Gestational hypertension resident survival guide

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Gestational hypertension Resident Survival Guide Microchapters
Overview
Causes
Diagnosis
Treatment
Dos
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rinky Agnes Botleroo, M.B.B.S. Samah Obaiah, MD[2]

Synonyms and Keywords: Approach to pregnancy-induced hypertension; Gestational hypertension workup, Gestational hypertension management

Overview

Gestational hypertension or Pregnancy-induced hypertension (PIH) , is defined as systolic blood pressure (SBP) >140 mmHg and diastolic blood pressure (DBP) >90 mmHg on at least two occasions at least 6 hours apart after the 20th week of gestation in women known to be normotensive before pregnancy and before 20 weeks’ gestation. The BP recordings used to establish the diagnosis should be no more than 7 days apart. [Gestational hypertension]] is considered severe if there is sustained elevations in systolic blood pressure to at least 160 mm Hg and/or in diastolic blood pressure to at least 110 mm Hg for at least 6 hours. It is classified as mild , moderate , and severe . The WHO classified it is one of the main causes of maternal, fetal, and neonatal mortality and morbidity.[1].gestational hypertension is one of the most common medical disorders affecting pregnancy. The most serious maternal complications of gestational hypertension include intracerebral hemorrhage,eclampsia, and renal failure, as well as hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome and posterior reversible encephalopathy syndrome (PRES).[2]Treatment of gestational hypertension depends on blood pressure levels, gestational age, presence of symptoms and associated risk factors.

Causes

The cause of gestational hypertension is unknown. If untreated will be life-threatening, severe gestational hypertension may cause dangerous seizures (eclampsia) and even death in the mother and fetus. Because of these risks, it may be necessary for the baby to be delivered early, before the full term of pregnancy. Some conditions may increase the risk of developing the condition, including the following[3][4]:

Common Causes

Pathogenesis theories developed about the passable causes:

Diagnosis

Shown below is an algorithm summarizing the diagnosis of Gestational Hypertension. [5][3][6]

 
 
 
 
 
 
Pregnant woman with complaints of elevated blood pressure
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Take complete history
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Take obstetric history:

❑ Date of last menstrual period?

❑ Estimated date of delivery

❑ Confirm the gestational age, gravidity and parity.

❑ Check if this is a single or multiple gestation.

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ask about previous obstetric history if she was previously pregnant:

❑ Ask about previous pregnancies including miscarriages and terminations.

❑ Length of gestation.

❑ Ask about mode of delivery.

❑ Ask if there was similar complaints during previous pregnancy?

❑ Was there any complications throughout the pregnancy or during delivery such as shoulder dystocia, postpartum haemorrhage ?

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ask the following questions about menstrual history:

❑ Age of menarche

❑ Last menstrual period

❑ Is the menstrual flow normal? How many pads she has to use in a day?

❑ Is there any foul smell or colour change?

❑ How many days does the menstruation stay?

Contraceptive history for example oral contraceptives, intrauterine device

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
See if following factors are present:

❑ History of hypertension

Kidney disease

Diabetes

Hypertension with a previous pregnancy

❑ Mother's age younger than 20 or older than 40

❑ Multiple fetuses (twins, triplets)

❑ African-American race

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ask about present complaints:

❑ Ask if there is any discomfort or pain in the chest

❑ Ask if the patient has swelling of legs

❑ Ask if there is any changes in vision

❑ Ask if there is any history of headache
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Gestational Hypertension [7]

Blood pressure higher than 140/90 measured on two separate occasions, more than 6 hours apart. [7]

❑ Absence of protein in the urine and diagnosed after 20 weeks of gestation. [7]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ask about associated symptoms to exclude preeclampsia: [6]

❑ Severe headaches

❑ Changes in vision, including temporary loss of vision, blurred vision or light sensitivity

Upper abdominal pain, usually under ribs on the right side

Nausea or vomiting

❑ Decreased urine output

❑ Decreased levels of platelets in your blood (thrombocytopenia)

❑ Impaired liver function

Shortness of breath, caused by fluid in the lungs

 
 
 
 
 
 
 
 
 
 
 
 
 
 

Treatment

Management of gestational hypertension remains controversial, as does the classification of its severity. Delaying the interruption of pregnancy may lead to the progression of pre-eclampsia, eventually resulting in placental insufficiency and maternal organ dysfunction, with increased risk of maternal and perinatal mortality. Aims of management are minimizing further pregnancy-related complications, avoiding unnecessary prematurity, and maximizing maternal and infant survival.

Shown below is an algorithm summarizing the treatment of gestational hypertension.

 
 
 
 
 
 
 
Woman comes with gestational hypertension
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Non-pharmacological treatment [5]
 
 
 
 
 
 
 
Pharmacological treatment[5]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 




❑ 30 minutes of moderate exercise on most days of the week to stimulate placental angiogenesis and improve maternal endothelial dysfunction.

❑ Strict bed rest should be avoided and encouraged to maintain normal physical activity levels, as prolonged bed rest can increase the risk for venous thromboembolism, especially given the physiological hypercoagulability of pregnancy. [8]

 
 
 
 
 
 
 

Methyl-dopa: [5] a centrally acting alpha-2 adrenergic agonist, used as a first line agent mainly because of its longstanding history of safety and use in pregnancy. Blood pressure control is gradual over 6-8 hours because of the indirect mechanism of action and is best for treatment of mild hypertension rather than moderate or severe hypertension.

Labetalol: [5] a nonselective beta-blocker. Should not be given in patients withasthma as it can cause bronchospasm. It is used widely in pregnancy and has proven effective in the treatment of mild to moderate hypertension, though some data shows a slight increase in small for gestational age (SGA) infants.

Procardia: [5] a calcium channel blocker, often used in pregnancy to treat mild to moderate hypertension. It has shown indication of adverse perinatal outcomes or decreased uterine blood flow.

Diuretics: [5] can be used as second line medication. It has some usefulness in pregnancy, specifically with salt-sensitive hypertension and for patients with reduced renal function. It should be carefully prescribed to avoid hypokalemia and fetal growth restriction from intravascular volume depletion.

Hydralazine and clonidine: [5] have been used in certain circumstances, but are not commonly used in the longitudinal treatment of gestational or chronic hypertension.

ACE inhibitors, angiotensin receptor blockers, mineralocorticoid receptor antagonists, and nitroprusside are contraindicated in pregnancy as these are teratogenic. [3]

Nitroprusside can be used as a last resort in treatment-resistant hypertension. [3]

❑ Low dose aspirin of 81 mg or less to be initiated before 20 weeks of gestation to prevent preeclampsia as a sequelae of hypertension.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fetal evaluation[9]

❑ An ultrasound should be done at 16-20 weeks to provide an accurate baseline reading to evaluate the baby’s growth.

Fetal movement should be counted by checking the kicks and movements. Any change in the number of kicks or how often the baby kicks may mean it is under stress.

Non-stress test: this measures baby’s heart rate in response to his or her movements.

Biophysical profile: this test combines a non-stress test with an ultrasound to observe the baby.

Doppler flow studies: ultrasound that uses sound waves to measure the flow of the baby’s blood through a blood vessel.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Indications for preterm delivery [5]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
The recommendations for delivery are as follows: [5]
❑ 38-39 6/7 weeks of gestation for women not requiring medication.

❑ 37- 39 6/7 weeks of gestation for women with hypertension controlled with medication.

❑36-37 6/7 weeks of gestation for women with severe hypertension difficult to control
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Intrapartum management: [5]
❑ It is outside of the scope of the primary care provider and includes intravenous medications for acute blood pressure treatment, intravenous magnesium sulfate administration for seizure prophylaxis with suspected preeclampsia and serial serology.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Postpartum management: [5]
Postpartum hypertension until 12 weeks postpartum should be managed with medications that are safe for breastfeeding.
 
 
 
 
 

Dos[3]

Don'ts

References

  1. Kintiraki E, Papakatsika S, Kotronis G, Goulis DG, Kotsis V (2015). "Pregnancy-Induced hypertension". Hormones (Athens). 14 (2): 211–23. doi:10.14310/horm.2002.1582. PMID 26158653.
  2. Marik PE (2009). "Hypertensive disorders of pregnancy". Postgrad Med. 121 (2): 69–76. doi:10.3810/pgm.2009.03.1978. PMID 19332964.
  3. 3.0 3.1 3.2 3.3 3.4 3.5 3.6 "Hypertension In Pregnancy - StatPearls - NCBI Bookshelf".
  4. Villar J, Carroli G, Wojdyla D, Abalos E, Giordano D, Ba'aqeel H, Farnot U, Bergsjø P, Bakketeig L, Lumbiganon P, Campodónico L, Al-Mazrou Y, Lindheimer M, Kramer M (April 2006). "Preeclampsia, gestational hypertension and intrauterine growth restriction, related or independent conditions?". Am J Obstet Gynecol. 194 (4): 921–31. doi:10.1016/j.ajog.2005.10.813. PMID 16580277.
  5. 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 5.11 Spiro L, Scemons D (2018). "Management of Chronic and Gestational Hypertension of Pregnancy: A Guide for Primary Care Nurse Practitioners". Open Nurs J. 12: 180–183. doi:10.2174/1874434601812010180. PMC 6128013. PMID 30258507.
  6. 6.0 6.1 Portelli M, Baron B (2018). "Clinical Presentation of Preeclampsia and the Diagnostic Value of Proteins and Their Methylation Products as Biomarkers in Pregnant Women with Preeclampsia and Their Newborns". J Pregnancy. 2018: 2632637. doi:10.1155/2018/2632637. PMC 6046127. PMID 30050697.
  7. 7.0 7.1 7.2 Lo JO, Mission JF, Caughey AB (April 2013). "Hypertensive disease of pregnancy and maternal mortality". Curr Opin Obstet Gynecol. 25 (2): 124–32. doi:10.1097/GCO.0b013e32835e0ef5. PMID 23403779.
  8. Abdul Sultan A, West J, Tata LJ, Fleming KM, Nelson-Piercy C, Grainge MJ (November 2013). "Risk of first venous thromboembolism in pregnant women in hospital: population based cohort study from England". BMJ. 347: f6099. doi:10.1136/bmj.f6099. PMC 3898207. PMID 24201164.
  9. "Treatment Options for Gestational Hypertension".
  10. Yeo S, Steele NM, Chang MC, Leclaire SM, Ronis DL, Hayashi R (April 2000). "Effect of exercise on blood pressure in pregnant women with a high risk of gestational hypertensive disorders". J Reprod Med. 45 (4): 293–8. PMID 10804484.