When should postpartum hypertension present to the Emergency Department (ED)?

When to Present to the Emergency Department for Postpartum Hypertension

Women with postpartum blood pressure ≥160/110 mmHg should immediately present to the Emergency Department, as this is considered a hypertensive emergency requiring urgent treatment within 60 minutes to prevent stroke and other severe complications. 1

Criteria for Emergency Department Presentation

Immediate ED Presentation Required:

• Severe hypertension: BP ≥160/110 mmHg lasting >15 minutes 1
• Any symptoms of preeclampsia, even with lower BP readings:
  • Severe headache (especially if unrelieved by analgesics)
  • Visual disturbances (blurring, flashing lights, scotomata)
  • Epigastric/right upper quadrant pain
  • Shortness of breath or chest pain
  • Altered mental status
  • Seizure activity (eclampsia) 1, 2

Urgent Medical Attention (Same Day):

• BP 140-159/90-109 mmHg with any of the following:
  • New-onset proteinuria
  • Symptoms suggestive of end-organ damage
  • Oliguria (<500 mL/24h)
  • Abnormal laboratory values (elevated liver enzymes, low platelets, rising creatinine) 1

Timing of Postpartum Hypertension

Postpartum hypertension can present:

• Immediately after delivery
• 3-6 days postpartum (when BP typically peaks) 3
• Up to 6 weeks postpartum 1

It's critical to understand that over half (55%) of women who develop postpartum preeclampsia had no diagnosis of preeclampsia during pregnancy 4. This makes patient education and vigilant monitoring essential.

Monitoring Recommendations

Hospital Monitoring:

• Monitor BP at least every 4-6 hours for at least 3 days postpartum 1
• Continue monitoring for at least 72 hours in hospital for women with hypertensive disorders 5

After Discharge:

• All women with hypertension during pregnancy should have BP checked within 7-10 days postpartum 5
• Women with severe features should be seen earlier (within 72 hours of discharge) 2
• All women should have BP and urine checked at 6 weeks postpartum 1

Treatment Thresholds

• Severe hypertension (≥160/110 mmHg): Requires immediate treatment with IV labetalol, IV hydralazine, or oral nifedipine within 60 minutes 6
• Mild-moderate hypertension (140-159/90-109 mmHg): Oral antihypertensives should be started if persistent, with labetalol, nifedipine, enalapril, or metoprolol being safe options for breastfeeding mothers 5

Patient Education

All women with hypertensive disorders of pregnancy should be educated about:

• The risk of postpartum hypertension/preeclampsia
• Warning signs requiring immediate medical attention
• The importance of medication adherence if prescribed
• The need for follow-up BP checks
• The increased lifetime risk of cardiovascular disease 1

Common Pitfalls to Avoid

1. Delayed recognition: Many cases of severe postpartum hypertension are undertreated or recognized late, with only 26.8% receiving guideline-concordant treatment within 60 minutes 6

2. Inadequate follow-up: Postpartum women are often focused on their newborn rather than their own health, leading to missed follow-up appointments

3. NSAIDs use: Routine postpartum pain management with NSAIDs may worsen hypertension in susceptible women 1

4. Overnight presentation: Treatment is less likely if hypertensive emergency occurs overnight (7:00 PM to 6:59 AM) 6

5. Dismissing symptoms: Headache and visual changes may be attributed to fatigue or normal postpartum changes rather than recognized as warning signs of preeclampsia 4

Remember that postpartum hypertension can lead to severe complications including stroke, eclampsia, and death if not promptly recognized and treated 7. When in doubt about symptom severity, it is always safer to seek immediate medical evaluation.