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Chapter 5: Hypertensive Emergencies

Baha M. Sibai

INTRODUCTION

Hypertensive disorders are the most common medical complications of pregnancy, affecting 5% to 10% of all pregnancies. Approximately 30% of hypertensive disorders in pregnancy are due to chronic hypertension and 70% are due to gestational hypertension-preeclampsia. The spectrum of the disease ranges from mildly elevated blood pressures with minimal clinical significance to severe hypertension and multiorgan dysfunction. Understanding the disease process and its impact on pregnancy is of utmost importance, as hypertensive disorders remain a major cause of maternal and perinatal morbidity and mortality worldwide (Table 5-1).

TABLE 5-1.Adverse Outcomes in Severe Hypertensive Disorders of Pregnancy
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TABLE 5-1. Adverse Outcomes in Severe Hypertensive Disorders of Pregnancy

Maternal complications

• Abruptio placentae

• Disseminated intravascular coagulopathy

• Eclampsia

• Renal failure

• Liver hemorrhage or failure

• Intracerebral hemorrhage

• Hypertensive encephalopathy

• Pulmonary edema

• Death

Fetal-neonatal complications

• Severe intrauterine growth retardation

• Oligohydramnios

• Preterm delivery

• Hypoxia-acidosis

• Neurologic injury

• Death

DEFINITIONS AND CLASSIFICATIONS

Hypertension is defined as a systolic blood pressure greater than or equal to 140 mm Hg or a diastolic blood pressure greater than or equal to 90 mm Hg. These measurements must be made on at least 2 occasions, no less than 6 hours and no more than a week apart. It is important to note that choosing the appropriate blood pressure cuff size will help to eliminate inaccurate blood pressure measurements. Abnormal proteinuria in pregnancy is defined as the excretion of greater than or equal to 300 mg/dL of protein in 24 hours, a protein:creatinine ratio of greater than or equal to 0.30 The most accurate measurement of total urinary excretion of protein is with the use of a 24-hour urine collection. However, in certain instances the use of semiquantitative dipstick analysis may be the only measurement available to assess urinary protein. Table 5-2 lists the classification of hypertension.

TABLE 5-2.Classification of Hypertension
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TABLE 5-2. Classification of Hypertension

  1. Gestational hypertension

    Mild

    • Systolic <160 mm Hg or

    • Diastolic <110 mm Hg

    Severe

    • Systolic ≥160 mm Hg or

    • Diastolic ≥110 mm Hg

  2. Gestational proteinuria ≥300 mg/24 h or

    Protein/creatinine ratio . 0.30 or

    ≥1 + on dipstick

  3. Preeclampsia (hypertension +/– proteinuria)

    Preeclampsia with severe features (any of the following):

     • Severe hypertension

     • Mild hypertension and severe proteinuria

     • Persistently severe cerebral symptoms

     • Thrombocytopenia 100,000/mm3

     • Elevated liver enzymes >2 × upper limit normal

     • Pulmonary edema

     • Serum creatinine 1.1 mg/dL

  4. Chronic hypertension

    Hypertension before pregnancy

    Hypertension before 20 weeks’ gestation

  5. Superimposed preeclampsia

    Exacerbation of hypertension and/or new-onset proteinuria

Gestational Hypertension

Gestational hypertension is the elevation of blood pressure during the second half of pregnancy or in the first 24 hours postpartum, without ...

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