Background:
Blood pressure associated with pre-eclampsia generally improves following delivery, although a transient postpartum rise is recognised. Severe postpartum deterioration requiring prolonged admission and multiple antihypertensive therapies is uncommon.
Case:
A 37 -year-old Pacific Islander with obesity and mild hypertension identified during IVF assessment, treated with methyldopa, developed superimposed pre-eclampsia at 36+4 weeks gestation. It was characterised by elevated BP up to 190/117 mmHg, proteinuria and headaches. Prior to emergency delivery, she received antihypertensive therapy and magnesium sulphate.
From postpartum day 2, severe hypertension worsened despite escalating therapy and natural diuresis. Systolic blood pressure reached 180, requiring IV hydralazine infusion on day 5 postpartum for 3 consecutive nights. Management was further complicated by allergy to nifedipine. Treatment ultimately required six breastfeeding-compatible antihypertensive agents.
Secondary hypertension investigations were unrevealing, including endocrine screening, TTE and renal CT angiogram. Obesity and ethnicity raised a suspicion for obstructive sleep apnoea.
Blood pressure stabilised by postpartum days 11-12. She was discharged on day 14 following gradual treatment de-escalation.
Conclusion
Delivery does not invariably result in resolution of hypertension associated with pre-eclampsia. Persistent or worsening postpartum hypertension, although uncommon, should alert clinicians to reconsider the diagnosis, exclude secondary causes, and anticipate the need for ongoing escalation of therapy.
In this regional case, severe hypertension persisted despite progressive escalation to six breastfeeding-compatible antihypertensive agents and repeated intravenous rescue therapy, creating significant diagnostic and therapeutic challenges for the treating multidisciplinary team. This unexpected postpartum trajectory reinforces the importance of sustained vigilance and multidisciplinary collaboration to optimise maternal outcome.