Management of Postpartum Hypertensive Disorders of Pregnancy

What are the effectiveness, benefits, and harms of management strategies for hypertensive disorders of pregnancy during the postpartum period?

Home blood pressure (BP) monitoring likely doubles the number of people who have their BP checked at recommended intervals (number needed to treat [NNT] = 2). (Strength of Recommendation [SOR]: C, disease-oriented evidence.) Patient satisfaction is high with home BP monitoring. (SOR: C, disease-oriented evidence.) Home BP monitoring likely reduces hypertension-related readmissions (NNT = 28). (SOR: B, inconsistent or limited-quality patient-oriented evidence.) Home BP monitoring likely reduces the disparity in recommended BP monitoring by one-half between non-Black and Black patients. (SOR: C, disease-oriented evidence.) Oral furosemide may shorten the duration of postpartum hypertension (adjusted risk ratio = 0.40; CI, 0.20 to 0.81). (SOR: B, inconsistent or limited-quality patient-oriented evidence.) There is insufficient evidence on the benefits and harms of other antihypertensive medications in the postpartum period. Shorter duration magnesium sulfate (MgSO₄) leads to a shorter time from delivery to contact with the infant (mean difference = −5.4 hours; 95% CI, −10.0 to −0.80). (SOR: B, inconsistent or limited-quality patient-oriented evidence.) Loading dose–only MgSO₄ increases the risk of recurrent seizures in patients with eclampsia (odds ratio [OR] = 2.09; 95% CI, 1.21 to 3.63). (SOR: B, inconsistent or limited-quality patient-oriented evidence.) Lower doses of MgSO₄ decrease the risk of reduced deep tendon reflexes (OR = 0.16; 95% CI, 0.09 to 0.28).¹ (SOR: B, inconsistent or limited-quality patient-oriented evidence.)

Hypertensive disorders of pregnancy, which include chronic hypertension and pregnancy-associated hypertension, have steadily increased in prevalence to 15.9% of hospital deliveries in 2019.² The prevalence of these disorders identified post-partum in patients who were normotensive during pregnancy is estimated to be 3% to 12%.³ Because of the increasing prevalence of hypertensive disorders of pregnancy and their frequency during the postpartum period, even family physicians who do not provide perinatal care will likely find themselves diagnosing and initiating the management of hypertensive disorders of pregnancy.

This Agency for Healthcare Research and Quality (AHRQ) review assessed the evidence of monitoring and managing hypertensive disorders of pregnancy in the postpartum period. The review identified 13 studies, including three randomized controlled trials (RCTs), two nonrandomized comparative studies, and eight single-arm studies that examined home BP monitoring. Home BP monitoring increased the number of people adhering to BP-monitoring recommendations from about 44% to 60% to about 92% to 94% (NNT = 2) and may reduce the number of hospital readmissions for hypertension (NNT = 28).¹ Home BP monitoring reduced the racial disparity in adherence to BP checks between Black and non-Black patients, with one study showing this gap decreasing from 24.6% to 0.4% with home BP monitoring.¹

Many family physicians are already familiar with home BP monitoring in their patients. For their nonpregnant patients, home BP monitoring is more sensitive and specific for identifying elevated BP; this practice is also recommended by the U.S. Preventive Services Task Force and the American College of Cardiology/American Heart Association. A previous American Family Physician article describes home BP monitoring in detail.⁴