What is the recommended treatment for postpartum preeclampsia, inpatient or outpatient?

Management of Postpartum Preeclampsia: Inpatient vs. Outpatient Treatment

Patients with postpartum preeclampsia with severe features should be managed as inpatients with antihypertensive treatment and magnesium sulfate administration until stabilized, followed by careful outpatient monitoring. 1, 2

Initial Management of Postpartum Preeclampsia

Criteria for Inpatient Treatment

• Severe hypertension: SBP ≥160 mmHg and/or DBP ≥110 mmHg persisting for >15 minutes 1
• Presence of severe features: Neurologic symptoms (headache), visual disturbances, epigastric pain, altered mental status, oliguria, or laboratory abnormalities 2, 3
• End-organ damage: Abnormal laboratory values (elevated liver enzymes, thrombocytopenia, renal dysfunction) 2

Inpatient Management Protocol

1. Antihypertensive therapy:

   • First-line medications: IV labetalol, oral nifedipine, or IV hydralazine 2
   • Target blood pressure: 140-150/90-100 mmHg (15-25% reduction initially) 2
   • Avoid abrupt blood pressure reduction which may compromise organ perfusion

2. Magnesium sulfate administration:

   • Loading dose: 4-5g IV in 250mL of 5% Dextrose or 0.9% Sodium Chloride over 3-4 minutes 2
   • Maintenance: 1-2g/hour by continuous IV infusion 2
   • Continue for 24 hours after the last seizure or after stabilization 2

3. Laboratory monitoring:

   • Daily complete blood count with platelets
   • Liver function tests
   • Renal function tests
   • Urinalysis for proteinuria 2

Transition to Outpatient Management

Discharge Criteria

• Blood pressure stabilized below 150/100 mmHg for at least 36 hours 4
• Resolution of severe symptoms
• Laboratory values trending toward normal
• Patient able to monitor blood pressure at home and recognize warning signs 2

Outpatient Management

1. Medication management:

   • Safe antihypertensives for breastfeeding: labetalol, nifedipine, enalapril, metoprolol 2
   • Gradual tapering of medications over days (not abrupt cessation) 2

2. Follow-up protocol:

   • First follow-up within 1 week if still on antihypertensives at discharge 2
   • Complete evaluation at 3-6 months postpartum 2
   • Annual medical review for women with history of preeclampsia due to increased long-term cardiovascular risk 2

3. Home monitoring instructions:

   • Daily blood pressure measurements
   • Report readings ≥160/110 mmHg immediately 2
   • Monitor for warning signs: severe headache, visual changes, epigastric pain, shortness of breath

Important Considerations and Pitfalls

Risk Factors for Requiring Extended Treatment

• Chronic hypertension (7.5 times higher risk of needing postpartum antihypertensives) 5
• High-dose intrapartum hydralazine use 5
• Older maternal age, Black race, obesity, and cesarean delivery 3

Common Pitfalls to Avoid

1. Early discharge without adequate stabilization

   • Most women with delayed-onset postpartum preeclampsia present within 7-10 days after delivery 3
   • Extended monitoring with strict blood pressure goals has not been shown to decrease readmissions for severe preeclampsia 4

2. Inadequate patient education

   • Patients need clear instructions on warning signs and when to seek immediate medical attention
   • Postpartum preeclampsia may be associated with higher maternal morbidity than antepartum preeclampsia 3

3. Insufficient long-term follow-up

   • Women with history of preeclampsia require screening for depression, anxiety, and post-traumatic stress disorder 2
   • Long-term cardiovascular risk requires lifelong annual medical review and lifestyle modifications 2

Special Considerations

• Medicalised transport should be considered for patients with severe preeclampsia being transferred between facilities 1
• Consultation with obstetric and anaesthetic-intensivist teams is recommended when initiating treatment 1
• Patients with persistent symptoms at 3 months should be referred to specialists (nephrology, cardiology) 2