What is the most likely diagnosis for a 3-week postpartum patient presenting with frequent headaches, intermittent blurred vision, significant weight gain, and hypertension (elevated blood pressure)?

Postpartum Preeclampsia

This patient most likely has postpartum preeclampsia, a serious hypertensive disorder that can develop de novo after delivery and requires urgent evaluation and treatment to prevent life-threatening complications including stroke and eclampsia.

Diagnostic Criteria

The clinical presentation meets diagnostic criteria for postpartum preeclampsia based on:

• New-onset hypertension (BP 156/92 mmHg, defined as ≥140/90 mmHg) at 3 weeks postpartum 1
• Neurological symptoms including frequent headaches and intermittent blurred vision, which are classic severe features of preeclampsia 1
• Rapid weight gain (2 pounds in 3 days), suggesting fluid retention and edema 2
• Timing within the typical window, as most postpartum preeclampsia cases occur within 7-10 days after delivery, though it can present up to 6 weeks postpartum 3, 4

Why This Diagnosis Takes Priority

Postpartum preeclampsia should be suspected in any patient with elevated BP combined with persistent headache, vision changes, or severe abdominal pain in the postpartum period. 1 This is a medical emergency requiring urgent evaluation, as:

• Headaches in the presence of hypertension should be considered part of preeclampsia until proven otherwise—this is the safest clinical approach 1
• Visual changes combined with hypertension represent severe features that significantly increase risk for maternal complications 1, 2
• Ten percent of maternal deaths from hypertensive disorders occur in the postpartum period 1
• Postpartum preeclampsia may carry higher maternal morbidity risk than antepartum preeclampsia 4

Immediate Management Algorithm

1. Confirm Severe Hypertension

• Repeat BP measurement within 15 minutes if systolic BP ≥160 mmHg or diastolic BP ≥110 mmHg 1
• For less severe elevations (as in this case), confirm with repeated readings over a few hours 1

2. Initiate Laboratory Workup

The following tests must be performed to evaluate for maternal organ dysfunction 1:

• Complete blood count (hemoglobin and platelet count)
• Liver enzymes (AST, ALT, LDH) and function tests (INR, bilirubin, albumin)
• Serum creatinine, electrolytes, and uric acid
• Urinalysis with protein-to-creatinine ratio or albumin-to-creatinine ratio 1

3. Antihypertensive Treatment

• Initiate treatment for BP ≥140/90 mmHg in the postpartum period 1, 5
• Safe medications for breastfeeding mothers include labetalol, nifedipine, enalapril, and metoprolol 1, 5
• Target BP goal of <130/80 mmHg consistent with current cardiovascular guidelines 1

4. Seizure Prophylaxis

• Administer intravenous magnesium sulfate for patients with severe features (headache, visual changes) to prevent eclampsia 1, 5
• All four patients who seized in one case series had prodromal symptoms like this patient 2

5. Consider Hospitalization

• All preeclamptic women should be hospitalized and closely monitored in centers with adequate maternal intensive care resources 1
• Consider ICU transfer if respiratory support needed, abnormal ECG findings, or failure of first-line antihypertensive medications 5

Critical Differential Considerations

While postpartum preeclampsia is most likely, rapidly exclude:

• Postpartum cardiomyopathy: Would show more gradual onset over days to weeks, not acute presentation at 3 weeks with primarily neurological symptoms 6
• Cerebrovascular accident/stroke: A devastating complication of severe postpartum hypertension that this patient is at risk for 1
• Iatrogenic causes: NSAIDs for postpartum analgesia can elevate BP and should be avoided in women with suspected preeclampsia 1, 5

Common Pitfalls to Avoid

• Do not assume normal antepartum course excludes postpartum preeclampsia: Over 55% of women with postpartum preeclampsia had no diagnosis of preeclampsia during pregnancy 2, 4
• Do not wait for "classic" severe BP elevations: Only 3 of 19 women in one series had diastolic BP ≥110 mmHg, yet all required treatment 2
• Do not dismiss symptoms as postpartum stress or anxiety: Headache and visual changes in the setting of any hypertension must be treated as preeclampsia 1, 2
• Proteinuria is not required for diagnosis: Proteinuria is present in only approximately 75% of preeclampsia cases 1

Follow-Up Requirements

• Review at 3 months postpartum to ensure BP, urinalysis, and laboratory abnormalities have normalized 5
• Annual medical review lifelong given significantly increased cardiovascular risk (hypertension, stroke, ischemic heart disease) 5
• Cardiovascular risk reduction through lifestyle modifications, weight management, and regular BP monitoring 5