Postpartum Preeclampsia Diagnosis And Treatment

Overview

According to the World Health Organisation (WHO), 14% of global maternal deaths are caused by hypertension (high blood pressure).¹ A common manifestation of maternal hypertension is postpartum preeclampsia, defined as the sudden onset of hypertension and proteinuria (the presence of protein in the urine) up to four weeks after childbirth.² If left untreated, preeclampsia can develop into eclampsia and cause women to experience seizures or enter into a coma. The failure to promptly recognise and treat eclampsia can therefore be fatal.³ Alarmingly, 99% of the global maternal deaths caused by hypertension are associated with women from developing areas.¹ While some postpartum disorders are increasingly acknowledged in medical care, postpartum preeclampsia remains one of the many pregnancy-related disorders that have yet to be addressed in new mothers. Diagnosing postpartum preeclampsia is fundamental because it lays the foundation for providing new mothers with prompt and effective treatments. However, the diagnosis of this disorder is currently challenging due to the lack of research-based and clinically proven guidance.⁴

Diagnosis 

Despite the existence of limited guidance on the clinical diagnosis of postpartum preeclampsia, scientific research has identified a set of signs and symptoms which are commonly associated the disorder. Women who experience any of the following signs and symptoms within six weeks of delivery should urgently seek medical care to ensure that they are not at risk of developing eclampsia:

• Severe headaches
• Visual difficulties characterised by vision blurring or the sensation of flashing lights
• Pain below the ribs
• Vomiting
• Sudden swelling of the feet, ankles, face, and hands⁵

Standard clinical practice following a consultation discussing these symptoms involves taking blood pressure measurements and conducting a urine test. Early indicators of postpartum preeclampsia include blood pressure measurements consistently over 140/90 mmHg within every four-hour intervals and a protein-to-creatinine ratio of 0.3 in the urine.⁴ According to guidance from the National Institute of Health and Care Excellence (NICE), the presence of hypertension coupled with either proteinuria or at least one of the following symptoms justifies the diagnosis of preeclampsia up to 20 weeks after childbirth:

• Renal insufficiency: characterised by creatinine concentration above 90 µM/L
• Impaired liver function: characterised by high levels of the liver enzyme transaminase with or without abdominal pain 
• Thrombocytopenia (low blood platelet levels): characterised by a blood platelet count below 150,000 per µL
• Neurological issues: including blindness, stroke, partial loss of vision, the presence of a blindspot or changes in mental state⁶

Immediate intervention through blood pressure monitoring and conducting diagnostic tests to discard the occurrence of alternative health conditions is vital to determine and proceed with the appropriate course of treatment. 

Treatment 

Upon the diagnosis of postpartum preeclampsia, patients should be tested for the Haemolysis, Elevated Liver enzymes and Low Platelets (HELLP) syndrome.⁷ The HELLP syndrome is a rare and life-threatening complication of postpartum preeclampsia that affects the liver and blood clotting,; up to a week after childbirth.⁸ It is diagnosed through a complete blood count, a peripheral smear, and liver enzyme and creatinine tests ⁹. Once the health status of the patient is clear, it is safe to proceed with the appropriate treatment for postpartum preeclampsia. 

Preeclampsia treatments aim to reduce the patient’s high blood pressure and stabilise their condition, thereby preventing further complications. To control a patient’s blood pressure, clinicians prescribe antihypertensive medications during and after hospitalisation. Methyldopa is commonly prescribed as a first line of treatment and administered twice a day at a dosage of 250 to 500mg. Labetalol can be used as a more effective alternative than methyldopa and administered twice a day at a dosage of 100 to 200mg. Additionally, clinicians often prescribe Nifedipine as a second line of treatment administered once per day in the case of emergency at a dosage of 20 to 30mg.^7,10 

While medication is key to improving the patient’s condition, the latter must still be actively monitored at the hospital to ensure that the treatment is successful. Frequent blood pressure measurements, urinalysis, and other diagnostic tests may be carried out to assess if the patient’s condition has improved. In addition, a robust aftercare plan should be set in place to reduce the possibility of future complications. Open communication about potential side effects and any changes in symptoms or overall well-being will ultimately benefit the patient and the hospital. 

Precautions

Postpartum preeclampsia cannot be prevented, but related complications can be prevented through the implementation of precautionary measures. The first of these measures should be to monitor patients during their pregnancy for the emergence of any of the preeclampsia symptoms, especially those who have a higher risk of developing the condition. It would also be good practice to manage patients’ primary health conditions to reduce the risk of pregnancy-related issues, especially if patients have a history of hypertension. According to a case-control study of 65 Ghanaian women with postpartum preeclampsia,¹¹ these are the most significant risk factors for the emergence of postpartum preeclampsia:

• Lack of exercise or physical activity 
• High use of painkillers
• Infrequent visits to the hospital during pregnancy
• Cesarean delivery 
• Use of contraceptives¹¹

The NHS states that the best solution to reduce the risk of preeclampsia-related complications is to deliver the baby early, typically at the 37-38th week mark. This can help stabilise the mother’s health status. It is also important to discuss placental growth factor protein (PLGF) testing with your obstetrician. Since lower levels of the placental growth factor protein (PLGF) are present in the blood serum and urine of women with preeclampsia, the protein has been hypothesised to have a role in preeclampsia. More precisely, decreased levels of PLGF are thought to be indicative of abnormalities during the early phases of placental development.¹³ Otherwise, immediate acknowledgement of symptoms, diagnosis and treatment are some of, if not the most, important precautions to take if you or someone you know show signs of postpartum preeclampsia.

FAQ’s

Can a person breastfeed whilst on antihypertensive drugs to treat postpartum preeclampsia?

Not every antihypertensive drug is suitable for women who are breastfeeding. Research has shown that the majority of the antihypertensive drugs available on the market are excreted into a mother’s breast milk.¹⁴ Whether or not these are recommended to breastfeeding women depends on the implications of taking and abstaining from the medication. A NICE meta-analysis of antihypertensive drug trials and studies showed that, while complications such as hypoglycaemia can occur in newborns, there is not enough high-quality evidence to refrain clinicians from prescribing these drugs to mothers with high blood pressure. Ultimately, the NICE committee reached the consensus that treating the mother’s hypertension is more important, given the evident risk of eclampsia in mothers in comparison to the minimal risks associated with the presence of these drugs in breastfed newborns.^15,16 It is recommended to consult an obstetrician to assess which antihypertensive drug is most appropriate for you and your baby.

Does postpartum preeclampsia increase the risk of complications in future pregnancies?

Recent findings have revealed that a history of postpartum preeclampsia increases the likelihood of cardiovascular events in the future. A meta-analysis of 43 articles and a systemic review of 50 articles found that women with this clinical history were at significantly higher odds of fatal or diagnosed cardiovascular disease, cerebrovascular disease, and hypertension: odds ratio of 2.28, 1.76, and relative risk of 3.13 respectively.¹⁷ While postpartum preeclampsia reoccurs in only 15% of future pregnancies,¹⁸ there is a common repetitive pattern of cardiovascular disease when compared to women who have not had the condition. Hence, women with a history of postpartum preeclampsia should be referred to educational programmes, commit to regular check-ups, and maintain a healthy lifestyle to prevent any cardiovascular-related health problems. 

Summary

Postpartum preeclampsia is one of several pregnancy-related conditions unheard of by the general public, leading many women to overlook their symptoms for ordinary postpartum symptoms. As with any health concern, recognising new and troubling symptoms and reaching out to a healthcare professional is pivotal to getting a timely diagnosis and receiving adequate treatment to ensure that symptoms do not escalate. Postpartum preeclampsia diagnosis involves taking frequent blood pressure measurements to check for hypertension and undergoing urinalysis to test for proteinuria. Treatment is then prescribed to tackle these symptoms, in particular hypertension with antihypertensive drugs. Nonetheless, there is still a need to improve awareness around postpartum preeclampsia so that women can promptly identify its symptoms and seek treatment before they are at risk of developing eclampsia.