What is the management for postpartum preeclampsia?

Management of Postpartum Preeclampsia

Postpartum preeclampsia management requires close blood pressure monitoring, antihypertensive therapy, and magnesium sulfate administration to prevent serious maternal complications including eclampsia, stroke, and death. 1

Immediate Management

• Monitor blood pressure at least every 4-6 hours during the day for at least 3 days postpartum, as preeclampsia may develop de novo or persist during this period 1
• Continue antihypertensive medications postpartum and taper slowly only after days 3-6, unless blood pressure becomes low (<110/70 mmHg) or the patient becomes symptomatic 1
• Maintain systolic BP <160 mmHg and diastolic BP <110 mmHg to prevent cerebrovascular complications 1
• Administer magnesium sulfate for seizure prophylaxis in women with severe features of preeclampsia, with careful monitoring of deep tendon reflexes, respiratory rate, and urine output 2
• Monitor for neurological status as eclampsia may occur postpartum 1

Laboratory Monitoring

• Repeat hemoglobin, platelets, creatinine, and liver transaminases the day after delivery and then every second day until stable if any were abnormal before delivery 1
• Assess for signs of worsening preeclampsia (headache, visual disturbances, right upper quadrant pain) 3
• Monitor urine output, maintaining at least 100 mL over four hours preceding each magnesium dose 2

Medication Management

Antihypertensive Therapy

• Select antihypertensive medications with respect to breastfeeding status 1
• First-line oral agents include labetalol, nifedipine (extended-release), and methyldopa 1
• For severe hypertension requiring IV therapy, options include:
  • Labetalol (IV): Safe and effective for severe preeclampsia 1
  • Hydralazine (IV): Widely used but requires close monitoring due to risk of maternal hypotension 1
  • Nicardipine (IV): Alternative option at 5 mg/h, increasing by 2.5 mg/h every 5-15 minutes to maximum 15 mg/h 1

Pain Management

• Avoid NSAIDs (including ibuprofen) if possible, especially in women with acute kidney injury, as they may worsen renal function and interfere with blood pressure control 1, 3
• Use acetaminophen as first-line analgesic for postpartum pain in women with preeclampsia 3

Adjunctive Therapy

• Consider furosemide (40 mg/day orally for five days) in women with severe preeclampsia after spontaneous diuresis has begun, as it can reduce mean daily systolic and diastolic blood pressure and shorten time to blood pressure control 4, 5
  • Most beneficial for women with severe preeclampsia rather than mild preeclampsia 5

Discharge Planning and Follow-up

• Most women can be discharged by day 5 postpartum, especially when they can monitor BP at home 1
• All women should be reviewed at 3 months postpartum to ensure BP, urinalysis, and laboratory tests have normalized 1
• Persistent abnormalities require further investigation, including work-up for secondary causes of hypertension or underlying renal disease 1
• Women with persisting hypertension or proteinuria at 6 weeks postpartum should be referred to a specialist 1
• Assess for depression, anxiety, or post-traumatic stress disorder symptoms at follow-up 1

Long-term Considerations

• Advise women with preeclampsia that they have approximately 15% risk for developing preeclampsia again and 15% risk for gestational hypertension in future pregnancies 1
• Counsel about increased lifetime risks of cardiovascular disease, stroke, diabetes mellitus, venous thromboembolism, and chronic kidney disease 1
• Recommend regular follow-up with a primary care provider for BP monitoring and periodic measurement of fasting lipids and blood sugar 1
• Encourage healthy lifestyle with maintenance of ideal weight and regular aerobic exercise 1

Pitfalls and Caveats

• Postpartum preeclampsia may present with atypical symptoms such as dyspnea, which should prompt consideration of differential diagnoses including postpartum cardiomyopathy and pulmonary embolism 6
• Most cases of de novo postpartum preeclampsia occur within 7-10 days after delivery, with headache being the most common presenting symptom 7
• The postpartum period remains a high-risk time for eclamptic seizures for at least 3 days 3
• Women with preeclampsia under age 40 with persistent hypertension should be assessed for secondary causes of hypertension 1