hypertension%20in%20pregnancy
HYPERTENSION IN PREGNANCY
Hypertension in pregnancy is defined as a systolic blood pressure of ≥140 mmHg or a diastolic blood pressure of ≥90 mmHg, or both, based on at least 2 measurements ≥4 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.

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
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