In a woman 4 weeks postpartum after gestational hypertension who is currently normotensive, what is the most appropriate next step in management?

Management of Postpartum Gestational Hypertension with Current Normotension

At 4 weeks postpartum with current blood pressure of 120/80 mmHg following gestational hypertension, the most appropriate next step is to continue close blood pressure monitoring with a formal reassessment at 6 weeks postpartum, followed by a comprehensive 3-month review to ensure complete resolution. 1, 2

Immediate Management Strategy

Your patient is currently normotensive (120/80 mmHg), which falls below the treatment threshold of ≥140/90 mmHg for postpartum hypertension. 1, 3 However, this does not mean she can be dismissed to annual follow-up, as gestational hypertension typically resolves within 6-12 weeks postpartum, and she is still within this critical window. 2

Key action points at 4 weeks postpartum:

• Do not initiate antihypertensive medication at this time, as her blood pressure is currently normal and does not meet treatment criteria. 1
• Do not defer monitoring to annual follow-up, as this would miss the critical 6-week and 3-month assessment windows required by guidelines. 4, 2
• Continue home blood pressure monitoring if already established, or initiate it now to track for any elevation before the 6-week visit. 2

Structured Follow-Up Algorithm

6-Week Postpartum Visit (Required):

• Measure blood pressure and perform urinalysis to confirm resolution of gestational hypertension. 1, 2
• If blood pressure remains ≥140/90 mmHg at 6 weeks, confirm with 24-hour ambulatory blood pressure monitoring. 1, 2
• If hypertension persists at 6 weeks, initiate antihypertensive therapy with first-line agents safe for breastfeeding (nifedipine extended-release, amlodipine, or enalapril). 1
• For women under age 40 with persistent hypertension at 6 weeks, assess for secondary causes of hypertension. 1, 2

3-Month Postpartum Review (Critical):

• Comprehensive assessment to ensure blood pressure, urinalysis, and all laboratory abnormalities have normalized. 4, 2
• If hypertension persists beyond 12 weeks postpartum, this suggests pre-existing chronic hypertension rather than gestational hypertension and requires referral to a specialist. 1, 2
• If proteinuria or hypertension persists at 3 months, initiate appropriate referral for further investigations. 2

Long-Term Cardiovascular Risk Management

This patient requires lifelong annual medical review, not just a single annual follow-up, because women with gestational hypertension have significantly elevated lifetime cardiovascular risk. 4, 2

Specific long-term risks include:

• Approximately 25% risk of recurrent gestational hypertension in future pregnancies. 2
• Increased lifetime risk of chronic hypertension, stroke, ischemic heart disease, and thromboembolic disease. 1, 2
• Need for cardiovascular risk assessment using ASCVD or PREVENT calculator at postpartum visits. 1

Lifestyle modifications to recommend:

• Aim to achieve pre-pregnancy weight by 12 months and limit interpregnancy weight gain. 2
• Regular exercise, healthy diet, and maintaining ideal body weight. 2
• Periodic measurement of fasting lipids and blood sugar. 2

Common Pitfalls to Avoid

• Do not discharge to annual follow-up without completing the 6-week and 3-month assessments, as this misses the window to detect persistent hypertension that may represent chronic disease. 1, 2
• Do not prescribe NSAIDs liberally for postpartum pain in women with history of gestational hypertension, as NSAIDs can elevate blood pressure. 4, 2
• Do not assume resolution just because blood pressure is normal at 4 weeks; gestational hypertension can persist or recur through 12 weeks postpartum. 2

Answer to Multiple Choice Question

The correct answer is B: Prescribe antihypertensive medication if high blood pressure remains (at the 6-week or subsequent visits). 1, 2

• Option A (restrict salt intake and rest) is insufficient as a standalone management strategy and does not address the need for structured follow-up. 2
• Option C (annual follow-up only) is incorrect and potentially dangerous, as it bypasses the required 6-week and 3-month assessments that are critical for detecting persistent hypertension and managing long-term cardiovascular risk. 4, 1, 2