A postpartum woman three days after surgery for severe pre‑eclampsia is on losartan twice daily and amlodipine 5 mg daily, but her blood pressure remains 180/120 mmHg; what additional medication should be given?

Immediate Management of Severe Postpartum Hypertension

Add intravenous labetalol immediately for this hypertensive emergency (BP 180/120 mmHg), as blood pressure ≥160/110 mmHg lasting >15 minutes requires urgent treatment to prevent stroke and other cerebrovascular complications. 1

Critical First Steps

Immediate IV Antihypertensive Therapy

• Administer IV labetalol as the first-line agent for this hypertensive emergency, with dosing of 20 mg IV bolus initially, followed by 40-80 mg every 10 minutes (maximum cumulative dose 300 mg) until BP is controlled 1
• Alternative immediate options if IV labetalol is unavailable include IV hydralazine (5-10 mg IV bolus, repeat every 20 minutes as needed) or immediate-release oral nifedipine (10-20 mg, repeat every 20-30 minutes) 1
• Target BP should be systolic <160 mmHg and diastolic <110 mmHg to prevent cerebrovascular accidents, which are life-threatening at these pressure levels 1, 2

Critical Medication Review

• Discontinue losartan immediately – this medication is contraindicated in the postpartum period for breastfeeding mothers and lacks safety data in this population 2, 3
• Continue amlodipine 5 mg but consider increasing to 10 mg daily once acute crisis is controlled, as this is a preferred agent for postpartum hypertension 1, 2, 4

Transition to Oral Regimen

Preferred Oral Antihypertensives for Postpartum

Once BP is acutely controlled with IV therapy, transition to or optimize oral medications:

• Oral labetalol (starting 200 mg twice daily, titrate up to maximum 900 mg/day in divided doses) – safe for breastfeeding 1, 2
• Oral nifedipine (immediate or extended-release, 30-60 mg daily in divided doses) – safe for breastfeeding and highly effective 1, 2
• Continue amlodipine and increase to 10 mg daily if needed – this is compatible with breastfeeding and achieves sustained control 2, 4
• Consider adding oral methyldopa (250-500 mg 2-3 times daily) as a third agent if needed, though it should NOT be used for acute BP reduction 1

Additional Adjunctive Therapy

• Consider adding furosemide 20 mg daily for 5 days – this has been shown in severe postpartum preeclampsia to lower systolic BP more rapidly (mean 142 vs 153 mmHg by day 2) and reduce need for antihypertensive therapy at discharge (6% vs 26%) 5
• Furosemide enhances postpartum diuresis and may accelerate resolution of severe hypertension 5

Critical Monitoring and Safety Measures

Magnesium Sulfate Considerations

• Assess need for magnesium sulfate – if this patient has severe features (BP ≥160/110 mmHg qualifies), neurological symptoms (headache, visual changes), or repeated severe hypertensive episodes, administer magnesium sulfate 4-5g IV loading dose over 5-10 minutes, followed by 1-2g/hour infusion for seizure prophylaxis 1, 6, 2
• CRITICAL PITFALL: Never give calcium channel blockers (nifedipine/amlodipine) concomitantly with magnesium sulfate due to risk of severe hypotension from synergistic effects 6

Intensive Monitoring Protocol

• Monitor BP every 15 minutes until controlled, then every 4-6 hours while awake for minimum 3 days 1, 2
• Assess for neurological warning signs: severe headache, visual scotomata, altered mental status, right upper quadrant pain 1, 2
• Monitor for early signs of pulmonary edema: tachycardia, oliguria, shortness of breath 6, 2
• Repeat laboratory tests (hemoglobin, platelets, creatinine, liver transaminases) daily until stable 1, 2

Medication Precautions

• Avoid NSAIDs (ibuprofen, ketorolac) for postpartum analgesia – these worsen hypertension through sodium/water retention and can precipitate acute kidney injury in preeclampsia 2, 7
• Use acetaminophen as first-line analgesic instead 7
• Avoid ergot derivatives for postpartum hemorrhage management as these can worsen hypertension 1

Common Pitfalls to Avoid

• Do not delay IV antihypertensive therapy – BP ≥160/110 mmHg for >15 minutes is a medical emergency requiring immediate treatment 1
• Do not continue losartan postpartum – switch to labetalol, nifedipine, or increase amlodipine instead 1, 2
• Do not use methyldopa for acute BP reduction – it is too slow-acting for urgent management 1, 6
• Do not abruptly discontinue antihypertensives – taper gradually only after days 3-6 postpartum unless BP falls <110/70 mmHg 6, 2
• Do not discharge before 24 hours or until BP is stable and neurological symptoms have resolved 6

Discharge Planning

• Most women can be discharged by day 5 if BP is controlled and they have home BP monitoring capability 2
• Arrange follow-up within 1 week if still on antihypertensives at discharge 2
• All women should be reviewed at 3 months postpartum to confirm normalization of BP, urinalysis, and laboratory parameters 1, 2
• Counsel about 15% recurrence risk in future pregnancies and increased lifetime cardiovascular disease risk 2