Clinical opinion
Obstetrics
Etiology and management of postpartum hypertension-preeclampsia

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Postpartum hypertension can be related to persistence of gestational hypertension, preeclampsia, or preexisting chronic hypertension, or it could develop de novo postpartum secondary to other causes. There are limited data describing the etiology, differential diagnosis, and management of postpartum hypertension-preeclampsia. The differential diagnosis is extensive, and varies from benign (mild gestational or essential hypertension) to life-threatening such as severe preeclampsia-eclampsia, pheochromocytoma, and cerebrovascular accidents. Therefore, medical providers caring for postpartum women should be educated about continued monitoring of signs and symptoms and prompt management of these women in a timely fashion. Evaluation and management should be performed in a stepwise fashion and may require a multidisciplinary approach that considers predelivery risk factors, time of onset, associated signs/symptoms, and results of selective laboratory and imaging findings. The objective of this review is to increase awareness and to provide a stepwise approach toward the diagnosis and management of women with persistent and/or new-onset hypertension-preeclampsia postpartum period.

Section snippets

Incidence

The exact incidence of postpartum hypertension is difficult to ascertain. In clinical practice, most women will not have their blood pressure (BP) checked until the 6 weeks' postpartum visit in physician's offices or in postpartum clinics. As a result, women with mild hypertension who are asymptomatic are usually not reported. In addition, postpartum women who have hypertension in association with symptoms such as headaches or blurred vision are often seen and managed in the emergency

Etiology and differential diagnosis

The etiology and different diagnosis of postpartum hypertension is extensive (Table), but it can be focused based on clinical and laboratory findings as well as response to treatment of BP. GH-preeclampsia (new onset or preexisting prior to delivery) is the most common cause, however, other life-threatening conditions such as pheochromocytoma and cerebrovascular accidents should also be considered.

New-onset postpartum hypertension-preeclampsia

Normal pregnancy is characterized by increased plasma volume in association with sodium and water retention in the interstitial tissue. This is further exaggerated in women with multifetal gestation. In addition, many women receive intravenously a large volume of fluids during labor, delivery, and postpartum. Large volumes of fluids are also given because of regional analgesia-anesthesia or during cesarean section. In some women, acute or delayed mobilization of large volume of fluid into the

Persistence/exacerbation of hypertension-proteinuria in women with preexisting GH-preeclampsia

Maternal hypertension and proteinuria will usually resolve during the first week postpartum in most women with GH or preeclampsia, however, there are conflicting data regarding the time it takes for resolution in such women.20, 21, 22, 23, 24, 25 The differences among various studies are due to the population studied, severity of disease process (mild, severe, with superimposed preeclampsia, HELLP syndrome), duration of follow-up, management (aggressive vs expectant), and criteria used for

Persistence/exacerbation of hypertension in chronic hypertension

Women with chronic hypertension during pregnancy are at increased risk for exacerbation of hypertension and/or superimposed preeclampsia.32 The risk depends on severity of hypertension, presence of associated medical conditions (obesity, type 2 diabetes, renal disease), or whether antihypertensive medications were used during pregnancy.32, 33 Hypertension or exacerbation of hypertension postpartum may be due to either undiagnosed essential chronic hypertension (women with limited medical care

Maternal complications

Maternal complications depend on ≥1 of the following: severity and etiology of the hypertension, maternal status at presentation (presence of organ dysfunction), and the quality of management used. Potential life-threatening complications include cerebral infarction or hemorrhage, congestive heart failure or pulmonary edema, renal failure, or death. Maternal outcome is usually good in those with only isolated hypertension or preeclampsia, whereas it is poor with pheochromocytoma,38, 39 stroke,

Evaluation and management of postpartum hypertension

Evaluation of patients with postpartum hypertension should be performed in a stepwise fashion and may require a multidisciplinary approach. Consequently, management requires a well-formulated plan that takes the following factors into consideration: predelivery risk factors, time of onset in relation to delivery, presence of signs/symptoms, results of laboratory/imaging findings, and response to initial therapy (Figure).

The most common cause for persistent hypertension beyond 48 hours after

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