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The Postpartum Danger That Can Go Undetected

Many women have masked hypertension after pregnancy.

Photo credit: Getty Images/Nick Stevens

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Shortly after arriving at the hospital for my scheduled C-section in my 38th week of pregnancy with twins, I got some alarming news. I had developed pre-eclampsia—a potentially serious pregnancy complication that results in high blood pressure and protein in the urine. Left untreated, the condition can be fatal to both mother and baby, and the only cure is delivery.

A couple of hours later, I breathed a huge sigh of relief when my boy/girl twins arrived and were promptly dubbed “pink and perfect” by the examining pediatrician. Although my obstetrician had told me that the high blood pressure associated with pre-eclampsia usually goes away soon after giving birth, that wasn’t the case with me. My numbers didn’t go back to normal until a few months after I delivered.

A new study published in the American Heart Association’s journal Hypertension suggests that if a woman has had severe pre-eclampsia, she may continue to have high blood pressure for a lot longer than a few months. In fact, one year after giving birth, more than 41 percent of the women in the study still had high blood pressure. What’s more, the most common type of hypertension detected (17.5 percent of the women had it) was what’s known as masked hypertension, meaning a woman has normal blood pressure in the doctor’s exam room, but high readings outside of the office.

I wondered what these new findings meant for women who were either diagnosed with or at high risk for pre-eclampsia, so I talked to Dr. Burton Rochelson, chief of maternal-fetal medicine for Northwell Health and director of obstetrics and gynecology at North Shore University Hospital. Here’s what he said:

Q: Were you surprised by the findings of this study?
A:

Yes. Historically, obstetricians felt that pre-eclampsia was cured by delivery. It might take a little while for that to happen, even up to six weeks or so, but certainly blood pressures were not expected to be high as far out as one year after delivery. What many will find surprising about this study is that more than 40 percent of women have elevated blood pressures one year after giving birth. That’s a staggering number—resulting in many more women being diagnosed with chronic hypertension than previously believed.

Q: Did it surprise you that so many women had normal readings in the office but high readings at home?
A:

No, not as much. Blood pressure is more like a movie than a snapshot and I think when you go to the doctor’s office, you’re just taking a snapshot. The idea that we’re getting an overall sense of somebody’s well-being and vascular status by a single blood pressure at a single visit to a doctor’s office is somewhat simplistic of us.

It’s the same with white coat hypertension, which is when you have normal readings at home but high readings in the doctor’s office. The implication is that the reason your pressure is up is that you’re nervous because you’re seeing the doctor. But this implies that the only thing that’s going to make our blood pressure go up and make us nervous or anxious is going to the doctor’s office. I’m fairly certain that there are other things in our everyday lives that cause us to be nervous or anxious, making it likely that our blood pressure might at times be higher at home, as well.

Q: How were the researchers able to tell that some women had normal pressures in the office but high pressures at home? Did the women use home blood pressure monitors?
A:

Yes, sort of. The women in the study wore ambulatory blood pressure monitors. This is a very different device than the home blood pressure monitor that you can buy in a drug store. Ambulatory blood pressure monitoring involves wearing a blood pressure cuff on your arm for 24 hours straight, during which time the monitor periodically takes your blood pressure.

Q: Do you think all women with pre-eclampsia should periodically use an ambulatory blood pressure monitor at home in the year after giving birth?
A:

It may be that more studies will prove the value of ambulatory blood pressure monitoring, but based on this one study, I don’t think you can say that every patient needs to use this device. In addition, many insurance companies don’t cover it. But I do think there’s value in purchasing a home blood pressure monitor so you can take your pressure routinely at home rather than just once a year at the doctor’s office.

Q: How do you treat pre-eclampsia-related high blood pressure when it doesn’t go away soon after delivery?
A:

Once you get past six to eight weeks after delivery, it’s not considered pre-eclampsia anymore. At that point, if a woman’s blood pressure is still high, then I would treat her like any woman in that age group and give her the same medications and dietary and lifestyle modifications that I’d give anybody else. If a woman needs to take medication for high blood pressure, the great majority of them are safe to use while breastfeeding, but this should be discussed with your provider.

Q: Any other reasons why this new research is important?
A:

This is a valuable study because it emphasizes the segue between obstetrical care and routine health and wellness. Because usually, women don’t visit their obstetrician regularly after delivery, so they may not have their blood pressures taken routinely. And when a woman goes to see her family doctor or internist, that doctor may not relate anything to the pre-eclampsia.

What this study does is raise a flag for all of us—obstetricians and primary care doctors—to take a careful look at women with a history of pre-eclampsia, and maybe see them more frequently in that first year after giving birth; for instance at three months postpartum and then again at six months. It also underscores the importance of communication between obstetricians and other doctors that are going to be taking care of the patient going forward, after delivery.

Next Steps and Useful Resources

Published April 10th, 2018

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