CHAPTER 5
A 32 year-old G2P1 woman presents for her routine prenatal visit at 32 weeks gestation. Her BP is 140/90. In the
past, it has been 115/75 to 130/85 throughout the pregnancy. Her weight is 105 kg. What steps do you perform as
part of your initial investigation?
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Repeat blood pressures over the next three hours range from 140/90 to 155/95. What is your management plan?
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A 25-year-old G1 woman at 38 weeks presents with right upper quadrant pain. Her blood pressure is 170/105 and
her urine dips 3+ for protein. What are your initial investigations?
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What is your management plan?
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Hypertensive disorders in pregnancies are the leading causes of maternal death in emerging countries.
All caregivers must be able to promptly recognize the signs, symptoms and laboratory findings of gestational
hypertension with or without proteinuria and with other adverse manifestations. Caregivers must appreciate fully
the seriousness of gestational hypertension, its potential for multi-organ involvement and the risks for perinatal and
maternal morbidity and mortality.
The appropriate management of gestational hypertension may vary based on the availability of resources. The roles
for rural and remote primary obstetrical caregivers may be quite different when factors such as geography, weather
and access to specialists or tertiary care centres are considered. Primary caregivers may be faced with emergent
situations such as stabilising or treating women with gestational hypertension. The management of gestational
hypertension with proteinuria and other adverse manifestations is relevant to all maternity health care givers.
Although gestational hypertension is often viewed as a disease of nulliparous women, several important exceptions
occur. Those situations where multiparous women are at increased risk of gestational hypertension include:
1) Classification:
1.
2.
3.
4.
2) Definitions
Hypertension
An absolute systolic or diastolic BP reading is the preferred criterion rather than an incremental rise of 30/15
mmHg, although this observation may have clinical significance.
Proteinuria
Edema
Manifestations of Severity
The criteria for gestational hypertension with or without proteinuria and with adverse conditions are hypertension
plus any of:
Platelets <100,000/mm
Proteinuria >3g/d
Pulmonary edema
Convulsion (eclampsia)
RUQ/epigastric pain
Frontal headache
Visual disturbance
Abruptio placenta
Hematologic
bleeding, petechiae
Hepatic
RUQ and epigastric pain
severe nausea and vomiting
Renal
Non-dependent edema
Assessment of Mother - Laboratory
Hematologic
Hemoglobin,
platelets,
PTT,
PT(INR),
blood
Fibrinogen,
film
FDP
Hepatic
ALT, AST, LDH, bilirubin
Glucose and ammonia may be tested to rule out acute fatty liver of pregnancy
Renal
Assessment of Fetus
Minimal assessment of the fetus includes documentation of fetal movements , fetal heart rate and fundal height.
Additional studies include:
Fetal movement
2) Treatment
Immediate treatment should include managing symptoms such as nausea and vomiting with an antiemetic to
minimize maternal discomfort. Maternal pain (right upper quadrant, headache, etc.) should be managed
appropriately. A component of maternal hypertension is adrenergic and may be modified by stress reduction.
Stress Reduction
Quiet environment
Clear explanation of management plan to patient/family
Minimize of negative stimuli
Consistent, confident team approach
The decision to institute antihypertensives may vary from one centre to the next because clear evidence is lacking
about the benefit of medicating women whose diastolics are in the range of 95-105.
The use of antihypertensives reduces the risk of cardiovascular accident (CVA) in the mother but does not
necessarily reduce the risk of seizures (eclampsia) or prevent adverse fetal outcomes such as International U Growth
Restriction (IUGR).
Antihypertensives - When to Institute
The agents used can be divided into those used for acute and ongoing therapy.
Acute therapy
Arteriolar Dilators
- hydralazine
-Blockers
- labetalol
Calcium Channel Blockers
- nifedipine
Maintenance therapy
The Cochrane Database states that there is no evidence to justify a strong preference for any one of the various
drugs that are available for treating severe hypertension in pregnancy. Obstetrical caregivers should choose the
agents with which they are most familiar. Sublingual (adolate) should not be used in gestational hypertension.
Prevention of seizures is the next step in stabilizing a woman who has gestational hypertension. Blood pressure is
not a reliable predictor of the risk of seizures. There is a high "number needed to treat" to prevent seizures in women
with gestational hypertension with proteinuria. There is no benefit to prophylaxis in the absence of proteinuria.
Anticonvulsant agents are not innocuous nor completely effective.
When to Deliver
recurring seizures
symptoms unresponsive to appropriate therapy
- severe headaches or visual disturbance
- nausea, vomiting or RUQ/epigastric pain
Peripartum Management
POSTPARTUM MANAGEMENT
Gestational hypertension may worsen following delivery. All women must be followed carefully in the postpartum
period with ongoing attention to blood pressure control. Gestational hypertension may occasionally also present in
the postpartum period.
5.0.3 Summary
Severe gestational hypertension is an obstetrical emergency, which requires prompt recognition, stabilization of
mother and fetus and a multi-disciplinary approach to management and treatment. The primary obstetrical caregiver
in rural and remote areas may have to assume the role of one or several specialists until help or transfer is available.
The cure of severe gestational hypertension is delivery, but the decision to deliver is based on maternal status and
fetal maturity and well-being. The rationale for antihypertensive treatment is to prevent maternal CVA, not seizures.
Seizure prophylaxis when appropriate should be magnesium sulfate. Currently there is no agent that has been shown
to be useful in the prevention of gestational hypertension
Suggested Reading:
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