What to order if suspected postpartum preeclampsia (postpartum hypertension with proteinuria)?

From the Guidelines

For suspected postpartum preeclampsia, order blood pressure monitoring, complete blood count, comprehensive metabolic panel, liver function tests, urine protein assessment (spot protein/creatinine ratio or 24-hour collection), and lactate dehydrogenase. If severe features are present, initiate magnesium sulfate for seizure prophylaxis with a 4-6g IV loading dose followed by 1-2g/hour maintenance infusion for 24 hours 1. Treat hypertension with labetalol (20-80mg IV every 10-30 minutes or 200-400mg orally twice daily), nifedipine (10-20mg orally every 4-6 hours), or hydralazine (5-10mg IV every 20-40 minutes) to maintain blood pressure below 160/110 mmHg 1. Some key points to consider in the management of postpartum preeclampsia include:

• Monitoring blood pressure at least 4 to 6 hourly during the day for at least 3 days postpartum 1
• Assessing for signs of severe hypertension, such as systolic blood pressure > 160 mmHg, and treating promptly if present 1
• Using antihypertensive medications that are safe for breastfeeding mothers, such as labetalol, nifedipine, and metoprolol 1
• Educating patients about warning signs of postpartum preeclampsia, including severe headache, visual disturbances, epigastric pain, and shortness of breath, and instructing them to seek immediate medical attention if these symptoms occur 1. Close monitoring is essential as postpartum preeclampsia can develop up to 6 weeks after delivery and may progress rapidly to eclampsia or HELLP syndrome 1. The pathophysiology involves persistent endothelial dysfunction and inflammatory response even after placental delivery 1. It is also important to consider the long-term cardiovascular consequences of gestational hypertension and to recommend lifestyle modifications and cardiovascular risk assessment for women with a history of hypertensive disorders in pregnancy 1.

From the Research

Diagnosis and Management of Postpartum Preeclampsia

• Postpartum preeclampsia is a condition characterized by new-onset hypertension and severe features, such as severely elevated blood pressure, occurring 48 hours to 6 weeks after delivery 2.
• The diagnosis of postpartum preeclampsia should be considered in women with new-onset hypertension and severe features, after excluding other etiologies 2.
• The cornerstones of treatment for postpartum preeclampsia include the use of antihypertensive agents, magnesium, and diuresis 2.

Use of Magnesium Sulfate in Postpartum Preeclampsia

• Magnesium sulfate is the preferred anticonvulsant used to prevent the development of fits in severe pre-eclampsia 3.
• The duration of postpartum magnesium sulfate for seizure prophylaxis in women with preeclampsia is a topic of debate, with some studies suggesting shortened courses may be effective 4.
• However, a systematic review and meta-analysis found that women who received <24 hours of postpartum magnesium sulfate had a significantly faster time to ambulation postpartum and shorter durations of indwelling urinary catheter placement, but the results did not show a difference in the rate of eclampsia 4.
• Another study suggested that reserving magnesium sulfate therapy for the subset of patients with neurologic symptoms who may be at highest risk for an eclamptic seizure may be a reasonable approach 5.

Presentation and Management in the Emergency Department

• Postpartum preeclampsia/eclampsia can present to the emergency department without a history of preeclampsia during the pregnancy, and not all women with this diagnosis will have the "classic" features of the disease 6.
• Common prodromal symptoms and signs in the postpartum presentation include headache, visual changes, hypertension, edema, proteinuria, elevated uric acid, and elevated liver function tests 6.
• Women with postpartum preeclampsia/eclampsia often present to the emergency department 3 to 10 days postpartum, with a median presentation time of 5 days 6.