What is the treatment for postpartum preeclampsia (postpartum hypertension with proteinuria)?

Treatment of Postpartum Preeclampsia

For postpartum preeclampsia, first-line treatment includes intravenous labetalol or oral nifedipine for blood pressure control, with magnesium sulfate for seizure prophylaxis, targeting systolic BP <160 mmHg and diastolic BP <110 mmHg. 1, 2

Acute Management Algorithm

Step 1: Blood Pressure Control

• For severe hypertension (≥160/110 mmHg lasting >15 minutes):

  • IV labetalol: 10-20 mg IV initially, then 20-80 mg every 10-30 minutes as needed (maximum 300 mg) 1
  • OR oral nifedipine: 10-20 mg, repeat in 30 minutes if needed 1
  • OR IV hydralazine: 5 mg initially, then 5-10 mg every 30 minutes as needed (maximum 30 mg) 1

• Target blood pressure: Decrease mean BP by 15-25% with goal of SBP 140-150 mmHg and DBP 90-100 mmHg 1

Step 2: Seizure Prophylaxis

• Magnesium sulfate: 4-6g IV loading dose over 15-20 minutes, followed by maintenance infusion of 1-2g/hour for 24 hours after the last seizure 2
• Monitor for magnesium toxicity (respiratory depression, loss of deep tendon reflexes)
• Have calcium gluconate readily available as antidote 2

Step 3: Additional Management

• If pulmonary edema is present: Consider IV nitroglycerine (5 mg/min, gradually increased every 3-5 min to maximum 100 mg/min) 1
• Consider furosemide 20 mg daily to manage fluid mobilization from extravascular space and reduce need for additional antihypertensives 3

Maintenance Therapy

After acute management, transition to oral antihypertensives:

• Labetalol: Starting dose 100-200 mg twice daily, maximum 2400 mg/day 4
• Nifedipine (extended release): 30-60 mg daily
• Methyldopa: 250 mg 2-3 times daily initially, may increase to maximum 3g daily 5

Monitoring and Follow-up

• Monitor BP every 4 hours for at least 3 days postpartum 2
• Continue magnesium sulfate for 24 hours after the last seizure 2
• Check for other signs of preeclampsia: headache, visual disturbances, epigastric pain, oliguria
• Monitor for maternal early warning signs: SBP >160 mmHg, tachycardia, oliguria, altered mental status 1

Discharge Planning and Long-term Follow-up

• Home BP monitoring at least 4 times daily 2
• Follow-up within 1 week if still on antihypertensives at discharge 2
• Complete evaluation at 6 weeks postpartum including 24-hour ambulatory BP monitoring 1
• Referral to specialist if persistent hypertension or proteinuria at 6 weeks 1
• Consider assessment for secondary causes of hypertension in women under 40 with persistent hypertension 1

Medication Considerations for Breastfeeding

Safe options for breastfeeding mothers include 1:

• Labetalol
• Nifedipine
• Enalapril
• Metoprolol

Clinical Pearls and Pitfalls

• Postpartum preeclampsia can develop de novo 48 hours to 6 weeks after delivery, even in women without previous hypertension 6
• Most women with delayed-onset postpartum preeclampsia present within the first 7-10 days after delivery, typically with headache 6
• Avoid immediate-release nifedipine when combined with magnesium sulfate due to risk of uncontrolled hypotension 1
• Women with history of preeclampsia have increased risk of future cardiovascular disease and should have annual medical reviews 2
• Risk factors for postpartum preeclampsia include older maternal age, black race, obesity, and cesarean delivery 6

By following this treatment algorithm, healthcare providers can effectively manage postpartum preeclampsia, reducing the risk of serious maternal complications such as stroke, pulmonary edema, and eclampsia.