hypertension%20in%20pregnancy
HYPERTENSION IN PREGNANCY
Hypertension in pregnancy is defined as an average diastolic blood pressure of ≥90 mmHg, based on at least 2 measurements ≥4 hours apart or systolic blood pressure of ≥140 mmHg taken at least 6 hours apart.
Diagnosis of severe hypertension is made when blood pressure is ≥160/110 mmHg.
Measurement should be repeated after 15 minutes for confirmation of severe hypertension.

Diagnosis

Preeclampsia/Eclampsia

  • Always presents potential danger to the mother and baby; therefore, prevention relies on identifying high-risk women
    • Close clinical and lab monitoring aimed at early recognition and institution of monitoring or delivery when indicated

Evaluation

Clinical Blood Pressure (BP) Measurement
  • Patient should be seated quietly for at least 5 minutes in a chair with feet on the floor and arm supported at heart level prior to measurement of BP (or left lateral recumbent position during labor)
  • Appropriately-sized cuff should be placed at heart level of the patient and should not be placed over any clothing
  • Use the appearance of phase I Korotkoff’s sounds for systolic blood pressure (SBP) and the disappearance of phase V for diastolic blood pressure (DBP)
  • Differences of BP between 2 arms should be noted, and the arm with consistently higher measurement should be used for all subsequent BP readings
  • Make sure devices to be used are professionally validated 
Confirmation of Elevated BP
  • Definition of hypertension is based on office or in-hospital BP measurements
    • Ambulatory BP monitoring is preferred over routine BP measurement in predicting outcome of pregnancy
  • Hypertension in pregnancy is defined as an average DBP of ≥90 mmHg, based on at least 2 measurements ≥4 hours apart or SBP ≥140 mmHg taken at least 6 hours apart
  • Diagnosis of severe hypertension is made when BP is ≥160/110 mmHg and mild when BP is 140-159/90-109 mmHg  
    • Measurement should be repeated after 15 minutes for confirmation of severe hypertension  
  • It is recommended to admit the patient in a hospital if BP is ≥170/110 mmHg
Findings that Support the Diagnosis of Severe Preeclampsia

One or more of the following:
  • SBP ≥160 mmHg and/or DBP ≥110 mmHg on 2 occasions at least 4 hours apart during bed rest
  • Platelet <100,000 cells/mm3 or microangiopathic hemolytic anemia (with increased lactic acid dehydrogenase)
  • Elevated liver enzymes [aspartate aminotransferase (AST) or alanine aminotransferase (ALT)]
  • Persistent headache or other cerebral or visual disturbances
  • Persistent epigastric or right upper quadrant pain
  • Pulmonary edema and/or congestive heart failure
  • Severe proteinuria  and oliguria <500 mL/day
  • Serum creatinine >1.1 mg/dL or increased to twice the normal concentration without other renal disease
  • HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count)

Assessment

Risk Stratification
  • Decisions on the management of hypertension should be based on BP levels along with other cardiovascular (CV) risk factors, target organ damage (TOD) and concomitant disorders
Low-Risk Hypertension
  • SBP 140-179 mmHg or DBP 90-110 mmHg
  • Normal physical exam
  • Normal electrocardiogram (ECG) and echocardiography
  • Without proteinuria
High-Risk Hypertension
  • SBP ≥180 mmHg or DBP ≥110 mmHg
  • End-organ involvement
  • Poor obstetric history, comorbidity with renal impairment, diabetes mellitus (DM) or collagen vascular diseases
Work-up for Chronic Hypertension
  • Evaluate patients with preexisting hypertension before pregnancy to define its severity and to facilitate planning for changes in lifestyle and pharmacotherapy if required
  • If a woman’s BP elevation is confirmed and especially if it is severe, a woman should be evaluated for potentially reversible causes
  • Woman with a history of high BP for several years should be evaluated for TOD

Laboratory Tests

 Lab Tests for Chronic Hypertension

  • Should be taken, if not yet done previously or recently, to exclude secondary causes, risk factors and TOD
    • Complete blood count (CBC), urinalysis, renal function test, fasting blood sugar, lipid profile (after 9- to 12-hour fast), serum sodium (Na), potassium (K), uric acid, liver enzymes
    • Chest X-ray
    • 12-lead electrocardiogram (ECG)
Presence of Secondary Cause or Evidence of TOD
  • Patient should be referred to a specialist and treated appropriately if a secondary cause of hypertension is found
  • Further tests should be done, if TOD is found, in order to evaluate the level of severity
Pregnancy Assessment

Check for Proteinuria
  • All pregnant women should be checked for proteinuria
    • 24-hour urine collection is recommended but other acceptable methods are urine dipstick test or urine protein:creatinine ratio
    • Proteinuria should be suspected in patients with ≥2+ protein on urine dipstick
    • Confirmation of proteinuria: ≥300 mg/day in a 24-hour urine sample or ≥30 mg/mmol protein:creatinine ratio in a random urine sample
Other Lab Tests
  • It is important to rule out preeclampsia in pregnant women with hypertension
  • The following are used to distinguish preeclampsia from chronic hypertension: CBC, platelet count, blood smear, coagulation profile, serum creatinine, uric acid, liver enzymes, serum albumin, lactic acid dehydrogenase
  • Other lab work-up that may be considered in patients at risk of developing preeclampsia includes Doppler ultrasound of the uterine arteries and measurement of soluble fms-like tyrosine kinase 1:placental growth factor ratio 
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