INTRODUCTION:

High blood pressure in the postpartum period is most commonly seen in women with antenatal hypertensive disorders but it can develop in the postpartum period also. It is a serious condition where seizures occur after childbirth which is often linked to preeclampsia and can lead to complications like strokes, seizures and organ damage if not promptly treated.

The majority of reports on postpartum preeclampsia are limited to smaller case series. Hypertensive disorders of pregnancy complicate between 10–20% of pregnancies in the United States.¹ Literature estimates on the prevalence range between 0.3% to 27.5% of all pregnancies in the United States.² Reports published from 1976 to 2015 (January–February) reveal that incidence of eclampsia in India ranges from 0.179 to 5%, the average being 1.5 %. Further In India, postpartum eclampsia, while less common than antepartum or intrapartum eclampsia, has a reported incidence ranging from 0.31% to 10.91% of all deliveries³. Whether postpartum preeclampsia/eclampsia represents a distinct entity from preeclampsia/eclampsia with antepartum-onset is unclear and remains a source of debate. In this case report, we do not propose to label it as a separate disease process, but will discuss the limited literature surrounding and importance of postpartum care and the need for better recognition and timely management.⁴

Case Report:

A 26 years old primigravida mother was admitted in the labour room on 04/03/2025 at 8:35p.m. with the chief complaints of amenorrhea since 38 weeks and 6 days, lower backache since 1 day, and abdominal pain since 1 day, vaginal discharge since 2 days. On 05/03/2025 at 6 p.m. she delivered baby girl with birth weight of 2.6kg. APGAR score was normal.

Past Medical History:

There was no significant history of Gestational Diabetes Mellitus, Tuberculosis, Hepatitis, Sexually Transmitted Diseases, HIV and Other Communicable Diseases. Patient was having history of epilepsy since childhood when she was 12 years old and cause was unknown after that she tool treatment from Dehradun and was well till her pregnancy. During her pregnancy she was again had seizure in late first semester. Then she had seizure in her postpartum period after 28hours of delivery.

Past Surgical History:

There was no significant history of any general, Gynaecological surgery.

Present Surgical History:

Patient underwent Lower Segment Cesarean Section on 05/03/2025 under Spinal Anesthesia.

Intraoperative findings:

· Lower uterine segment well formed.

· Bladder not advanced.

· Curvilinear incision given over lower uterine segment.

· Baby extracted as cephalic and cried immediately.

· Delayed cord clamping is done.

· Liquor was suctioned and was clear.

· Cord cut and baby was handed over to the pediatrician.

· Placenta delivered by controlled cord traction with 430 grams and discoid in shape complete with membranes.

· Cord 42 cm long centric origin with 2 arteries and 1 vein with no gross congenital malformation.

General Examination:

Weight – 65kg

Height – 160cm

BMI – 25.03Kg/m2

On examination uterus was flabby, atonic, heavy vaginal bleeding was present and further on per vaginal speculum examination there was no vaginal and cervical tear present. Mother was restless, pale a lethargic and drowsy.

Vital Signs:

Temperature – 98.3°F

Pulse – 82 beats/minutes

Respiration – 20 breath/minute

Blood Pressure –110/78 mm/hg

SPO2 – 98%

Pain – Moderate pain on lower abdomen due to LSCS assessed by pain rating scale (Score was 6 on numeric rating scale).

Special Investigation:

Complete Blood Count for Hb estimation, Prothrombin time, Urine analysis for presence of protein, sugar and albumin in urine findings was normal. RBS was 80.5 mg/dl, RFT was normal, LFT the value of total bilirubin was 0.14mg/dl, alkaline phosphatase was 202 U/L, Albumin was 2.5gm/dl, Globulin was 4.1gm/dl, Electrolytes value was normal and USG was normal. Further opinion was taken from medicine department during postnatal period and suggested investigation were MRI Brain, T3, T4 and TSH testing, and suggested for Psychiatrist Opinion.

Treatment and Management

Injection Ceftriaxone 1g IV BD, Injection Metrogyl 500 mg IV BD, Injection Pantop 40mg IV BD, Injection Perinom 10mg IV BD, Injection PCM 1G IV TDS, Injection Trenaxa 500mg SOS, Injection Voveron 75mg IV SOS, Injection Emset 4mg IV SOS and Injection Lopez 2mg IV SOS.

The cornerstones of treatment include the use of anti-hypertensive agents, magnesium and diuresis. Postpartum preeclampsia may be associated with a higher risk of maternal morbidity as compare to pre-eclampsia with onset in Antepartum period, still remains understudied disease process even in today’s senario⁴. Anti hypertensive agents are used to treat women with sustained, severe hypertension (≥160/110mmHg) with rapid-acting anti-hypertensive agents within thirty to sixty minutes. These medicines are used for management of acute, severe hypertension in the postpartum period are similar to those used during pregnancy and include IV labetalol, IV hydralazine and oral nifedipine as first-line agents⁵. Some indirect evidence suggests that oral nifedipine may be superior to hydralazine or labetalol for management of acute, severe hypertension⁶. Magnisium sulphate for seizure prophylaxis is a key component of management of antepartum-onset preeclampsia with severe features, few evidence-based recommendations exist to guide the use of magnesium sulfate in women with postpartum preeclampsia⁷. women with postpartum preeclampsia most frequently present with neurologic symptoms, including headache and eclampsia has been documented in 10–15% of women in larger case series.⁸ Diuretics lower blood pressure by promoting natriuresis and decreasing intravascular volume which help to decrease cardiac preload and cardiac output.⁹ A more recent study demonstrated about improved blood pressure and less need for anti-hypertensive medication among all women with hypertensive disorders of pregnancy randomized to furosemide 20mg orally daily for the first five days postpartum compared to women treated with placebo¹⁰

Figure 1: Postpartum management of women with hypertension during pregnancy¹¹

REFERENCES:

1. Data on Pregnancy Complications | Pregnancy | Maternal and Infant Health |CDC. https://www.cdc.gov/reproductivehealth/ maternalinfanthealth/pregnancy-complications-data.htm.

2. Sibai BM. Etiology and management of postpartum hypertension-preeclampsia. Am J Obstet Gynecol. 2012; 206(6): 470–475. doi: 10.1016/j.ajog.2011.09.002

3. Nobis PN, Hajong A. Eclampsia in India through the Decades. J Obstet Gynaecol India. 2016 Oct; 66(Suppl 1): 172-6. doi: 10.1007/s13224-015-0807-5. Epub 2016 Jan 8. PMID: 27651598; PMCID: PMC5016424.

4. Hauspurg A, Jeyabalan A. Postpartum preeclampsia or eclampsia: defining its place and management among the hypertensive disorders of pregnancy. Am J Obstet Gynecol. 2022 Feb; 226(2S): S1211-S1221. doi: 10.1016/j.ajog.2020.10.027. Epub 2021 Jul 7. PMID: 35177218; PMCID: PMC8857508.

5. ACOG Committee Opinion No. 767 Summary: Emergent Therapy for Acute-Onset, Severe Hypertension During Pregnancy and the Postpartum Period. Obstet Gynecol. 2019 Feb; 133(2): 409-412. doi: 10.1097/AOG.0000000000003082. PMID: 30681541.

6. Vermillion ST, Scardo JA, Newman RB, Chauhan SP. A randomized, double-blind trial of oral nifedipine and intravenous labetalol in hypertensive emergencies of pregnancy. Am J Obstet Gynecol. 1999 Oct; 181(4): 858-61. doi: 10.1016/s0002-9378(99)70314-5. PMID: 10521742.

7. Vigil-De Gracia P, Ludmir J. The use of magnesium sulfate for women with severe preeclampsia or eclampsia diagnosed during the postpartum period. J Matern Fetal Neonatal Med. 2015; 28(18): 2207-9. doi: 10.3109/14767058.2014.982529. Epub 2014 Nov 27. PMID: 25373431.

8. Skurnik G, Hurwitz S, McElrath TF, Tsen LC, Duey S, Saxena AR, Karumanchi A, Rich-Edwards JW, Seely EW. Labor therapeutics and BMI as risk factors for postpartum preeclampsia: A case-control study. Pregnancy Hypertens. 2017 Oct; 10: 177-181. doi: 10.1016/j.preghy.2017.07.142. Epub 2017 Jul 24. PMID: 29153674; PMCID: PMC5747249.

9. Burlingame JM, Yamasato K, Ahn HJ, Seto T, Tang WHW. B-type natriuretic peptide and echocardiography reflect volume changes during pregnancy. J Perinat Med. 2017 Jul 26; 45(5): 577-583. doi: 10.1515/jpm-2016-0266. PMID: 28195551; PMCID: PMC5683168.

10. Perdigao JL, Lewey J, Hirshberg A, Koepler NC, Srinivas SK, Elovitz MA, Levine LD. LB 4: furosemide for accelerated recovery of blood pressure postpartum: a randomized placebo controlled trial (FoR BP). American Journal of Obstetrics and Gynecology. 2020 Jan 1; 222(1): S759-60.

11. Prejbisz A, Dobrowolski P, Kosiński P, Bomba-Opoń D, Adamczak M, Bekiesińska-Figatowska M, et al. Management of hypertension in pregnancy: Prevention, diagnosis, treatment and long-term prognosis: A position statement of the Polish Society of Hypertension, Polish Cardiac Society and Polish Society of Gynecologists and Obstetricians. Kardiol Pol. 2019; 77(78): 757–806.

Received on 09.05.2025 Revised on 27.05.2025

Accepted on 11.06.2025 Published on 18.08.2025

Available online from August 27, 2025

A and V Pub J. of Nursing and Medical Res. 2025;4(3):75-77.

DOI: 10.52711/jnmr.2025.18

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Creative Commons License.