Delayed Postpartum Preeclampsia

and Eclampsia
Demographics, Clinical Course, and Complications
Zain Al-Safi, MD, Anthony N. Imudia, MD, Lusia C. Filetti, MD, Deslyn T. Hobson,
Ray O. Bahado-Singh, MD, MBA, and Awoniyi O. Awonuga, MD
OBJECTIVE: To estimate and evaluate the demographics,
clinical course, and complications of delayed postpartum
preeclampsia in patients with and without eclampsia.
METHODS: We conducted a retrospective cohort study
of patients who were discharged and later readmitted
with the diagnosis of delayed postpartum preeclampsia
more than 2 days to 6 weeks or less after delivery
between January 2003 and August 2009.
RESULTS: One hundred fifty-two patients met criteria
for the diagnosis of delayed postpartum preeclampsia. Of
these, 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. Twenty-two patients (14.5%) developed
postpartum eclampsia, and more than 90% of these
patients presented within 7 days after discharge from the
hospital. The most common presenting symptom was
headache in 105 (69.1%) patients. Patients who developed
eclampsia were significantly younger than those who did
not (meanstandard deviation, 23.26.2 compared with
28.36.7 years; adjusted odds ratio [OR] 1.13, 95% confidence interval [CI] 1.021.26, P.03), and other demographic variables were no different. A lower readmission
hemoglobin was associated with a lower odds of progresFrom the Department of Obstetrics and Gynecology and the Division of
Reproductive Endocrinology and Infertility, Wayne State University School of
Medicine/Detroit Medical Center, Detroit, Michigan; and the Division of
Reproductive Medicine and Infertility, Massachusetts General Hospital, Boston,
Massachusetts.
Corresponding author: Awoniyi O. Awonuga, MD, Division of Reproductive
Endocrinology and Infertility, Department of Obstetrics and Gynecology, 60
West Hancock, Detroit, MI 48201; e-mail: aawonuga@med.wayne.edu;
niyiawonuga@aol.com.
Financial Disclosure
The authors did not report any potential conflicts of interest.
2011 by The American College of Obstetricians and Gynecologists. Published
by Lippincott Williams & Wilkins.
ISSN: 0029-7844/11

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MD,

sion to eclampsia (10.71.7 compared with 11.62.2 g/dL,

adjusted OR 0.75, 95% CI 0.57 0.98, P.04).
CONCLUSION: One week after discharge appears to be
a critical period for the development of postpartum
eclampsia. Education about the possibility of delayed
postpartum preeclampsia and eclampsia should occur
after delivery, whether or not patients develop hypertensive disease before discharge from the hospital.
(Obstet Gynecol 2011;118:11027)
DOI: 10.1097/AOG.0b013e318231934c

LEVEL OF EVIDENCE: III

reeclampsia is responsible for major maternal and

perinatal morbidity and mortality. The disorder
affects approximately 5%9% of pregnancies, and if
untreated, it can lead to eclampsia, a serious obstetric
complication that accounts for maternal deaths in the
United States and abroad.13 There has been a marked
reduction in the incidence of eclampsia in recent
years, which may be attributed in part to improved
prenatal care, including early detection of signs and
symptoms of preeclampsia and prophylactic use of
magnesium sulfate in the peripartum period.4 However, there has been a shift toward an increased
frequency of eclampsia in the postpartum period with
most cases occurring in the late postpartum period.5
This shift could be the result of the persistence and
progression of preeclampsia that started during the
intrapartum period or late manifesting disease after
delivery but unrecognized before discharge.
Because preeclampsia abates with placental delivery, obstetric units tend to discontinue seizure
prophylaxis within 48 hours postpartum. However,
up to 26% of eclamptic seizures occur beyond 48
hours5 and as late as 6 weeks after delivery.6 In a rare
case of an advanced extrauterine, intra-abdominal
pregnancy, in which removal of the placenta was not
possible, preeclampsia was reported to persist for 99

OBSTETRICS & GYNECOLOGY

days instead of resolving after delivery of the fetus.7

These facts are consistent with a current theory on the
pathogenesis of preeclampsia that suggests that the
disease is caused by placental-related widespread
endothelial cell dysfunction8 as a result of increased
circulating levels of antiangiogenic factors such as
soluble truncated FMS-like tyrosine kinase-1 receptor
isoform9 and soluble endoglin.10 Therefore, the onset
of symptoms and signs of the disease may be dictated
by the degree and time course of resolution of the
endothelial damage. Indeed, Blaauw and collaborators11 demonstrated evidence of persistent endothelial
dysfunction in a group of women with early onset
preeclampsia up to 11 months after delivery.
There is a paucity of data in the literature regarding the natural history, progression, management, and
treatment outcome of delayed onset preeclampsia in
patients more than 2 days postpartum who present
after hospital discharge. In addition, the extent to
which development or progression of preeclampsia is
influenced by either the patients demographic or
antecedent obstetric characteristics is also unclear. In
this study, our objective was to estimate the demographics, clinical course, and complications of patients who were readmitted with a diagnosis of
postpartum preeclampsia after discharge from the
hospital and to compare those in this cohort who
developed eclamptic seizures with those who did
not. Knowledge of these variables may be helpful in
formulating strategies aimed at prevention, early
diagnosis, and timely treatment of delayed-onset
preeclampsia.

MATERIALS AND METHODS

This study was approved by the institutional review
board of the Wayne State University (HIC No.
037909M1E). We conducted a chart review of patients who were discharged and later readmitted with
the diagnosis of postpartum preeclampsia more than
2 days to 6 weeks or less after delivery between
January 2003 and August 2009 at the Detroit Medical
Center. Based on the International Classification of
Diseases, 9th Revision, code, a total of 253 patients were
coded to have been readmitted with postpartum
preeclampsia from their diagnosis at discharge; 101
patients were excluded from the final analysis because
they did not fulfill criteria for the diagnosis of postpartum preeclampsia. The medical records of 152
patients with a readmission diagnosis of preeclampsia and or eclampsia were reviewed for demographic information, obstetric and medical history,
intrapartum and postpartum management, presenting symptoms and signs, management in the emer-

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Al-Safi et al

gency department, and inpatient hospital course

and complications. A separate article analyzes the
characteristics of cases developing delayed onset
postpartum preeclampsia with and those without
antecedent hypertensive diatheses in the antepartum and early peripartum period before initial
discharge in the index pregnancy.12
All statistical analyses were performed using Statistical Package for Social Sciences. All tests were
conducted using P.05 for statistical significance.
Normally distributed numerical variables were summarized with meansstandard deviations, whereas
other variables were summarized with medians and
ranges. Frequencies and percentages with 95% confidence intervals (CIs) were used to summarize categorical variables. For numerical variables, univariable
comparisons were conducted with either Students t test
(for normally distributed data) or Wilcoxons rank test
(for nonnormal data). Chi-square and Fishers exact tests
were used for categorical data. To model gravidity, the
data were dichotomized into gravidity less than three
and three or more. Categorization was done because the
residuals for a linear model with gravidity did not meet
the assumptions of normality. Adjusted odds ratios
(ORs) and 95% CIs were computed by logistic regression for the risk of the eclampsia. Potential confounders
were included in the full model if they were risk factors
for eclampsia based on a P.05.

RESULTS
During the study period, 48,498 deliveries were recorded, and preeclampsia occurred in 3,072 patients
(6.3%, 95% CI 6.1 6.6). One hundred fifty-two patients (5.0%, 95% CI 4.25.8) were readmitted to the
hospital within 6 weeks of their initial discharge with
the diagnosis of postpartum preeclampsia or eclampsia. The meanstandard deviation and median
(range) maternal age and gestational age at delivery
were 27.66.8 and 28 (15 44) years and 38.22.5
and 39 (28 42) weeks, respectively. Twenty-three
percent (23.3%, 95% CI 17.330.7) of the patients
were primigravid, 32.9% (95% CI 26.3 41.2) were
nulliparous, 78.9% (95% CI 71.8 84.7) were on
Medicaid, and 96.7% (95% CI 92.598.6) were
African American. Information about the gravidity
and parity was missing in two patients. The mode of
delivery was vaginal in 57.9% (95% CI 49.9 65.5),
whereas 42.1% (95% CI 34.6 50.1) underwent cesarean deliveries. Four (2.6%, 95% CI 0.9 7.0)
patients had twin gestations.
Of the 152 patients readmitted with the diagnosis
of delayed postpartum preeclampsia or eclampsia, 96
(63.2%, 95% CI 55.370.4) had no antecedent diag-

Delayed Postpartum Preeclampsia and Eclampsia

1103

nosis of hypertensive disease in the current pregnancy, whereas seven (4.6%, 95% CI 2.39.2) had
gestational hypertension, 14 (9.2%, 95% CI 5.6 14.9)
had chronic hypertension, 28 (18.4%, 95% CI 13.1
25.3) had preeclampsia, and seven (4.6%, 95% CI
2.39.2) were diagnosed with preeclampsia superimposed on chronic hypertension during the peripartum
period. Twenty-seven (17.8%, 95% CI 12.524.6) of
the patients readmitted with the diagnosis of delayed
postpartum preeclampsia were treated with magnesium sulfate during the peripartum period. These
patients were equally distributed across the eclampsia
and noneclampsia groups (Table 1). The mean (range)
number of days postpartum and between discharge
and readmission were 7.6 days (323) and 4.7 days
(0 19), respectively.
The highest systolic blood pressure on readmission was (mean [range]) 176 (116 240) mmHg and
the highest diastolic blood pressure was 101 (72131)
mmHg. Symptoms and signs at presentation were not
mutually exclusive. Headache (n105, 69.1%, 95%
CI 61.375.9) was the most common presenting
symptom. Other symptoms included shortness of
breath (n41, 30.0%, 95% CI 20.6 34.5), blurry
vision (n32, 21.1%, 95% CI 15.328.2), nausea
(n19, 12.5%, 95% CI 8.218.7), vomiting (n17,
11.2%, 95% CI 7.117.2), edema (n16, 10.5%, 95%
CI 6.6 16.4), seizure (n6, 4.0%, 95% CI 1.8 8.4),
other neurological deficit (n8, 5.3%, 95% CI 2.7
10.0), and epigastric pain (n8, 5.3%, 95% CI 2.7
10.0). Six patients were admitted with a history of
eclamptic seizures at home, five seized while in the
emergency department, and another 11 seized during
the readmission period. The overall rate of eclampsia
for patients readmitted with the diagnosis of postpar-

tum preeclampsia was 14.5% (n22, 95% CI 9.8

20.9). Over 90% (90.9%, 95% CI 72.297.5) of patients with eclampsia presented within 7 days after
discharge from hospital. Eclampsia was more common (n17, 77.3%, 95% CI 56.6 89.9) in patients
with no antecedent hypertensive disease in the index
pregnancy. None of the patients with preeclampsia
superimposed on chronic hypertension had postpartum
eclampsia. Three (13.6%, 95% CI 3.6 36.0) patients
with peripartum preeclampsia, one (4.6%, 95% CI 0.2
24.9) with chronic hypertension, and one (4.6%, 95% CI
0.224.9) with gestational hypertension also developed
postpartum eclampsia on readmission.
Other complications diagnosed after readmission
included pulmonary edema (n17, 11.2%, 95% CI
7.117.2), cardiomyopathy (n4, 2.6%, 95% CI 0.9
7.0), hemolysis, elevated liver enzymes, low platelet
count syndrome (n3, 2.0%, 95% CI 0.5 6.1), pneumonia (n1, 0.7%, 95% CI 0.03 4.2), and maternal
death secondary to hemorrhagic stroke (n1, 0.7%,
95% CI 0.03 4.2). Blood pressure medications were
used in the emergency department in 103 (67.8%,
95% CI 60.0 74.7) patients and 74 (48.7%, 95% CI
40.9 56.6) who were discharged on oral medications
were equally distributed across the eclamptic and
noneclamptic groups (Table 2). Calcium channel
blockers were the most common antihypertensive
medication prescribed and were used by 47 (30.9%,
95% CI 24.138.7) patients. One hundred twentynine (84.9%, 95% CI 78.3 89.7) patients were treated
with magnesium sulfate during their admission. Compared with women who did not develop postpartum
eclampsia during their second admission, those who
did were significantly younger (P.001) with a relatively lower gravidity (P.03) and a higher serum

Table 1. Hospital Course and Some Laboratory Data in Patients With Postpartum Eclampsia Compared
With Those Who Did Not Develop Postpartum Eclampsia

Highest systolic blood pressure (mmHg)

Highest diastolic blood pressure (mmHg)
MgSO4 use peripartum
MgSO4 use in the emergency department
Days since delivery
Days since discharge
Readmission days 7 or fewer
Hemoglobin at delivery (g/dL)
Hemoglobin at readmission (g/dL)
Platelet at delivery (103/microliter)
Platelet at readmission (103/microliter)
Aspartate aminotransferase at readmission (units/L)
Creatinine no. at readmission (mg/dL)
Proteinuria 1 or more

No Eclampsia

Eclampsia

130
130
130
130
130
130
130
128
130
128
130
123
127
125

175.219.4
101.711.6
23 (17.7)
108 (83.1)
7.73.8
4.0 (019)
108 (83.1)
11.31.4
10.71.7
236.672.0
323.6145.1
77 (241,044)
0.7 (11)
50 (40.0)

22
22
22
22
22
22
22
20
22
20
22
22
20
21

177.323.7
100.011.4
4 (18.2)
21 (95.5)
6.82.7
3.50 (012)
20 (90.9)
11.01.5
11.62.2
233.675.2
304.1126.2
32 (1945)
0.6 (11)
9 (42.9)

.64
.52
.96
.57
.28
.26
.53
.32
.03
.62
.55
.92
.56
.97

Data are meanstandard deviation, n (%), or median (range) unless otherwise specified.

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Delayed Postpartum Preeclampsia and Eclampsia

OBSTETRICS & GYNECOLOGY

Table 2. Oral Antihypertensive Medications

During Second Admission

No antihypertensive used
Calcium channel blockers
Alpha or -blockers or both

Others
Combination (24 drugs)

3.6 7.4) were readmitted to the hospital for postpartum

preeclampsia and none developed eclampsia.

No Eclampsia*

Eclampsia*

68 (52.3)
31 (23.8)
9 (6.9)
3 (2.3)
19 (14.6)

10 (45.5)
7 (31.8)
1 (4.5)
1 (4.5)
3 (13.6)

Data are n (%).

* P.90.

Includes diuretics, angiotensin-converting enzyme inhibitors,

and clonidine.

Includes calcium channel blockers, -blockers, -blockers, and -blockers, diuretics, and clonidine.

hemoglobin (P.03). When these variables were entered into a logistic regression model, young age was
associated with greater odds of developing eclampsia
(adjusted OR 1.13, 95% CI 1.021.26, P.03),
whereas a lower readmission hemoglobin was associated with a lower odds of progression to eclampsia
(adjusted OR 0.75, 95% CI 0.57 0.98, P.04). Gravidity was not associated with risk of eclampsia (gravidity less than three compared with three or more;
adjusted OR 1.29, 95% CI 0.37 4.45, P.69). Although patients who developed eclampsia appeared
less likely to have peripartum preeclampsia, chronic
hypertension, and diabetes, these differences were not
statistically significant (Table 3). There were no significant differences between patients with postpartum
preeclampsia with and without seizures with respect to
other demographic variables, medical disorders associated with pregnancy, hospital course, or laboratory
findings (Tables 1 and 3). Of 543 patients diagnosed
with preeclampsia superimposed on chronic hypertension during the study period, only 28 (5.2%, 95% CI

DISCUSSION
In this large series of 152 patients with delayed postpartum preeclampsia who were readmitted after initial
discharge from the hospital, we identified several variables that could help stratify patients who are more
likely to develop the disease. In our study, over 96% of
the patients were African American, 78% were on
Medicaid, and 63.2% had no antecedent diagnosis of
hypertensive disease in the index pregnancy. Similar to
the 78% reported by Chames and colleagues,5 those
with no antecedent diagnosis of hypertensive disease
seem to be particularly at risk, because the highest rate
of eclampsia (77.3%) occurred in this group of patients.
This could be the result of the fact that patients and their
physicians might not be aware that there is still a
measurable risk of preeclampsia even after postpartum
discharge despite an uneventful pregnancy and delivery.
In contrast, of the 543 patients diagnosed with
preeclampsia superimposed on chronic hypertension
during the study period, only 28 (5.2%) were readmitted
to the hospital for postpartum preeclampsia and none
developed eclampsia. However, it is possible that some
of these patients were discharged from the emergency
department after merely increasing the dose of their
antihypertensive(s) if they were asymptomatic and
therefore were not recorded.
Only maternal age and preadmission hemoglobin distinguished between those who did or did not
develop postpartum eclampsia. In contrast, other
maternal demographic variables, history of medical
disorders, symptoms and signs on presentation, hospital course, and laboratory data were not associated

Table 3. Demographic Data and Medical History of Patients With Postpartum Eclampsia Compared
With Those Who Did Not Develop Postpartum Eclampsia

Maternal age (y)

Gravidity
Body mass index (kg/m2)
African American
Medicaid insurance
Smoking
Gestational age (wk)
Fetal birth weight (g)
Gestational hypertension
Peripartum preeclampsia
History of chronic hypertension
History of diabetes
History of renal disease

No Eclampsia

Eclampsia

130
128
115
130
130
129
129
105
130
130
130
130
130

28.36.7
4 (113)
35.58.6
126 (96.9)
102 (78.5)
21 (16.3)
38.12.5
3,180.8786.8
6 (4.6)
25 (19.2)
20 (15.4)
18 (13.8)
3 (2.3)

22
22
17
22
22
22
20
14
22
22
22
22
22

23.26.2
2 (16)
34.97.3
21 (95.5)
20 (90.9)
2 (9.1)
38.72.1
3,159.1754.6
1 (4.5)
3 (13.6)
1 (4.5)
1 (4.5)
1 (4.5)

.001
.03
.76
.55
.25
.53
.30
.92
1.0
.77
.31
.31
.47

Data are meanstandard deviation, median (range), or n (%) unless otherwise specified.

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Delayed Postpartum Preeclampsia and Eclampsia

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with the development of postpartum eclampsia. Similarly, intrapartum use of magnesium sulfate was not
associated with the development of delayed postpartum eclampsia.
Although more common in the ante- and intrapartum periods, 44% of eclampsia occurred postpartum in one study,13 and nearly one-third of patients
developed eclamptic seizures more than 48 hours
postpartum in another.5 Thus, it is essential that
patients at risk for this condition be identified so that
prompt diagnosis of preeclampsia can be made and
measures to prevent progression instituted.
Headache was the most common presenting
symptom in our study population and was present in
over two-thirds (69.1%) of the patients. Furthermore,
we found that all of our patients (100%) admitted with
postpartum eclampsia presented with prodromal
symptoms, a rate slightly higher than the 91% reported in a previous study.14 This stresses the importance of evaluating postpartum patients carefully for
the signs and symptoms enumerated previously, especially when they are associated with elevated blood
pressures. Given that many patients will be seen in the
emergency department, as most of our patients were,
it is important for emergency department physicians
to have a high index of suspicion for postpartum
preeclampsia including the early involvement of obstetric staff in the care of such patients.
At the present time, there are no data to suggest
that the pathology of preeclampsia in the postpartum
period is different from those that occur in the antepartum and the peripartum periods. In addition,
laboratory values were no different between those
who developed eclampsia and those who did not;
therefore, the findings of normal laboratory values
should not preclude the use magnesium sulfate prophylaxis for seizure prophylaxis. One way to avoid
complications of eclampsia is to continue to educate
all patients and our emergency department colleagues
not to ignore the symptoms, signs, and the possibility
of preeclampsia or its progression. This should take
place before patients are discharged from the hospital
and should include verbal instructions and a printed
instruction sheet.14 Patients should be informed that
they may be at risk for preeclampsia or eclampsia up
to 6 weeks after delivery.
In our study, 90% of those who developed eclampsia presented within 7 days of being discharged in our
study. Two other patients that developed eclampsia did
so on the 11th and 12th days after they were discharged
from the hospital. Whether active postpartum surveillance at home for these eclamptic patients for at least 1

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Al-Safi et al

week after discharge might have prevented the development of eclampsia is an intriguing question.
Several limitations of our study must be acknowledged. First, this was a retrospective cohort study and
some results did not include all of the participants
because of missing data. Although we attempted a
comprehensive review, we may not have identified all
patients with delayed postpartum preeclampsia because mild forms of the disease may have resolved
spontaneously without patients seeking hospital care.
In addition, some of our patients may have sought
care elsewhere rather than at our institution. Furthermore, asymptomatic patients with a history of chronic
hypertension who presented with atypical symptoms
may have been discharged by emergency department
physicians with adjustment of their blood pressure
medication(s) without work-up to determine whether
they had postpartum preeclampsia superimposed on
chronic hypertension. Lastly, the lack of association
between antecedent hypertension, preeclampsia, renal
disease, and diabetes and delayed postpartum eclampsia
may have been the result of a type 2 error. However, the
data for those with history of gestational hypertension
and renal disease show little evidence of trends that
might achieve statistical significance in a larger sample
size. A larger data set may show that patients with
diabetes and chronic hypertension are less likely to
develop delayed postpartum eclampsia.
In summary, we found that younger women are at
a higher risk for eclamptic seizures in the late postpartum period and that the overwhelming majority of
seizures occur within 7 days of postpartum hospital
discharge. Education about the possibility of delayed
postpartum preeclampsia and eclampsia should occur
after delivery whether or not a patient develops hypertensive disease before discharge from the hospital.
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