Severe headache nine days after delivery
A 31-year-old woman, G2P2, is seen in the community clinic nine days after an uncomplicated vaginal delivery. She had normal blood pressure throughout pregnancy and no proteinuria. She presents with a two-day history of severe frontal headache and blurred vision. Blood pressure is 162/104 mmHg, confirmed on repeat after 15 minutes of rest, with no proteinuria on dipstick. Reflexes are brisk with two beats of clonus. She has taken paracetamol with no relief and denies epigastric pain. She has no history of hypertension outside pregnancy and no previous migraine. She is breastfeeding and is reluctant to be admitted 'over a headache', saying her mother is looking after the baby and her husband cannot take leave. Platelets 128 × 10⁹/L, ALT 68 U/L, creatinine 82 µmol/L.
1. What is the most likely diagnosis, and what is your immediate disposition and treatment plan?
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This is postpartum preeclampsia with severe features. The key teaching point is that preeclampsia can present for the first time after delivery, typically between day 4 and day 10, and up to six weeks postpartum. Proteinuria is absent, but it is not required when there is new hypertension with end-organ involvement - here the visual symptoms and hyperreflexia with clonus are the warning signs. Her platelets and ALT are abnormal but not yet at severe-feature thresholds (platelets under 100, transaminases more than twice the upper limit), so she is on a trajectory, not at the endpoint. Differential diagnoses to keep in mind are cerebral venous sinus thrombosis, postpartum cardiomyopathy, pituitary apoplexy and migraine, but none of them justifies sending her home.
Disposition: direct admission to an obstetric high-dependency unit. Do not send her home with tablets. She is at risk of eclampsia in the next 24–48 hours.
Immediate management:
- Magnesium sulfate 4 g IV loading over 20 minutes, then 1 g/hour for 24 hours, with hourly reflexes, respiratory rate and urine output.
- Lower the blood pressure to roughly 130–150/80–100 with IV labetalol or hydralazine, or oral nifedipine.
- Strict fluid balance, aiming around 80 mL/hour to avoid pulmonary oedema.
- Twelve-hourly platelets, liver enzymes and creatinine; urinalysis and protein quantification.
- Urgent neuroimaging if she develops focal neurology, a seizure, or a headache that does not respond within hours.
2. Which antihypertensive would you choose, and how would you counsel her about breastfeeding?
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Labetalol is a good first choice: it is effective, familiar in obstetric practice, and only a very small fraction enters breast milk. Start 100 mg twice daily and titrate in steps to 200 mg three times daily, or use nifedipine modified-release 10–20 mg twice daily as an alternative. Both are considered compatible with breastfeeding by the major lactation resources, and neither requires interrupting feeding.
Practical counselling points:
- Continue breastfeeding. The amount of drug in milk is too small to affect a healthy term infant; the theoretical concerns are bradycardia and poor feeding with beta-blockers, so mention them and tell her what to watch for.
- Take the dose after a feed where practical, and do not stop the drug abruptly - rebound hypertension is a real risk.
- Watch for postural dizziness; advise rising slowly.
- Avoid atenolol (accumulates in milk) and avoid starting methyldopa postpartum because of its association with low mood.
- Avoid NSAIDs for the headache; use paracetamol.
- Ask directly about headache, visual change, epigastric pain and reduced urine output, and give a number to call.
The decision that matters most is that her reluctance to be admitted is driven by childcare and money, not by a judgement that the risk is small. Name that openly, involve her husband and mother in the plan, and explain that 24–48 hours of monitored treatment is what prevents a seizure.
3. What follow-up and future-pregnancy advice should she receive before discharge?
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Short term: blood pressure checked at 7–10 days after discharge and again at 6 weeks postpartum. If she is still hypertensive at 6 weeks, she has chronic hypertension and needs long-term treatment and investigation rather than being told it was 'just pregnancy-related'. Antihypertensives can usually be stepped down once BP is stable below 140/90.
Future pregnancies: she has had preeclampsia, so recurrence risk in a subsequent pregnancy is around 15–20%, and higher if it had been preterm. She should book early, have blood pressure and urine checked at each visit, and start low-dose aspirin (75–150 mg) from 12 weeks if she develops any additional risk factors - many services offer it to all women with a history of preeclampsia. Advise on interpregnancy interval and on avoiding smoking.
Long-term health: preeclampsia is a recognised marker of future cardiovascular and metabolic disease. She should have annual blood pressure and weight checks, lipids and fasting glucose at intervals, and be told this explicitly, framed as useful information rather than a threat.
Contraception: progesterone-only methods, including the implant and progestogen-only pill, are safe in breastfeeding; combined hormonal contraception should be avoided while she is hypertensive and in the early postpartum period.
Safety netting: she should return immediately for headache, visual disturbance, epigastric pain, breathlessness or swelling, and should be told that postpartum preeclampsia can recur in the days after discharge.