Hypertension%20in%20pregnancy Signs and Symptoms
Introduction
Categories of Hypertension in Pregnancy
Chronic Hypertension
- Defined as blood pressure (BP) measurement of ≥140/90 mmHg on 2 occasions prior to pregnancy or before 20 weeks of gestation; also used to refer to hypertension that is diagnosed for the first time during pregnancy and persists beyond 6 weeks postpartum; proteinuria may be present
- Risk of developing preeclampsia is increased
Gestational Hypertension
- Refers to women who develop hypertension without proteinuria after 20 weeks of gestation
- May correspond to the preproteinuric phase of preeclampsia or recurrence of chronic hypertension abated in midpregnancy
- May progress to preeclampsia
- A diagnosis that is made retrospectively if preeclampsia is not present at the time of delivery and blood pressure returns to normal by 6 weeks postpartum
Preeclampsia
- Term used to describe condition presenting as de novo hypertension after 20 weeks of gestation, with 1 or more of the following:
- Proteinuria (≥300 mg/day) or protein to creatinine ratio ≥0.3 mg/mmol
- Hematologic disorder: Hemolysis, thrombocytopenia, coagulopathy
- Liver problems: Elevated liver enzymes and/or severe epigastric or right upper quadrant pain
- Neurologic signs: Severe headache, persistent visual disturbance (scotoma), hyperreflexia with clonus, seizures (eclampsia)
- Renal insufficiency: Oliguria or serum creatinine >1.1 mg/dL or increased to twice the normal concentration without other renal disease
- Pulmonary edema
- Fetal growth restriction
Eclampsia
- A severe convulsive manifestation of the hypertensive disorders of pregnancy that is not caused by drug use, epilepsy, intracranial hemorrhage or cerebral arterial ischemia and infarction
- Can occur without warning signs or symptoms and can happen before, during or after labor
Unclassifiable Antenatal Hypertension
- Hypertension first noted after 20 weeks of gestation requiring re-evaluation at 6 weeks postpartum in order to differentiate chronic from gestational hypertension
Preeclampsia Superimposed on Chronic Hypertension
- Also called preexisting hypertension plus superimposed gestational hypertension with proteinuria
- Diagnosis is based on lab tests as above and should be used to distinguish between superimposed preeclampsia and worsening chronic hypertension
- This refers to patients having preexisting hypertension or chronic hypertension with any of the following:
- New-onset proteinuria (≥3 g/24 hr) presents at >20 weeks of gestation
- Proteinuria in <20 weeks of gestation that is worsening
- Sudden increase in BP that was previously well-controlled
- Thrombocytopenia
- Elevated liver enzymes
- Appearance of preeclampsia/eclampsia features
Risk Factors
Preeclampsia
- Identify at-risk patients with normal BP in early gestation for close monitoring to prevent preeclampsia
- Moderate risk:
- First pregnancy
- Extremes of maternal age (<20 years or >40 years)
- Obesity (BMI ≥35 kg/m2) or excessive weight gain >1 kg/week
- Family history of preeclampsia/eclampsia
- Pregnancy interval >10 years
- Multifetal pregnancy
- High risk:
- History of preeclampsia/eclampsia, intrauterine growth restriction (IUGR) or unexplained stillbirth
- Chronic hypertension
- History of hypertension in previous gestation before week 34
- Preexisting medical conditions [eg diabetes mellitus (DM), collagen vascular diseases, chronic kidney disease, renal vascular or parenchymal diseases]
- Autoimmune disease, eg SLE or antiphospholipid antibody syndrome
Preeclampsia Superimposed on Chronic Hypertension
- Renal insufficiency
- History of hypertension >4 years
- Hypertension in previous pregnancy
- An increase in alanine aminotransferase (ALT) and aspartate aminotransferase (AST) to abnormal levels