We hope you found our Week 2 review of Preterm Labor helpful as you gear up to start orientation. You can check out our Week 1 and 2 content on the District IV Junior Fellow Website if you didn’t get a chance to see it!
This week, we continue our “Countdown to Intern Year” series with a review of Hypertensive Disorders of Pregnancy. Be sure to check out the additional resources below, including advice from our seasoned JFAC physicians and links to ACOG wellness and clinical resources.
We can’t wait to see you on the wards soon, doctors!
Week 3: Hypertensive Disorders
Diagnoses, Risk Factors, and Management
Content adapted from relevant ACOG Practice Bulletins and AAFP Guidelines
What are the types of hypertension in pregnancy?
- Chronic Hypertension
- Preeclampsia with and without severe features
- Chronic Hypertension with superimposed preeclampsia
- Gestational Hypertension
Risk Factors for Preeclampsia
- Multifetal gestations
- Preeclampsia in a previous pregnancy
- Chronic hypertension
- Pregestational diabetes
- Gestational diabetes
- Systemic lupus erythematosus
- Prepregnancy body mass index greater than 30
- Antiphospholipid antibody syndrome
- Maternal age 35 years or older
- Kidney disease
- Assisted reproductive technology
- Obstructive sleep apnea
Criteria for Preeclampsia +/- Severe Features
Preeclampsia: Elevated BP + Proteinuria OR New Onset End Organ Damage
|Elevated Blood Pressure||Proteinuria|
|End Organ Damage|
Preeclampsia with Severe Features
Systolic blood pressure of 160 mm Hg or more, or diastolic blood pressure of 110 mm Hg or more on two occasions at least 4 hours apart (unless antihypertensive therapy is initiated before this time)
Thrombocytopenia (platelet count less than 100
Impaired liver function that is not accounted for by alternative diagnoses and as indicated by abnormally elevated blood concentrations of liver enzymes (to more than twice the upper limit normal concentrations), or by severe persistent right upper quadrant or epigastric pain unresponsive to medications
Renal insufficiency (serum creatinine concentration more than 1.1 mg/dL or a doubling of the serum creatinine concentration in the absence of other renal disease)
New-onset headache unresponsive to medication and not accounted for by alternative diagnoses
Preeclampsia Prophylaxis (see chart below)
Who should receive prophylaxis for preeclampsia?
- Women with any of the high-risk factors and those with more than one of the moderate-risk factors should receive low-dose (81 mg/day)
When should they start and stop?
- Initiate between 12-28 weeks of gestation (optimally before 16 weeks) and continuing until delivery
Management of Hypertensive Disorders
- Mixed and limited data on when to initiate and discontinue anti-hypertensive therapy.
- Limited data on ideal blood pressure range but recommendations are to maintain blood pressure levels for pregnant women with chronic hypertension treated with antihypertensive medications at or above 120 mm Hg but below 160 mm Hg systolic and at or above 80 mm Hg but below 110 mm Hg diastolic.
Gestational Hypertension or Preeclampsia WITHOUT Severe Features
- Serial ultrasonography to determine fetal growth
- Weekly antepartum testing
- Close monitoring of blood pressure
- Weekly laboratory tests for preeclampsia.
The frequency of these tests may be modified based on clinical findings and patient symptoms.
- Continued monitoring until delivery at 37w 0d in the absence of abnormal antepartum testing, preterm labor, preterm prelabor rupture of membranes or vaginal bleeding.
Gestational Hypertension or Preeclampsia WITH Severe Feature
Gestational Hypertension ≥ 37w 0d
Gestational Hypertension < 37w 0d
Consider expectant Management with close maternal and fetal clinical monitoring. Serial laboratory testing (complete blood count including platelets, liver enzymes, and serum creatinine).
Delivery is recommended at any time in the case of deterioration of maternal or fetal condition!
Initiate as soon as possible for acute-onset severe hypertension:
- SBP >=160 mm Hg or DBP >=110 mm Hg, or both) that is confirmed as persistent (15 minutes or more)
Treatment options (see below for dosing!):
- Intravenous hydralazine
- Intravenous labetalol
- Oral nifedipine
For more information on the diagnosis and management of hypertensive disorders, check out the resources below. We’ll be back next week with a brief review of fetal heart tracings!
Relevant ACOG Resources
- Practice Bulletin: Gestational Hypertension and Preeclampsia
- Practice Bulletin: Chronic Hypertension in Pregnancy
- Committee Opinion: Emergent Therapy for Acute-Onset, Severe Hypertension During Pregnancy and the Postpartum Period
- CREOG Eclampsia Practice Questions
- APGO: Preeclampsia and Eclampsia
- OnlineMedEd: Eclampsia
- Osmosis: Preeclampsia & Eclampsia - Causes, Symptoms, Diagnosis, Treatment, Pathology
- Stay up to date on all Ob-Gyn virtual happenings
- Junior Fellow Advisory Council: Advice for surviving and succeeding during intern year
- ACOG Wellness Resources: Wellness resource bank with helpful links and opportunities available to you to get you through this difficult period.
If you have any feedback or requests for topics to be covered, please reach out to Samhita Nelamangala at [email protected]