Postpartum Preeclampsia Symptoms And Causes

Overview

Are you a new parent looking for answers regarding symptoms you are facing after birth, for example, high blood pressure? Giving birth takes a heavy toll on the body and may be associated with some illnesses. One is known as postpartum preeclampsia, which will be the focus of our topic today. Preeclampsia is one of the leading causes of maternal death and mortality worldwide. It can involve short or long-term complications.¹

So, what is postpartum preeclampsia (PE)? It is a condition that can occur after childbirth. It is characterised by high blood pressure (≥ 140/90), proteinuria (≥300mg in 24-hr urine sample) and damage to organs. The organs most commonly affected are the liver and the kidneys.² Preeclampsia itself is a pregnancy-related condition. It occurs either immediately (within the first 48 hours) or delayed (48 hours to 6 weeks after delivery).³ If preeclampsia persists or develops after childbirth, it is then referred to as postpartum preeclampsia.

Hypertensive disorders of pregnancy can increase complications during pregnancy by 10-20%.³ Most cases are diagnosed during the antepartum period. However, postpartum PE is recognised as an important factor in maternal morbidity.³ 

There are several risk factors for postpartum PE. These risk factors include age, race, obesity and caesarean delivery.³ All of these factors can increase the risk of PE. Most women with a delayed onset of postpartum PE have symptoms within 7-10 days after delivery. These are usually associated with neurological symptoms (for example, headaches).³ Hence, it is important to shed light on this topic and diagnose it ASAP to have the proper care and interventions. This is vital because this condition can progress to severe preeclampsia, eclampsia or HELLP (haemolysis, elevated liver enzymes, and low platelets) syndrome rapidly.^2,4

Symptoms of postpartum preeclampsia

There are multiple signs and symptoms of postpartum PE, including:^2,4,5,6

• Hypertension (persistent high blood pressure (≥ 140/90)
• Proteinuria (the presence of different and persistent amounts of protein in the urine). This can be a sign of kidney damage. It can also lead to increased risk of cardiovascular disease. Hence, it is important to test for the presence of these proteins. This is usually done through urine dipstick, blood pressure, albumin/creatinine ratio and serum creatinine tests
• Severe headaches that do not go away
• Visual changes and disturbances
• Swelling (oedema) in the face and hands
• Nausea and vomiting
• Stomach pain
• Shortness of breath
• Seizures
• Strokes
• Organ damage
• Death

Causes and origin of postpartum preeclampsia

There is no single definitive cause for postpartum PE. However, contributing factors were suggested to include placental dysfunction and an altered immune system. This results in poor uteroplacental perfusion, leading to placental hypoxia (low oxygen). This is seen as stage 1.² 

The consequence of stage 1 is the release of soluble factors into the mother's circulation. These soluble factors bring about stage 2. Stage 2 consists of systemic endothelial dysfunction and hypertension.² Aside from the cause, certain risk factors can contribute to the development of postpartum PE (Table 1).

Table 1. Clinical risk factors of PE²

Diagnosis and detection of preeclampsia

Diagnosis of PE is well established. It is usually done by monitoring blood pressure, urine analysis (urinalysis), and physical examination.² The diagnostic criteria for preeclampsia are listed below.

• Blood pressure:
  • Before pregnancy: blood pressure elevations (≥ 140/90) diagnosed before 20 weeks on 2 occasions at least 4 hours apart
  • During pregnancy: 2 elevated blood pressure readings (≥140/90) after 20 weeks on 2 occasions at least 4 hours apart
• Urinalysis: 300 mg protein or more in a 24-hour urine sample; a protein/creatinine ratio of 0.3 or higher on urine dipstick; 2+ protein on urine dipstick

Management and treatment options of postpartum PE

There are multiple treatment options. Delivery, in most cases, is the acute treatment. However, it is not a cure. According to James N. Martin (MD, past president of the American College of Obstetricians and Gynaecologists and member of the Preeclampsia Foundation Medical Advisory Board): “It takes time for the uterus to shed its lining after birth, so this process may be behind the delay that's sometimes seen in [postpartum preeclampsia] after delivery”.⁴ Other forms of treatment are listed in Table 2.

Table 2. Approach to managing postpartum PE³

Note: BP = blood pressure, IV: intravenous

Prevention and risk reduction

Prevention and risk reduction in PE can be handled through regular prenatal check-ups. These can consist of regular blood pressure monitoring as well as urinalysis for early detection of proteinuria. Furthermore, lifestyle modifications and adjustments are just as important.

A healthy diet, exercise, and weight management can improve blood pressure and make the appearance of PE less likely. Additionally, it is important for healthcare clinicians to stay updated with new advancements in science (including PE) and relay this information to their patients.

This can help detect early signs of the illness and provide a personalised plan for illness management/prevention. It is also important to continue with a postpartum follow-up session to detect any changes in blood pressure. This is important since PE can manifest 6 weeks after delivery, as mentioned before.

Research recommendations

There are still many unanswered questions when it comes to the aetiology, diagnosis, and management of postpartum preeclampsia. These gaps in knowledge are addressed in Table 3.

Table 3. Future research gaps and priorities in postpartum PE³

Summary

Postpartum preeclampsia is an illness that contributes massively to maternal and foetal morbidity and mortality. Understanding how to prevent and treat this disorder is crucial to improving maternal and foetal health.

An accurate understanding of preeclampsia and disease progression development is important in improving patient care. It would also allow the prevention of unfortunate outcomes. PE significantly impacts overall heart health and the development of future cardiovascular disease.

PE also affects the development of chronic hypertension and liver, kidney and neurologic consequences. This disease has important immediate and long-term effects on the newborn child. This further illustrates the importance of accurate treatment and prevention of PE.

Given the enormity of this impact on short-term and long-term health, more research looking into ways to prevent this disease is needed. Additionally, particular emphasis should be placed on long-term follow-up after a pregnancy complicated by PE.