Blood pressure checks are an integral part of the prenatal care experience. Many patients have heard about the dangers of preeclampsia, or high blood pressure during pregnancy.
But what about hypertension after you go home with your newborn?
The Texas Maternal Mortality and Morbidity Review Committee's (MMMRC) 2020 biennial report shows serious gaps in postpartum preeclampsia care and education. According to the report, two of the top six causes of maternal morbidity and mortality in Texas are preeclampsia (disorder of high blood pressure related to pregnancy) and eclampsia (seizures resulting from preeclampsia).
Of the 54 women who died from pregnancy-related causes in 2013, 29 percent died in pregnancy – 71 percent died within a year after delivery. The MMMRC states that there was some level of preventability in 89 percent of these cases.
Maternal complications resulting from severe hypertension during or after pregnancy are largely preventable. However, severe hypertension, particularly in the postpartum period, often goes unrecognized and untreated because women are not receiving the tools, education, or empowerment they need to monitor and maintain their health after going home with their baby.
This is why the state of Texas has selected severe hypertension as the focus of its 2021 Alliance for Innovation on Maternal Health (AIM) bundle. Much like our 2019 AIM for maternal hemorrhage, we are closely examining our hypertension data and protocols, both during and after pregnancy.
Our goal is to uncover opportunities to improve patient care and empower women to monitor and manage high blood pressure between Ob/Gyn visits. And patient education is the foundation of making effective change.
What causes high blood pressure?
During pregnancy, existing high blood pressure can get worse and new blood pressure issues can develop. Total blood volume doubles during pregnancy, putting additional strain on the blood vessels.
Usually, the patient's blood pressure levels off after delivery. But this can take time. Additionally, some women don’t develop blood pressure issues until after delivery. When a patient's blood pressure exceeds 140/90 for the first time in the postpartum period, the patient may have postpartum preeclampsia.
What are the symptoms during or after delivery?
High blood pressure often causes no noticeable symptoms, which is part of what makes the condition so dangerous. Go to the emergency room immediately if you experience any of these emergency symptoms, especially during pregnancy or after having a baby:
- Blood pressure of 160/110 or higher
- Seeing spots or sparkles
- Severe headache
- Stomach pain, nausea, or vomiting
- Swelling in the hands or face
- Trouble breathing or shortness of breath
How high is too high?
The American College of Obstetricians and Gynecologists (ACOG) estimates that 1.5 percent of patients enter pregnancy with chronic hypertension – a number that increased 67 percent from 2000 to 2009 due in part to the obesity epidemic and increased maternal age.
Having high blood pressure in pregnancy or postpartum puts you at greater risk for stroke, preterm birth, seizures, and death. Chronic hypertension increases your risk of stroke, heart attack, and death. Keeping your blood pressure in check dramatically reduces your risks.
Follow these parameters when monitoring your blood pressure:
- Normal: A normal, healthy blood pressure reading is 120/80. Once we creep over that, the brain's ability to regulate blood flow is impacted at varying levels, depending on the patient.
- High: During pregnancy and the few weeks after, your blood pressure may be 140/90. This is considered high, but not severe. You and your doctor should keep an eye on your blood pressure to make sure it goes no higher.
- Emergency: Having a blood pressure reading of 160/110 or higher is a medical emergency.
Women who had preeclampsia may still be at risk up to six weeks after delivery. Women who had high blood pressure before and during pregnancy continue to be at risk as long as their blood pressure remains high.
"Maternal complications resulting from severe hypertension during or after pregnancy are largely preventable. However, severe hypertension, particularly in the postpartum period, often goes unrecognized and untreated because women are not receiving the tools, education, or empowerment they need to monitor and maintain their health after going home with their baby."
How do we treat it?
ACOG guidelines for preeclampsia recommend IV medication treatment that begins within 30 to 60 minutes of confirmed severe, acute hypertension. The goal is to lower the patient's blood pressure to between 140/90 and 150/100 to prevent prolonged exposure to severely high blood pressure.
During this time, the care team will frequently check your blood pressure and monitor the baby for signs of distress, such as changes in fetal activity or heart rate. The only way to "cure" preeclampsia is to deliver the baby – often, patients with preeclampsia must deliver early to prevent the mother from having a potentially deadly stroke or seizure.
Emergency postpartum hypertension may also be treated with IV therapy or oral medication. In some cases, the doctor may recommend magnesium therapy to prevent preeclampsia-induced seizures. Patients who go to their local doctor's office with very high postpartum blood pressure should be transferred to a hospital for treatment and monitoring.
Chronic hypertension, while not usually an emergency, is a long-term health risk that must be controlled. Most patients can achieve a healthy blood pressure through a combination of medication, exercise, and diet changes. Increasing exercise and reducing sodium are two key factors in getting blood pressure to a healthier level.
In general, blood pressure medication is safe to take if you are breastfeeding. Research suggests that the common hypertension drug labetalol is safe to take while lactating. The estimated amount of the drug that enters breast milk is .004 to .07 percent – too low to interfere with milk production or harm the baby. However, some women experience a burning sensation on the nipples while taking labetalol.
How do we reduce the risk?
Patient education and empowerment are cornerstones of our program. Women need to understand that any patient with a hypertensive disorder of pregnancy is at risk for developing severe hypertension in the postpartum period.
Two ways you can help reduce your risks include visiting the doctor prior to the six-week checkup and monitoring your blood pressure at home.
Earlier postpartum visits
ACOG has published frequently about the fourth-trimester care gap – when maternal care drops off between leaving the hospital and the traditional six-week checkup.
Six weeks is too long to wait for a blood pressure check. By that time, the problem could reach dangerous levels. So, ACOG recommends that patients with hypertension during pregnancy see their Ob/Gyn specialist three days after discharge from the hospital. At this visit, we’ll ask you about your health and check your blood pressure. If it is elevated, we may recommend taking medication to lower it, potentially preventing a medical crisis.
Related reading: How health care after pregnancy is evolving
How to take your blood pressure at home
UT Southwestern cardiologist Angela Price provides some easy-to-follow tips on how to use a blood pressure cuff at home, and what the systolic (top) and diastolic (bottom) numbers mean.
Home blood pressure checks
We strongly encourage women to own and use a home blood pressure cuff. Devices can be purchased from local drug stores or online for $20 to $50.
When checking your blood pressure at home:
- Check it at the same time every day when possible.
- Sit upright and slightly reclined. Lying down may lead to a false low reading.
- Record your blood pressure readings in a journal or on your phone. Show it to your doctor to assess trends related to your daily life. Get more tips now.
Morbidity and mortality related to postpartum hypertension should be 100 percent preventable. Our goal is to help educate and care for more women to prevent maternal blood pressure issues postpartum. It won’t take much to make a big difference.