What are the hypertensive disorders that occur during pregnancy?
What tests can be done to ascertain the severity of a patient's disease?
How is preeclampsia managed?
How should an acute hypertensive crisis be treated?
A 41 y.o. G1P0 woman presents for a routine prenatal visit at 35 1/7 weeks gestation and is found to have a blood pressure of 154/97 mmHg and 2+ protein on urine dipstick testing. She denies headaches, blurry vision, or RUQ pain. She has been normotensive throughout her prenatal visits. A repeat blood pressure reading is 150/95 mmHg. She is sent to L&D for evaluation.
On L&D, laboratory tests are performed. Her CBC shows normal platelets, and her hematocrit is 34%. Her CMP shows mild elevation in AST and ALT, with a serum creatinine of 0.9 mg/dl. A 24-hour urine is started, and the patient is observed overnight. Betamethasone is given due to the risk of late preterm delivery. Her blood pressure is serially evaluated.
Hypertension is one of the most common conditions affecting pregnancy, with an incidence of 5% to 10%. It accounts for a significant portion of maternal morbidity and mortality. It is also a major contributor to adverse fetal and neonatal outcomes. The disease spectrum ranges from mild to severe and is classified as a major health issue for the United States and the world. In the United States, studies report a maternal death rate from preeclampsia of 12.3%,1 and there is evidence that half of these cases are preventable.2 Due to its tremendous impact on obstetrics, hypertension in pregnancy has been given a great deal of attention, including the formation of a task force by the American College of Obstetricians and Gynecologists (ACOG) to provide recommendations for clinical practice.3 Of course, the best form of therapy is prevention, which is discussed in this chapter, as well as classification, physiology, and management.
DEFINITION AND CLASSIFICATIONS
Hypertension in pregnancy refers to a wide spectrum of hypertension, ranging from mild blood pressure elevation to severe blood pressure elevation with end-organ damage. There have been classifications for hypertension in pregnancy since the 1970s; however, the need for uniformity of classification has become more evident in recent years, for the purpose of better communication among providers and in research. The initial classification was in 1972 by ACOG, and it was modified in 1990 and 2000. More recently, in 2013,3 the ACOG task force made additional modifications; however, the four-category classification was maintained: namely, preeclampsia-eclampsia, chronic hypertension, chronic hypertension with superimposed preeclampsia, and gestational hypertension. Hypertension is diagnosed when a correctly taken blood pressure exceeds a systolic pressure of 140 mmHg or a diastolic of 90 mmHg.
Preeclampsia has been on the rise in the United States over the last 20 years. It is a pregnancy-specific, multisystem, progressive syndrome. The risk ...