In a postpartum woman with a history of pre‑eclampsia who experienced palpitations for two years that have now resolved, what evaluation and follow‑up are recommended?

Recommended Evaluation and Follow-Up

This patient should undergo a comprehensive cardiovascular assessment at 3 months postpartum (if not already done), and if palpitations have truly resolved with normal findings, she requires lifelong annual cardiovascular surveillance given her significantly elevated long-term risk of hypertension, stroke, and heart disease. 1, 2

Immediate Assessment (If Not Already Completed)

Even though palpitations have resolved, this patient needs evaluation to ensure no persistent cardiac dysfunction:

• Blood pressure measurement – Essential hypertension develops in approximately 40% of women with postpartum pre-eclampsia within 1-2 years, and she remains at elevated risk 3
• Urinalysis and urine protein-to-creatinine ratio – To confirm resolution of proteinuria and exclude underlying renal disease 1
• Basic metabolic panel and liver function tests – To ensure complete resolution of organ dysfunction 1, 4
• Transthoracic echocardiogram – Critical to exclude peripartum cardiomyopathy and assess for persistent left ventricular dysfunction or geometric abnormalities 4, 3
• 12-lead ECG – To screen for arrhythmias or conduction abnormalities 3

Why Cardiac Imaging Matters

Women with pre-eclampsia frequently develop asymptomatic left ventricular dysfunction during the acute phase. In preterm pre-eclampsia, 56% have moderate-to-severe left ventricular dysfunction or hypertrophy at 1 year postpartum, compared to only 8% of controls 3. While cardiac function typically improves over the first year, palpitations lasting 2 years suggest the possibility of underlying cardiac remodeling that warrants documentation 3, 5.

Differential Diagnosis for Her Palpitations

The 2-year duration of palpitations in the context of postpartum pre-eclampsia raises several possibilities:

• Peripartum cardiomyopathy (PPCM) – Can present with palpitations and has significant overlap with pre-eclampsia; most commonly presents 2-62 days postpartum but symptoms can persist 1
• Persistent cardiac remodeling – Pre-eclampsia causes left ventricular geometric changes and diastolic dysfunction that can manifest as palpitations 3, 5
• Hypertensive heart disease – Pre-eclampsia unmasks or accelerates essential hypertension 1
• Arrhythmias secondary to electrolyte disturbances – Pre-eclampsia can cause persistent metabolic derangements 4

The fact that pre-eclampsia and PPCM frequently coexist makes distinguishing them challenging, and confusion often arises when cardiac changes accompany pregnancy-induced hypertension 1.

Long-Term Cardiovascular Risk Counseling

This patient must understand she has substantially elevated lifetime cardiovascular risk:

• Approximately 15% risk of recurrent pre-eclampsia and 15% risk of gestational hypertension in future pregnancies 1
• Increased risk of cardiovascular disease, stroke, diabetes mellitus, venous thromboembolism, and chronic kidney disease compared to women with normotensive pregnancies 1, 6
• Women with pre-eclampsia have reduced life expectancy with increased cardiovascular and cerebrovascular events 6

Ongoing Surveillance Strategy

Lifelong annual follow-up is mandatory 1, 2:

• Annual blood pressure monitoring with her primary care physician 1, 2
• Periodic fasting lipid panels and glucose screening 1
• Maintenance of ideal body weight through regular aerobic exercise 1, 2
• Return to pre-pregnancy weight by 12 months postpartum 2

Future Pregnancy Planning

If she desires future pregnancies:

• Low-dose aspirin (75-100 mg daily) starting between 12-28 weeks gestation (ideally before 16 weeks) and continuing until delivery to reduce pre-eclampsia recurrence risk 1
• Aspirin reduces preterm pre-eclampsia from 4.3% to 1.6% in high-risk patients and is safe, well-tolerated, and cost-effective 1

Common Pitfalls to Avoid

• Do not assume resolution of symptoms means resolution of cardiovascular risk – Even asymptomatic women with prior pre-eclampsia have persistent subclinical cardiac dysfunction 3, 5
• Young women may have low 10-year cardiovascular risk scores using standard tools, leading clinicians to underestimate their true lifetime risk 1
• Do not delay the 3-month postpartum assessment – This visit is critical for distinguishing transient pregnancy-related changes from persistent dysfunction requiring specialist referral 1, 2
• Screen for postpartum depression, anxiety, and post-traumatic stress disorder at follow-up visits, as these are common after complicated pregnancies 1