Hypertension Management in Pregnancy and Postpartum

ABSTRACT: Hypertensive disorders of pregnancy affect approximately 9% of pregnancies in the United States and are a leading cause of maternal morbidity and mortality. For nephrologists, these conditions sit at a critical intersection: chronic kidney disease is among the strongest risk factors for preeclampsia, and pregnancy itself can unmask previously unrecognized kidney disease. The physiologic demands of gestation stress renal and vascular reserve in ways that make the pregnant and immediately postpartum patient particularly vulnerable. Preeclampsia, driven by placental release of anti-angiogenic factors and widespread maternal endothelial dysfunction, produces acute cardiorenal injury that does not entirely resolve with delivery. Postpartum hypertension peaks between days 3 to 6 after delivery and is under-recognized, yet this period carries the greatest risk of preventable maternal death, with cardiovascular causes accounting for more than one third of pregnancy-related deaths. Beyond the acute phase, women with hypertensive pregnancies face accelerated trajectories toward chronic hypertension, chronic kidney disease, and overall cardiometabolic risks that compound with each affected pregnancy. The postpartum visit represents a critical and underutilized opportunity to identify women who warrant nephrology evaluation, initiate renoprotective therapy, and interrupt a long-term cardiorenal disease course. Nephrologists are well-positioned to recognize cardiorenal sequelae of hypertensive pregnancy and ensure that the postpartum period is not a missed opportunity for intervention. This review addresses the diagnosis, pathophysiology, and management of hypertensive disorders across the full peripartum continuum, with particular attention to the role of nephrologists in recognizing kidney disease that pregnancy has brought to light and in ensuring that delivery is not treated as a clinical endpoint.