Hypertension in Pregnancy
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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]
Organ system affected | Adverse conditions (that increase the risk of severe complications) | Severe complications (that warrant delivery) | |
---|---|---|---|
CNS | Headache/visual symptoms |
|
|
- {| 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]
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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.