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Unexpected hypertension in the early and late puerperium
UNEXPECTED
HYPERTENSION IN THE PUERPERIUM
D. FRANKKALTREIDER,
M.D., AND C.RICHARD BALTIMORE,
(From
the
Department
of
EARLY
Obstetrics,
Uniuersity
AND
LATE
A. GILBERT, M.D.,
MD. of
Maryland
School
of
Medicine)
N 1934 Stout1 reported on 102 patients in whom unexpected hypertension was I recorded at the six weeks post partum examination. All of these patients during that particular pregnancy and labor showed normal blood pressure readings. Meyer2 in 1938 and Meyer and Nadler3 in 1941 reported, respectively, 23 and 51 cases df the same phenomenon. This report will deal with similar material with the addition of another group of patients, in whom the blood pressure elevations began after 48 hours post partum and before the six weeks examination. The illness which this group experienced has been designated ‘ ‘ early unexpected puerperal hypertension. ” Its earliest appearance is at 48 hours post partum, so that there can be no chance of its being called preeclampsia. A concise definition may be somewhat as follows: Unexpected puerperal hypertension is an elevation of blood pressure in the parturient woman in whom previous pregnancies, if any, prenatal course, labor, and the first 48 hours post partum have not been accompanied by any readings of hypertensive character (130/90 and above). Any patient with a prior diastolic blood pressure of 90 or more was excluded. Material During the years 1940 to 1949, there were recorded on the “home delivery service ’ ’ of the University of Maryland Hospital 5,612 Negro and 353 white registered patients. In this group there were 1 white and 164 Negro patients whose cases satisfied the definition given above. An accurate incidence cannot be given because many of the deliveries were repeat deliveries on the same patient, and several had two or more deliveries during this period of time on our “home service. ” We suspect that the true incidence will be close to Meyer’s, 4.6 per cent. It certainly is not as high as Stout’s incidence of 1’7.2 per cent. This wide range of incidence may be explained by the fact that any patient in our series, who, in any pregnancy of which we have a record, had a single elevation of blood pressure to 130/90, was excluded, as well as those whose blood pressure rose to abnormal levels immediately post partum (within 48 hours). The average age level was somewhat above the clinic average, since in 88 per cent of deliveries the patients were over 20 years of age. One would expect a somewhat higher age level in an individual with hypertension (Fig. 1). For the reason that few primigravidas are delivered on the “home service, ” only ten of these are in this group. From 1945 on, no primigravidas were accepted for home deliveries, and that lowers the incidence. The most frequent parity was one, and the number fell rather abruptly after parity four, as one would expect (Fig. 2). 161
-AGE
Pip.
o
1
2
3
4
1
5
6
7
8
9
10 OR
In Stout’s and Meyer’s series, there was no record of unexpected hypertension occurring before the six weeks examination or earlier in the puerperium. Of our 165 patients, 94 had elevations of blood pressure before the six weeks examination (Group “A”) and 71 had their first recorded elevations at that time (Group “I%“). Fifty percent, of the group with early unexpeeted hypertension (Group A) began their hyperpietic rise between the third and fifth postpartum days. In those who began having hypertension later, the number of primary elevations gradually decreased so that only 5 pep cent of Gronp A had the initial rise between two and six weeks (Fig. 3). The blood pressure elevations following pregnancy lasted varying periods of time during the puerperium : in 2 patients only 2 days ; in 29, 3 to 7 days; in 16, 8 to 14 days; and in 44, 2 to 6 weeks. Thirty per eent of those in whom a six weeks recording was made had normal blood pressures, while 70 per cent were still hypertensive (Table I).
Volume 61 Number
UNEXPECTED
HYPERTENSION
IN
THE
PUERPERIUM
163
I
TABLE
I.
D~~RATION 2 3- 7 8-14 2- 6
OF ELEVATED
BLOOD PRESSURE
MAINTENANCE
IN GROUP A 2 29 16 44 91
days days days weeks Total
In approximately 75 per cent of both groups the highest blood pressure rise at any time during the puerperium was of a less severe degree (130/90159/99), and the remaining 25 per cent had elevations to 160/100 or more (Fig. 4). Follow-Up The follow-up results were most interesting, but quite contrary to those of Stout and Meyer. Stout reported 91 per cent of his patients as having only transient hypertension, and becoming normal by the end of one year, while 9 per cent had hypertension at the end of a year. Meyer and Nadler report that the phenomenon is self-limited and lasts from six to seventeen weeks. Our results show a high incidence of hypertension in follow-ups of one to ten These diverse results may be associated with the marked difference in years. the length of time of follow-up, but the incidence of hypertension in our series Our results can in which the follow-up was only one year was still excessive. be seen in Table II. Sixty-five per cent of the patients who were followed :I to 10 years, had hypertension. Of those, two-thirds had mild hypertension (130/90-159/99), and the other one-third had the more severe grade (160/100 and over). Contact was lost wit.h 37 patients, 2 of whom had died, one of carcinoma and the other from renal failure following an operation for nephrolithiasis. TABLE
II.
FOLLOW-UP
RESULTS
_--
__--~
None Died Normal blood pressure 130/90-159/99 160/100 and over Total Of 128 patients followed,
83 or 65 per
cent
35 2 45 57 26 165 had hypertension.
Table III shows the varying length of follow-up. Most were from eight years, 16 were less than two years, and 10 were over eight years. TABLE zlzzXzZ=
.-
None O-1 year 2-4 years 5-8 years Over 5 years Total
III.
LENGTH
two to
OF FOLLOW-UP 37 16 65 37 10 165
Some correlation can be seen between the permanence of the hypertension ancl the height of the blood pressure in the early and late puerperium (Table IV). In Group A with the lower hypertension, about 50 per cent still ha.ve hypertension ; in Group B with the lower hypertension, about 70 per cent still maintain elevated blood pressures; in Group A with the more severe elevations, puerperally, only 1 of 22 had normal blood pressure readings; and in Group B with the more severe hypertension, 60 per cent still have hypertension. This
has the greater chance of keeping her hypertension, but the number of patients is too small to make any definite conclusions. The higher blood pressure group in the puerperium also had a tendency to have a greater incidence of permanent hypertension and also higher permanent blood pressure. TABLE
Group Group
Group Group
A B A B
IV.
Fomow-Ur
Br,oou
PRFXWRE ACCORDING POST PART~W
NORMAI, 24 15 1 5
130-159 130-159 160 and over 160 and over
TO HEIGIIT
130-159 20 20 11 -.G
OF BLOOD
160 & OVER 6 7 10 3
PRESSURE No RECORD 19 13 3 2
Those patients in Group A who still had hypertension at the six weeks examination were also analyzed (Table V). Their follow-up blood pressure recordings showed nothing unusual, except a tendency to have a somewhat higher rate of permanent hypertension. TABLE
V.
GROUP
A.
FOLLOW-UP
ACCORDIS~:
/
6 WEEKS Bl.OOD PRESSURE
T O SIX
T~EEKS -
-
BLOOD
I
130-159 7 13 ____~ ___2
NORMAL
Normal 130-159 160 or more
9 7 1
PRESSURE
I 160
AND
OVER
NO-- RECORD __-
2 4 4
-
" 9 3
Group A was also analyzed from the point of view of the length of elevation Two patients had elevations of only two days, and one of them (Table VI). has hypertension now. In the group whose elevation lasted 3 to 7 days, about 50 per cent are now normal. In those in whom it lasted 1 to 2 weeks, only 1 of 13 has a normal blood pressure and in the longer-lasting group, 10 of 31 have normal blood pressures. The length of elevation, originally, does not seem necessarily to be a factor in the long-range view of hypertension. TABLE
VI.
LENGTH OF EI.EVATIOI\
FOLLOW-UI, FORMhI,
XCCORDIKG TO LEZTGTFI - .___I
1x-159
OF ELEVATION.
GROUP
,4 -
lfitj
AND
OVER
NO RECORD
Does the length of follow-up influence the results concerning permanent hypertension? These results can be seen in Table VII. There seems to bc a Obviously, these consistently higher rate as length of follow-up increases. patients are also older and hypertensive rates increase with age. TABLE
VII.
HYPERTENSION
BASED
ON LEXGTFI
OF FOLLOW-CP --
NORMAL
1 2, 5, 8
year 3, and 4 years G, and 7 years years and over
8 26 8 3
130-159 5 25 19 7
160
,&I)
3 12 G 3
OV&R
SO‘70 f-W% 7G70 7770
Volume
6I
MumberI
UNEXPECTEDHYPERTENSIONIN THE PUERPERIUM
165
Seventy-five of these 165 patients were followed through one or more pregnancies subsequent to the onset of this phenomenon. Only four patients in both groups had evidence of hypertensive disease during their subsequent pregnancies. However, 24 of 30 in Group A and 33 of 42 in Group B again had hypertension during the puerperium of subsequent pregnancies. The 4 patients who did show hypertension during pregnancy had the elevation late This observation and on two occasions it was associated with albuminuria. emphasizes the difficulty of recognizing hypertensive disease during pregnancy. If the past history of these patients were not known, 71 of 75 would be classified as normal patients during pregnancy and the remaining 4, who did show hypertension, might very well have been classified as pre-eclamptic. Blood pressure drops normally during normal pregnancy and this also holds true for the chronic hypertensive individual.
Fig.
3.-Time
of
onset
of
uoh@
elevated
- 159/99
A Fig.
4.-Height
of
blood Group
pressure post R, Hypertension
blood
B par’um. at
six
pressure
16O/lao
AND
A
B
Grow A, Immediate \veeks examination
post
partuln.
OVER
postpartum only.
hypertension.
Comment Unexpected puerperal hypertension can occur both earlv and late in the puerperium, and it is not uncommon. It is essentially limited to the Negro race; however, it can occur in the white race. Previous reports on this subject indicated that it is largely a transitory phenomenon and needs no consistent follow-up. We found, however, that there was permanent hypertension in 65 per cent of the cases. This study also emphasizes the importance of past history in the final analysis of all hypertensive states during pregnancy to arrive at the correct diagnosis of the toxemia that the individual is experiencing. Because many of these hypertensive rises occur fairly earlv in the puerperium, we should not refrain from recording blood pressures”in post-
KALTREIDER
166
AND
GILBERT
Am. J. Obst. & Gynec. Januar,-, 19; I
partum patients after 48 hours ; but the blood pressure should be taken repeatedly as long as possible in order that these rises may be noted and the patient followed for a much longer period of time.
Conclusions 1. Unexpected puerperal hypertension should be considered because of its remote hypertensive effects. 2. The study of these patients emphasizes the difficulty of making the diagnosis of hypertensive disease during pregnancy. 3. In the postpartum period, the recording of blood pressure should be more frequent and over a longer period of time, so that remote permanent hypertension can be suspected and adequate medical therapy instituted immediately, rather than too late. The follow-up.
authors
express
their
appreciation
to
Miss
Ellen
Lloyd
for
some
of
References 1. Stout, 2. Meyer, 3. Meyer,
Merrell Harry: Harry,
L.: AM.
and
J. OBST. & GYNEC. 27: 730, 103-L J. OBST. & GYNEC. 35: 150, 1938. Nadler, Samuel B.: AM. J. OBST. b GYNEC.
AM.
41:
231,
1’341.
the
detail
HYPERTENSION IN THE PUERPERIUM
D. FRANKKALTREIDER,
M.D., AND C.RICHARD BALTIMORE,
(From
the
Department
of
EARLY
Obstetrics,
Uniuersity
AND
LATE
A. GILBERT, M.D.,
MD. of
Maryland
School
of
Medicine)
N 1934 Stout1 reported on 102 patients in whom unexpected hypertension was I recorded at the six weeks post partum examination. All of these patients during that particular pregnancy and labor showed normal blood pressure readings. Meyer2 in 1938 and Meyer and Nadler3 in 1941 reported, respectively, 23 and 51 cases df the same phenomenon. This report will deal with similar material with the addition of another group of patients, in whom the blood pressure elevations began after 48 hours post partum and before the six weeks examination. The illness which this group experienced has been designated ‘ ‘ early unexpected puerperal hypertension. ” Its earliest appearance is at 48 hours post partum, so that there can be no chance of its being called preeclampsia. A concise definition may be somewhat as follows: Unexpected puerperal hypertension is an elevation of blood pressure in the parturient woman in whom previous pregnancies, if any, prenatal course, labor, and the first 48 hours post partum have not been accompanied by any readings of hypertensive character (130/90 and above). Any patient with a prior diastolic blood pressure of 90 or more was excluded. Material During the years 1940 to 1949, there were recorded on the “home delivery service ’ ’ of the University of Maryland Hospital 5,612 Negro and 353 white registered patients. In this group there were 1 white and 164 Negro patients whose cases satisfied the definition given above. An accurate incidence cannot be given because many of the deliveries were repeat deliveries on the same patient, and several had two or more deliveries during this period of time on our “home service. ” We suspect that the true incidence will be close to Meyer’s, 4.6 per cent. It certainly is not as high as Stout’s incidence of 1’7.2 per cent. This wide range of incidence may be explained by the fact that any patient in our series, who, in any pregnancy of which we have a record, had a single elevation of blood pressure to 130/90, was excluded, as well as those whose blood pressure rose to abnormal levels immediately post partum (within 48 hours). The average age level was somewhat above the clinic average, since in 88 per cent of deliveries the patients were over 20 years of age. One would expect a somewhat higher age level in an individual with hypertension (Fig. 1). For the reason that few primigravidas are delivered on the “home service, ” only ten of these are in this group. From 1945 on, no primigravidas were accepted for home deliveries, and that lowers the incidence. The most frequent parity was one, and the number fell rather abruptly after parity four, as one would expect (Fig. 2). 161
-AGE
Pip.
o
1
2
3
4
1
5
6
7
8
9
10 OR
In Stout’s and Meyer’s series, there was no record of unexpected hypertension occurring before the six weeks examination or earlier in the puerperium. Of our 165 patients, 94 had elevations of blood pressure before the six weeks examination (Group “A”) and 71 had their first recorded elevations at that time (Group “I%“). Fifty percent, of the group with early unexpeeted hypertension (Group A) began their hyperpietic rise between the third and fifth postpartum days. In those who began having hypertension later, the number of primary elevations gradually decreased so that only 5 pep cent of Gronp A had the initial rise between two and six weeks (Fig. 3). The blood pressure elevations following pregnancy lasted varying periods of time during the puerperium : in 2 patients only 2 days ; in 29, 3 to 7 days; in 16, 8 to 14 days; and in 44, 2 to 6 weeks. Thirty per eent of those in whom a six weeks recording was made had normal blood pressures, while 70 per cent were still hypertensive (Table I).
Volume 61 Number
UNEXPECTED
HYPERTENSION
IN
THE
PUERPERIUM
163
I
TABLE
I.
D~~RATION 2 3- 7 8-14 2- 6
OF ELEVATED
BLOOD PRESSURE
MAINTENANCE
IN GROUP A 2 29 16 44 91
days days days weeks Total
In approximately 75 per cent of both groups the highest blood pressure rise at any time during the puerperium was of a less severe degree (130/90159/99), and the remaining 25 per cent had elevations to 160/100 or more (Fig. 4). Follow-Up The follow-up results were most interesting, but quite contrary to those of Stout and Meyer. Stout reported 91 per cent of his patients as having only transient hypertension, and becoming normal by the end of one year, while 9 per cent had hypertension at the end of a year. Meyer and Nadler report that the phenomenon is self-limited and lasts from six to seventeen weeks. Our results show a high incidence of hypertension in follow-ups of one to ten These diverse results may be associated with the marked difference in years. the length of time of follow-up, but the incidence of hypertension in our series Our results can in which the follow-up was only one year was still excessive. be seen in Table II. Sixty-five per cent of the patients who were followed :I to 10 years, had hypertension. Of those, two-thirds had mild hypertension (130/90-159/99), and the other one-third had the more severe grade (160/100 and over). Contact was lost wit.h 37 patients, 2 of whom had died, one of carcinoma and the other from renal failure following an operation for nephrolithiasis. TABLE
II.
FOLLOW-UP
RESULTS
_--
__--~
None Died Normal blood pressure 130/90-159/99 160/100 and over Total Of 128 patients followed,
83 or 65 per
cent
35 2 45 57 26 165 had hypertension.
Table III shows the varying length of follow-up. Most were from eight years, 16 were less than two years, and 10 were over eight years. TABLE zlzzXzZ=
.-
None O-1 year 2-4 years 5-8 years Over 5 years Total
III.
LENGTH
two to
OF FOLLOW-UP 37 16 65 37 10 165
Some correlation can be seen between the permanence of the hypertension ancl the height of the blood pressure in the early and late puerperium (Table IV). In Group A with the lower hypertension, about 50 per cent still ha.ve hypertension ; in Group B with the lower hypertension, about 70 per cent still maintain elevated blood pressures; in Group A with the more severe elevations, puerperally, only 1 of 22 had normal blood pressure readings; and in Group B with the more severe hypertension, 60 per cent still have hypertension. This
has the greater chance of keeping her hypertension, but the number of patients is too small to make any definite conclusions. The higher blood pressure group in the puerperium also had a tendency to have a greater incidence of permanent hypertension and also higher permanent blood pressure. TABLE
Group Group
Group Group
A B A B
IV.
Fomow-Ur
Br,oou
PRFXWRE ACCORDING POST PART~W
NORMAI, 24 15 1 5
130-159 130-159 160 and over 160 and over
TO HEIGIIT
130-159 20 20 11 -.G
OF BLOOD
160 & OVER 6 7 10 3
PRESSURE No RECORD 19 13 3 2
Those patients in Group A who still had hypertension at the six weeks examination were also analyzed (Table V). Their follow-up blood pressure recordings showed nothing unusual, except a tendency to have a somewhat higher rate of permanent hypertension. TABLE
V.
GROUP
A.
FOLLOW-UP
ACCORDIS~:
/
6 WEEKS Bl.OOD PRESSURE
T O SIX
T~EEKS -
-
BLOOD
I
130-159 7 13 ____~ ___2
NORMAL
Normal 130-159 160 or more
9 7 1
PRESSURE
I 160
AND
OVER
NO-- RECORD __-
2 4 4
-
" 9 3
Group A was also analyzed from the point of view of the length of elevation Two patients had elevations of only two days, and one of them (Table VI). has hypertension now. In the group whose elevation lasted 3 to 7 days, about 50 per cent are now normal. In those in whom it lasted 1 to 2 weeks, only 1 of 13 has a normal blood pressure and in the longer-lasting group, 10 of 31 have normal blood pressures. The length of elevation, originally, does not seem necessarily to be a factor in the long-range view of hypertension. TABLE
VI.
LENGTH OF EI.EVATIOI\
FOLLOW-UI, FORMhI,
XCCORDIKG TO LEZTGTFI - .___I
1x-159
OF ELEVATION.
GROUP
,4 -
lfitj
AND
OVER
NO RECORD
Does the length of follow-up influence the results concerning permanent hypertension? These results can be seen in Table VII. There seems to bc a Obviously, these consistently higher rate as length of follow-up increases. patients are also older and hypertensive rates increase with age. TABLE
VII.
HYPERTENSION
BASED
ON LEXGTFI
OF FOLLOW-CP --
NORMAL
1 2, 5, 8
year 3, and 4 years G, and 7 years years and over
8 26 8 3
130-159 5 25 19 7
160
,&I)
3 12 G 3
OV&R
SO‘70 f-W% 7G70 7770
Volume
6I
MumberI
UNEXPECTEDHYPERTENSIONIN THE PUERPERIUM
165
Seventy-five of these 165 patients were followed through one or more pregnancies subsequent to the onset of this phenomenon. Only four patients in both groups had evidence of hypertensive disease during their subsequent pregnancies. However, 24 of 30 in Group A and 33 of 42 in Group B again had hypertension during the puerperium of subsequent pregnancies. The 4 patients who did show hypertension during pregnancy had the elevation late This observation and on two occasions it was associated with albuminuria. emphasizes the difficulty of recognizing hypertensive disease during pregnancy. If the past history of these patients were not known, 71 of 75 would be classified as normal patients during pregnancy and the remaining 4, who did show hypertension, might very well have been classified as pre-eclamptic. Blood pressure drops normally during normal pregnancy and this also holds true for the chronic hypertensive individual.
Fig.
3.-Time
of
onset
of
uoh@
elevated
- 159/99
A Fig.
4.-Height
of
blood Group
pressure post R, Hypertension
blood
B par’um. at
six
pressure
16O/lao
AND
A
B
Grow A, Immediate \veeks examination
post
partuln.
OVER
postpartum only.
hypertension.
Comment Unexpected puerperal hypertension can occur both earlv and late in the puerperium, and it is not uncommon. It is essentially limited to the Negro race; however, it can occur in the white race. Previous reports on this subject indicated that it is largely a transitory phenomenon and needs no consistent follow-up. We found, however, that there was permanent hypertension in 65 per cent of the cases. This study also emphasizes the importance of past history in the final analysis of all hypertensive states during pregnancy to arrive at the correct diagnosis of the toxemia that the individual is experiencing. Because many of these hypertensive rises occur fairly earlv in the puerperium, we should not refrain from recording blood pressures”in post-
KALTREIDER
166
AND
GILBERT
Am. J. Obst. & Gynec. Januar,-, 19; I
partum patients after 48 hours ; but the blood pressure should be taken repeatedly as long as possible in order that these rises may be noted and the patient followed for a much longer period of time.
Conclusions 1. Unexpected puerperal hypertension should be considered because of its remote hypertensive effects. 2. The study of these patients emphasizes the difficulty of making the diagnosis of hypertensive disease during pregnancy. 3. In the postpartum period, the recording of blood pressure should be more frequent and over a longer period of time, so that remote permanent hypertension can be suspected and adequate medical therapy instituted immediately, rather than too late. The follow-up.
authors
express
their
appreciation
to
Miss
Ellen
Lloyd
for
some
of
References 1. Stout, 2. Meyer, 3. Meyer,
Merrell Harry: Harry,
L.: AM.
and
J. OBST. & GYNEC. 27: 730, 103-L J. OBST. & GYNEC. 35: 150, 1938. Nadler, Samuel B.: AM. J. OBST. b GYNEC.
AM.
41:
231,
1’341.
the
detail