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Countdown to Intern Year, Week 3: Hypertensive Disorders

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

View Simplified Algorithm

 

Risk Factors for Preeclampsia

  • Nulliparity
  • Multifetal gestations
  • Preeclampsia in a previous pregnancy
  • Chronic hypertension
  • Pregestational diabetes
  • Gestational diabetes
  • Thrombophilia
  • 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
  1. SBP >= 140, DBP >=90, on two occasions at least 4 hours apart in a woma\en with previously normal BP. 
    Or 
  2. SBP>=160, DBP>= 110
  1. 300 mg or more/24 hour urine collection
    or
  2. Pr:Cr >=0.3
    or
  3. Dipstick = 2+
 
End Organ Damage
  • Thrombocytopenia: Platelet count less than 100,000 × 10^9/L
  • Renal insufficiency: Serum creatinine concentrations greater than 1.1 mg/dL or a doubling of the serum creatinine concentration in the absence of other renal disease
  • Impaired liver function: Elevated blood concentrations of liver transaminases to twice normal concentration
  • Pulmonary edema
  • New-onset headache unresponsive to medication and not accounted for by alternative diagnoses or visual symptoms
 

 

 

Box 3.

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 100,000 × 109/L

  • 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)

  • Pulmonary edema

  • New-onset headache unresponsive to medication and not accounted for by alternative diagnoses

  • Visual disturbances

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 

Table 1. Clinical Risk Factors and Aspirin Use*

Management of Hypertensive Disorders

Chronic Hypertension
  • 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. 
Table 2. Common Oral Antihypertensive Agents in Pregnancy

 

Gestational Hypertension or Preeclampsia WITHOUT Severe Features
 

Monitoring

  • 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.

Delivery?

  • Continued monitoring until delivery at 37w 0d in the absence of abnormal antepartum testing, preterm labor, preterm prelabor rupture of membranes or vaginal bleeding.

View Algorithm: Management of Gestational Hypertension and Preeclampsia Without Severe Features

Gestational Hypertension or Preeclampsia WITH Severe Feature

Gestational Hypertension ≥ 37w 0d
Preeclampsia with Severe Feature > 34w 0d

Deliver!

Gestational Hypertension < 37w 0d
Preeclampsia with Severe Feature < 34w 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!

 

 

Intrapartum Management

Seizure Control

 

 

Antihypertensive Approach

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 
Table 3. Antihypertensive Agents Used for Urgent Blood Pressure Control in Pregnancy

 

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

BMJ Infographic

Video Resources

General Resources

If you have any feedback or requests for topics to be covered, please reach out to Samhita Nelamangala at d4medstudrep@gmail.com