Hypertension in pregnancy is a common complication, affecting approximately 10 percent of pregnancies, and can be quite devastating, even contributing to maternal death. Following birth, during the postpartum period, hypertension can also occur which seems to occur in about 2 percent of all pregnancies. Most always this is due to a worsening of chronic hypertension that occurs due to the increased work load required of pregnancy or may be a superimposed preeclampsia. Eclampsia is among the most common reasons hypertension will occur following birth and among the most dangerous, which is when seizures accompany a preeclampsia diagnosis. While most all of these cases present within 48 hours, prior to the mother being discharged home, risk does exist for the first six weeks postpartum.
Generally, blood pressure decreases somewhat following birth, but then peaks again three to six days after childbirth. This relates to the large amounts of sodium that mobilize and the free water in the intravascular system that redistribute following birth. However, sometimes, hypertension presents or chronic hypertension worsens. Interestingly, women aren't often seen before the sixth week postpartum in the obstetrical model. Midwives typical return clients at the two week mark to evaluate postpartum recovery and assist with breastfeeding challenges.
When severe, this condition needs to be managed within the hospital, as stroke is a significant risk. Eclampsia is also a risk within the first week, and more likely if the hypertension is new post-birth or with severe gestational hypertension. When hypertension continues through the postpartum period, long-acting oral antihypertensive agents are recommended. Oral nifedipine and oral labetalol are most commonly used, although nifedipine may be quicker. Interestingly, labetalol more commonly achieves blood pressure control at a lower dose with fewer side effects, so it is often the preferred medication if contraindications do not exist. Both are compatible with #breastfeeding.
Additional Testing Considerations
Postpartum hypertension should motivate the practitioner to dig into #thyroid health, evaluating both TSh and free T4. A complete metabolic panel and creatinine should also be evaluated, and a renal ultrasound with doppler flow may be indicated. If the client suffers with acne, striae, buffalo hump, moon facies, central obesity, and weakness, then a urinary free cortisol may be helpful. Sleep apnea should be ruled out and primary kidney disease.
Hypertension is inflammatory, so in my practice, when a client is willing to take a #functional approach, I like to dig in a bit to underlying causes which are more thoroughly discussed in the Detoxification and Wellness program exclusive to members of Eden Family Practice.
Sharma, K. J., & Kilpatrick, S. J. (2017). Postpartum hypertension: etiology, diagnosis, and management. Obstetrical and Gynecological Survey, 72(4), 248-252.
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