|
DON'T MAKE THIS MISTAKE!
Managing Postpartum Hypertension
Steven L. Clark, MD
A 19-year-old woman, gravida 1, was admitted at 38 weeks in active labor. Her blood pressure (BP) was noted to be 148/94 mm Hg, compared with 104/78 mm Hg at her 37-week prenatal visit. Also identified was 2+ proteinuria, and the admission note revealed 3+ pedal edema. Platelet count and serum transaminase levels were normal, and she had no symptoms. Magnesium sulfate was ordered at a 4-g loading dose and 2-g/hour infusion. Six hours later, at 9:00 am, she had a normal spontaneous vaginal delivery of an infant with an Apgar score of 8/9. The maximum BP during labor was 154/98 mm Hg.
Serial BPs following delivery were:
9:00 am — 156/94 mm Hg
9:30 am — 152/88 mm Hg
10:00 am — 158/102 mm Hg
10:30 am — 168/112 mm Hg
At this point, the clinician was called with a report of the BPs. The patient was feeling well. The magnesium sulfate infusion was increased to 3 g/hour.
11:00 am — 176/108 mm Hg
11:30 am — 186/114 mm Hg
As this BP was being taken, the patient became unresponsive. Another obstetrician was in the hospital and came to the bedside. She ordered hydralazine 10 mg IV slow push. Five minutes later, the BP was 158/102 mm Hg. The patient did not regain consciousness, and subsequent imaging studies demonstrated an intracerebral hemorrhage.
back to top
COMMENT
While preeclampsia is ultimately “cured” by delivery, it may worsen in the immediate postpartum period. Blood pressures must be followed carefully until the patient has completely stabilized and BPs have returned to normal or near-normal values, in order to prevent stroke. A measurement of 160/110 mm Hg has traditionally been viewed as the level at which acute lowering of BP is essential. Had this been done in this case, the intracerebral hemorrhage would likely have been avoided.
But what if only one of these values is exceeded? One approach is to use the mean arterial pressure: MAP = ([systolic] + 2[diastolic])/3. When this value exceeds the MAP represented by 160/110 mm Hg (MAP = 127 mm Hg), it is generally a good idea to administer an antihypertensive drug. There are several good drugs available; the most commonly used are hydralazine and labetalol. Remember, magnesium sulfate is given to prevent eclamptic seizures, but it is not an antihypertensive agent.
The author reports no actual or potential conflict of interest in relation to this article.
back to top
Steven L. Clark, MD, is Medical Director, Women and Newborns Clinical Services, Hospital Corporation of America, Nashville, TN.
|
