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So good, so good, so good.
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We get so used to our devices and our technology that sometimes we just got to go old school and find a result. I get it. We use automated blood pressure cuffs. You put a thing on the arm, you press a button and it gives you a blood pressure, man, and it's fine. But there's something about a manual blood pressure that is just way more accurate. And I get it. Those sounds, those Korakoff sounds, man, they're hard to hear sometimes. That little. Was that the last one? Is that the diastolic? I get that those sounds are not easy to appreciate, but we gotta get it right, especially when we're talking about a high stakes game like postpartum blood pressure control in patients with hypertensive disorders in pregnancy or any kind of, you know, issue, especially preeclampsia with severe features. And even if they didn't have a antepartum or intrapartum diagnosis, they can definitely get it postpartum. So it's very important that we figure out what these blood pressures are. And I'm all for automation, that's fine. But if there's a concern, there's something about knowing how to hear those Kor cough sounds. You gotta know how to do it. It's basic nursing. It's Medical School 101. Taking a blood pressure. Now, this episode idea comes from a podcast family member who. And I love this. Guys, look, I'm not your referee, all right? I'm gonna give you my opinion. But you all do what you all want to do. And I love this because somehow, like, hey, ask the podcast guy. Let's see what he says. I'm gonna give you an evidence Based answer. I'd love to play the game. You. You do you. I'm just telling you what the data suggests. Okay. And what I do. Now, we do have recent data on this to back me up. Like May of 2026. Yeah, this just came out, guys. But it's not in our world as OB gyn. This actually came out of the American College of Cardiology. Their expert consensus. They actually have a decision tree on the best gold blood pressure to send and our patients home. Thank you very much. And so this is built on the foundation of a previous publication from the American College of Cardiology called mop. That is the management of postpartum preeclampsia. That is a study, the MOP trial. The MOP study. Now we're going to get into this. Here's a simple question. Hey, Dr. Chapa, look, I like to send my patients home. I don't want to bottom them out too much because I know that their blood pressure is going to normalize. So I like to send them home, you know, 140s, 150s over 90s. But I have an attending who says, no, they're no longer pregnant. We should follow the non pregnant rules and kind of stick to under 140 over 90 with a goal of like 130 over 80s. Is that overcorrection? So the simple question that I responded back is, oh, super simple. You're asking what should we discharge our hypertensive disorders in pregnancy patients, preeclampsia or not, what should their discharge blood pressure be as a goal? And she responded back, yeah, it's exactly it. Is it 140s over 90s? Is it under 130s over 80s? And the short answer that I responded is, depends. Depends on who you ask. But we do have recent guidance as of May of 2026 that gives us the answer. Now this has changed a lot, guys, I'm going to give you the history here. But back in 2013, from the college, all right, from ACOG, the. They're like, ash, she's not pregnant anymore. We don't want to over, you know, overcorrect her. She'll be fine. You know, you can kind of use a higher threshold. She'll be okay. I'll give you that. From the task force on hypertension back in 2013. Yes, about 13 years ago. But it lets you know how things change because we went from that goal of 2013 to where we are now as of May of 2026. So in this episode, we're going to cover MOP and blood pressure control post postpartum. It's a great question. I think I've set it up enough. We will be right back. We're just trying to fulfill our life calling and our mission. This is Dr. Chapa's OBGYN no Spin podcast podcast family. I'm inviting you to elevate your coffee routine with the strong coffee company that is striving to reach our natural greatness. I use it, it's coffee 2.0. It has protein MCTS for energy and mental clarity and adaptogens. This is one of my favorite coffees. It comes in reg black and latte mixes. And now you get 20% off when you go through the link in our show notes. That's right. Just for being a podcast family member, go to strongcoffeecompany.com discount choppa no spinobg for your 20% discount. The link is in our show notes. Not long ago I did ask a medical student, I guess it was about a year ago, one of our third year medical students said, go over there and do a manual blood pressure. And the look of fear in the student's eyes was like a manual blood pressure. I'm like, yeah, go put the cuff on. Make sure it's an appropriate cuff for the size of the arm. Make sure she's appropriately positioned. Go check the Kortikoff sounds. And you would have thought I said, hey, go in there and draw, you know, drill a burr hole in her head. I mean, the look of fear. I'm like, what's going on, man? Like we just use the automated machines. O M G, you gotta know these sounds and how to take a blood pressure. Yep. Corticoff has been around. It is the standard. Manual blood pressures are the way to go. You gotta know how to do that. And I find it interesting that for all of the things that OB GYN and SMFM and you know, the Green Journal and ajog, all these publications that come out, then you've got the American College of Cardiology in May of 2026. They're like, hey, yeah, thank you guys. We deal with the heart. Why don't we come up with our own expert consensus here on how you guys should fix your postpartum patients. Thank you. I appreciate it. You know what? Hey, medicine doesn't, you know, belong to any one team. I understand that. I mean, I got plenty, plenty of reasons why I believe medicine needs to, you know, jump different boxes because we get different perspectives on things such as family medicine, has input on ob, ob gyn, of course, has commentary on endocrine and neonatology and vice versa, obviously with cardiology. That's why there's cardio obstetrics. So yes, we should share patients, we should share data. That's okay. There's more to go around. But this came out May 22, 2026. As point of reference. We're doing this in the middle of June of 2026. So, yeah, less than a month ago. The title of this is Optimization of Postpartum Care for Patients with and at Risk for Premature and Long Term Cardiovascular Disease. Let me stop there. That's a lot. And there's more, by the way. That's not the end of the title. Let me just read that again. Optimization of Postpartum Care. That's us. For patients with and at risk for premature and long term cardiovascular disease. So that implies anybody with hypertensive disorder in pregnancy. Because remember, pregnancy is a stress test that puts those patients at long term risk of future hypertension and cardiovascular issues. The rest of the title is. Hold on, let me catch my breath. 2026American College of Cardiology Expert Consensus Decision Pathway. A report of the American College of Cardiology Solution Set Oversight Committee. My goodness. Should I read it all together? It's way too long. Let me just read it all together just to be clear, because we're going to knock out this episode very quickly. Here it is. May 22, 2026. Optimization of postpartum Care for Patients with and at Risk for Premature and Long term cardiovascular disease. 2026 ACC expert consensus decision Pathway. A Report of the American College of Cardiology Solution Set Oversight Committee. My goodness. Okay. But we have come a long way and I'm glad that medicine moves fast. And if you're thinking, well in 2013 to now, it's 13 years. Is that fast? Yeah, yeah, kind of. For medicine because we made progress steps along the way. Okay, so let me just start with some basic stuff as a reminder. Remember that once you send a patient home that they're not necessarily in the clear because their blood pressure is going to peak as that fluid mobilizes. And the all the third space fluid that's going to re. Enter the pipes is going to go into a set number of pipes. So more water in the pipe, more pressure. That happens around day three, day to seven, or four to seven. Depends on who you read. Whatever the point is, happens after discharge. That's when their blood pressure starts to increase. That's why, as we've covered on this show in the past, we're not gonna get into it now. I'm a big fan for our preeclampsia patients to give these patients Lasix, oral Lasix for five days, 40 milligrams. That's a thing. We've covered this. That prevents blood pressure spike within the immediate short term interval and prevents bounce back for hypertension crisis. We've covered this because it helps mobilize, it helps decrease preload. All right, so you've got to get blood pressure tuned up because it may look quote unquote borderline when they discharge. But within a week postpartum that fluid is going to mobilize and may push him now into an hypertensive issue. All right, now look to how much we've learned here. Back in ACOG's Task Force on Hypertension and Pregnancy from 2013 it states look, blood pressure as long as they are non severe with a goal of around 150 or over 100, you know, they can go home as long as they're on a blood pressure medication. So you could consider blood pressure medication for those with a blood pressure of 150 over 100. So that was the bench. Okay, now remember we're talking about 13 years ago. That was ACOG task force on Hypertension in pregnancy. Consider anti hypertensive medications at 150100 meaning 140s over 50s, you're good 90s to 100, you're all right. Just kind of monitor it. That was before. We are not there anymore. Okay. And the reason is is that we have seen based on published data after published data that blood pressure really should be at the 140 over 90 cap postpartum to prevent readmission. One of the single most independent risk factors for bounce back for high blood pressure is a blood pressure of just 140 over 90. Gu Two of them, two within 24 hours before discharge is strongly associated with the need for readmission for worsening hypertension within the first two weeks. Just 140 over 90. So this is where we get into the goals here. Can I'm going to give you again it's not my opinion, I'm going to tell you where this data comes from and where these cutoffs arise even as of May of 2026. But there's two big studies I want to cover here. One is the MOP publication. MOP stands for Management of Postpartum Hypertension. That was MOP and that was a big, big study that looked at what is the best blood pressure to send patients home with at time of discharge. And then when you get into this 2026 from the Journal of American College of Cardiology. That set the threshold as it should be because once they deliver, they are no longer pregnant. So they're like, hey, you should kind of treat them in the American Heart association classification for hypertension. They're not pregnant anymore. None of these medications are going to be negative for breastfeeding. So be aggressive and prevent that. Bounce back. Okay, so the MOP publication was just last year in the Journal of the American College of Cardiology. Mop, that stands for Management of postpartum preeclampsia. Management of postpartum preeclampsia. That study found that tight control less than 130 over 80. So they used their top bench guys, 130 over 80. That was the biggest chance reduction for readmission through the ER for hypertensive disorder compared to standard care. That reduction guys 68%. So according to MOPP, management of postpartum preeclampsia. From the Journal of American College of Cardiology just from last year, using a goal set of 130 over 80, 68% reduction in ER visits and bounce back admissions for hypertension.
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super tight control. Okay, you see how things changed? Hey, at 150 over 100. Start medications back in 2013. Now MOP in 2025. Management of postpartum preeclampsias are like brother, you got to get that, you got to tune that up. She's no longer pregnant. Be aggressive. We're trying to prevent future cardiovascular issues and immediate complications like bounce back. That same message, guys. That same message of tight control is what's in the May 2026 expert consensus decision pathway that says, yeah, you start treatment at 140 over 90 to try to get to a goal of 130 over 80s for postpartum patients. Just like if they were non pregnant because guess what? They're no longer pregnant. Okay, so very tight control. And I found this so, so interesting that if there is a blood pressure of 140 over 90, start medication for sure. Of course, most like nifedipine as monotherapy because you could do an extended Release. So it's easy. So once a day, anywhere from 30, 60, or if you're really worried about 90 milligrams as an Excel, or there is a combination that is supported by the American College of Cardiology, again, May of 2026, because you had two different pathways, right? So you get nifedipine as a calcium channel blocker, which leads to afterload reduction plus labetalol. So that's the magic combo. Okay? Nifedipine and labetalol. Labetalol, of course. Now you're decreasing contractility. So by doing both of those, nifedipine and labetalol, you're hitting both mechanisms. And so whether it is a high contractile issue like hyperdynamic, or if it is a vasospastic issue where calcium channel blockers are gonna work, you're gonna cover both. So in other words, that's kind of cheating on the rule of 55, but whatever. Okay? The point is, get her. Get her taken care of correctly, either as monotherapy or as nifedipine for vasoconstrictive non hyperdynamic hypertension and labetalol together to cover the hyperdynamic portion, and they're gonna get greatly, greatly reduced risk of bounce back. Okay, do you all see where we're going here? So the short answer is be aggressive. So, yes, the more normal that you can get now, you know, don't make her 90 over 60. You've really overcorrected her there. But your goal should be to initiate treatment at 140s over 90s to try to get to a goal of 130 over 80s based on MOP and JAC. JACC. That's the Journal of the American College of cardiology. All right, Jack, 2026. Is that crazy or what? Look how far. Look what we've learned. And I've heard, you know, both things. Oh, she'll be fine. You know, 150. It's not that bad. It's not severe. It's going to get worse on day three to six or three to seven based on who you read. So be aggressive. Now, remember, this is outside of the foundation of Lasix. So Lasix is preload reduction. Okay? So that's another issue that if you are hyperdynamic, which is either too much volume or you've got too much contractility, you can give Lasix. So I do Lasix for all of my preeclamptic patients, especially if they're severe, because they're going to mobilize that fluid for five days. 40 milligrams for five days doesn't affect lactation. It's very low dose. I'm not going to, you know, affect somebody's electrolytes, although I do get a CMP at baseline just for record. And it's very low dose. Most healthy women with normal kidney function are going to be able to tolerate that. That's very well published, by the way. If this Lasix idea is like, novel to you, like, I've never heard of that, man. You've not been following the show because. Please. Plenty of data on the immediate use of Lasix to prevent readmission in these patients. Now, if they're on that and their blood pressure is still above 140s over 90, I hit them with single dose nifedipine. And for those that are, you know, one 150s high, 150s over 100, number one, I try not to send them home until they're. That walked them off the ledge. I look for 24 hours of blood pressure normality before I send them home, just to make sure that they're stable, to make sure that they're not having any blood pressure escalation. And if necessary, then I'll do combined medication like Jack says to do. The Journal of American College of Cardiology. Nifedipine and labetalol. Again, kind of cheating on the rule of 55. And if you don't know what that is, I'm not going to go over that. You got to go back and listen. I've got plenty of episodes on the pathophysiology of hypertension in pregnancy, whether it's hyperdynamic or vasoconstrictive. And that is called the rule of 55. If you're hyperdynamic, you can give labetalol and or Lasix. And if you are not hyperdynamic, but vasospastic, nifedipine, along with methyl dopa and other peripheral vasodilators, hydralazine. Okay, so the short answer is yes. Be aggressive. Be aggressive with these without bodying them out and tell the patient your biggest risk of coming back to the hospital, like within the first seven to 10 days is the blood pressure that I send you home with. So we're gonna be aggressive with this. And our goal is 130s over 80s. I'm gonna tolerate 140s over 90s if you're on medication, but you definitely need medicine at 140 over 90 to bring that down. So two main publications here to answer this question and then we're done. The MOP publication from 2025, Management of Postpartum Preeclampsia. And then the second is the expert review from the American College of Cardiology from May of 2026. Recent data here, guys, we've got recent data to back this up. Podcast family, as always, we're thankful for you. We're glad you're part of our podcast community, Michael. And now that we've done all that, should we take it home? Yeah, let's take it home. This is Dr. Chapman's obgyn no spin podcast, Sam.