What is the management plan for a postpartum patient with preeclampsia?

Postpartum Preeclampsia Management

Blood Pressure Monitoring and Control

Women with postpartum preeclampsia require intensive blood pressure monitoring at least every 4-6 hours while awake for a minimum of 3 days postpartum, as preeclampsia may develop de novo or worsen during this critical period. 1, 2

• Treat severe hypertension (≥160/110 mmHg) immediately if sustained for >15 minutes to prevent cerebrovascular complications including stroke 1, 3, 2
• Target blood pressure should be maintained at systolic <160 mmHg and diastolic <110 mmHg throughout the postpartum period 3, 2
• For acute severe hypertension, use IV labetalol, oral nifedipine (immediate-release), or IV hydralazine as first-line agents 1, 3, 4
• Nifedipine may achieve blood pressure control fastest among the options 4

Antihypertensive Medication Management

Continue or restart antihypertensive medications postpartum and taper slowly only after days 3-6, unless blood pressure drops below 110/70 mmHg or the patient becomes symptomatic. 1, 2

• For persistent postpartum hypertension requiring long-acting agents, use labetalol, nifedipine, or methyldopa as first-line options compatible with breastfeeding 3, 2, 4
• Amlodipine is also an acceptable calcium channel blocker option for postpartum hypertension management in breastfeeding mothers 2
• Never abruptly discontinue antihypertensives—taper gradually over days 1

Magnesium Sulfate Prophylaxis

Continue magnesium sulfate for 24 hours postpartum in women with preeclampsia, as eclamptic seizures may occur for the first time in the early postpartum period. 1, 3

• Use standard dosing: 4-5g IV loading dose over 5-10 minutes, followed by 1-2g/hour continuous infusion 3
• Monitor neurological status continuously for headache, visual disturbances, altered mental status, and signs of worsening cerebral edema 3, 2

Laboratory Monitoring

Repeat hemoglobin, platelets, creatinine, and liver transaminases the day after delivery, then every second day until stable if any were abnormal before delivery. 1, 2

• Monitor for signs of worsening preeclampsia including headache, visual disturbances, and right upper quadrant pain 2
• Assess general well-being and neurological status as eclampsia may occur postpartum 1, 2

Critical Pitfalls to Avoid

Avoid NSAIDs for postpartum analgesia in women with preeclampsia, especially if acute kidney injury, renal disease, placental abruption, sepsis, or postpartum hemorrhage are present. 1, 3

• NSAIDs can worsen hypertension and renal function in this population 1, 3
• Use alternative analgesics as first-choice pain management 1
• Never administer calcium channel blockers (nifedipine) concomitantly with magnesium sulfate due to risk of severe hypotension from synergistic effects 3

Fluid Management

Limit total fluid intake to 60-80 mL/hour to avoid pulmonary edema risk. 1

• Replace insensible losses (30 mL/h) along with anticipated urinary losses (0.5-1 mL/kg per hour) 1
• There is no rationale to "run dry" a preeclamptic woman as she is already at risk of acute kidney injury 1
• Monitor for early warning signs of pulmonary edema: tachycardia, oliguria, and elevated hematocrit 3

Discharge Planning

Most women can be discharged by day 5 postpartum if blood pressure is controlled and they can monitor BP at home. 1, 2

• Women should not be discharged before 24 hours postpartum or until vital signs are stable and neurological symptoms have resolved 3
• Women requiring antihypertensives at discharge should be reviewed within 1 week 1
• Provide home blood pressure monitoring equipment and clear instructions on when to seek emergency care 1

Follow-Up Requirements

All women must be reviewed at 3 months postpartum to ensure blood pressure, urinalysis, and all laboratory tests have normalized. 1, 2

• Women with persistent hypertension or proteinuria at 3 months require further investigation for secondary causes of hypertension or underlying renal disease 1, 2
• Assessment should include screening for depression, anxiety, or posttraumatic stress disorder symptoms 1

Long-Term Counseling

Counsel women that they have approximately 15% risk for developing preeclampsia again and an additional 15% risk for gestational hypertension in future pregnancies. 1, 2

• Advise about increased lifetime risks of cardiovascular disease, death, stroke, diabetes mellitus, venous thromboembolic disease, and chronic kidney disease compared to women with normotensive pregnancies 1, 2
• Recommend annual medical review lifelong with adoption of healthy lifestyle including exercise, healthy eating, and achieving ideal body weight 1
• Aim to achieve prepregnancy weight by 12 months and limit interpregnancy weight gain 1