Introduction

Postpartum preeclampsia is a rare condition that causes someone to have high blood pressure and increased levels of protein in their urine for up to 6 weeks after childbirth. It can develop in anyone who has just given birth to a baby. Postpartum preeclampsia can be a silent, yet deadly condition. If left untreated, it can result in seizures and other serious complications, such as brain damage, organ damage, stroke and even death. 

The condition can develop suddenly with the potential to escalate rapidly, highlighting the need for public awareness and education for early detection and intervention. 

This article will detail the symptoms, causes and risk factors of postpartum preeclampsia, alongside methods of diagnosis and detection. Read on to find out whether you are at risk of developing this condition, and the treatment options that are available to manage and prevent the severe complications associated with postpartum preeclampsia.

What is postpartum preeclampsia?

Preeclampsia is a condition affecting some pregnant people during the second half of their pregnancy. The condition can affect both mother and baby, accounting for at least 5-8% of all pregnancies. It is defined as the development of hypertension and proteinuria (protein in your urine) after 20 weeks gestation (20 weeks of pregnancy).¹ Hypertension, or high blood pressure (BP) is characterised as having a BP reading of 140/90 mmHg or more. Though usually resolved following birth, preeclampsia can be fatal, accounting for 15% of direct maternal deaths in the UK.²

Postpartum preeclampsia differs from preeclampsia as the former condition occurs after birth and thus only affects the mother and the latter during pregnancy. The majority of postpartum preeclampsia cases affect people from 48 hours after childbirth. However, it can also develop up to 6 weeks postpartum and is sometimes referred to as late postpartum preeclampsia.³ Those who have never suffered from hypertension or preeclampsia during pregnancy are still susceptible to developing the condition after childbirth.

Signs and symptoms of postpartum preeclampsia

Those who experience postpartum preeclampsia may show no signs or symptoms during their pregnancy and can be difficult to identify without a doctor. 

However, noticeable symptoms you may experience after delivery that indicate postpartum preeclampsia can involve:

• Hypertension - a BP reading of 140/90 mmHg or more
• Proteinuria
• Pain in the upper right side of the abdomen 
• Severe headaches that do not go away after taking over-the-counter (OTC) medications
• Disturbances to vision, including blurred vision, photophobia, or seeing spots
• Nausea
• Vomiting
• Decreased urination
• Shortness of breath
• Rapid weight gain
• Swelling in the face, arms and legs

What causes postpartum preeclampsia?

The exact causes of both preeclampsia during pregnancy and postpartum preeclampsia are not well understood. However, quick changes in hormone levels and fluid shifts that arise after delivery can increase BP.³ Certain factors can increase the development of the condition.

Risk factors for postpartum preeclampsia

Although there is limited research, risk factors for postpartum preeclampsia may include:³

• Chronic high BP - If you have a history of uncontrolled high BP prior to pregnancy, you are at a greater risk of preeclampsia and postpartum preeclampsia
• Diabetes
• Older maternal age - an age of 35 years or older may mean you have a two-fold increased risk of developing postpartum preeclampsia
• Black race - Those who are of black race have a 2-4 fold increased risk in comparison to other races
• Pre-pregnancy obesity - Having a body mass index (BMI) larger than 40 kg/m² is associated with greater risk
• Caesarean delivery is linked to a greater risk of developing the condition compared to vaginal delivery
• Having multiples, such as twins or triplets
• Family history of either preeclampsia or postpartum preeclampsia

Diagnosis of postpartum preeclampsia

If it is suspected that you have postpartum preeclampsia and you have been discharged from the hospital following delivery, you may be readmitted. The following diagnostic tests may be performed:

• Blood pressure tests - Measuring blood pressure to determine whether you are suffering from hypertension. Your BP will be checked before leaving the hospital after delivery and at post-birth doctor visits. If postpartum preeclampsia is suspected, a blood test and urinalysis may be performed to get a more accurate diagnosis
• Blood tests - Blood tests to ensure the normal function of your liver and kidneys. A platelet count is also performed to check that your blood has a normal level of platelets (cells that aid the blood to clot)
• Urinalysis - A urine sample will be collected to identify excess levels of  protein
• Brain scan - This test can be conducted to look for possible brain damage caused by any seizures 

Treatment and management 

Postpartum preeclampsia does not resolve itself and therefore requires immediate medical attention. 

BP is known to peak around three to six days postpartum in normotensive patients and those with previous hypertension. Drugs such as nonsteroidal anti-inflammatory drugs (NSAIDs), excess fluid administration, or restoration of vascular tone to reach pre-pregnancy levels can increase BP.⁴ If it is determined that you are suffering from postpartum preeclampsia, the use of NSAIDs should be avoided for pain control and you will most likely be immediately referred to the hospital for treatment with medications to tackle high BP, and prevent seizures and blood clots.

Antihypertensive treatments 

Antihypertensive treatments help lower high BP which can result in an increased risk of maternal morbidity, such as stroke and eclampsia. Treatments used are similar to those used during pregnancy and examples include intravenous labetalol, intravenous hydralazine and oral nifedipine.² As foetal consideration is no longer a requirement in this condition, a lower BP threshold of 150/100 mmHg may be considered to prevent progression to severe hypertension. Severe hypertension is classified as a BP reading of 160/110 mmHg or greater.³

Antiseizure medication

A common example of this type of medication is magnesium sulphate, which can prevent seizures, a common risk of postpartum preeclampsia.² It is administered to those with new-onset hypertension associated with headaches and blurred vision in the postpartum period. However, it is typically recommended within the first week postpartum as eclampsia mostly presents itself within this time period.³ 

Diuresis 

Diuretics also lower BP by promoting natriuresis (sodium excretion in the urine by the kidneys). This reduces the volume of fluid in the blood vessels and allows the muscles in the walls of the blood vessels to relax, aiding blood flow. They can be used in patients with fluid overload to further lower BP. Fluid overload is characterised by having too much fluid in your body as a result of increased salt in your body, or hormones retaining more sodium and water. Diuresis can be achieved with the use of IV or oral furosemide.³

Anticoagulants 

The role of anticoagulant medications as blood thinners is to decrease the risk of blood clots. Common examples include warfarin and heparin which are used to treat venous thrombosis. 

It is important to make it known to your doctor whether you are breastfeeding, to ensure the medications are safe for your baby.

Complications and risks 

If postpartum preeclampsia is left untreated, it can lead to multiorgan damage and failure. High BP can damage blood vessels, resulting in permanent damage to the brain, liver, kidneys and heart. Additional complications include:⁵

• Pulmonary Oedema - This is an excess of fluid in the lungs making it difficult to breathe, and is thus a life-threatening condition
• Posterior reversible encephalopathy syndrome (PRES) - A rare condition characterised by headaches and seizures, issues with vision and swelling in the brain. It is often caused by the rapid development of hypertension causing vasogenic oedema (excess fluid resulting in disruption of the blood-brain barrier)
• Stroke - Strokes are a medical emergency, caused when the blood supply to the brain is reduced, depriving the brain tissue of oxygen
• Thromboembolism - A life-threatening condition in which a blood clot blocks the flow of blood through the veins 
• Hemolysis elevated liver enzymes and low platelet count (HELLP syndrome) - This rare complication of pregnancy consists of hemolysis (the breakdown of red blood cells), elevated liver enzymes and a low platelet count. Symptoms can include headache, blurred vision, nausea and upper right abdominal pain. HELLP is a separate disorder from preeclampsia as patients may not have hypertension or proteinuria. It can also develop suddenly before hypertension is detected and sometimes without the presence of symptoms
• Seizures, called eclampsia, are present in 10-15% of patients with delayed postpartum preeclampsia³
• Death

Prevention and prognosis

Postpartum preeclampsia cannot be prevented. However, it is important to be aware of the symptoms so that you can discuss them with your doctor, get an early and accurate diagnosis and start treatment promptly to avoid severe complications. Additionally, you may be encouraged to have an active lifestyle, adopt a healthy diet, avoid smoking, and limit alcohol intake to lower BP levels.

Postpartum preeclampsia can last several days or weeks as the medication lowers your BP to a safe and manageable level. Further research is required to assess the risk of cardiovascular disease in those with postpartum preeclampsia. However, a study depicted that 45% of patients remain on antihypertensive treatments a year after delivery.⁶ Those with the condition may require longer hospital stays and close monitoring of BP so complications do not arise after being discharged. 

Summary

Postpartum preeclampsia is a rare and deadly condition, characterised by high blood pressure and proteinuria any time between 48 hours and 6 weeks following childbirth. The exact cause is unknown but several risk factors are known to increase the risk of development. Symptoms can include headaches, visual disturbances, abdominal pain and swelling. As the condition cannot be prevented, close monitoring and immediate medical attention are required, with treatments to lower BP, and prevent seizures and blood clots. If left untreated, postpartum preeclampsia can give rise to multi-organ damage and other complications, such as pulmonary oedema, PRES, stroke, eclampsia, thromboembolism, HELLP syndrome and death. Therefore, awareness and early intervention are vital in aiding maternal outcomes and well-being.