ORIGINAL RESEARCH

Postpartum Recovery Trends in Women with Hypertensive Disorders of Pregnancy

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Bhagyarekha P. Yattinamani, MBBS, DGO, Shyamala Guruvare, MBBS, MD, and Lavanya Rai, MBBS, DGO, MD

From the Department of Obstetrics and Gynecology, Kasturba Medical College, Manipal, Karnataka, India.

 

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ABSTRACT

Objective: To examine the association of the patient’s obstetric profile and time to normalization of blood pressure in the postnatal period among women with hypertensive disorders in pregnancy.

Methods: We conducted a prospective cohort study at a tertiary level hospital between November 2014 and May 2015. Women with pregnancy hypertension who required antihypertensive treatment were recruited after delivery. The normalization trends in blood pressure were tested for associations with patient demographic data and details of pregnancy hypertension.

Results: Among 109 women included in the study, earlier gestational age at onset of hypertension and earlier gestational age at delivery was correlated with slower resolution of hypertension. Time to resolution also was correlated with age, BMI, severity of hypertension, associated complications, and the number of antihypertensive medications received. There was no correlation with highest recorded systolic or diastolic blood pressures. Only 15% of women with gestational hypertension had persistent hypertension beyond 6 weeks. In the groups with nonsevere preeclampsia, severe preeclampsia, and eclampsia, blood pressure remained high after 6 weeks in 26%, 14%, and 50% of women, respectively.

Conclusion: Women with advanced age, higher body mass index, early gestational age at the onset of hypertension, severe hypertension and who had complications of hypertension require prolonged monitoring and treatment when indicated for hypertension in postnatal period.

 

Key words: intensive care unit; communication; family meeting; critical illness; decision making; end of life care.

 

Hypertension is the most common medical problem encountered during pregnancy, complicating up to 10% of pregnancies worldwide [1]. The disorders of hypertension in pregnancy are generally classified as chronic hypertension, preeclampsia–eclampsia, preeclampsia superimposed on chronic hypertension, and gestational hypertension. The hypertensive disorders of pregnancy are a leading cause of mortality and morbidity in the perinatal period.

Women with hypertensive disorders in pregnancy show varying trends of blood pressure normalization, with the recovery period ranging from a few hours to several months after delivery. In one study, nearly one-fourth of women with preeclampsia/eclampsia had persistent high blood pressure after puerperium [2]. Identifying the obstetric risk factors for persistent hypertension will help in focusing care and research in this group of patients.

We undertook a prospective study to assess possible correlations of obstetric profile with time to normalization of blood pressure in the postnatal period among women with hypertensive disorders in pregnancy.

 

METHODS

Setting

This prospective cohort study was conducted in the department of obstetrics and gynecology at Kasturba Hospital, Manipal, between November 2014 and May 2015. Permission for the study was obtained from the Institution Ethical Committee (IEC264/2015).

 

Patients

Women who had hypertension in pregnancy and required antihypertensive treatment were approached on the first postnatal day and invited to participate in the study. Women with chronic hypertension (women with known pre-pregnancy hypertension and with hypertension diagnosed before 20 weeks gestation) or secondary hypertension were excluded. After granting informed consent, enrolled women were followed until the time they no longer required antihypertensive medication (“reversion of hypertension”) or until 10 weeks postpartum, whichever came first.

During the hospital stay in the postnatal period, women had their blood pressure monitored and antihypertensives were adjusted as needed. After discharge from the hospital, blood pressure was monitored by the family physician who also made decisions regarding antihypertensive management. All women had a follow-up visit in the hospital in the 6th postnatal week as per the postnatal clinic protocol.

 

Definitions

Hypertension was defined as BP ≥ 140/90 mm Hg. The hypertension disorders of pregnancy were defined as follows:

• Gestational hypertension: hypertension after 20 weeks gestation on two occasions 4 hours apart without meeting criteria for preeclampsia.

• Preeclampsia: hypertension after 20 weeks gestation on two occasions 4 hours apart with proteinuria (≥ 300 mg/24 hour) or, in the absence of proteinuria, new onset of any of the following: thrombocytopenia, renal insufficiency, impaired liver function, pulmonary edema, or cerebral or visual symptoms [1]. Severe preeclampsia was defined as preeclampsia with any of the following: systolic blood pressure > 160 mm Hg diastolic BP > 110 mm Hg or more on 2 occasions 4 hours apart, thrombocytopenia (platelet count < 100,00/mL), renal insufficiency, impaired liver function, pulmonary edema, or cerebral or visual symptoms. Preeclampsia without any of these features was considered nonsevere preeclampsia.

• Eclampsia: Women with hypertension with epigastric pain, headache, vomiting, and blurring of vision were diagnosed with imminent eclampsia and those with hypertension-related convulsions were diagnosed with eclampsia.

• Complications of preeclampsia included eclampsia, placental abruption, pulmonary edema, thrombocytopenia, HELLP syndrome, disseminated intravascular coagulation, multiorgan failure, severe intrauterine growth restriction, and fetal demise.

 

Main Outcome Measure

Time to reversion of hypertension was the main outcome measure. We defined the reversion date as the day that hypertension medications were stopped. This information was obtained via in-person questioning on the 2nd postpartum day and at the 6-week postnatal visit and via telephonic survey on the 10th postnatal day and at 10 weeks postdelivery. Women who missed the 6-week postnatal visit were also followed up by telephone.

 

Data Collection

Demographic details (age, parity, BMI) as well as information regarding gestational age at onset of hypertension, severity, highest systolic and diastolic blood pressure recordings, treatment received, complications related to hypertension, pregnancy termination and delivery was obtained from the medical charts and/or via telephonic follow-up.

 

Analysis

We used Pearson’s chi-square test to assess the association between recovery trends in blood pressure and the patient’s demographic profile and details of pregnancy hypertension. Statistical analysis was done using SPSS16.

 

RESULTS

OR_Postpartum_Figure1Of 145 women approached, 17 were excluded as they had chronic and secondary hypertension. Of the 128 women enrolled, 19 were lost to follow-up; therefore 109 women with complete follow-up were included in the analysis (Figure 1). The obstetric profile of the women, including details of pregnancy hypertension, is shown in Table 1.

In our study, earlier the gestational age at onset of hypertension and earlier gestation at delivery was associated with slower recovery from hypertension (Table 2). Time taken for recovery also was associated with age, BMI, severity of hypertension, associated complications, and the number of antihypertensive medications received (Table 2). Among women who received more than 3 antiphypertensives in pregnancy, nearly 50% continued to have hypertension beyond 6 weeks (Table 2). OR_Postpartum_Table1There was no correlation with highest recorded systolic BP > 160 or highest diastolic BP > 110 mm Hg (Table 2).

On testing for strength of correlation, it was found that body mass index and time to blood pressure normalization had a strong positive correlation (r = 0.8). The remaining parameters (ie, gestational age at onset, gestational age at delivery, severity and complications of hypertension and number of antihypertensive medications) and time to recovery were weakly correlated (r = 0.3 to 0.5 [+/–]).

Women with gestational hypertension and mild preeclampsia had faster normalization of blood pressure compared to those with severe preeclampsia and eclampsia (Figure 2). Only 15% of women with gestational hypertension had persistent hypertension beyond 6 weeks, whereas in the groups with nonsevere preeclampsia, severe preeclampsia, and eclampsia, blood pressure OR_Postpartum_Table2remained high even after 6 weeks in 26%, 14%, and 50%, respectively.

Eighteen women had additional medical problems: gestational diabetes (n = 5), anemia (n = 3), hypothyroidism (n = 4), rheumatic heart disease (n = 2), antiphospholipid antibody syndrome (n = 1) chronic kidney disease (n = 1), post atrial septal defect closure (n = 1), and tricuspid valve prolapse (TVP) with regurgitation and pulmonary arterial hypertension (n = 1). With the exception of the woman with chronic kidney disease, all reverted to normal blood pressure by 6 weeks; the woman with TVP reverted after corrective cardiac surgery in puerperium.

 

OR_Postpartum_Figure2DISCUSSION

In the present study we assessed possible correlations of obstetric profile with time to postpartum recovery of blood pressure in women with pregnancy hypertension. Women with advanced age, higher body mass index, early gestational age at the onset of hypertension, early gestational age at delivery, severe hypertension, and those with complications of hypertension took longer time in the postnatal period for normalization of blood pressure.

The strength of this study was its prospective design and high rate of follow-up. Those who missed a visit were followed up over telephone. However, 19 women were not available even by phone. A limitation of this study is that the information regarding when the antihypertensive was stopped was obtained by patient recall, raising the possibility of recall bias. However, as the range of recovery times was wide, an error of few days may not be significant.

In the study we noted that women with preeclampsia took a longer time to recovery compared with women with gestational hypertension. Earlier and more severe disease was associated with delay to recovery or persistence of hypertension beyond 10 weeks postpartum.

Similar to our observation, other authors have observed a consistent association of time to reversion of hypertension and early-onset hypertension in pregnancy [3–5]. Ferrazzani explained the longer time to normalization of blood pressure in preeclampsia compared to gestational hypertension as the recovery time of the endothelial damage in preeclampsia [4].

Berks et al [6] found a correlation of maximum diastolic blood pressure, maximum proteinuria in pregnancy, and diagnosis-to-delivery interval with time taken for resolution of hypertension; however, they did not find that time to resolution was correlated with gestational age at onset of preeclampsia. They opined that their observations reflected endothelial recovery after preeclampsia. They also suggested further research in the area of temporizing management of preeclampsia to determine if a conservative approach increases remote cardiovascular risk [6]. We did not study the diagnosis-to-delivery interval, but those with early delivery in our group had late postpartum recovery, indicating that they had severe/complicated preeclampsia that demanded early termination.

In conclusion, women with advanced age, higher body mass index, early gestational age at the onset of hypertension, severe and with complications of hypertension require prolonged monitoring and treatment when indicated for hypertension in the postnatal period. Women with a history of pregnancy hypertension have increased risk of stroke, cardiac ischemia, venous thrombosis within 10 to 20 years after pregnancy and higher risk of hypertension and type 2 diabetes mellitus [7–9]. Extended postnatal follow-up and regular monitoring is recommended to address the needs of these high-risk women.

 

Corresponding author: Dr. Shyamala Guruvare, 1-167 (C4), Lahari, Eshakripa Road, Parkala, Udupi District, Karnataka, India 576107, shyamaladoc@gmail.com.

Financial disclosures: None reported.

 

References

1. American College of Obstetricians and Gynecologists; Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet Gynecol 2013;122:1122–31.

2. Ndayambagye EB, Nakalembe M, Kaye DK. Factors associated with persistent hypertension after puerperium among women with preeclampsia/ eclampsia in Mulago Hospital, Uganda. BMC Pregnancy Childbirth 2010;10:12.

3. Mikami Y,Takagi K, Itaya Y, et al. Post-partum recovery course in patients with gestational hypertension and preeclampsia. J Obstet Gynaecol Res 2014;40:919–25.

4. Ferrazzini S, Carolis SD, Pomini F, et al. The duration of hypertension in the puerperium of preeclamptic women: Relationship with renal impairment and week of delivery. Am J Obstet Gynecol 1994;171:506–12.

5. Kaze FF, Njukeng FA , Kengne A, et al. Post-partum trend in blood pressure levels, renal function and proteinuria in women with severe preeclampsia and eclampsia in Sub-Saharan Africa: a 6-months cohort study.BMC Pregnancy Childbirth 2014;14:134

6. Berks D, Steegers EA, Molas M, Visser W. Resolution of hypertension and proteinuria after preeclampsia. Obstet Gynecol 2009;114:1307–14.

7. Gongora MC, Wenger NK. Cardiovascular complications of pregnancy. Int J Mol Sci 2015;16:23905–28.

8. Garovic VD, August P. Preeclampsia and the future risk of hypertension: the pregnant evidence. Curr Hypertens Rep 2013;114–21.

9. Zandstra M, Stekkinger E, van der Vlugt MJ, et al. Cardiac diastolic dysfunction and metabolic syndrome in young women after placental syndrome. Obstet Gynecol 2010;115:101–8.

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