A postpartum woman, 4 weeks after delivery, with prior gestational hypertension and a current blood pressure of 120/80 mm Hg, what is the most appropriate next step in management?

Management of Postpartum Woman with Resolved Gestational Hypertension at 4 Weeks

At 4 weeks postpartum with a blood pressure of 120/80 mmHg, this patient requires continued monitoring with a mandatory follow-up visit at 6 weeks (up to 3 months) postpartum, but does not need antihypertensive medication at this time. 1

Current Blood Pressure Assessment

• A blood pressure of 120/80 mmHg is normal and does not meet the diagnostic threshold for postpartum hypertension, which requires ≥140/90 mmHg on repeated measurements 1
• No antihypertensive medication is indicated at this blood pressure level 1
• Salt restriction is not recommended in the early postpartum period, as it may lead to intravascular volume depletion 1

Required Follow-Up Timeline

Critical 6-Week Postpartum Visit (Must Be Scheduled)

All women with a history of gestational hypertension must have a comprehensive evaluation between 6 weeks and 3 months postpartum to confirm complete resolution. 2, 1

This visit must include:

• Blood pressure measurement to verify normalization 2, 1
• Urinalysis to confirm resolution of any proteinuria 2, 1
• Laboratory testing to ensure normalization of any prior abnormalities 2, 1

When to Initiate Antihypertensive Therapy

• Medication should only be started if blood pressure remains ≥140/90 mmHg at the 6-week assessment 1
• If elevated readings are found, confirm with repeat office measurement during the same visit 1
• Consider 24-hour ambulatory blood pressure monitoring (ABPM) when office readings are elevated, as it better predicts adverse outcomes 1
• Home blood pressure monitoring should be initiated to track trends if any elevation is detected 2, 1

Critical Safety Consideration

Approximately 10% of maternal deaths related to hypertensive disorders occur after delivery, with blood pressure typically peaking between days 3-7 postpartum and potentially remaining elevated for several weeks. 1 This patient must not be discharged from postpartum care without the 6-week visit being scheduled.

Long-Term Cardiovascular Risk Management

Annual Lifelong Monitoring Required

Women with prior gestational hypertension face markedly increased lifetime cardiovascular risk and require:

• Annual medical review for life, including at minimum a blood pressure check 2, 1
• ABPM to confirm persistent hypertension when office readings are elevated 1
• Periodic measurement of fasting lipids and blood glucose 1

Lifestyle Modifications to Reduce Future Risk

• Achieve pre-pregnancy weight by 12 months postpartum 2, 1
• Limit interpregnancy weight gain 2, 1
• Maintain regular physical activity and ideal body weight 2, 1
• Adopt a healthy diet 2

Future Pregnancy Risk

Women with gestational hypertension have:

• Approximately 25% risk of recurrent gestational hypertension in future pregnancies 1
• Increased lifetime risk of cardiovascular disease, stroke, ischemic heart disease, and thromboembolic disease 1

If Hypertension Persists Beyond 12 Weeks

• Persistent hypertension or proteinuria beyond 12 weeks postpartum indicates chronic hypertension rather than gestational hypertension 1
• This requires referral for further investigation and workup for secondary causes of hypertension, especially in women under age 40 1

Safe Antihypertensive Medications for Breastfeeding (If Needed)

If treatment becomes necessary at future visits:

• First-line agents: Labetalol, nifedipine (long-acting), methyldopa, enalapril 1
• Avoid diuretics: They may reduce milk production 2, 1

Answer: The most appropriate next step is to ensure a follow-up visit is scheduled at 6 weeks postpartum (option closest to monitoring, though none of the provided options perfectly captures the guideline-recommended approach). Annual follow-up alone (option C) is insufficient, and immediate treatment (option B) is not indicated at this normal blood pressure.