Hypertension in Pregnancy: Difference between revisions
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== Introduction == | == Introduction == | ||
Hypertensive disorders of pregnancy is a leading cause of maternal and neonatal morbidity and mortality. Hypertension in pregnancy should be defined as a hospital systolic blood pressure (SBP) ⩾ 140 mmHg and/or dystolic blood pressure (DBP) ⩾ 90 mmHg, based on the average of ''at least'' two measurements, taken at least 15 min apart, using the same arm.<ref>Magee LA, Pels A, Helewa M, Rey E, von Dadelszen P. [https://www.sciencedirect.com/science/article/pii/S221077891400004X Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy.] Pregnancy Hypertension: An International Journal of Women's Cardiovascular Health. 2014 Apr 1;4(2):105-45.</ref> | Hypertensive disorders of pregnancy is a leading cause of maternal and neonatal morbidity and mortality. Hypertension in pregnancy should be defined as a hospital systolic blood pressure (SBP) ⩾ 140 mmHg and/or dystolic blood pressure (DBP) ⩾ 90 mmHg, based on the average of ''at least'' two measurements, taken at least 15 min apart, using the same arm.<ref name=":0">Magee LA, Pels A, Helewa M, Rey E, von Dadelszen P. [https://www.sciencedirect.com/science/article/pii/S221077891400004X Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy.] Pregnancy Hypertension: An International Journal of Women's Cardiovascular Health. 2014 Apr 1;4(2):105-45.</ref> | ||
== Classification == | == Classification == | ||
{| | |||
|'''A. Pre-existing (chronic) hypertension''' | |||
|This is defined as hypertension that was present either pre-pregnancy or that develops at <20 weeks of gestation | |||
|- | |||
|• With comorbid condition(s) | |||
|Comorbid conditions (e.g., pre-gestational type I or II diabetes mellitus or kidney disease) warrant tighter BP control outside of pregnancy because of their association with heightened cardiovascular risk | |||
|- | |||
|• With evidence of preeclampsia | |||
|This is also known as ‘superimposed preeclampsia’ and is defined by the development of one or more of the following at ⩾ 20 weeks: | |||
* Resistant hypertension, or | |||
* New or worsening proteinuria, or | |||
* One/more adverse condition(s) or | |||
* One/more severe complication(s) | |||
Severe preeclampsia is defined as preeclampsia with one or more severe complication(s) | |||
|- | |||
|'''B. Gestational hypertension''' | |||
|This is defined as hypertension that develops for the first time at ⩾ 20 weeks of gestation. | |||
|- | |||
|• With comorbid condition(s) | |||
|Comorbid conditions (e.g., pregestational type I or II diabetes mellitus or kidney disease) warrant tighter BP control outside of pregnancy because of their association with heightened cardiovascular risk | |||
|- | |||
|• With evidence of preeclampsia | |||
|Evidence of preeclampsia may appear many weeks after the onset of gestational hypertension. | |||
|- | |||
|'''C. Preeclampsia''' | |||
|Preeclampsia is defined by gestational hypertension and one or more of the following: | |||
* New proteinuria, or | |||
* One/more adverse conditions, or | |||
* One/more severe complication(s) | |||
|- | |||
| | |||
|Severe preeclampsia is defined as preeclampsia with one or more severe complication(s) | |||
|- | |||
| colspan="2" |'''’Other hypertensive effects’∗''' | |||
|- | |||
|Transient hypertensive effect | |||
|Elevated BP may be due to environmental stimuli or the pain of labour, for example | |||
|- | |||
|White coat hypertensive effect | |||
|BP that is elevated in the office (sBP ⩾ 140 mmHg or dBP ⩾ 90 mmHg) but is consistently normal outside of the office (<135/85 mmHg) by ABPM or HBPM | |||
|- | |||
|Masked hypertensive effect | |||
|BP that is consistently normal in the office (sBP < 140 mmHg or dBP < 90 mmHg) but is elevated outside of the office (⩾135/85 mmHg) by ABPM or repeated HBPM | |||
|} | |||
ABPM, ambulatory BP monitoring; BP, blood pressure; HBPM, home BP monitoring.<ref name=":0" /> | |||
; | |||
=== Adverse conditions and severe complications of preeclampsia. === | |||
; {| class="wikitable" !Organ system affected !Adverse conditions (that increase the risk of severe complications) !Severe complications (that warrant delivery) |- |CNS | | |||
; ○ | |||
: Headache/visual symptoms | | |||
; ○ | |||
: Eclampsia | |||
; ○ | |||
: PRES | |||
; ○ | |||
: Cortical blindness or retinal detachment | |||
; ○ | |||
: Glasgow coma scale < 13 | |||
; ○ | |||
: Stroke, TIA, or RIND |- | colspan="3" | |- |Cardiorespiratory | | |||
; ○ | |||
: Chest pain/dyspnoea | |||
; ○ | |||
: Oxygen saturation < 97% [79] | | |||
; ○ | |||
: Uncontrolled severe hypertension (over a period of 12hr despite use of three antihypertensive agents), | |||
; ○ | |||
: Oxygen saturation < 90%, need for ⩾ 50% oxygen for > 1hr, intubation (other than for Caesarean section), pulmonary oedema | |||
; ○ | |||
: Positive inotropic support | |||
; ○ | |||
: Myocardial ischaemia or infarction |- | colspan="3" | |- |Haematological | | |||
; ○ | |||
: Elevated WBC count | |||
; ○ | |||
: Elevated INR or aPTT [80] | |||
; ○ | |||
: Low platelet count | | |||
; ○ | |||
: Platelet count < 50x109/L | |||
; ○ | |||
: Transfusion of any blood product |- | colspan="3" | |- |Renal | | |||
; ○ | |||
: Elevated serum creatinine [81] | |||
; ○ | |||
: Elevated serum uric acid | | |||
; ○ | |||
: Acute kidney injury (creatinine > 150 μM with no prior renal disease) | |||
; ○ | |||
: New indication for dialysis |- | colspan="3" | |- |Hepatic | | |||
; ○ | |||
: Nausea or vomiting | |||
; ○ | |||
: RUQ or epigastric pain | |||
; ○ | |||
: Elevated serum AST, ALT, LDH, or bilirubin | |||
; ○ | |||
: Low plasma albumin [82] | | |||
; ○ | |||
: Hepatic dysfunction (INR > 2 in absence of DIC or warfarin) | |||
; ○ | |||
: Hepatic haematoma or rupture |- | colspan="3" | |- |Feto-placental | | |||
; ○ | |||
: Non-reassuring FHR | |||
; ○ | |||
: IUGR [83], [84] | |||
; ○ | |||
: Oligohydramnios | |||
; ○ | |||
: Absent or reversed end-diastolic flow by Doppler velocimetry | | |||
; ○ | |||
: Abruption with evidence of maternal or fetal compromise | |||
; ○ | |||
: Reverse ductus venosus A wave [85], [86] | |||
; ○ | |||
: Stillbirth |} AST, aspartate aminotransferase; ALT, alanine aminotransferase; DIC, disseminated intravascular coagulation; FHR, fetal heart rate; LDH, lactate dehydrogenase; PRES, posterior reversible leukoencephalopathy syndrome; RIND, reversible neurological deficit < 48hr; RUQ, right upper quadrant; TIA, transient ischaemic attack. <ref name=":0" /> | |||
== Causes and Risk factor == | == Causes and Risk factor == |
Revision as of 11:21, 27 August 2020
Original Editor - User Name
Top Contributors - Manisha Shrestha, Kirenga Bamurange Liliane, Nupur Smit Shah, Kim Jackson and Lucinda hampton
Introduction[edit | edit source]
Hypertensive disorders of pregnancy is a leading cause of maternal and neonatal morbidity and mortality. Hypertension in pregnancy should be defined as a hospital systolic blood pressure (SBP) ⩾ 140 mmHg and/or dystolic blood pressure (DBP) ⩾ 90 mmHg, based on the average of at least two measurements, taken at least 15 min apart, using the same arm.[1]
Classification[edit | edit source]
A. Pre-existing (chronic) hypertension | This is defined as hypertension that was present either pre-pregnancy or that develops at <20 weeks of gestation |
• With comorbid condition(s) | Comorbid conditions (e.g., pre-gestational type I or II diabetes mellitus or kidney disease) warrant tighter BP control outside of pregnancy because of their association with heightened cardiovascular risk |
• With evidence of preeclampsia | This is also known as ‘superimposed preeclampsia’ and is defined by the development of one or more of the following at ⩾ 20 weeks:
Severe preeclampsia is defined as preeclampsia with one or more severe complication(s) |
B. Gestational hypertension | This is defined as hypertension that develops for the first time at ⩾ 20 weeks of gestation. |
• With comorbid condition(s) | Comorbid conditions (e.g., pregestational type I or II diabetes mellitus or kidney disease) warrant tighter BP control outside of pregnancy because of their association with heightened cardiovascular risk |
• With evidence of preeclampsia | Evidence of preeclampsia may appear many weeks after the onset of gestational hypertension. |
C. Preeclampsia | Preeclampsia is defined by gestational hypertension and one or more of the following:
|
Severe preeclampsia is defined as preeclampsia with one or more severe complication(s) | |
’Other hypertensive effects’∗ | |
Transient hypertensive effect | Elevated BP may be due to environmental stimuli or the pain of labour, for example |
White coat hypertensive effect | BP that is elevated in the office (sBP ⩾ 140 mmHg or dBP ⩾ 90 mmHg) but is consistently normal outside of the office (<135/85 mmHg) by ABPM or HBPM |
Masked hypertensive effect | BP that is consistently normal in the office (sBP < 140 mmHg or dBP < 90 mmHg) but is elevated outside of the office (⩾135/85 mmHg) by ABPM or repeated HBPM |
ABPM, ambulatory BP monitoring; BP, blood pressure; HBPM, home BP monitoring.[1]
Adverse conditions and severe complications of preeclampsia.[edit | edit source]
- {| class="wikitable" !Organ system affected !Adverse conditions (that increase the risk of severe complications) !Severe complications (that warrant delivery) |- |CNS |
- ○
- Headache/visual symptoms |
- ○
- Eclampsia
- ○
- PRES
- ○
- Cortical blindness or retinal detachment
- ○
- Glasgow coma scale < 13
- ○
- Stroke, TIA, or RIND |- | colspan="3" | |- |Cardiorespiratory |
- ○
- Chest pain/dyspnoea
- ○
- Oxygen saturation < 97% [79] |
- ○
- Uncontrolled severe hypertension (over a period of 12hr despite use of three antihypertensive agents),
- ○
- Oxygen saturation < 90%, need for ⩾ 50% oxygen for > 1hr, intubation (other than for Caesarean section), pulmonary oedema
- ○
- Positive inotropic support
- ○
- Myocardial ischaemia or infarction |- | colspan="3" | |- |Haematological |
- ○
- Elevated WBC count
- ○
- Elevated INR or aPTT [80]
- ○
- Low platelet count |
- ○
- Platelet count < 50x109/L
- ○
- Transfusion of any blood product |- | colspan="3" | |- |Renal |
- ○
- Elevated serum creatinine [81]
- ○
- Elevated serum uric acid |
- ○
- Acute kidney injury (creatinine > 150 μM with no prior renal disease)
- ○
- New indication for dialysis |- | colspan="3" | |- |Hepatic |
- ○
- Nausea or vomiting
- ○
- RUQ or epigastric pain
- ○
- Elevated serum AST, ALT, LDH, or bilirubin
- ○
- Low plasma albumin [82] |
- ○
- Hepatic dysfunction (INR > 2 in absence of DIC or warfarin)
- ○
- Hepatic haematoma or rupture |- | colspan="3" | |- |Feto-placental |
- ○
- Non-reassuring FHR
- ○
- IUGR [83], [84]
- ○
- Oligohydramnios
- ○
- Absent or reversed end-diastolic flow by Doppler velocimetry |
- ○
- Abruption with evidence of maternal or fetal compromise
- ○
- Reverse ductus venosus A wave [85], [86]
- ○
- Stillbirth |} AST, aspartate aminotransferase; ALT, alanine aminotransferase; DIC, disseminated intravascular coagulation; FHR, fetal heart rate; LDH, lactate dehydrogenase; PRES, posterior reversible leukoencephalopathy syndrome; RIND, reversible neurological deficit < 48hr; RUQ, right upper quadrant; TIA, transient ischaemic attack. [1]
Causes and Risk factor[edit | edit source]
Pathological process[edit | edit source]
Epidemiology[edit | edit source]
Medical management[edit | edit source]
Physiotherapy intervention[edit | edit source]
Resources[edit | edit source]
- bulleted list
- x
or
- numbered list
- x
References[edit | edit source]
- ↑ 1.0 1.1 1.2 Magee LA, Pels A, Helewa M, Rey E, von Dadelszen P. Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy. Pregnancy Hypertension: An International Journal of Women's Cardiovascular Health. 2014 Apr 1;4(2):105-45.