A woman with a history of gestational hypertension who delivered four weeks ago now has a blood pressure of 133/88 mm Hg; what is the most appropriate next step in management?

Management of Postpartum Blood Pressure After Gestational Hypertension

At 4 weeks postpartum with a blood pressure of 133/88 mmHg, this woman should be scheduled for a 3-month postpartum follow-up visit to confirm normalization of blood pressure and laboratory values, as her current BP does not require antihypertensive treatment. 1

Current Blood Pressure Assessment

• Her BP of 133/88 mmHg is elevated but does not meet the treatment threshold for postpartum hypertension, which is widely considered to be ≥150/100 mmHg in the postpartum period 1

• Many clinicians also treat postpartum individuals who develop stage 2 hypertension (BP >140/90 mmHg) to a BP goal of <130/80 mmHg, but at 133/88 mmHg, she falls below even this more aggressive threshold 1

• Blood pressure typically rises over the first 5 postpartum days and women may become hypertensive again after initial normalization, but by 4 weeks postpartum, this acute phase has passed 1, 2

Recommended Management Plan

Immediate Actions (None Required)

• No antihypertensive medication is indicated at this BP level 1, 3
• No urgent evaluation or hospitalization is needed, as she does not have severe hypertension (≥160/110 mmHg) or symptoms suggesting postpartum preeclampsia 1

Short-Term Follow-Up

• Schedule a 3-month postpartum visit where BP, urinalysis, and all laboratory tests should have normalized 1
• If BP remains elevated at 3 months, further investigation for secondary causes of hypertension or underlying renal disease is required 1
• Assessment should also include screening for depression, anxiety, or posttraumatic stress disorder symptoms 1

Home Monitoring Considerations

• Consider home BP monitoring if available, with a diagnostic threshold of ≥135/85 mmHg for home readings 2
• If home readings consistently exceed 135/85 mmHg or clinic readings exceed 140/90 mmHg before the 3-month visit, earlier reassessment is warranted 3, 2

Long-Term Cardiovascular Risk Counseling

This patient requires lifelong follow-up due to significantly increased cardiovascular risk following gestational hypertension:

• Women with gestational hypertension have almost 4-fold increased risk of developing chronic hypertension and more than twice the risk of ischemic heart disease compared to women with normotensive pregnancies 1

• Annual medical review is recommended lifelong for cardiovascular risk assessment 1, 2

• Counsel on lifestyle modifications including weight management, regular exercise, healthy diet, and avoidance of smoking to reduce future cardiovascular risk 1

• Regular BP control and monitoring of metabolic factors (lipids, glucose) are essential 1

Common Pitfalls to Avoid

• Do not dismiss mildly elevated BP readings in the postpartum period - while 133/88 mmHg doesn't require treatment now, it signals the need for close long-term surveillance 1

• Do not delay the 3-month postpartum visit - this is when persistent abnormalities requiring further workup should be identified 1

• Do not fail to counsel about future pregnancy risk - women with gestational hypertension in their first pregnancy are at increased risk in subsequent pregnancies, with earlier onset correlating with greater recurrence risk 1

• Be alert for postpartum preeclampsia, which can develop de novo in the early postpartum period and would present with BP ≥160/110 mmHg combined with persistent headache, severe abdominal pain, shortness of breath, or vision changes 1