What is postpartum (after childbirth) preeclampsia?

Postpartum Preeclampsia: Definition and Management

Postpartum preeclampsia is defined as new-onset hypertension (≥140/90 mmHg) with proteinuria or other signs of end-organ dysfunction that develops between 48 hours and 6 weeks after delivery. 1

Definition and Diagnostic Criteria

• Postpartum preeclampsia is characterized by hypertension and at least one of the following: proteinuria (≥300 mg/24 hours), or other maternal organ dysfunction (renal, liver, neurological, or hematological complications) 2
• While preeclampsia typically develops after 20 weeks of gestation, postpartum preeclampsia occurs after childbirth 2, 1
• Most cases present within the first 7-10 days after delivery, though it can occur up to 6 weeks postpartum, with rare cases reported up to 12 weeks after delivery 1, 3
• Neurological symptoms, particularly headache, are the most common presenting symptom 1

Risk Factors

• Older maternal age, Black race, maternal obesity, and cesarean delivery are associated with higher risk of postpartum preeclampsia 1
• Women with a history of preeclampsia during pregnancy are at increased risk, though postpartum preeclampsia can also develop de novo in women without antepartum hypertensive disorders 1, 4
• Postpartum preeclampsia may be associated with higher maternal morbidity than preeclampsia with antepartum onset 1

Clinical Presentation

• Common symptoms include:
  • Headache (most frequent presenting symptom) 1
  • Visual disturbances (blurred vision, photophobia) 5
  • Right upper quadrant/epigastric pain 6
  • Shortness of breath or chest pain 1
  • Nausea and vomiting 1
• Physical findings may include:
  • Hypertension (≥140/90 mmHg) 2
  • Hyperreflexia and clonus 6
  • Edema (though no longer part of diagnostic criteria) 6

Management

Immediate Management

• Monitor blood pressure at least every 4 hours while awake for at least 3 days postpartum 6, 2
• Treat hypertension with antihypertensive medications, aiming for systolic BP <160 mmHg 6, 2
• For severe preeclampsia or eclampsia, administer magnesium sulfate to prevent seizures 7:
  • Initial dose: 4-5g IV in 250 mL of 5% Dextrose or 0.9% Sodium Chloride over 3-4 minutes 7
  • Maintenance: 1-2g/hour by continuous IV infusion 7
  • Continue until paroxysms cease; serum magnesium level of 6 mg/100 mL is considered optimal 7
• Avoid NSAIDs for postpartum analgesia, especially in women with renal disease, placental abruption, or acute kidney injury 6, 2

Follow-up Care

• Continue antihypertensive medications after delivery and taper slowly only after days 3-6 postpartum 2
• Women still requiring antihypertensives at discharge should be reviewed within 1 week 2
• All women with postpartum preeclampsia should be reviewed at 3 months postpartum 6, 2
• By 3 months, blood pressure, urinalysis, and laboratory tests should have normalized; persistent abnormalities require further investigation 2, 8

Long-term Implications

• Women with a history of preeclampsia (including postpartum) have increased risks of:
  • Cardiovascular disease 6, 2, 9
  • Stroke 2, 9
  • Diabetes mellitus 2, 9
  • Venous thromboembolic disease 2
  • Chronic kidney disease 2, 8
• Annual medical review is advised lifelong, with emphasis on maintaining healthy lifestyle 6
• Women should aim to achieve pre-pregnancy weight by 12 months postpartum and limit interpregnancy weight gain 6

Pathophysiology

• The exact pathophysiology of postpartum preeclampsia remains poorly understood 9
• Like antepartum preeclampsia, it involves systemic inflammation and widespread maternal endothelial dysfunction 9
• Postpartum preeclampsia may represent a separate entity from preeclampsia with antepartum onset, or it may be part of the same disease spectrum 1
• Research suggests that women after preeclampsia may display cardiovascular risk factors including hypertension, microalbuminuria, renal hyperfiltration, and elevated CRP 8

Postpartum preeclampsia remains an understudied condition with limited evidence-based guidelines for diagnosis and management. Early recognition and prompt treatment are essential to prevent serious maternal complications.