Postpartum hypertension and preeclampsia — structured SAQ (15 marks)

(a) Immediate priorities in the first hour (5 marks)

One mark per point, maximum five. Marks are for specifics — "give antihypertensives" scores nothing. ^[2]

• Recognise and declare de novo postpartum preeclampsia with severe features — severe hypertension plus neurological and epigastric symptoms. Call the obstetric consultant and alert anaesthetics; nurse in an area with continuous monitoring.^[1][4]
• Treat the severe hypertension within one hour. Choose one: labetalol 20 mg IV over 2 minutes, then 40 mg, then 80 mg at 10-minute intervals to a cumulative maximum of 300 mg; or nifedipine 10 mg immediate-release orally, repeated every 20 to 30 minutes up to 3 doses; or hydralazine 5 to 10 mg IV over 2 minutes, repeated every 20 minutes to a maximum of 20 mg.^[2]
• Intravenous access, bloods and continuous observation — repeat blood pressure every 15 minutes until below 160/110 mmHg, then at least every 30 minutes.^[2]
• Restrict fluid to approximately 80 mL per hour of total input unless there is haemorrhage — postnatal pulmonary oedema is largely iatrogenic.^[1]
• Full symptom and neurological review including reflexes, clonus, fundi and chest, and a stated plan for imaging if the headache is atypical, focal or persists after the pressure is controlled.^[1][4]

A mark is available for stating the one-hour target explicitly. Candidates who name a drug but no time frame lose it. ^[2]

(b) Investigations and severe-feature thresholds (3 marks)

One mark for the correct panel, two for accurate thresholds. ^[1]

Add a coagulation screen if platelets are falling or there is bleeding, and repeat the panel every 24 to 48 hours. Proteinuria quantification adds little here — preeclampsia is diagnosable after birth on end-organ features without proteinuria.^[1]

(c) Magnesium sulfate — justification, regimen and monitoring (3 marks)

• Justify: she has preeclampsia with severe features and neurological symptoms, so seizure prophylaxis is indicated. The Magpie trial showed magnesium sulfate more than halved the risk of eclampsia (relative risk 0.42), and delivery does not remove that risk — late postpartum eclampsia occurs beyond 48 hours and up to four weeks after birth.^[3][4]
• Regimen: 4 g IV loading dose over 15 to 20 minutes, then a maintenance infusion of 1 g per hour. A recurrent seizure receives a further 2 g IV bolus and prompts reconsideration of the diagnosis.^[2][3]
• Monitoring: hourly deep tendon reflexes, respiratory rate and urine output; magnesium is renally cleared, so oliguria mandates review of the infusion rate and a serum level. Have calcium gluconate available for toxicity.^[2]
• Duration: conventionally 24 hours after birth or after the last seizure; systematic review evidence suggests shorter courses may be adequate in selected women, so state the standard and acknowledge the debate.^[3]

(d) Ongoing therapy, discharge criteria and follow-up (4 marks)

One mark for lactation-appropriate agent with dose, one for weaning, one for discharge criteria, one for follow-up including long-term risk. ^[5]

• Ongoing agent, breastfeeding-compatible: nifedipine modified release 20 mg orally twice daily, titrated up to 60 mg twice daily; or labetalol 100 to 200 mg orally twice daily up to 600 mg three times daily. If a second agent is needed, enalapril 5 mg orally daily is compatible with breastfeeding and is permissible postnatally even though it is contraindicated in pregnancy. Avoid methyldopa because of its association with depressed mood.^[5]
• Weaning: reduce one agent at a time, no faster than every 24 to 48 hours in hospital or weekly in the community, with a documented target and a measurement before each step.^[5][6]
• Discharge criteria: blood pressure consistently under 150/100 mmHg with no severe readings in the preceding 24 hours; symptom-free; laboratory parameters improving; a written medication plan naming agent, dose and reviewer; and a blood pressure check arranged for day 3 to 7 after discharge because that is when the postnatal peak lands.^[6][2]
• Follow-up: review at 1 to 2 weeks and again at 6 weeks; consider self-monitoring with clinician-guided titration, which in the POP-HT trial produced a 24-hour mean diastolic pressure 5.8 mmHg lower at around 9 months. Counsel on recurrence risk and on long-term cardiovascular risk — after preeclampsia the relative risk of later hypertension is about 3.7 and of ischaemic heart disease about 2.2 — and arrange annual blood pressure, lipid and glucose review with her general practitioner.^[7][8]