Hypertension%20in%20pregnancy Signs and Symptoms

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 with previously normal BP 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 BP returns to normal by 6 weeks postpartum

Preeclampsia

• Term used to describe a condition presenting as de novo hypertension after 20 weeks of gestation, with 1 or more of the following:
  • Proteinuria (≥300 mg/day) or protein:creatinine ratio ≥30 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, altered mental status, persistent visual disturbance (scotoma), blindness, hyperreflexia with clonus, seizures (eclampsia), stroke
  • Renal insufficiency: Oliguria or serum creatinine >1.1 mg/dL or increased to twice the normal concentration without other renal disease
  • Pulmonary edema
  • Uteroplacental dysfunction: Fetal growth restriction, placental abruption, stillbirth, abnormal umbilical artery Doppler waveform analysis 
• Subclassification of preeclampsia   
  • Early-onset: With delivery at <34⁺⁰ weeks of gestation
  • Preterm: With delivery at <37⁺⁰ weeks of gestation
  • Late-onset: With delivery at ≥34⁺⁰ weeks of gestation
  • Term: With delivery at ≥37⁺⁰ weeks of gestation
• Atypical preeclampsia   
  • Early signs and symptoms of preeclampsia-eclampsia occurring at <20 weeks of gestation
  • Late postpartum preeclampsia-eclampsia occurring >48 hours after delivery
  • Gestational hypertension with ≥1 of the following:
    • Preeclampsia symptoms
    • Hemolysis
    • Elevated liver enzymes (aspartate aminotransferase [AST] and alanine aminotransferase [ALT]) 2x the upper limit of normal value
    • Thrombocytopenia <100,000/mm³
  • Gestational proteinuria with ≥1 of the following:
    • Preeclampsia symptoms
    • Hemolysis
    • Elevated liver enzymes 
    • Thrombocytopenia

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
• 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

Preeclampsia 

• Identify at-risk patients with normal BP in early gestation for close monitoring to prevent preeclampsia
• Moderate risk (≥2 of the following):
  • 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
  • History of placental abruption, intrauterine growth restriction or unexplained stillbirth
• High risk (any 1 of the following):
  • History of preeclampsia/eclampsia
  • 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 systemic lupus erythematosus or antiphospholipid antibody syndrome

Preeclampsia Superimposed on Chronic Hypertension 

• Renal insufficiency
• History of hypertension >4 years
• Hypertension in previous pregnancy
• An increase in ALT and AST to abnormal levels