A 27‑year‑old woman, 2 weeks postpartum after cesarean delivery for severe pre‑eclampsia at 30 weeks gestation (infant 1 kg), now has persistent severe hypertension (150‑170 mmHg systolic), elevated serum creatinine (284 µmol/L), modestly elevated blood urea nitrogen (10.97 mg/dL), elevated alanine aminotransferase (137 U/L), aspartate aminotransferase (66 U/L), lactate dehydrogenase (579 U/L), metabolic acidosis (pH 7.27, bicarbonate 14.4 mmol/L, PCO₂ 26 mmHg), hyponatremia (Na 130 mmol/L), borderline hypokalemia (K 3.6 mmol/L), hypomagnesemia (Mg 0.76 mg/dL), and is taking losartan 50 mg. What is the complete differential diagnosis, which investigations are still missing, and what is the comprehensive management plan according to Harrison and Philippine obstetric‑nephrology guidelines, presented as a SOAP‑formatted chart with orders?

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Postpartum Preeclampsia with Acute Kidney Injury and Metabolic Acidosis

This patient has persistent postpartum preeclampsia with acute kidney injury (AKI), hepatic dysfunction, metabolic acidosis, and severe hypertension requiring immediate hospitalization, discontinuation of losartan (contraindicated in breastfeeding), and urgent nephrology consultation. 1

SOAP Format Chart Documentation

SUBJECTIVE

  • 27-year-old G1P1 (1001), postpartum day 14 following cesarean delivery at 30 weeks for severe preeclampsia
  • Infant: 1 kg birthweight, current status [document]
  • Current symptoms to assess and document:
    • Headache severity, visual changes (scotomata, blurred vision, photophobia) 1
    • Right upper quadrant or epigastric pain 1
    • Nausea, vomiting
    • Shortness of breath, chest pain
    • Urine output over past 24 hours (oliguria <400 mL/day suggests severe AKI) 2
    • Seizure activity
    • Breastfeeding status (critical for medication selection)
  • Past medical history: No chronic hypertension prior to pregnancy [document if confirmed]
  • Medications: Losartan 50 mg daily (MUST BE STOPPED—contraindicated postpartum if breastfeeding) 1

OBJECTIVE

Vital Signs:

  • BP: 150-170/[diastolic needed] mmHg (severe hypertension ≥160/110) 1
  • Heart rate, respiratory rate, temperature, oxygen saturation [document]

Laboratory Values (Current):

  • Renal: Creatinine 284 µmol/L (3.2 mg/dL)—severe AKI, BUN 10.97 mg/dL 1
  • Hepatic: ALT 137 U/L, AST 66 U/L, LDH 579 U/L (elevated, concerning for HELLP spectrum) 1
  • Electrolytes: Na 130.62 mmol/L, K 3.58 mmol/L, Mg 0.76 mg/dL (severe hypomagnesemia) 1
  • ABG: pH 7.27, PCO₂ 26.2 mmHg, HCO₃ 14.4 mmol/L (metabolic acidosis with respiratory compensation) 1

Physical Examination (Document):

  • General appearance, mental status
  • Cardiovascular: Heart sounds, peripheral edema
  • Pulmonary: Breath sounds, crackles (pulmonary edema?) 1
  • Abdominal: Right upper quadrant tenderness, hepatomegaly 1
  • Neurologic: Deep tendon reflexes, clonus (≥3 beats pathologic) 1
  • Extremities: Edema severity

ASSESSMENT

Primary Diagnosis:

  1. Postpartum preeclampsia with severe features (persistent >2 weeks postpartum with severe hypertension, AKI, hepatic dysfunction) 1, 2

Complications: 2. Acute kidney injury, Stage 3 (creatinine 3.2 mg/dL, likely acute tubular necrosis from preeclampsia-associated glomeruloendotheliosis) 2 3. Metabolic acidosis (pH 7.27, HCO₃ 14.4, likely from renal dysfunction and possible lactic acidosis) 1 4. Hepatic dysfunction (elevated transaminases, LDH—HELLP spectrum disorder) 1 5. Severe hypomagnesemia (0.76 mg/dL, normal 1.7-2.2 mg/dL) 1 6. Hyponatremia (130.62 mmol/L) 1

Differential Considerations (Lower Priority but Exclude):

  • Thrombotic microangiopathy (atypical HUS, TTP)—requires peripheral smear, haptoglobin, LDH trend 2
  • Acute fatty liver of pregnancy (unlikely at 2 weeks postpartum, but check ammonia, glucose if altered mental status)
  • Postpartum cardiomyopathy (requires echocardiogram) 3

PLAN

1. IMMEDIATE MANAGEMENT (Within 1 Hour)

Hypertension Control:

  • STOP losartan immediately (contraindicated in breastfeeding; ACE inhibitors/ARBs unsafe) 1, 4
  • Start oral nifedipine immediate-release 10 mg PO now, repeat every 20 minutes PRN to maximum 30 mg until BP <160/110 mmHg 1
  • Alternative if nifedipine unavailable: Oral labetalol 200 mg PO, repeat every 20-30 minutes to maximum 1200 mg/day 1
  • Target BP: Systolic 110-140 mmHg, diastolic 80-85 mmHg 1
  • Maintenance antihypertensive: Transition to long-acting nifedipine 30-60 mg PO daily OR labetalol 200-400 mg PO TID (both safe in breastfeeding) 1

Seizure Prophylaxis:

  • Magnesium sulfate NOT indicated unless patient develops neurologic symptoms (severe headache, visual changes, hyperreflexia with clonus) or BP remains ≥160/110 despite treatment 1
  • If indicated: MgSO₄ 4-6 g IV loading dose over 20 minutes, then 1-2 g/hour infusion 1

Electrolyte Correction:

  • Magnesium replacement: 2 g MgSO₄ IV over 2 hours, then recheck level (target >1.7 mg/dL) 1
  • Sodium correction: Restrict free water, monitor closely (correct slowly to avoid osmotic demyelination) 1

Metabolic Acidosis:

  • Do NOT give sodium bicarbonate unless pH <7.1 with hemodynamic instability (treat underlying cause—renal failure) 1
  • Monitor serial ABGs every 6-12 hours 1

2. MISSING DIAGNOSTICS (Order STAT)

Laboratory:

  • Complete blood count with peripheral smear (platelets, hemolysis, schistocytes for TTP/HUS) 1, 2
  • Coagulation panel: PT/INR, aPTT, fibrinogen, D-dimer (DIC screening) 1
  • Haptoglobin, indirect bilirubin (hemolysis assessment) 1
  • Uric acid (prognostic marker, not for delivery decision postpartum) 1
  • Albumin (nephrotic syndrome assessment) 2
  • Urine protein-to-creatinine ratio (quantify proteinuria, should be >0.3 mg/mg in preeclampsia) 1
  • Urinalysis with microscopy (RBC casts, dysmorphic RBCs suggest glomerular disease) 1, 2
  • Lactate (if acidosis worsens, rule out tissue hypoperfusion) 1

Imaging:

  • Renal ultrasound with Doppler (rule out obstruction, assess kidney size, resistive indices) 1, 2
  • Transthoracic echocardiogram (assess for peripartum cardiomyopathy, pulmonary hypertension, volume status) 1, 3
  • Head CT without contrast (if severe headache, visual changes, or altered mental status—rule out posterior reversible encephalopathy syndrome [PRES], hemorrhage) 1

3. CONSULTATIONS (Urgent)

  • Nephrology consult STAT for AKI management, possible dialysis indication (creatinine 3.2 mg/dL with metabolic acidosis) 1, 2
    • Indications for dialysis: Refractory acidosis (pH <7.1), hyperkalemia >6.5 mmol/L, volume overload with pulmonary edema, uremic symptoms 2
  • Maternal-Fetal Medicine or Obstetrics consult for postpartum preeclampsia management 1
  • Critical Care/ICU consult if BP uncontrolled, altered mental status, or pulmonary edema develops 1, 3

4. MONITORING

  • Admit to high-dependency unit or ICU 1, 3
  • Continuous BP monitoring (automated cuff every 15 minutes until stable <160/110, then hourly) 1
  • Strict intake/output monitoring (Foley catheter, target urine output >0.5 mL/kg/hour) 1, 2
  • Daily weights 1
  • Neurologic checks every 4 hours (reflexes, clonus, mental status) 1
  • Repeat labs in 12-24 hours: CBC, CMP, LFTs, coagulation panel 1

5. SUPPORTIVE CARE

  • Fluid management: Restrict to 80-100 mL/hour (avoid volume overload in AKI and preeclampsia) 1
  • Avoid NSAIDs (including celecoxib) for pain—nephrotoxic in preeclampsia with AKI 4
    • Use acetaminophen up to 4 g/day for analgesia 4
    • Consider opioids (oxycodone, morphine) if acetaminophen insufficient 4
  • Thromboprophylaxis: Enoxaparin 40 mg SC daily (if platelets >50,000/µL and no active bleeding) 1

6. DISPOSITION & FOLLOW-UP

  • Expected hospital stay: 3-7 days minimum until BP controlled, creatinine stabilizing, no end-organ progression 1, 5
  • Discharge criteria:
    • BP <140/90 mmHg on oral medications for 24 hours 1
    • Creatinine stable or improving 1, 2
    • No severe symptoms (headache, visual changes, RUQ pain) 1
    • Patient able to monitor BP at home 1
  • Outpatient follow-up:
    • Obstetrics/MFM in 1 week 1
    • Nephrology in 1-2 weeks (assess for chronic kidney disease—women with preeclampsia have 23-39% risk of chronic hypertension at 10 years) 5
    • Primary care in 2 weeks 1
    • Home BP monitoring twice daily 1

Chart Orders (Write Verbatim)

ADMIT to: High-Dependency Unit/ICU
Diagnosis: Postpartum preeclampsia with severe features, acute kidney injury Stage 3, metabolic acidosis
Condition: Serious
Allergies: [Document]
Code Status: Full code

VITAL SIGNS:

  • BP every 15 minutes until <160/110 mmHg, then every 1 hour
  • Continuous pulse oximetry
  • Neuro checks (reflexes, clonus) every 4 hours

DIET: Regular, sodium restriction 2 g/day, fluid restriction 1500 mL/day

IV FLUIDS: Lactated Ringer's at 80 mL/hour (strict I/O monitoring)

MEDICATIONS:

  1. DISCONTINUE losartan
  2. Nifedipine immediate-release 10 mg PO now, repeat every 20 minutes PRN for SBP ≥160 or DBP ≥110 mmHg (max 30 mg)
  3. Nifedipine extended-release 30 mg PO daily (start after BP controlled)
  4. Magnesium sulfate 2 g IV over 2 hours now (for hypomagnesemia)
  5. Acetaminophen 650 mg PO every 6 hours PRN pain
  6. Enoxaparin 40 mg SC daily (hold if platelets <50,000/µL)
  7. Docusate 100 mg PO BID

LABORATORY (STAT):

  • CBC with differential and peripheral smear
  • CMP (repeat creatinine, electrolytes)
  • Magnesium level (repeat after replacement)
  • PT/INR, aPTT, fibrinogen, D-dimer
  • Haptoglobin, indirect bilirubin
  • Uric acid, albumin
  • Lactate
  • Urine protein-to-creatinine ratio
  • Urinalysis with microscopy
  • Repeat in AM: CBC, CMP, LFTs, coagulation panel

IMAGING (STAT):

  • Renal ultrasound with Doppler
  • Transthoracic echocardiogram
  • Head CT without contrast if severe headache/visual changes

CONSULTATIONS (STAT):

  • Nephrology
  • Maternal-Fetal Medicine/Obstetrics
  • Critical Care (if BP uncontrolled or clinical deterioration)

MONITORING:

  • Foley catheter, strict intake/output
  • Daily weights
  • Telemetry monitoring

Critical Pitfalls to Avoid

  • Do NOT continue losartan—ACE inhibitors/ARBs are contraindicated in breastfeeding and postpartum 1, 4
  • Do NOT use NSAIDs (celecoxib, ibuprofen, ketorolac) for pain—nephrotoxic in preeclampsia with AKI 4
  • Do NOT aggressively fluid resuscitate—preeclampsia patients are volume-sensitive and at risk for pulmonary edema 1
  • Do NOT assume preeclampsia resolves immediately postpartum—can persist or worsen up to 6 weeks postpartum, with peak risk at 3-7 days 1, 2
  • Do NOT delay nephrology consultation—creatinine 3.2 mg/dL with metabolic acidosis may require dialysis 2
  • Do NOT use magnesium sulfate routinely—only indicated for seizure prophylaxis if severe features with neurologic symptoms 1

This patient requires intensive monitoring for at least 48-72 hours with twice-daily laboratory assessments until clinical improvement is documented 1. Long-term cardiovascular and renal follow-up is mandatory given the 23-39% risk of chronic hypertension and persistent renal dysfunction after severe preeclampsia 5, 2.

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

3
Guideline

Amniotic Fluid Embolism Diagnosis and Management

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

4
Guideline

Nephrotoxicity of Celecoxib in Postpartum Preeclampsia Patients

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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