What is the most appropriate next step in management for a postpartum woman with a history of gestational hypertension, currently 4 weeks post-delivery, with a blood pressure reading of mild hypertension?

Management of Postpartum Hypertension at 4 Weeks

The most appropriate next step is to prescribe antihypertensive medication (Option B), as this woman has persistent mild hypertension (133/88 mmHg) at 4 weeks postpartum following gestational hypertension, which requires pharmacological treatment rather than observation alone. 1, 2

Rationale for Immediate Treatment

• A blood pressure of 133/88 mmHg at 4 weeks postpartum represents persistent hypertension that is unlikely to resolve spontaneously, as gestational hypertension typically resolves within 6-12 weeks but persistence at this timepoint suggests need for intervention 2
• The American College of Cardiology recommends that this blood pressure level in a woman with history of gestational hypertension requires close monitoring and treatment rather than waiting until annual follow-up 2
• While the threshold for treatment is traditionally ≥140/90 mmHg, consideration of treatment at 133/88 mmHg is appropriate given the history of gestational hypertension and the fact that this represents persistent rather than resolving hypertension 1
• Postpartum hypertension can have devastating consequences including stroke and death, with the majority of hypertension-related maternal deaths occurring in the first six days postpartum but complications extending through the first several weeks 2

Why Other Options Are Inappropriate

• Salt restriction and rest alone (Option A) are insufficient for persistent hypertension at 4 weeks postpartum and are explicitly not recommended as sole treatment 2
• Annual follow-up only (Option C) is dangerous and inappropriate, as this woman requires 3-month postpartum review to ensure normalization of blood pressure and laboratory abnormalities 1, 2
• Ambulatory blood pressure monitoring (Option D) may be useful to confirm persistent hypertension but should not delay treatment initiation in a woman with documented gestational hypertension and persistent elevation at 4 weeks 1

Recommended Medication Selection

First-line agent: Extended-release nifedipine 30-60 mg once daily is the preferred choice due to once-daily dosing, excellent safety with breastfeeding, and superior efficacy in the postpartum period 2, 3

Alternative agents include:

• Amlodipine 5-10 mg once daily - equally safe with minimal breast milk excretion and convenient once-daily dosing 2, 3
• Labetalol 200-800 mg twice daily - safe but requires more frequent dosing and may be less effective postpartum with higher readmission risk compared to calcium channel blockers 2, 3
• Enalapril 5-20 mg once daily - safe during breastfeeding but requires documented contraception plan due to teratogenicity risk in future pregnancies 2, 3

Medications to Avoid

• Methyldopa should be avoided postpartum due to increased risk of postpartum depression 4, 2, 3
• Diuretics should be avoided as they may reduce milk production and suppress lactation 1, 2, 3
• NSAIDs for postpartum analgesia should be avoided in women with hypertensive disorders of pregnancy 1, 2

Follow-Up Protocol

• Home blood pressure monitoring should be initiated with twice-daily measurements (morning and evening), with each session including 2 measurements taken at least 1 minute apart 2
• 3-month postpartum review is essential to ensure blood pressure, urinalysis, and laboratory abnormalities have normalized 1, 2
• If hypertension persists beyond 12 weeks postpartum, this suggests pre-existing chronic hypertension rather than gestational hypertension and requires appropriate referral for further investigations 2
• Women with persisting hypertension under age 40 should be assessed for secondary causes of hypertension 1

Long-Term Cardiovascular Risk

• Women with gestational hypertension have approximately 25% risk for gestational hypertension in future pregnancies and significantly increased lifetime risk of cardiovascular disease, stroke, ischemic heart disease, and thromboembolic disease 2
• Annual medical review is advised lifelong for women with gestational hypertension 1, 2
• Lifestyle modifications including achieving pre-pregnancy weight by 12 months, regular exercise, and healthy diet are essential 1