[Note: This article is being published in draft form for use in an active research study. Its contents may be adjusted as we recieve feedback from collaborating health care professionals.]
The only definitive treatment for gestational pre-eclampsia is child delivery.1 Preeclampsia symptoms, most notably hypertension and proteinuria, usually resolve within three months postpartum. In a 2014 retrospective study conducted on 145 patients diagnosed with gestational hypertension (GH) or preeclampsia (PE), the median interval for normalization of blood pressure (BP) without anti-hypertension medication was 31.5 days and for resolution of proteinuria was 27.0 days.2 By 77 and 60 days postpartum, 90% of participants had recovered from hypertension and proteinuria, respectively. Since the study was only conducted for only 12 weeks postpartum, they note that 16 patients (11.0%) required antihypertensive medication and seven patients (4.8%) continued to experience proteinuria beyond the study period. They also found that the time at which patients developed GH affected the resolution time post-delivery. Patients with early-onset (<32 weeks of gestation) required a longer amount of time to normalize BP (49.8±43.1 days) than patients with later-onset (≥32 weeks of gestation) of GH (36.8±13.8 days).
Another 2010 retrospective cohort study of 62 patients also found that symptoms resolve within three months postpartum.3 Among women with GH or PE, 81% experienced BP normalization by three months, with the average time to normalization of 5.4±3.7 weeks. Among the 19% of women that remained hypertensive beyond six months, the main risk factors were older age at the time of pregnancy (38.8 years vs. 34.3 years, p=0.018), an earlier gestational age at diagnosis (23.5±9.1 weeks vs. 32.8±5.7 weeks, p=0.001), and the length of hypertension during gestation (9.6±8.1 weeks vs. 2.3±4.1 weeks, p=0.0001).
Pre-eclampsia symptoms can last for at least two years post-delivery. A prospective cohort study of 205 preeclamptic patients admitted between 1990-1992 found that of the 39% of patients who still had hypertension at 3 months postpartum, 18% were still hypertensive at two years postpartum.4 They also found that of the 14% of patients who still had proteinuria at three months postpartum, 2% still had proteinuria at two years postpartum (0.28% of the total study population). Worse severity of PE symptoms as well as an earlier onset were associated with longer postpartum time to resolution of hypertension and proteinuria.
It is important to note that although these symptoms resolve after child delivery, the American College of Obstetrics and Gynecology (ACOG) recognizes that women with a history of preeclampsia continue to have an elevated risk of cardiovascular disease in subsequent years.1 An observational cohort study of 58,671 Nurses’ Health Study II participants without cardiovascular disease or risk factors at baseline examined the incidence of cardiovascular-related conditions among those with GH and PE.5 Compared to women who were normotensive during pregnancy, those with GH during their first pregnancy (2.9%, n=1,699) had increased rate of chronic hypertension (16.1 excess cases per 1,000 person-years, Hazard Ratio [HR] 2.8, 95% Confidence Interval [CI] [2.6-3.0]), hypercholesterolemia (6.6 excess cases per 1,000 person-years, HR 1.4, 95% CI [1.3-1.5]), and type 2 diabetes (1.9 excess cases per 1,000 person-years, HR 1.7, 95% CI [1.4-1.9]). Those with PE during their first pregnancy (6.3%, n=3,687) also had increased chronic hypertension (12.2 excess cases per 1,000 person-years, HR 2.2, 95% CI [2.1-2.3]), hypercholesterolemia (5.0 excess cases per 1,000 person-years, HR 1.3, 95% CI [1.3-1.4]), and type 2 diabetes (2.0 excess cases per 1,000 person-years, HR 1.8, 95% CI [1.6-1.9]).
Finally, it is important to distinguish between gestational PE and postpartum PE. While the first develops during pregnancy and resolves with delivery, the latter develops shortly after birth. The International Society for the Study of Hypertension in Pregnancy defines postpartum PE as PE that develops within days and up to three weeks after delivery.6 Postpartum PE can either be secondary to persistent hypertension; an exacerbation of previous GH, gestational PE, or chronic hypertension; or a new onset condition.1,7 Postpartum PE is very rare, although its exact incidence has not been ascertained. A 1997 retrospective study conducted in Glasgow, Scotland found that of the 40,041 deliveries from 1981-1990, there were 29 cases of eclampsia (0.07% incidence). Of those cases, 14 developed from postpartum PE (48% of eclampsia cases, 0.03% incidence in overall study population).8
A retrospective cohort study found that out of 152 patients diagnosed with delayed postpartum PE, 96 (63.2%) patients had no antecedent diagnosis of hypertensive disease in the current pregnancy, whereas seven (4.6%), 14 (9.2%), 28 (18.4%), and seven (4.6%) patients had gestational hypertension, chronic hypertension, preeclampsia, and preeclampsia superimposed on chronic hypertension, respectively, during the peripartum period.9 As such, the ACOG guidelines recommend that women who had any form of hypertension during pregnancy have their BP monitored either in the hospital or in the outpatient setting for at least 72 hours postpartum and again 7-10 days after delivery or earlier in women with symptoms.7 They further advise that both providers and patients should be made aware of the possibility as well as signs and symptoms of postpartum PE to avoid it developing into eclampsia.1 Signs and symptoms of pre-eclampsia include persistent occipital or frontal headaches, blurred vision and other visual disturbances, hyperreflexia, severe nausea or vomiting, right upper quadrant/epigastric pain, and chest pain/dyspnea.1,10
References
- Gestational Hypertension and Preeclampsia: ACOG Practice Bulletin, Number 222. Obstet Gynecol. Jun 2020;135(6):e237-e260. doi:10.1097/aog.0000000000003891
- Mikami Y, Takagi K, Itaya Y, et al. Post-partum recovery course in patients with gestational hypertension and pre-eclampsia. J Obstet Gynaecol Res. Apr 2014;40(4):919-25. doi:10.1111/jog.12280
- Podymow T, August P. Postpartum course of gestational hypertension and preeclampsia. Hypertens Pregnancy. 2010;29(3):294-300. doi:10.3109/10641950902777747
- Berks D, Steegers EAP, Molas M, Visser W. Resolution of hypertension and proteinuria after preeclampsia. Obstet Gynecol. Dec 2009;114(6):1307-1314. doi:10.1097/AOG.0b013e3181c14e3e
- Stuart JJ, Tanz LJ, Missmer SA, et al. Hypertensive Disorders of Pregnancy and Maternal Cardiovascular Disease Risk Factor Development: An Observational Cohort Study. Ann Intern Med. Aug 21 2018;169(4):224-232. doi:10.7326/m17-2740
- Magee LA, Pels A, Helewa M, Rey E, von Dadelszen P. Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy. Pregnancy Hypertens. Apr 2014;4(2):105-45. doi:10.1016/j.preghy.2014.01.003
- Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet Gynecol. Nov 2013;122(5):1122-1131. doi:10.1097/01.aog.0000437382.03963.88
- Leitch CR, Cameron AD, Walker JJ. The changing pattern of eclampsia over a 60-year period. Br J Obstet Gynaecol. Aug 1997;104(8):917-22. doi:10.1111/j.1471-0528.1997.tb14351.x
- Al-Safi Z, Imudia AN, Filetti LC, Hobson DT, Bahado-Singh RO, Awonuga AO. Delayed postpartum preeclampsia and eclampsia: demographics, clinical course, and complications. Obstet Gynecol. Nov 2011;118(5):1102-1107. doi:10.1097/AOG.0b013e318231934c
- von Dadelszen P, Payne B, Li J, et al. Prediction of adverse maternal outcomes in pre-eclampsia: development and validation of the fullPIERS model. Lancet. Jan 15 2011;377(9761):219-27. doi:10.1016/S0140-6736(10)61351-7
