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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Occurs after 20 weeks of gestation or up to 6 weeks postpartum in previously normotensive women

  • Usually diagnosed after a rise in blood pressure of ≥ 30/15 mm Hg to a level above 140/90 mm Hg supine in the left lateral position after resting for at least 5 minutes

  • May progress to preeclampsia when complicated by proteinuria, edema, or hematologic or hepatic abnormalities

  • May progress to cerebral symptoms, leading to convulsions

GENERAL CONSIDERATIONS

  • Hypertensive disorders of pregnancy can be divided into 4 groups:

    • – Chronic persistent hypertension, which occurs before pregnancy or before 20 weeks of gestation and persists

    • – Gestational hypertension, which develops after 20 weeks and is not associated with preeclampsia or eclampsia

    • – Preeclampsia or eclampsia: gestational hypertension with 1 or more of the following: proteinuria, renal insufficiency, liver involvement, neurologic (including seizure) or hematologic complication, uteroplacental dysfunction, or fetal growth restriction

    • – White coat hypertension

  • Is a leading cause of maternal mortality

  • Is an endothelial disorder that results in placental ischemia

  • Occurs more frequently in women with hypertension predating pregnancy

  • Occurs more frequently in primigravidas, those > 45 years old, and diabetics

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Nonspecific symptoms are common, such as headache, nausea, and visual disturbances

PHYSICAL EXAM FINDINGS

  • Increased blood pressure

  • Edema

  • Hyperreflexia and clonus can occur

DIFFERENTIAL DIAGNOSIS

  • Chronic hypertension

  • Unclassified hypertension when blood pressure status before conception and during first trimester is unknown

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • Urinalysis: to check for protein

  • CBC, platelets (often low)

  • Uric acid: may be elevated

  • Serum albumin: may be low

  • Liver function tests: may be abnormal

ELECTROCARDIOGRAPHY

  • No specific abnormalities

IMAGING STUDIES

  • Fetal ultrasound: may show reduced size for gestational age

  • Umbilical Doppler: may show flow abnormalities

TREATMENT

CARDIOLOGY REFERRAL

  • Cardiac complications of hypertension

HOSPITALIZATION CRITERIA

  • Almost all with severe preeclampsia

  • Complications of hypertension such as heart failure

MEDICATIONS

  • Methyldopa is the primary treatment 250–1500 mg PO bid

  • Nifedipine (10–20 mg PO tid) and labetalol (100–400 mg PO bid) may be used in succession for severe hypertension

  • Hydralazine 10-mg boluses IV can be used every 20 minutes for acute elevations in blood pressure or IV labetalol 40–80 mg every 10 minutes prn to 300-mg maximum total dose

  • Angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and atenolol are contraindicated

  • For intrapartum management, IV magnesium prevents progression of preeclampsia to seizures

THERAPEUTIC PROCEDURES

  • Termination of pregnancy when fetal or maternal crisis develops

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