When can antihypertensive medication be stopped in a healthy postpartum woman who was treated for gestational hypertension, pre‑eclampsia, or chronic hypertension during pregnancy, assuming her blood pressure is stable (<140/90 mm Hg or <150/100 mm Hg for chronic hypertension) and she is asymptomatic?

When to Stop Antihypertensives After Pregnancy

Antihypertensive medications should be continued postpartum and tapered slowly only after days 3 to 6 postpartum, unless blood pressure becomes low (<110/70 mm Hg) or the woman becomes symptomatic in the meantime. 1

Critical Timing Considerations

Blood pressure typically worsens between days 3 to 6 postpartum, making this the highest-risk period for hypertensive complications including stroke and eclampsia. 1 This physiologic pattern explains why medications must be continued through this critical window rather than stopped immediately after delivery.

Early Postpartum Period (Days 0-3)

• Continue all antihypertensive medications administered antenatally without interruption. 1
• Monitor blood pressure at least every 4 to 6 hours while awake for a minimum of 3 days postpartum. 1
• Women with preeclampsia should be considered at high risk for complications for at least 3 days and require intensive monitoring. 1
• Eclamptic seizures may develop for the first time in the early postpartum period, necessitating continued vigilance. 1

Mid-Postpartum Period (Days 3-6 and Beyond)

• Begin tapering antihypertensives slowly after day 3 to 6 postpartum, but never cease abruptly. 1
• Withdraw therapy gradually over days, not all at once, to avoid rebound hypertension. 1
• Stop or reduce medications earlier if diastolic blood pressure falls below 80 mm Hg or systolic below 110 mm Hg, or if the woman becomes symptomatic from hypotension. 1

Medication-Specific Considerations

Methyldopa Must Be Switched Postpartum

• Switch methyldopa to an alternative agent (labetalol or nifedipine) in the postpartum period due to its association with postpartum depression. 1, 2
• This switch should occur as soon as feasible after delivery, ideally within the first few days. 1, 2

Preferred Postpartum Agents

• Labetalol and extended-release nifedipine are the preferred long-acting agents for persistent postpartum hypertension. 2, 3, 4
• Both medications are safe for breastfeeding mothers. 1, 2
• Enalapril is also safe during lactation and may be considered, though it requires documented contraception due to teratogenicity risk in future pregnancies. 2

Discharge Planning and Follow-Up

Safe Discharge Criteria

• Most women can be discharged by day 5 postpartum if blood pressure is stable, especially when they are able to monitor their blood pressure at home. 1
• Women still requiring antihypertensives at hospital discharge should be reviewed within 1 week. 1

Mandatory 3-Month Follow-Up

• All women should be reviewed at 3 months postpartum to ensure blood pressure, urinalysis, and laboratory abnormalities have normalized. 1, 5
• If proteinuria or hypertension persists at 3 months, appropriate referral for further investigation should be initiated. 1
• Persistent hypertension at 6 weeks postpartum requires specialist referral and workup for secondary causes. 1

Common Pitfalls to Avoid

Never Stop Medications Abruptly

• Abrupt cessation of antihypertensives can precipitate severe rebound hypertension and increase stroke risk. 1 The taper must be gradual over days.

Do Not Ignore the Day 3-6 Window

• Many clinicians mistakenly assume hypertension improves immediately after delivery, but the opposite is true—blood pressure often worsens between days 3 to 6 postpartum. 1 This is when most postpartum strokes occur.

Avoid NSAIDs in Preeclampsia

• NSAIDs should be avoided in women with preeclampsia, especially in the setting of acute kidney injury, placental abruption, sepsis, or postpartum hemorrhage. 1, 5
• Use alternative analgesia such as acetaminophen as first choice. 1, 5

Monitor for De Novo Postpartum Preeclampsia

• Preeclampsia may develop for the first time in the postpartum period. 1 Continue monitoring neurological status, blood pressure, and laboratory values even in women who were normotensive during pregnancy.

Long-Term Cardiovascular Risk

• All women with gestational hypertension or preeclampsia require lifelong follow-up because of their increased cardiovascular risk. 1
• These women have elevated risks of cardiovascular disease, death, stroke, diabetes mellitus, venous thromboembolic disease, and chronic kidney disease compared with women who had normotensive pregnancies. 1
• Annual medical review is advised lifelong, with emphasis on healthy lifestyle including exercise, eating well, and achieving ideal body weight. 1