Management of Postpartum Preeclampsia
Women with postpartum preeclampsia should be considered at high risk for complications for at least 3 days after delivery and require close monitoring of blood pressure and clinical condition at least every 4 hours while awake, with continuation of antihypertensive medications and consideration of magnesium sulfate therapy. 1
Initial Assessment and Monitoring
- Monitor blood pressure at least every 4-6 hours during the day for at least 3 days postpartum 1
- Assess for neurological symptoms (headache, visual changes, hyperreflexia) as eclampsia may develop for the first time in the early postpartum period 1
- Monitor general well-being and clinical status regularly 1
- Laboratory monitoring:
- Repeat hemoglobin, platelets, creatinine, liver transaminases the day after delivery
- Continue monitoring every 2 days until stable if any were abnormal before delivery 1
Acute Management
Blood Pressure Control
Treat severe hypertension (≥160/110 mmHg) urgently with: 1
- Oral nifedipine (10-20 mg)
- IV labetalol (20-80 mg boluses)
- IV hydralazine (5-10 mg boluses)
Target blood pressure: Keep SBP <160 mmHg and DBP <110 mmHg 1
Seizure Prevention and Management
Magnesium sulfate is indicated for: 1, 2
- Women with severe preeclampsia features
- Women with neurological symptoms (headache, visual changes)
- Women with eclampsia
Magnesium sulfate dosing: 2
- Loading dose followed by maintenance infusion
- Continue for 24 hours postpartum
- Monitor for magnesium toxicity (assess deep tendon reflexes, respiratory rate, urine output)
- Have calcium gluconate immediately available to counteract magnesium toxicity
Fluid Management
- Limit total fluid intake to 60-80 mL/hour to avoid risks of pulmonary edema 1
- Avoid "running dry" as these patients are at risk of acute kidney injury 1
Medication Management
- Continue antihypertensive medications administered antenatally 1
- Taper antihypertensives slowly only after days 3-6 postpartum 1
- Do not cease antihypertensives abruptly 1
- Avoid NSAIDs for postpartum analgesia in women with preeclampsia unless other analgesics are not working; especially important with renal disease, placental abruption, acute kidney injury, or other risk factors for kidney injury 1
Important Clinical Considerations
- Preeclampsia may develop de novo in the postpartum period; most commonly within the first 7-10 days after delivery 3
- Most common presenting symptom of postpartum preeclampsia is headache 3
- Risk factors for postpartum preeclampsia include older maternal age, Black race, obesity, and cesarean delivery 3
- Over half of women with postpartum preeclampsia may not have been diagnosed with preeclampsia during pregnancy 4
Discharge and Follow-up
- Most women can be discharged by day 5 postpartum if able to monitor BP at home 1
- Women still requiring antihypertensives at discharge should be reviewed within 1 week 1
- All women should be reviewed at 3 months postpartum to ensure BP, urinalysis, and laboratory abnormalities have normalized 1
- If proteinuria or hypertension persists at 3 months, refer for further investigation 1
Long-term Follow-up
Advise women with preeclampsia that they have:
Recommend:
Common Pitfalls to Avoid
- Failing to recognize that eclamptic seizures can occur for the first time postpartum
- Abrupt cessation of antihypertensive medications
- Overlooking the need for close monitoring in the first 3-7 days postpartum
- Using NSAIDs as first-line pain relief in women with preeclampsia
- Neglecting long-term cardiovascular risk assessment and follow-up
By following this structured approach to management, healthcare providers can effectively treat postpartum preeclampsia and reduce the risk of serious complications.