
- Type of postpartum hypertension; de novo or secondary to some other cause
The first important step is to identify any secondary cause of postpartum hypertension and treat it accordingly.
Regular postnatal visits and blood pressure monitoring are mandatory. High-risk patients should be monitored closely as there are higher chances of developing this condition.
Besides, many antihypertensive drugs have been used for postpartum hypertension. These drugs have shown varied responses in controlling high blood pressure, and include (2):
- Calcium channel blockers
- Angiotensin-Converting Enzyme Inhibitors
- Angiotensin Receptor Blockers
Complications of postpartum hypertension?
Any disorder in the natural homeostasis may lead to severe complications. Blood pressure maintenance is necessary for the normal functioning of all organ systems in the body, especially the brain. Any disturbance may lead to complicated presentation and may pose a danger to life.
Similarly, postpartum hypertension may increase the risks of the following complications:
- Eclampsia – seizures in addition to high blood pressure
- Stroke – it could be hemorrhagic or ischemic
- HELLP syndrome
- Anxiety – due to prolonged hospital stay and general worry about health and well being
- Cardiovascular disorders
- Chronic hypertension
Any of these or unexpected complications may arise. So it is better to avoid these complications by treating and managing the condition before it is too late.
Can I breastfeed if I have PPH?
Generally, with any disorder, a new mother’s first concern is the safety of her child. Is it safe to breastfeed the child when the mother has hypertension? Will the antihypertensive drugs affect the newborn? These are generally frequently asked questions to doctors and obstetricians.
The answer is YES. It is safe to breastfeed the child even if you have postpartum hypertension due to any cause. Most of the antihypertensive drugs that are being used to treat this condition are also safe to use. Except for diuretics and angioreceptor II blockers (ARBS), antihypertensive drugs can be used without any mental stress (3).
Some studies even suggest that breastfeeding help in lowering blood pressure. Women who developed pregnancy-induced hypertension were more likely to respond to breastfeeding and lowered blood pressure. Women with pre-eclampsia were less likely to respond to breastfeeding.
How to prevent postpartum hypertension?
It is always better to take precautionary measures. These precautionary measures may help in avoiding the occurrence and complications of the disease processes.
To prevent PPH, you can do following things:
- Use a low sodium diet as sodium can cause an increase in blood pressure
- Exercise daily as it can help in keeping your blood pressure within normal range
- Antihypertensive drugs usage by those who are already suffering from chronic or gestational hypertension as they are at increased risk for postpartum hypertension
- Regular monitoring of your blood pressure either at home or at a nearby health facility
- Regular postnatal visits to the doctor, even before six weeks if you identify yourself as a high-risk patient
Conclusion on postpartum hypertension
Postpartum hypertension can occur due to multiple causes and can present with varied symptoms in a pregnant woman. These causes must be addressed and strict monitoring of blood pressure should be done.
Treatment with antihypertensive drugs is better to avoid complications such as stroke, seizures, HELLP syndrome, and others.
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- Powles K, Gandhi S. Postpartum hypertension. Cmaj. 2017 Jul 10;189(27):E913-.
- Ghuman N, Rheiner J, Tendler BE, White WB. Hypertension in the postpartum woman: clinical update for the hypertension specialist. The Journal of Clinical Hypertension. 2009 Dec;11(12):726-33.
- Podymow T, August P. Antihypertensive drugs in pregnancy. InSeminars in nephrology 2011 Jan 1 (Vol. 31, No. 1, pp. 70-85). WB Saunders.