What is the next management step for a preeclampsia patient with hypertension (high blood pressure) after Lower Segment Caesarean Section (LSCS)?

Management of Postpartum Hypertension in Preeclampsia After LSCS

Immediate antihypertensive therapy must be initiated within 30-60 minutes when BP is 160/100 mmHg or higher, using IV labetalol, IV hydralazine, or oral immediate-release nifedipine as first-line agents to prevent maternal stroke. 1, 2, 3

Immediate Blood Pressure Management

Urgent treatment is required because BP ≥160/110 mmHg lasting >15 minutes warrants immediate drug intervention. 1, 4

First-Line Antihypertensive Options:

• IV Labetalol: 20 mg IV bolus, then 40 mg after 10 minutes, then 80 mg every 10 minutes for 2 additional doses (maximum 220 mg total) 1, 3
• IV Hydralazine: 5 mg IV bolus, then 10 mg every 20-30 minutes to maximum of 25 mg, repeat in several hours as necessary 1, 4
• Oral Nifedipine (immediate-release): 10 mg orally, repeat every 20 minutes to maximum of 30 mg (particularly useful when IV access unavailable) 1, 3

Target Blood Pressure:

• Aim for systolic BP 110-140 mmHg and diastolic BP 85-100 mmHg 1, 2
• Avoid dropping BP too rapidly to maintain uteroplacental perfusion 2
• Do not reduce diastolic BP below 80 mmHg 5

Seizure Prophylaxis

Magnesium sulfate must be administered immediately for seizure prevention in postpartum preeclampsia with severe hypertension. 2, 5

• Loading dose: 4-5g IV over 5 minutes 2
• Maintenance: 1-2g/hour continuous IV infusion 2
• Duration: Continue for at least 24 hours postpartum 5
• Monitor deep tendon reflexes, respiratory rate (must be >12/min), and urine output 2

Critical Caution:

Do not administer magnesium sulfate concomitantly with calcium channel blockers (nifedipine) due to risk of severe hypotension and myocardial depression. 1, 5 If both are needed, use close cardiac monitoring.

Medications to Avoid

• Methyldopa should NOT be used for urgent BP reduction (only for chronic management) 1
• ACE inhibitors and ARBs are absolutely contraindicated during breastfeeding period 2
• NSAIDs should be avoided as they can worsen hypertension and renal function 5

Monitoring Requirements

Maternal Monitoring:

• BP every 15 minutes until stable, then every 4-6 hours for at least 3 days postpartum 2, 5
• Continuous assessment of neurological status (headache, visual changes) 2
• Urine output monitoring (oliguria is a warning sign) 1
• Oxygen saturation 2

Laboratory Monitoring:

• Complete blood count (platelets, hemoglobin) 2
• Liver enzymes (AST, ALT) 2
• Creatinine and renal function 2
• Repeat labs at least twice weekly or more frequently if deteriorating 2

Transition to Oral Antihypertensives

Once BP is controlled with IV agents, transition to oral medications for ongoing management:

• Labetalol (safe for breastfeeding) 1, 5
• Nifedipine (safe for breastfeeding) 1, 5
• Enalapril (safe for breastfeeding, can be started postpartum) 1
• Metoprolol (safe for breastfeeding) 1

Continue antihypertensives postpartum and taper slowly only after days 3-6, unless BP becomes low (<110/70 mmHg). 5

When to Escalate Care

If first-line agents fail after successive appropriate doses, emergent consultation with anesthesiology, maternal-fetal medicine, or critical care is required for second-line intervention. 3

Indications for ICU Transfer:

• Persistent severe hypertension despite 3 classes of antihypertensives 5
• Neurological symptoms (severe headache, visual disturbances) 1, 2
• Pulmonary edema 5
• Progressive thrombocytopenia or HELLP syndrome 5
• Deteriorating renal function 5

Postpartum Follow-up

• BP and urine check at 6 weeks postpartum 1
• Confirm persistent hypertension with 24-hour ambulatory monitoring 1
• Women under age 40 with persistent hypertension should be assessed for secondary causes 1
• Refer to specialist if hypertension or proteinuria persists beyond 6 weeks 1

Key Pitfalls to Avoid

• Do not delay treatment waiting for "perfect" IV access - use oral nifedipine if needed 3
• Do not use short-acting nifedipine with magnesium sulfate without close monitoring 1, 5
• Do not withhold magnesium sulfate - 10% of maternal deaths from hypertensive disorders occur postpartum 1
• Do not assume resolution after delivery - preeclampsia can worsen in the first 48-72 hours postpartum 6