In a 43‑year‑old woman who is 8 weeks pregnant and has a remote history of postpartum preeclampsia but no hypertension, diabetes, or other medical problems, what is the recommended preventive management to reduce the risk of recurrent preeclampsia?

Preventive Management for Recurrent Preeclampsia

This patient should be started on low-dose aspirin (75-162 mg daily) before 16 weeks gestation, ideally now at 8 weeks, given her history of postpartum preeclampsia which qualifies as a strong clinical risk factor for recurrence. 1

Primary Prevention Strategy

Low-Dose Aspirin Therapy

• Start aspirin 75-162 mg daily immediately (ideally before 16 weeks, definitely before 20 weeks gestation) to reduce the risk of preterm preeclampsia 1
• Prior preeclampsia—even if postpartum—is classified as an established strong clinical risk factor requiring aspirin prophylaxis 1
• This intervention specifically prevents preterm preeclampsia (before 37 weeks) rather than term preeclampsia 1
• Continue aspirin throughout pregnancy until delivery 1

Calcium Supplementation

• Add calcium supplementation (1.2-2.5 g/day) if dietary calcium intake is likely below 600 mg/day 1
• When dietary calcium intake cannot be reliably assessed, it is reasonable to provide supplementation 1
• Calcium should be given in addition to aspirin, not as a substitute 1

Additional Preventive Measures

Lifestyle Modifications

• Encourage regular exercise during pregnancy to maintain health, appropriate body weight, and reduce the likelihood of hypertension 1
• Counsel on maintaining ideal body weight throughout pregnancy 1

What NOT to Do

• Do not prescribe low molecular weight heparin for preeclampsia prevention, even with a history of prior early-onset preeclampsia—it is not indicated 1

Monitoring and Follow-Up

Enhanced Surveillance

• Consider first-trimester screening for preeclampsia risk using a combination of maternal risk factors, blood pressure, placental growth factor (PlGF), and uterine artery Doppler if available in your health system 1
• However, no first or second trimester test can reliably predict all cases of preeclampsia 1

Recurrence Risk Counseling

• Inform the patient she has approximately 15% risk of developing preeclampsia again and an additional 15% risk for gestational hypertension in this pregnancy 1
• She also has increased risk of small-for-gestational-age babies even if preeclampsia does not recur 1
• Discuss her increased long-term cardiovascular risks including cardiovascular disease, death, stroke, diabetes mellitus, venous thromboembolic disease, and chronic kidney disease 1

Clinical Reasoning

The ISSHP (International Society for the Study of Hypertension in Pregnancy) 2018 guidelines provide the most comprehensive and authoritative recommendations for this scenario 1. While this patient's preeclampsia occurred postpartum rather than antepartum, it still represents a strong clinical risk factor that warrants aspirin prophylaxis. The timing is critical—she is currently at 8 weeks, which is ideal for initiating aspirin therapy to maximize benefit.

Common Pitfalls to Avoid

• Do not delay aspirin initiation—the window of opportunity closes at 20 weeks, with optimal benefit when started before 16 weeks 1
• Do not assume postpartum preeclampsia carries lower recurrence risk—it should be treated as equivalent to antepartum preeclampsia for risk stratification 1
• Do not rely solely on biomarker testing (PlGF or sFlt-1/PlGF ratio) for clinical decision-making, as these are not recommended for routine use outside clinical trials 1