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! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align="center" |{{fontcolor|#2B3B44|Gestational hypertension Resident Survival Guide Microchapters}}
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Gestational hypertension  resident survival guide#Overview|Overview]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Gestational hypertension  resident survival guide#Causes|Causes]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Gestational hypertension  resident survival guide#Diagnosis|Diagnosis]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Gestational hypertension  resident survival guide#Treatment|Treatment]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Gestational hypertension  resident survival guide#Dos|Dos]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Gestational hypertension  resident survival guide#Don'ts|Don'ts]]
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{{WikiDoc CMG}}; {{AE}} {{RAB}} {{ Samah Obaiah}}


{{WikiDoc CMG}}; {{AE}} {{SamahObiah}}
{{SK}} Approach to pregnancy-induced hypertension; Gestational hypertension workup, Gestational hypertension management
 
{{SK}} Pregnancy-induced hypertension; PIH; gestational hypertension; pre-eclampsia
==Overview==
==Overview==
[[gestational hypertension]] or [[Pregnancy-induced hypertension]] (PIH) , is defined as systolic blood pressure (SBP) >140 mmHg and diastolic blood pressure (DBP) >90 mmHg in pregnant woman who had normal blood pressure prior to 20 weeks and has no proteinuria (excess protein in the urine). It is classified as mild , moderate , and severe . It is about 6-10% of pregnancies. The WHO classified  it is one of the main causes of maternal, fetal, and neonatal mortality and morbidity<ref name="pmid26158653">{{cite journal| author=Kintiraki E, Papakatsika S, Kotronis G, Goulis DG, Kotsis V| title=Pregnancy-Induced hypertension. | journal=Hormones (Athens) | year= 2015 | volume= 14 | issue= 2 | pages= 211-23 | pmid=26158653 | doi=10.14310/horm.2002.1582 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26158653  }} </ref>.[[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).<ref name="pmid19332964">{{cite journal| author=Marik PE| title=Hypertensive disorders of pregnancy. | journal=Postgrad Med | year= 2009 | volume= 121 | issue= 2 | pages= 69-76 | pmid=19332964 | doi=10.3810/pgm.2009.03.1978 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19332964  }} </ref>Treatment of [[gestational hypertension]] depends on blood pressure levels, gestational age, presence of symptoms and associated risk factors.
[[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]].<ref name="pmid26158653">{{cite journal| author=Kintiraki E, Papakatsika S, Kotronis G, Goulis DG, Kotsis V| title=Pregnancy-Induced hypertension. | journal=Hormones (Athens) | year= 2015 | volume= 14 | issue= 2 | pages= 211-23 | pmid=26158653 | doi=10.14310/horm.2002.1582 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26158653  }} </ref>.[[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).<ref name="pmid19332964">{{cite journal| author=Marik PE| title=Hypertensive disorders of pregnancy. | journal=Postgrad Med | year= 2009 | volume= 121 | issue= 2 | pages= 69-76 | pmid=19332964 | doi=10.3810/pgm.2009.03.1978 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19332964  }} </ref>Treatment of [[gestational hypertension]] depends on blood pressure levels, [[gestational]] age, presence of symptoms and associated risk factors.


==Causes==
==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:


* History of [[hypertension]]  
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<ref name="urlHypertension In Pregnancy - StatPearls - NCBI Bookshelf">{{cite web |url=https://www.ncbi.nlm.nih.gov/books/NBK430839/ |title=Hypertension In Pregnancy - StatPearls - NCBI Bookshelf |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref><ref name="pmid16580277">{{cite journal |vauthors=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 |title=Preeclampsia, gestational hypertension and intrauterine growth restriction, related or independent conditions? |journal=Am J Obstet Gynecol |volume=194 |issue=4 |pages=921–31 |date=April 2006 |pmid=16580277 |doi=10.1016/j.ajog.2005.10.813 |url= |issn=}}</ref>:
* [[Kidney disease]]
*History of [[hypertension]]
* [[Diabetes]]
*[[Kidney disease]]
* [[Hypertension]] with a previous [[pregnancy]]
*[[Diabetes]]
* Mother's age younger than 20 or older than 40
*[[Hypertension]] with a previous [[pregnancy]]
* Multiple fetuses (twins, triplets)
*Mother's age younger than 20 or older than 40
* African-American race
*Multiple [[fetuses]] ([[twins]], [[triplets]])
*African-American race
===Common Causes===
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]]


==Diagnosis==
Shown below is an algorithm summarizing the diagnosis of [[Gestational]] [[Hypertension]]. <ref name="pmid30258507">{{cite journal |vauthors=Spiro L, Scemons D |title=Management of Chronic and Gestational Hypertension of Pregnancy: A Guide for Primary Care Nurse Practitioners |journal=Open Nurs J |volume=12 |issue= |pages=180–183 |date=2018 |pmid=30258507 |pmc=6128013 |doi=10.2174/1874434601812010180 |url= |issn=}}</ref><ref name="urlHypertension In Pregnancy - StatPearls - NCBI Bookshelf">{{cite web |url=https://www.ncbi.nlm.nih.gov/books/NBK430839/ |title=Hypertension In Pregnancy - StatPearls - NCBI Bookshelf |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref><ref name="pmid30050697">{{cite journal |vauthors=Portelli M, Baron B |title=Clinical Presentation of Preeclampsia and the Diagnostic Value of Proteins and Their Methylation Products as Biomarkers in Pregnant Women with Preeclampsia and Their Newborns |journal=J Pregnancy |volume=2018 |issue= |pages=2632637 |date=2018 |pmid=30050697 |pmc=6046127 |doi=10.1155/2018/2632637 |url= |issn=}}</ref>


===Common Causes ===
{{Family tree/start}}
Pathogenesis theories developed about the passable causes:-
{{Family tree | | | | | | | A01 | | | | | | | |A01= Pregnant woman with complaints of elevated [[blood pressure]]}}
{{Family tree | | | | | | | |!| | | | | | | | |}}
{{Family tree | | | | | | | B01 | | | | | | | |B01=<div style="float: left; text-align: left; "> Take complete history}}
{{Family tree | | | | | | | |!| | | | | | | | |}}
{{Family tree | | | | | | | B02 | | | | | | | |B02= <div style="float: left; text-align: left;  height: 17em; "> '''Record the [[Vital signs|vitals]]:'''<br>
----
❑ [[Blood pressure]]<br><br>
❑ [[Temperature]]<br><br>❑ [[Respiratory rate]]<br><br>❑ [[Heart rate]] </div>| | | | | | | |}}
{{Family tree | | | | | | | |!| | | | | | | | |}}
{{Family tree | | | | | | | B02 | | | | | | | |B02= <div style="float: left; text-align: left;"> '''Take [[obstetric]] history:'''<br>
----
❑ Date of last  [[menstrual]] period?  <br><br>❑ Estimated date of [[delivery]]<br><br>❑ Confirm the [[gestational]] age, [[gravidity]] and [[parity]].<br><br> ❑ Check if this is a single or multiple [[gestation]].<br><br> </div>| | | | | | | |}}
{{Family tree | | | | | | | |!| | | | | | | | |}}
{{Family tree | | | | | | | B01 | | | | | | | |B01= <div style="float: left; text-align: left;"> '''Ask about previous obstetric history if she was previously [[pregnant]]:'''<br>
----
❑ Ask about previous [[pregnancies]] including [[miscarriages]] and [[Termination of pregnancy|terminations]]. <br><br>❑ Length of [[gestation]]. <br><br>❑ Ask about mode of delivery. <br><br>❑ Ask if there was similar complaints during previous [[pregnancy]]?<br><br>❑ Was there any complications throughout the [[pregnancy]] or during [[delivery]] such as [[shoulder dystocia]], [[postpartum haemorrhage]] ?<br><br></div>| | | | | | | | }}
{{Family tree | | | | | | | |!| | | | | | | | |}}
{{Family tree | | | | | | | B02 | | | | | | | |B02= <div style="float: left; text-align: left;"> '''Ask the following questions about [[menstrual]] history:'''<br>
----
❑ Age of [[menarche]] <br><br>❑ Last [[menstrual]] period<br><br>❑ Is the [[menstrual]] flow normal? How many pads she has to use in a day? <br><br>❑ Is there any foul smell or colour change?<br><br>❑ How many days does the [[menstruation]] stay?<br><br>❑ [[Contraceptive]] history for example [[oral]] [[contraceptives]], [[intrauterine device]]<br><br></div>| | | | | | | |}}
{{Family tree | | | | | | | |!| | | | | | | | |}}
{{Family tree | | | | | | | B02 | | | | | | | |B02= <div style="float: left; text-align: left;  height: 28em; "> '''See if following factors are present:'''<br>
----
❑ History of [[hypertension]]<br><br>
❑ [[Kidney disease]]<br><br>
❑ [[Diabetes]]<br><br>
❑ [[Hypertension]] with a previous [[pregnancy]]<br><br>
❑ Mother's age younger than 20 or older than 40<br><br>
❑ Multiple [[fetuses]] ([[twins]], [[triplets]])<br><br>
❑ African-American race<br><br> </div>| | | | | | |}}
{{Family tree | | | | | | | |!| | | | | | | | |}}
{{Family tree | | | | | | | B02 | | | | | | | |B02= <div style="float: left; text-align: left;  height: 20em; "> '''Ask about present complaints:'''<br>
----
❑ Ask if there is any discomfort or [[pain]] in the [[chest]]<br><br>
❑ Ask if the patient has [[swelling]] of legs<br><br>❑ Ask if there is any changes in [[vision]]<br><br>❑ Ask if there is any history of [[headache]] </div>| | | | | | | |}}
{{Family tree | | | | | | | |!| | | | | | | | |}}
{{Family tree | | | | | | | B02 | | | | | | | |B02= <div style="float: left; text-align: left;  height: 16em; "> '''[[Gestational Hypertension]] <ref name="pmid23403779">{{cite journal |vauthors=Lo JO, Mission JF, Caughey AB |title=Hypertensive disease of pregnancy and maternal mortality |journal=Curr Opin Obstet Gynecol |volume=25 |issue=2 |pages=124–32 |date=April 2013 |pmid=23403779 |doi=10.1097/GCO.0b013e32835e0ef5 |url= |issn=}}</ref>'''<br>
----
❑ [[Blood pressure]] higher than 140/90 measured on two separate occasions, more than 6 hours apart. <ref name="pmid23403779">{{cite journal |vauthors=Lo JO, Mission JF, Caughey AB |title=Hypertensive disease of pregnancy and maternal mortality |journal=Curr Opin Obstet Gynecol |volume=25 |issue=2 |pages=124–32 |date=April 2013 |pmid=23403779 |doi=10.1097/GCO.0b013e32835e0ef5 |url= |issn=}}</ref><br><br>
❑  Absence of [[protein]] in the [[urine]] and diagnosed after 20 weeks of gestation. <ref name="pmid23403779">{{cite journal |vauthors=Lo JO, Mission JF, Caughey AB |title=Hypertensive disease of pregnancy and maternal mortality |journal=Curr Opin Obstet Gynecol |volume=25 |issue=2 |pages=124–32 |date=April 2013 |pmid=23403779 |doi=10.1097/GCO.0b013e32835e0ef5 |url= |issn=}}</ref>  </div>| | | | | | | |}}
{{Family tree | | | | | | | |!| | | | | | | | |}}
{{Family tree | | | | | | | B02 | | | | | | | |B02= <div style="float: left; text-align: left;  height: 37em; "> '''Ask about associated symptoms to exclude [[preeclampsia]]: <ref name="pmid30050697">{{cite journal |vauthors=Portelli M, Baron B |title=Clinical Presentation of Preeclampsia and the Diagnostic Value of Proteins and Their Methylation Products as Biomarkers in Pregnant Women with Preeclampsia and Their Newborns |journal=J Pregnancy |volume=2018 |issue= |pages=2632637 |date=2018 |pmid=30050697 |pmc=6046127 |doi=10.1155/2018/2632637 |url= |issn=}}</ref>'''<br>
----
❑ Severe [[headaches]]<br><br>
❑ Changes in [[vision]], including temporary loss of [[vision]], [[blurred vision]] or [[light sensitivity]]<br><br>
❑ [[Upper abdominal pain]], usually under [[ribs]] on the right side<br><br>
❑ [[Nausea and vomiting|Nausea or vomiting]]<br><br>
❑ Decreased [[urine output]]<br><br>
❑ Decreased levels of [[platelets]] in your blood (thrombocytopenia)<br><br>
❑ Impaired [[liver function]]<br><br>
❑ [[Shortness of breath]], caused by [[fluid]] in the [[lungs]]<br><br> </div>| | | | | | | |}}
{{familytree/end}}


* [[Insufficient blood flow to the uterus or abnormal placental implantation ]]
==Treatment==
* [[Damage to the blood vessels]]
* [[A problem with the immune system]]
* [[Certain genes]]
* [[platelet activation ]]
* [[hyperlipidaemia and insulin resistance]]


==Diagnosis==
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|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 diagnosis of <nowiki>[[disease name]]</nowiki> according the the [...] guidelines.
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree | | | | A01 | | | A01=Pregnant woman
previously normotensive
BP ≥140/90 mmHg
>20 weeks' gestation
absence of symptoms that suggest preeclampsia
nulligravidity
black or Hispanic ethnicity
obesity
mother small for gestational age }}
{{familytree | | | | |!| | | | }}
{{familytree | | | | B01 | | | B01= }}
{{familytree | | |,|-|^|-|.| | }}
{{familytree | | C01 | | C02 | C01= | C02= }}


{{familytree/end}}
Shown below is an algorithm summarizing the treatment of [[gestational hypertension]].


==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 <nowiki>[[disease name]]</nowiki> according the the [...] guidelines.
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree | | | | | | | | A01 |A01= }}  
{{familytree | | | | | | | | A01 |A01= Woman comes with [[gestational hypertension]]}}  
{{familytree | | | | |,|-|-|-|^|-|-|-|-|.| | | }}
{{familytree | | | | |,|-|-|-|^|-|-|-|-|.| | | }}
{{familytree | | | B01 | | | | | | | | B02 | | |B01= |B02= }}
{{familytree | | | B01 | | | | | | | | B02 | | |B01= Non-pharmacological treatment <ref name="pmid30258507">{{cite journal |vauthors=Spiro L, Scemons D |title=Management of Chronic and Gestational Hypertension of Pregnancy: A Guide for Primary Care Nurse Practitioners |journal=Open Nurs J |volume=12 |issue= |pages=180–183 |date=2018 |pmid=30258507 |pmc=6128013 |doi=10.2174/1874434601812010180 |url= |issn=}}</ref>|B02= [[Pharmacological treatment]]<ref name="pmid30258507">{{cite journal |vauthors=Spiro L, Scemons D |title=Management of Chronic and Gestational Hypertension of Pregnancy: A Guide for Primary Care Nurse Practitioners |journal=Open Nurs J |volume=12 |issue= |pages=180–183 |date=2018 |pmid=30258507 |pmc=6128013 |doi=10.2174/1874434601812010180 |url= |issn=}}</ref> }}
{{familytree | | | |!| | | | | | | | | |!| }}
{{familytree | | | |!| | | | | | | | | |!| }}
{{familytree | | | C01 | | | | | | | | |!| |C01= }}
{{familytree | | | |!| | | | | | | | | |!| }}
{{familytree | |,|-|^|.| | | | | | | | |!| }}
{{familytree | | | L01 | | | | | | | | K01 | K01=<div style="float: left; text-align: left;height: 62em; width: 32em ">
{{familytree | D01 | | D02 | | | | | | D03 |D01= |D02= |D03= }}
 
{{familytree | |!| | | | | | | | | |,|-|^|.| }}
❑ [[Methyl-dopa]]: <ref name="pmid30258507">{{cite journal |vauthors=Spiro L, Scemons D |title=Management of Chronic and Gestational Hypertension of Pregnancy: A Guide for Primary Care Nurse Practitioners |journal=Open Nurs J |volume=12 |issue= |pages=180–183 |date=2018 |pmid=30258507 |pmc=6128013 |doi=10.2174/1874434601812010180 |url= |issn=}}</ref> a centrally acting [[Alpha-2 receptor|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]].<br><br>
{{familytree | E01 | | | | | | | E02 | | | E03 |E01= |E02= |E03= }}
❑ [[Labetalol]]: <ref name="pmid30258507">{{cite journal |vauthors=Spiro L, Scemons D |title=Management of Chronic and Gestational Hypertension of Pregnancy: A Guide for Primary Care Nurse Practitioners |journal=Open Nurs J |volume=12 |issue= |pages=180–183 |date=2018 |pmid=30258507 |pmc=6128013 |doi=10.2174/1874434601812010180 |url= |issn=}}</ref> a nonselective [[beta-blocker]]. Should not be given in patients with[[asthma]] 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.<br><br>
{{familytree | | | | | | | | | | |!| | | | |!| }}
❑ [[Procardia]]: <ref name="pmid30258507">{{cite journal |vauthors=Spiro L, Scemons D |title=Management of Chronic and Gestational Hypertension of Pregnancy: A Guide for Primary Care Nurse Practitioners |journal=Open Nurs J |volume=12 |issue= |pages=180–183 |date=2018 |pmid=30258507 |pmc=6128013 |doi=10.2174/1874434601812010180 |url= |issn=}}</ref> 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]]. <br><br>
{{familytree | | | | | | | | | | F01 | | | F02 |F01= |F02= }}
❑ [[Diuretics]]: <ref name="pmid30258507">{{cite journal |vauthors=Spiro L, Scemons D |title=Management of Chronic and Gestational Hypertension of Pregnancy: A Guide for Primary Care Nurse Practitioners |journal=Open Nurs J |volume=12 |issue= |pages=180–183 |date=2018 |pmid=30258507 |pmc=6128013 |doi=10.2174/1874434601812010180 |url= |issn=}}</ref> 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.<br><br>
❑ [[Hydralazine]] and [[clonidine]]: <ref name="pmid30258507">{{cite journal |vauthors=Spiro L, Scemons D |title=Management of Chronic and Gestational Hypertension of Pregnancy: A Guide for Primary Care Nurse Practitioners |journal=Open Nurs J |volume=12 |issue= |pages=180–183 |date=2018 |pmid=30258507 |pmc=6128013 |doi=10.2174/1874434601812010180 |url= |issn=}}</ref> have been used in certain circumstances, but are not commonly used in the longitudinal treatment of gestational or chronic hypertension.<br><br>
❑ [[ACE inhibitors]], [[angiotensin receptor blockers]], [[mineralocorticoid]] receptor antagonists, and [[nitroprusside]] are contraindicated in [[pregnancy]] as these are [[teratogenic]]. <ref name="urlHypertension In Pregnancy - StatPearls - NCBI Bookshelf">{{cite web |url=https://www.ncbi.nlm.nih.gov/books/NBK430839/ |title=Hypertension In Pregnancy - StatPearls - NCBI Bookshelf |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref><br><br>
❑ [[Nitroprusside]] can be used as a last resort in treatment-resistant [[hypertension]]. <ref name="urlHypertension In Pregnancy - StatPearls - NCBI Bookshelf">{{cite web |url=https://www.ncbi.nlm.nih.gov/books/NBK430839/ |title=Hypertension In Pregnancy - StatPearls - NCBI Bookshelf |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>
❑ Low [[dose]] [[aspirin]] of 81 mg or less to be initiated before 20 weeks of [[gestation]] to prevent [[preeclampsia]] as a sequelae of [[hypertension]]. </div> | L01=<div style="float: left; text-align: left;height: 62em;">
<br><br><br>
❑ 30 minutes of moderate exercise on most days of the week to stimulate [[placental]] [[angiogenesis]] and improve maternal [[endothelial]] dysfunction.<br><br>❑ 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]]. <ref name="pmid24201164">{{cite journal |vauthors=Abdul Sultan A, West J, Tata LJ, Fleming KM, Nelson-Piercy C, Grainge MJ |title=Risk of first venous thromboembolism in pregnant women in hospital: population based cohort study from England |journal=BMJ |volume=347 |issue= |pages=f6099 |date=November 2013 |pmid=24201164 |pmc=3898207 |doi=10.1136/bmj.f6099 |url= |issn=}}</ref><br><br>}}
{{familytree | | | |!| | | | | | | | | |!| }}
{{familytree | | | |`|-|-|-|v|-|-|-|-|-|'| | }}
{{familytree | | | | | | | |!| | | | | | | }}
{{familytree | | | | | | | M01 | | | | | |M01=Fetal evaluation<ref name="urlTreatment Options for Gestational Hypertension">{{cite web |url=https://www.verywellfamily.com/treatment-options-for-gestational-hypertension-1764122 |title=Treatment Options for Gestational Hypertension |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref><div style="float: left; text-align: left;height: 29em;>
 
❑ An [[ultrasound]] should be done at 16-20 weeks to provide an accurate baseline reading to evaluate the baby’s [[growth]].<br><br>❑ [[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.<br><br>
❑ [[Non-stress test]]: this measures baby’s heart rate in response to his or her movements.<br><br>❑ [[Biophysical profile]]: this test combines a [[non-stress test]] with an [[ultrasound]] to observe the baby.<br><br>❑ [[Doppler]] flow studies: ultrasound that uses sound waves to measure the flow of the baby’s blood through a [[blood vessel]]. </div> || }}
{{familytree | | | | | | | |!| | | | | | | }}
{{familytree | | | | | | | K01| | | | | |K01=Indications for [[preterm]] [[delivery]] <ref name="pmid30258507">{{cite journal |vauthors=Spiro L, Scemons D |title=Management of Chronic and Gestational Hypertension of Pregnancy: A Guide for Primary Care Nurse Practitioners |journal=Open Nurs J |volume=12 |issue= |pages=180–183 |date=2018 |pmid=30258507 |pmc=6128013 |doi=10.2174/1874434601812010180 |url= |issn=}}</ref> }}
{{familytree | | | | | | | |!| | | | | | | }}
{{familytree | | | | | | | l01| | | | | |l01= <div style="float: left; text-align: left;height: 15em; width: 32em ">The recommendations for [[delivery]] are as follows: <ref name="pmid30258507">{{cite journal |vauthors=Spiro L, Scemons D |title=Management of Chronic and Gestational Hypertension of Pregnancy: A Guide for Primary Care Nurse Practitioners |journal=Open Nurs J |volume=12 |issue= |pages=180–183 |date=2018 |pmid=30258507 |pmc=6128013 |doi=10.2174/1874434601812010180 |url= |issn=}}</ref>
----
❑ 38-39 6/7 weeks of [[gestation]] for women not requiring [[medication]].<br><br>❑ 37- 39 6/7 weeks of [[gestation]] for women with [[hypertension]] controlled with [[medication]].<br><br>❑36-37 6/7 weeks of [[gestation]] for women with severe [[hypertension]] difficult to control</div>| }}
{{familytree | | | | | | | |!| | | | | | | }}
{{familytree | | | | | | | K01| | | | | |K01=<div style="float: left; text-align: left;height: 12em; width: 32em ">[[Intrapartum]] management: <ref name="pmid30258507">{{cite journal |vauthors=Spiro L, Scemons D |title=Management of Chronic and Gestational Hypertension of Pregnancy: A Guide for Primary Care Nurse Practitioners |journal=Open Nurs J |volume=12 |issue= |pages=180–183 |date=2018 |pmid=30258507 |pmc=6128013 |doi=10.2174/1874434601812010180 |url= |issn=}}</ref>
----
 
❑ 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]]. </div> }}
{{familytree | | | | | | | |!| | | | | | | }}
{{familytree | | | | | | | K01| | | | | |K01=<div style="float: left; text-align: left;height: 10em; width: 32em ">[[Postpartum]] management: <ref name="pmid30258507">{{cite journal |vauthors=Spiro L, Scemons D |title=Management of Chronic and Gestational Hypertension of Pregnancy: A Guide for Primary Care Nurse Practitioners |journal=Open Nurs J |volume=12 |issue= |pages=180–183 |date=2018 |pmid=30258507 |pmc=6128013 |doi=10.2174/1874434601812010180 |url= |issn=}}</ref>
----
 
❑ [[Postpartum]] [[hypertension]] until 12 weeks [[postpartum]] should be managed with [[medications]] that are safe for [[breastfeeding]]. </div> }}
 
{{familytree/end}}
{{familytree/end}}


==Do's==
==Dos<ref name="urlHypertension In Pregnancy - StatPearls - NCBI Bookshelf">{{cite web |url=https://www.ncbi.nlm.nih.gov/books/NBK430839/ |title=Hypertension In Pregnancy - StatPearls - NCBI Bookshelf |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>==
* The content in this section is in bullet points.
* [[Pregnant]] woman with [[gestational hypertension]] should be advised to visit her health care provider regularly throughout the [[pregnancy]].<ref name="urlHypertension In Pregnancy - StatPearls - NCBI Bookshelf">{{cite web |url=https://www.ncbi.nlm.nih.gov/books/NBK430839/ |title=Hypertension In Pregnancy - StatPearls - NCBI Bookshelf |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>
* 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]].


==Don'ts==
==Don'ts==
* The content in this section is in bullet points.
 
* 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]].<ref name="pmid10804484">{{cite journal |vauthors=Yeo S, Steele NM, Chang MC, Leclaire SM, Ronis DL, Hayashi R |title=Effect of exercise on blood pressure in pregnant women with a high risk of gestational hypertensive disorders |journal=J Reprod Med |volume=45 |issue=4 |pages=293–8 |date=April 2000 |pmid=10804484 |doi= |url= |issn=}}</ref>
* 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 [[Pre-eclampsia|preeclampsia]].
* [[Pregnant]] woman should avoid [[alcohol]],recreational [[drugs]], [[smoking]].<ref name="urlHypertension In Pregnancy - StatPearls - NCBI Bookshelf">{{cite web |url=https://www.ncbi.nlm.nih.gov/books/NBK430839/ |title=Hypertension In Pregnancy - StatPearls - NCBI Bookshelf |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}


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Latest revision as of 19:10, 4 October 2021

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.

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