Download file (Treatment of Hypertension in the Breastfeeding Mother)

Samantha Allen
June 14, 2011
Treatment of Hypertension in the Breastfeeding Mother
Objectives:





Define criteria for diagnosis of hypertension in breastfeeding women
Identify appropriate resources for determining compatibility of a pharmacologic treatment
agent with breastfeeding
Define characteristics of pharmacologic agents likely not to concentrate in breast milk
Identify appropriate pharmacological interventions to treat hypertension in a breastfeeding
mother
List pharmacologic agents incompatible with breastfeeding
Patient Review:
HA is a 35 y/o Somalian female who presented to the clinic on May 9, 2011 for a follow-up of new onset
Stage II Hypertension. She was first noted to be hypertensive in office on April 27, 2011 with a blood
pressure reading of 162/116 mmHg. At a follow-up visit on May 2, 2011, she was again hypertensive
with a blood pressure reading of 148/102 mmHg. She was then started on a regimen of
hydrochlorothiazide 12.5 mg by mouth once daily with instructions to follow-up with in 1 week to assess
the need for an additional medication. All information was obtained through a phone translator.

Chief Complaint
Headaches and pressure in back of neck

PMH
Hypertension (Diagnosed 5/2/11), Eight Normal Vaginal Deliveries (Last 7/2010), 1 miscarriage
(Date unknown), Sciatica
*Note: This is NOT post-partum hypertension

Allergies
NKDA

Family History
Negative for diabetes, hypertension, or early death
Father still living

Social History
Negative for tobacco or alcohol use
Currently Sexually Active

Current Medications
Hydrochlorothiazide 12.5 mg PO daily
Acetaminophen 500 mg PO q6hr PRN
Ferrous Sulfate 325 mg PO daily
Docusate 100 mg PO daily
Medroxyprogesterone 150 mg IM q84 days

Review of Systems
Positive: Headaches
Negative: Vision changes, chest pain, SOB, heart palpitations, changes or problems with urinary
output.

Physical Exam Findings
Vitals 5/9/11:
BP:
Temp:
TempSrc:
Resp:
Weight:
150/110
96.2 °F (35.7 °C)
Oral
18
140 lb 9.6 oz (63.776 kg)
Historical BP Readings:
05/02/11- 148/102 mmHg (LAS RC)
04/27/11- 162/116 mmHg and 150/110 mmHg (LAS RC)
02/02/11- 110/70 mmHg (RAS RC)
11/09/10- 120/80 mmHg (RAS RC)
08/26/10- 140/100 mmHg (Post-Partum)
07/17/10- 122/82 mmHg
06/24/10- 126/93 mmHg (Pregnant)

Tests Performed
EKG: 5/2/11 – Evidence LVH
Discussion of Hypertension in Breastfeeding Mothers:

Background
Chronic hypertension complicates approximately 3% of pregnancies and is the most common
reason patients require long-term pharmacologic treatment for hypertension while
breastfeeding. Some women may require treatment for postpartum hypertension, which occurs
in the first few days following delivery, but this treatment usually is required for only a few days
to weeks until a patient’s blood pressure normalizes and can then be discontinued.

Pathophysiology
Postpartum hypertension generally occurs within the first 5 days postpartum and will usually
normalize within several days to weeks. This is likely attributed to a period of time postpartum
of physiological volume expansion and fluid mobilization.
The cause of chronic hypertension in breastfeeding mothers is most commonly primary
hypertension, also known as essential hypertension. The cause of essential hypertension is
largely unknown and may be multifactorial, with genetics playing an important role. Some
proposed factors behind primary hypertension include alterations in sodium balance, nitric
oxide release, and excretion of aldosterone, angiotension, or certain adrenal steroids. Several
mechanisms that are utilized to treat essential hypertension may also be responsible for the
development of essential hypertension, including the effects of the renin-angiotensinaldosterone system (RAAS), vasodepressor mechanisms, neuronal mechanisms, peripheral
autoregulation, and alterations in sodium, calcium, and natriuretic hormones.

Patient Presentation/Diagnosis
Postpartum hypertension should be treated with antihypertensive agents if blood pressure
exceeds 150 mmHg systolic or 100 mmHg diastolic.
Chronic hypertension should be treated in accordance with the JNC7 guidelines, substituting
medications compatible with breastfeeding when appropriate. The BP classification is as
follows:
-Normal: SBP≤120 mmHg and DBP≤80 mmHg
-Prehypertension: SBP 120-139 mmHg or DBP 80-89 mmHg
-Stage I HTN: SBP 140-159 mmHg or DBP 90-99 mmHg
-Stage II HTN: SBP 160-179 mmHg or DBP 100-110 mmHg
-Stage III HTN: SBP 180-209 mmHg or DBP 110-119 mmHg

Goals of Therapy
BP <140/90 mmHg (Diabetic patients or CKD patients <130/80 mmHg)
Goals of therapy remain the same for breastfeeding mothers as the general population, which
are to normalize blood pressure and to reduce the morbidity and mortality related to targetorgan damage, including CV events, heart failure, and kidney disease that result from sustained
elevations in blood pressure.

Therapeutic Options
There are several resources available to determine if medications are compatible with
breastfeeding. Below are a few commonly used resources and several articles that may be
helpful in determining which medication is appropriate for the breastfeeding mother. In
addition, databases such as Lexi-Comp and Micromedex often provide information on the safety
of medications in both pregnancy and breastfeeding based on the recommendations of
organizations such as the World Health Organization (WHO) and the American Academy of
Pediatrics (AAP).
Resources:
-Gerald G. Briggs. Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk. 9th ed.
Philadelphia: Williams & Wilkins, 2011.
-Breastfeeding and Maternal Medication: Recommendations for Drugs in the Eleventh WHO Model List of
Essential Drugs. (http://whqlibdoc.who.int/hq/2002/55732.pdf)
-Dr. Hale’s Breastfeeding Pharmacology Page. (http://www.infantrisk.com/)
- Podymow T, August P. Update on the use of antihypertensive drugs in pregnancy. Hypertension.
2008:51;960-969.
- Spencer JP, Gonzalez LS, Barnhart DJ. Medications in the breast-feeding mother. Am Fam Physician.
2001:64(1);119-26.
- American Academy of Pediatrics Committee on Drugs. Transfer of drugs and other chemicals into human
milk. Pediatrics. 2001;108:776-789.
Medication Selection and Dosing Guidelines:
There are several considerations when choosing a medication for a breastfeeding mother. If
possible, drug therapy should be avoided or topical agents that are not systemically absorbed
utilized. Medications that are safe for the nursing infant’s age are usually safe for the
breastfeeding mother. However, not all medications that are safe in pregnancy are compatible
with breastfeeding. Here are some tips in selecting a medication:
Ideal Medication Properties
Short half-life
Highly protein bound
Poor oral absorption
Small Volume of Distribution
Low lipid solubility
Lack of charge at physiological pH
Well studied
Administering once daily medications after the bed-time feeding where the infant will be
sleeping the longest will help to minimize exposure. Dosing medications immediately after
breastfeeding will also help to minimize exposure to multiple daily doses.
First Line Antihypertensives
Labetolol
Propranolol
Hydrochlorothiazide
Methyldopa
Alternative Agents
Nifedipine XL
Verapamil SR
Hydralazine
Captopril/Enalapril
Overview Common Antihypertensives: (*=Preferred in class)
Medications Compatible with Breastfeeding
Beta Blockers
*Labetolol, Propranolol, Metoprolol,
Timolol, Oxprenolol
Medications to Avoid in Breastfeeding
Beta Blockers
Atenolol, Sotolol, Acebutolol
Accumulation in milk can occur
Thiazide Diuretics
*Hydrochlorothiazide, Chlorthalidone
Loop Diuretics
Furosemide, Bumetanide
Can suppress lactation
Not well studied
ACE Inhibitors
Captopril, Enalapril
ACE Inhibitors
Lisinopril
Not studied
Non-dihydropyridine CCB
*Verapamil SR, Diltiazem CD
Dihydropyridine CCB
Nifedipine XL
Dihydropyridine CCB
Amlodipine
Not well studied
Direct Vasodilators
Hydralazine, Minoxidil
Angiotensin II Receptor Blockers
Valsartan, Losartan
Not studied
Sympatholitic
Methyldopa
Alpha-1 Blockers
Doxazosin, Prazosin, Terazosin
Found to concentrate in animal milk
Aldosterone Receptor Blockers
Spironolactone
May suppress lactation

Monitoring of Therapy
Home monitoring of blood pressure may be useful in postpartum hypertension due to the short
duration of treatment and recommendation to discontinue therapy once blood pressure has
normalized.
Chronic hypertension should be monitored similarly to any other patient with essential
hypertension according to JNC-7 recommendations. Patients with Stage I HTN should follow-up
with their physician monthly until their blood pressure is controlled, then every 3-6 months.
Serum potassium and creatinine should also be measured 1-2 times per year. Patients with
complicating comorbid conditions or Stage II HTN may require more frequent follow-up.
Summary:
Initial Assessment & Plan 5/2/11:
1. Stage II HTN
BP elevated above goal of <140/90 mmHg. No signs end organ damage. Patient is currently in Stage
II HTN with evidence of LVH which warrants dual therapy, normally with an ACEI and a diuretic.
Regimen of a thiazide diuretic with consideration to add a beta blocker was chosen due to
breastfeeding.
*Initiate hydrochlorothiazide 12.5 mg QAM after morning feeding
*Monitor fluid intake and milk production
*Monitor infant for s/s hypotension (↑ HR, cold limbs, ↑ RR, Pale skin, lack urination)
*Return in 1 week for F/U and potential initiation of metoprolol 12.5 mg BID
2. Wellness
Patient reports use of acetaminophen for treatment of headaches. Patient tolerating other
medications w/o s/s ADR.
*Continue acetaminophen 500 mg q6hr PRN
*Continue medroxyprogesterone 150 mg IM q84 days
Follow-Up Assessment & Plan 5/9/11:
1. HTN
BP elevated above goal of <140/90 mmHg. No signs end organ damage. Patient did not take therapy
as prescribed before office visit. Reports decrease in milk production with use of
hydrochlorothiazide and need to supplement with formula. Change in therapy is warranted. MD
comfortable with use of nifedipine XL because she has used it in previous patients who were
breastfeeding.
*Discontinue hydrochlorothiazide 12.5 mg daily
*Initiate nifedipine XL 30 mg PO daily
*Monitor s/s ADR (Headache, dizziness, palpitations)
*Monitor infant for s/s hypotension (↑ HR, cold limbs, ↑ RR, Pale skin, lack urination)
*Return in 2 weeks for F/U
Patient was seen again at a future visit with uncontrolled hypertension and complaints of unacceptable
side effects of the nifedipine.
Follow-up Assessment & Plan 5/23/11:
1. HTN
BP elevated above goal of <140/90 mmHg at 164/115 mmHg (RAS RC). No signs end organ damage.
Patient stated she took nifedipine before office visit but is experiencing unacceptable side effects of
daily headaches and heart palpitations. Change in therapy is warranted.
*Discontinue nifedipine XL 30 mg PO daily
*Initiate labetolol 100 mg PO BID
*Monitor s/s ADR (Nausea, Dizziness, Fatigue, tingling sensation)
*Monitor infant for s/s hypotension (↑ HR, cold limbs, ↑ RR, Pale skin, lack urination)
*Return in 1 weeks for F/U
Patient was seen again on 6/1/11 with controlled HTN at a BP of 130/80 mmHg and w/o complaints of s/s
ADR to therapy. She was continued on labetolol 100 mg BID and was to follow-up in 2 weeks.
References:

Podymow T, August P. Update on the use of antihypertensive drugs in pregnancy. Hypertension.
2008:51;960-969.

Spencer JP, Gonzalez LS, Barnhart DJ. Medications in the breast-feeding mother. Am Fam Physician.
2001:64(1);119-26.

American Academy of Pediatrics Committee on Drugs. Transfer of drugs and other chemicals into human
milk. Pediatrics. 2001;108:776-789.

Gerald G. Briggs. Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk. 9th ed.
Philadelphia: Williams & Wilkins, 2011.

Saseen JJ, Maclaughlin EJ. Hypertension. In: Dipiro JT, Talbert RL, Yee GC et al.,eds. Pharmacothearpy A
Pathophysiologic Approach. 7th ed. New York: McGraw-Hill; 2008: 139-169.