If you would like to view past exciting content, please click on the following link.Hypertension in pregnancy encompasses a range of disorders, all characterized by elevated blood pressure. These disorders include chronic hypertension, gestational hypertension, preeclampsia with or without severe features, HELLP syndrome, and eclampsia.The initial step in evaluating a patient presenting with a hypertensive disorder in pregnancy is to perform a CABCDE assessment along with a primary obstetric survey to determine their stability.For unstable patients, check for uncontrolled bleeding and manage any hemorrhage, as severely elevated blood pressure may cause placental abruption. Then, stabilize their airway, breathing, and circulation, considering intubation if necessary.Ensure IV access is established and continuously monitor maternal vital signs. During the primary obstetric survey, monitor the fetal heart rate and contraction pattern, test for rupture of amniotic membranes if needed, and consider checking cervical dilation if indicated.Here's a clinical pearl: urgent hypertension is defined as a blood pressure of 160/110 mmHg or higher that persists after 15 to 20 minutes, requiring antihypertensive medication to reduce the risk of maternal stroke.Now, let's focus on stable patients. For these patients, start with a focused history and physical examination, including an accurate blood pressure measurement. A systolic blood pressure of 140 mmHg or higher, a diastolic blood pressure of 90 mmHg or higher, or both, is considered abnormal during pregnancy. Once elevated blood pressure is recognized, the next step is to assess the patient’s gestational age.For patients less than 20 weeks gestation, assess whether they have a history of hypertension before pregnancy. If there is a history of hypertension, the diagnosis is chronic hypertension.If the patient denies any history of hypertension, still consider chronic hypertension and monitor them closely throughout the pregnancy.If a second elevated blood pressure is recorded before 20 weeks of gestation, the patient meets the diagnostic criteria for chronic hypertension.However, if they remain normotensive, the initial elevated blood pressure represents an isolated incident and not a true hypertensive disorder.For patients presenting with hypertension from 20 weeks of gestation through 12 weeks postpartum, closely monitor those with abnormal blood pressure to see if any repeat elevated readings occur.If no repeat blood pressures are elevated, continue to monitor the patient at subsequent prenatal visits, as they do not meet the criteria for a hypertensive disorder of pregnancy.If a second elevated blood pressure is recorded—specifically a systolic pressure of at least 140 mmHg or a diastolic pressure of at least 90 mmHg, or both, and it has been at least 4 hours since the first elevated measurement—a hypertensive disorder of pregnancy is diagnosed.Next, order labs to help determine the specific disorder present. This will include a CBC, CMP, LDH, a urine protein to creatinine ratio (P/C ratio), and possibly a 24-hour urine collection to measure total protein. A uric acid measurement can also be helpful in some cases.Once these labs are sent, assess if the patient has any history of hypertension prior to pregnancy.For patients reporting no history of chronic hypertension either during or outside of pregnancy, consider either gestational hypertension or preeclampsia. To make the diagnosis, review lab results, specifically the urine P/C ratio to assess for proteinuria. Proteinuria is defined as a urine P/C ratio greater than or equal to 0.30, or a 24-hour urine protein with at least 300 mg of protein.Additionally, assess for signs or symptoms of preeclampsia, which include new-onset headache, visual changes, right upper quadrant or epigastric pain, and possibly shortness of breath.If all labs are normal, the urine P/C ratio is less than 0.30, and the patient is asymptomatic, the diagnosis is gestational hypertension.If the patient’s lab shows proteinuria, the diagnosis is preeclampsia. Once preeclampsia is diagnosed, assess for severe features.Severe features include blood pressures of at least 160 systolic or 110 diastolic on two occasions at least 4 hours apart; laboratory abnormalities such as thrombocytopenia with a platelet count of less than 100,000, renal insufficiency with a creatinine greater than 1.1, elevated liver function tests greater than two times the upper limit of normal; and manifestations such as pulmonary edema, new-onset headache that does not improve with medication, visual symptoms like spots or blurry vision, severe, persistent right upper quadrant abdominal pain, or epigastric pain.Here’s a clinical pearl: if severe-range blood pressures are present, the full 4 hours of blood pressure monitoring is not required to make a presumptive diagnosis of preeclampsia with severe features. This allows for more timely initiation of antihypertensive therapy, which is key to reducing the patient’s risk of seizure, stroke, and other complications.If no severe features are present, the diagnosis is preeclampsia without severe features. If one or more severe features are present, the diagnosis is preeclampsia with severe features.And another clinical pearl: even though a patient may meet diagnostic criteria for gestational hypertension on presentation, remember that gestational hypertension can progress to preeclampsia quickly! Therefore, close monitoring and regular blood pressure measurements are essential throughout their antepartum, labor, and delivery course.Alright, now that we’ve covered patients at least 20 weeks gestation with no history of chronic hypertension, let’s move on to those who do report a history of chronic hypertension.In these patients, elevated blood pressure may simply represent an exacerbation of the patient’s known chronic hypertension, so that should be your first consideration. However, you must also consider superimposed preeclampsia on chronic hypertension, as patients with chronic hypertension have an increased baseline risk.To make your diagnosis, review the labs and note any symptoms or other clinical findings of preeclampsia.If proteinuria is absent or at the patient’s baseline, labs are normal, and the patient is asymptomatic, the diagnosis remains chronic hypertension.On the other hand, if the urine P/C ratio or 24-hour urine protein shows new onset or worsening proteinuria, the patient has superimposed preeclampsia on chronic hypertension. As before, the next step is assessing for severe features.If severe features are absent, the diagnosis is superimposed preeclampsia without severe features; if one or more severe features are present, the diagnosis is superimposed preeclampsia with severe features.Let’s discuss patients who may possibly have a history of chronic hypertension, but in whom clinical findings and labs play a much greater role. Your first step here is to review the clinical findings and laboratory results.Starting with HELLP syndrome, which represents one of the most severe forms of preeclampsia. HELLP stands for Hemolysis, Elevated Liver enzymes, and Low Platelets.Patients with HELLP have an LDH level of 600 or higher due to hemolytic anemia, elevated liver function tests, and thrombocytopenia. They might also have proteinuria, right upper quadrant pain with generalized malaise, or severe-range blood pressures. If you see these findings, the diagnosis is HELLP syndrome.Finally, let’s discuss eclampsia. If a patient presents with a new-onset tonic-clonic seizure in the absence of other etiologies for a seizure, the diagnosis is eclampsia.Eclampsia is the convulsive manifestation of the hypertensive disorders of pregnancy and represents an obstetric emergency. In addition to seizures, the patient could also have a severe headache, altered mental status, visual symptoms, or proteinuria. These findings support the diagnosis of eclampsia.Alright, to summarize: the hypertensive disorders of pregnancy are classified based on gestational age, the presence or absence of proteinuria, and the presence of severe features.
Before 20 weeks of gestation, elevated blood pressure usually indicates chronic hypertension.
From 20 weeks of gestation through 12 weeks postpartum, abnormal blood pressure can indicate gestational hypertension, preeclampsia (with or without severe features), superimposed preeclampsia on chronic hypertension, HELLP syndrome, or eclampsia.
"Gestational Hypertension and Preeclampsia" Obstet Gynecol. 135(6):e237-e260. (2020)"American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Obstetrics" Obstet Gynecol. 133(1):e26-e50. (2019)"Hypertension During Pregnancy." Curr Hypertens Rep. (2020;22(9):64.)"Practical guide for the management of hypertensive disorders during pregnancy. 40(7):1257-1264." J Hypertens (2022)" Hypertensive Disorders in Pregnancy 45(2):333-347. " Obstet Gynecol Clin North Am. ( 2018)"Hypertensive disorders of pregnancy. 381:e071653" BMJ (2023) - - - - - - - END - - - - - - -
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