Gestational hypertension resident survival guide
|Gestational hypertension Resident Survival Guide Microchapters|
Synonyms and Keywords: Approach to pregnancy-induced hypertension; Gestational hypertension workup, Gestational hypertension management
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..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).Treatment of gestational hypertension depends on blood pressure levels, gestational age, presence of symptoms and associated risk factors.
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:
- History of hypertension
- Kidney disease
- Hypertension with a previous pregnancy
- Mother's age younger than 20 or older than 40
- Multiple fetuses (twins, triplets)
- African-American race
Pathogenesis theories developed about the passable causes:
- Insufficient blood flow to the uterus or abnormal placental implantation
- Damage to the blood vessels
- A problem with the immune system
- Certain genes
- Platelet activation
- Hyperlipidaemia and insulin resistance
|Pregnant woman with complaints of elevated blood pressure|
Take complete history
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
Ask about associated symptoms to exclude preeclampsia: 
❑ Severe headaches
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 ||Pharmacological treatment|
❑ 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. 
❑ Methyl-dopa:  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.
❑ An ultrasound should be done at 16-20 weeks to provide an accurate baseline reading to evaluate the baby’s growth.
❑ 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 |
- Pregnant woman with gestational hypertension should be advised to visit her health care provider regularly throughout the pregnancy.
- Patient should be encouraged to take her blood pressure medication as prescribed.
- The health care provider should prescribe the safest medication at the most appropriate dose.
- Pregnant woman with gestational hypertension should stay active and follow her health care provider's recommendations for physical activity.
- Pregnant woman with gestational hypertension should have a healthy diet and if additional help is needed, she can speak with a nutritionist.
- Pregnant woman with gestational hypertension should talk to her health care provider before taking over-the-counter medications.
- Strength training and pure isometric exercise, such as lifting weights and aerobic exercise should be discouraged as it can acutely elevate blood pressure to severe levels. It can also increase the risk for adverse events such as stroke.
- There is no evidence that suggests benefits in restricting sodium intake during pregnancy, thus it is not recommended to limit the intake in the prevention of preeclampsia.
- Pregnant woman should avoid alcohol,recreational drugs, smoking.
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