Hypertension%20in%20pregnancy Management

Chronic Hypertension or Gestational Hypertension 

• Poorly controlled hypertension warrants weekly clinic appointments; if well controlled, it may be every 2-4 weeks  

Maternal Monitoring 

• In each physician visit, patients should be observed closely for early signs of preeclampsia
• Antihypertensive treatment should be started if severe hypertension develops before term
  • Regularly monitor the patient’s BP and for the presence of side effects from treatment or complications
• Women with high-risk chronic hypertension are more likely to have adverse maternal and perinatal complications
  • Maternal risks include disseminated vascular coagulation, placental abruption, stroke and multiple organ failure involving the kidney and the liver 
  • Perinatal loss and neonatal complications may occur in women with renal insufficiency (serum creatinine >1.4 mg/dL), DM with vascular involvement, severe collagen vascular disease, cardiomyopathy or coarctation of the aorta
  • Other potential maternal outcomes are congestive heart failure, myocardial infarction, spontaneous coronary artery dissection, acute renal failure requiring dialysis, or death

Fetal Monitoring 

• Ultrasound for assessment of fetal growth and amniotic fluid volume, and umbilical artery Doppler velocimetry may be done in women with chronic hypertension at 28, 32 and 36 weeks and with gestational hypertension at diagnosis and repeated every 2-4 weeks if normal 
• Cardiotocography may be done only if clinically indicated

Preeclampsia/Eclampsia 

Maternal Monitoring 

• Purpose is to observe progression of the condition both to prevent maternal complications during delivery and to assess fetal well-being
• Monitor BP twice weekly
• Order lab tests as in diagnosis of preeclampsia done weekly: CBC, platelet count, liver enzymes, LDH, uric acid, creatinine
• Assess for proteinuria weekly
• Invasive hemodynamic monitoring may be required
  • Monitor fluid volume expansion especially in cases of pulmonary edema, persistent oliguria unresponsive to fluid challenge, intractable severe hypertension and in delivery with epidural anesthesia
• Maternal mortality due to preeclampsia is caused by intracranial hemorrhage, acute pulmonary edema, acute renal failure, respiratory distress syndrome, cardiomyopathy 

Fetal Monitoring 

• With preeclampsia, risks of fetal prematurity or preterm birth, intrauterine growth retardation and intrauterine death are high 
• Do nonstress test (NST) twice weekly
• Determine amniotic fluid index (AFI) once or twice weekly
• Biophysical profile (BPP) weekly may replace one of the twice-weekly NSTs and AFIs
• Ultrasound examination of the fetus to assess fetal growth and an umbilical artery Doppler velocimetry should be done every 2-4 weeks
• Cardiotocography may be done at diagnosis of preeclampsia or severe gestational hypertension but may be repeated only if clinically indicated
• Intrauterine fetal death related to preeclampsia is caused by acute and chronic hypoxia, fetal growth restriction, placental abruption and placental insufficiency