Postpartum hypertension with a normal CBC: spotting preeclampsia after discharge
A 30-year-old G2P1 woman, now 6 days postpartum after an uncomplicated vaginal delivery, attends your clinic with a 2-day history of severe frontal headache and 'seeing spots.' She was discharged on day 2 with a blood pressure of 128/80 mmHg and a normal antenatal course. Today her blood pressure is 162/104 mmHg on repeat measurement, she has 2+ protein on urine dipstick, and reports right upper quadrant discomfort. She is breastfeeding and wants to go home because 'the baby is fine and my bloods were normal in the hospital.' She has no history of hypertension and is not on any medication.
1. What is the diagnosis and why does the normal antenatal course not reassure you?
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This is postpartum preeclampsia with severe features - new hypertension ≥160/110 (or ≥140/90 with severe features), proteinuria, and symptoms of severe disease (headache, visual disturbance, RUQ pain). Postpartum preeclampsia can present de novo up to 6 weeks after delivery, even in women with a normotensive pregnancy; the antenatal course does not exclude it.
Severe features present: systolic ≥160, symptoms of cerebral involvement (headache, visual changes), and RUQ pain suggesting hepatic involvement. These mandate immediate treatment, not outpatient monitoring. The RUQ pain is a warning sign for hepatic capsule involvement and should prompt consideration of HELLP syndrome (check platelets, LDH, AST/ALT, haemolysis).
2. Outline your immediate management in a clinic without obstetric beds.
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- Treat the blood pressure now - acute severe hypertension in pregnancy/postpartum should be lowered within 30–60 minutes with an agent appropriate in lactation, e.g., IV labetalol or oral nifedipine per protocol; avoid rapid over-correction.
- Seizure prophylaxis - magnesium sulphate is indicated for severe preeclampsia/eclampsia; arrange this at the receiving facility and do not delay transfer.
- Urgent transfer to an obstetric or high-dependency unit for monitoring, magnesium, and fetal/neonatal arrangements (baby is already delivered, so focus on maternal care and breastfeeding support).
- Investigations en route: full blood count, platelets, LDH, AST/ALT, creatinine, uric acid, urine protein:creatinine ratio.
- Do not send her home - document capacity and the risks of eclampsia, stroke, and hepatic rupture if she declines.
3. She asks whether she can continue breastfeeding and what follow-up she needs after discharge.
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Reassure her that breastfeeding should continue - labetalol, nifedipine, and magnesium sulphate are compatible with lactation, and stopping breastfeeding removes a protective factor and disrupts the newborn. Express milk or feed if clinically able during monitoring.
Follow-up: after stabilisation she needs blood pressure review within 1–2 weeks, repeat urine protein and bloods to confirm resolution (preeclampsia can persist for weeks), and counselling that she has an increased lifetime cardiovascular risk - arrange annual BP and metabolic screening and advise early booking and low-dose aspirin in future pregnancies. Document the diagnosis clearly in her record and inform her future maternity providers.