What is the appropriate work‑up for a woman presenting within six weeks postpartum with suspected preeclampsia?

Work-up for Postpartum Preeclampsia

For a woman presenting within six weeks postpartum with suspected preeclampsia, immediately obtain blood pressure measurement, complete blood count with platelets, serum creatinine, liver transaminases (AST/ALT), and urine protein assessment (dipstick or protein/creatinine ratio), while monitoring for neurological symptoms and general well-being. 1

Initial Assessment Components

Blood Pressure Monitoring

• Measure BP using proper technique with appropriate cuff size
• Confirm hypertension (≥140/90 mm Hg) with repeat measurements
• If BP ≥160/110 mm Hg, confirm within 15 minutes and treat urgently 1
• Continue monitoring every 4-6 hours during the day for at least 3 days if admitted 1

Laboratory Work-up

The essential laboratory tests include 1:

• Complete blood count: Focus on hemoglobin and platelet count
• Liver function tests: AST and ALT (transaminases)
• Renal function: Serum creatinine
• Proteinuria assessment: Either 24-hour urine collection (≥0.3 g/24h) or protein/creatinine ratio (≥30 mg/mmol)

Repeat these tests every other day until stable if any were abnormal initially 1

Clinical Monitoring

Assess for 1:

• Neurological status: Headache, visual disturbances, altered mental status (eclampsia can occur postpartum)
• Right upper quadrant or epigastric pain: Suggests liver involvement
• Symptoms of pulmonary edema: Shortness of breath, chest discomfort
• General well-being: Overall clinical status

Special Consideration: Retained Products

Perform careful assessment for retained products of conception, as de novo postpartum preeclampsia cases often take longer to resolve and may be associated with retained tissue 1

Diagnostic Criteria

Postpartum preeclampsia is defined by:

• New-onset hypertension (BP ≥140/90 mm Hg) occurring up to 4-6 weeks after delivery 2, 3
• Plus proteinuria (≥0.3 g/24h or protein/creatinine ratio ≥30 mg/mmol)
• OR evidence of end-organ dysfunction (thrombocytopenia, renal insufficiency, liver dysfunction, pulmonary edema, cerebral/visual symptoms) even without proteinuria 3

Important Clinical Pearls

Presentation Patterns

• Over half of postpartum preeclampsia cases had no antenatal diagnosis 2
• Most women present 3-10 days postpartum (median: 5 days) 2
• Not all women will have "classic" features—some may lack severe hypertension, edema, or proteinuria 2
• Common prodromal symptoms: headache, visual changes, hypertension, edema 2

Blood Pressure Thresholds

• Only 3 of 19 hypertensive women in one study had diastolic BP ≥110 mm Hg 2
• Do not dismiss the diagnosis based on "mild" hypertension alone—eclampsia can occur even with diastolic BP ≤100 mm Hg (occurred in 34% of eclamptic women in UK data) 4

What NOT to Do

Avoid Routine Use of:

• PlGF or sFlt-1/PlGF ratio testing: Not recommended routinely for postpartum preeclampsia work-up to reduce morbidity 5
• NSAIDs for analgesia: Avoid in women with preeclampsia, especially with renal involvement, as they can worsen hypertension and kidney injury; use alternative pain relief 1

Follow-up Laboratory Testing

If any laboratory values were abnormal at initial presentation, repeat hemoglobin, platelets, creatinine, and liver transaminases the day after delivery and then every other day until stable 1

Short-term Follow-up Plan

• Review within 1 week if requiring antihypertensives at discharge 1
• All women should be reviewed at 3 months postpartum, by which time BP, urinalysis, and laboratory tests should have normalized 1
• If abnormalities persist at 3 months, investigate for secondary causes of hypertension or underlying renal disease 1
• Screen for depression, anxiety, or post-traumatic stress disorder 1

Common Pitfalls to Avoid

1. Dismissing symptoms without objective testing: Headache and visual changes warrant full work-up even if BP appears only mildly elevated
2. Assuming no antenatal preeclampsia means no postpartum risk: De novo postpartum preeclampsia is common
3. Using NSAIDs liberally: These can precipitate severe hypertension in this population
4. Inadequate follow-up: Many women are lost to follow-up after hospital discharge, missing the critical 3-10 day window when most cases present 6, 7
5. Failing to counsel on long-term cardiovascular risk: 98% of women in one study were unaware of long-term consequences 7