66 JCOM February 2017 Vol. 24, No. 2 www.jcomjournal.com

PostPartum recovery trends

AbstrAct• Objective:Toexaminetheassociationofthepatient’s

obstetric profile and time to normalization of bloodpressureinthepostnatalperiodamongwomenwithhypertensivedisordersinpregnancy.

• Methods:WeconductedaprospectivecohortstudyatatertiarylevelhospitalbetweenNovember2014andMay2015.Womenwithpregnancyhypertensionwhorequired antihypertensive treatment were recruitedafterdelivery.Thenormalizationtrendsinbloodpres-sureweretestedforassociationswithpatientdemo-graphicdataanddetailsofpregnancyhypertension.

• Results: Among 109 women included in the study,earliergestationalageatonsetofhypertensionandearliergestationalageatdeliverywascorrelatedwithslowerresolutionofhypertension.Timetoresolutionalsowascorrelatedwithage,BMI,severityofhyper-tension,associatedcomplications,andthenumberofantihypertensivemedicationsreceived.Therewasnocorrelationwithhighestrecordedsystolicordiastolicbloodpressures.Only15%ofwomenwithgestationalhypertension had persistent hypertension beyond 6weeks. In thegroups with nonsevere preeclampsia,severepreeclampsia,andeclampsia,bloodpressureremainedhighafter6weeksin26%,14%,and50%ofwomen,respectively.

• Conclusion:Womenwithadvancedage,higherbodymass index, early gestational age at the onset ofhypertension,severehypertensionandwhohadcom-plicationsofhypertensionrequireprolongedmonitor-ingandtreatmentwhenindicatedforhypertensioninpostnatalperiod.

Key words: postnatal recovery, hypertensive disorders, pre-

eclampsia, puerperium.

Hypertension is the most common medical prob-lem encountered during pregnancy, complicat-ing up to 10% of pregnancies worldwide [1].

The disorders of hypertension in pregnancy are generally classified as chronic hypertension, preeclampsia–eclamp-sia, preeclampsia superimposed on chronic hypertension, and gestational hypertension. The hypertensive disorders of pregnancy are a leading cause of mortality and mor-bidity 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 normaliza-tion of blood pressure in the postnatal period among women with hypertensive disorders in pregnancy.

METHODS settingThis 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).

PatientsWomen 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 diag-nosed before 20 weeks gestation) or secondary hyperten-sion were excluded. After granting informed consent,

Postpartum Recovery Trends in Women with Hypertensive Disorders of Pregnancy 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.

www.jcomjournal.com Vol. 24, No. 2 February 2017 JCOM 67

enrolled women were followed until the time they no longer required antihypertensive medication (“reversion of hyper-tension”) or until 10 weeks postpartum, whichever came first.

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

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

• Gestationalhypertension:hypertensionafter20weeksgestation 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 func-tion, pulmonary edema, or cerebral or visual symp-toms. Preeclampsia without any of these features was considered nonsevere preeclampsia.

• Eclampsia:Womenwithhypertensionwithepigastricpain, 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, thrombo- cytopenia, HELLP syndrome, disseminated intravas-cular coagulation, multiorgan failure, severe intrauter-ine growth restriction, and fetal demise.

Main Outcome MeasureTime to reversion of hypertension was the main outcome measure. We defined the reversion date as the day that hypertension medications were stopped. This informa-tion 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 collectionDemographic details (age, parity, BMI) as well as infor-mation regarding gestational age at onset of hyperten-sion, severity, highest systolic and diastolic blood pressure recordings, treatment received, complications related to hyper-tension, pregnancy termination and delivery was obtained from the medical charts and/or via telephonic follow-up.

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

RESULTSOf 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 associ-ated 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). There 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 nor-malization had a strong positive correlation (r = 0.8). The remaining parameters (ie, gestational age at onset,

Original research

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PostPartum recovery trends

gestational age at delivery, severity and complications of hypertension and number of antihypertensive medi-cations) and time to recovery were weakly correlated (r = 0.3 to 0.5 [+/–]).

Women with gestational hypertension and mild pre-eclampsia had faster normalization of blood pressure com-pared to those with severe preeclampsia and eclampsia (Figure 2). Only 15% of women with gestational hyper- tension had persistent hypertension beyond 6 weeks, where-as in the groups with nonsevere preeclampsia, severe pre-eclampsia, and eclampsia, blood pressure remained high even after 6 weeks in 26%, 14%, and 50%, respectively.

Eighteen women had additional medical problems: ges-tational 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.

DISCUSSIONIn 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 antihyperten-

Figure 1. Studyflowdiagram.

Excluded:womenwithchronicandsecondaryhypertensionn=17

Womenwhoreceivedantihypertensivemedicationsinpregnancyn=145

Womenwithpregnancyhypertension(gestationalhypertension,preeclampsia,eclampsia)n=128

Totalwomeninstudygroupn=109

Table 1.DemographicandObstetricProfileofStudyParticipants(n=109)

Characteristic Number (%)

Age,yr

20–30 83(75.2)

>30 26(23.8)

Parity

Primi 60(55)

Multi 49(44.9)

BMI

<25 47(43.1)

>25 62(56.8)

Severityofhypertension

Mild 34(31.1)

Severe 75(68.8)

Gestationalageatonsetofhypertension,wk

<28 35(32.1)

28–34 43(39.4)

>34 31(28.4)

Gestationalageatdelivery,wk

<28 13(11.9)

28–34 39(35.7)

>34 57(52.2)

Numberofantihypertensivesinpregnancy

<3 82(75.2)

>3 27(24.7)

Complicationsofhypertension?

Yes 76(69.7)

No 33(30.2)

Highestsystolicbloodpressure,mmHg

≥160 24(21.1)

<160 85(77.9)

Highestdiastolicbloodpressure,mmHg

≥110 23(19.2)

<110 87(79.8)

Losttofollow-upn=19 48hours0 10days0 6weeks12 10weeks7

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sive 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 preeclamp-sia 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 ob-served a consistent association of time to reversion of hypertension and early-onset hypertension in pregnancy [3–5]. Ferrazzani explained the longer time to nor-malization of blood pressure in preeclampsia compared

Original research

Table 2.TimetoReversionofHypertensionandPatientVariables

Time to Reversion of Hypertension

Characteristic

Delivery– 48 hrs n (%)

48 hrs– 10 days

n (%)

10 days– 6 weeks

n (%)

6 weeks– 10 weeks

n (%)

> 10 weeks

n (%)

P Value*

Age,yr

20–30(n=83) 19(22) 1(20.7) 37(45.1) 6(7.3) 4(4.9)0.001

30–40(n=26) 2(7.7) 5(19.2) 6(23.1) 10(38.5) 3(11.5)

Parity

Primi(n=60) 11(18.3) 15(25.0) 27(45) 5(8.3) 2(3.3)0.059

Multi(n=49) 9(18.4) 7(14.3) 16(32.7) 12(24.5) 5(10.2)

Bodymassindex,kg/m2

<25(n=47) 20(42.5) 22(46.8) 5(10.6) 0 0<0.001

>25(n=62) 0 0 38(61.3) 17(27.4) 7(11.3)

Gestationalageatonsetofhypertension,wk

<28(n =35) 2(5.7) 6(17.1) 11(31.4) 12(34.3) 4(11.4)

28–34(n =43) 8(18.6) 8(18.6) 20(46.5) 4(9.3) 3(7) 0.003

>34(n =31) 10(32.3) 8(25.8) 12(38.7) 1(3.2) 0

Gestationalageatdelivery,wk

<28(n =13) 0 0 4(30.8) 5(38.5) 4(30.8)

28–34(n =39) 7(17.9) 9(23.1) 16(41) 6(15.4) 1(2.6) 0.001

>34(n =57) 13(22.8) 13(22.8) 23(40.4) 6(10.5) 2(3.5)

Severityofhypertension

Nonsevere(n =34) 13(38.2) 10(29.4) 11(32.4) 0 0<0.001

Severe(n =75) 7(9.3) 12(16) 32(42.7) 17(22.7) 7(9.3)

Complicationsofhypertension

No(n =33) 13(39.4) 10(30.3) 10(30.3) 0 0<0.001

Yes(n =76) 7(9.2) 12(15.8) 33(43.4) 17(22.4) 7(9.2)

No.ofantihypertensivemedicationsused

<3(n =82) 20(24.4) 21(25.6) 30(36.6) 7(8.5) 4(4.9)<0.001

3ormore(n =27) 0 1(3.7) 13(48.1) 10(37) 3(11.1)

SeverityofsystolicanddiastolicBP

SystolicBP,mmHg

≥ 160(n =24) 1(4.3) 7(30.4) 11(47.8) 2(8.7) 2(6.7)0.201

<160(n =85) 18(21.2) 15(17.6) 32(37.6) 15(17.6) 5(5.9)

DiastolicBP,mmHg

≥ 110(n =22) 1(4.8) 4(19.0) 9(42.9) 6(28.6) 2(4.8)0.252

<110(n =87) 18(20.7) 18(20.7) 34(39.1) 11(12.6) 6(6.9)

*Pearsonchisquaretest.

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PostPartum recovery trends

to gestational hypertension as the recovery time of the endothelial damage in preeclampsia [4].

Berks et al [6] found a correlation of maximum dia-stolic 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 hyperten-sion, severe and with complications of hypertension re-quire prolonged monitoring and treatment when indicat-ed 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, Kar-nataka, India 576107, shyamaladoc@gmail.com.

Financial disclosures: None reported.

references1. American College of Obstetricians and Gynecologists; Task

Force on Hypertension in Pregnancy. Hypertension in preg-nancy. 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 associ-ated 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 pre-eclampsia. 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: Re-lationship 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 Af-rica: a 6-months cohort study.BMC Pregnancy Childbirth 2014; 14:134

6. Berks D, Steegers EA, Molas M, Visser W. Resolution of hy-pertension 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 di-astolic dysfunction and metabolic syndrome in young women after placental syndrome. Obstet Gynecol 2010;115:101–8.

Copyright 2017 by Turner White Communications Inc., Wayne, PA. All rights reserved.

Figure 2. Timetoreversionofhypertensionbytypeofpregnancyhypertension.

% o

f Wo

men

Gestationalhypertension(n=42)

Nonseverepreeclampsia(n=29)

Severepreeclampsia(n=32)

Imminenteclampsia(n=1)

Eclampsia(n=5)

Delivery–48hours 48hours–10days 10days–6weeks 6weeks–10weeks >10weeks

100

80

0

60

40

20