Gestational hypertension 

During pregnancy the systemic vascular resistance falls, resulting in a lower blood pressure. Elevated blood pressure in a pregnant women is always pathological and can have consequences for the baby and the mother alike. 

Etiologies 

• Transient hypertension 
  • 
  • Can be seen in pregnant and non-pregnant patients 
  • One measurement of BP >140/80
  • It is not sustained over long periods of time
  • Labs
    • No changes 
  • Complications
    • None 
  • Management 
    • Ambulatory blood pressure log
    • No medical treatment because not sustained
• Chronic hypertension 
  • Measurement of BP >140/80
  • Sustained 
  • Shows up before 20 weeks gestation
  • Labs 
    • No changes 
  • Complications  
    • None (acute)
  • Management 
    • Need to treat medically
    • Many antihypertensives are teratogens 
    • Methyldopa, labetalol (short-acting), hydralazine
    • Can lead to pre-eclampsia 
      • Frequent creatinine, liver enzymes, U/A, fetal ultrasounds, follow-ups 
• Gestational hypertension
  • 
  • Measurement of BP >140/80
  • Sustained 
  • Shows up after 20 weeks gestation
  • Labs 
    • No changes 
  • Complications 
    • None (acute) 
  • Management 
    • Can lead to pre-eclampsia 
      • Frequent creatinine, liver enzymes, U/A, fetal ultrasounds, follow-ups
• Pre-eclampsia 
  • Without severe features 
    • BP over 140/80 
    • Sustained after 20 weeks 
    • End organ damage present 
      • Proteinuria on urinalysis 
        • >300 mg/dL
    • Complications 
      • Not severe (proteinuria is the main one) 
    • Management 
      • If term, go through with delivery = cures the Htn 
      • If preterm 
        • Don't deliver yet
        • Frequent follow-ups 
        • Trend proteinuria and complications 
        • If worsening symptoms or proteinuria may have to treat medically 
  • With severe features 
    • BP over 160/110 
    • Sustained after 20 weeks 
    • End organ damage present 
      • Proteinuria on urinalysis
        • >5g/dL 
    • Severe features
      • Decreased platelets 
      • Transaminitis 
      • RUQ abdominal pain due to decreased blood flow 
      • Creatinine can be elevated 
        • Normal Cr in pregnancy is decreased (35-70 umol/L)
        • Cr >97 or doubling of Cr in the absence of renal disease = abnormal 
        • Consider pre-eclampsia
      • Vasoconstriction 
        • Pulmonary edema
        • Chest pain 
        • Headaches 
        • Vision changes 
    • Management 
      • 
      • Administer magnesium sulphate 
      • Go through with delivery 
        • Induced vaginal delivery 
• Eclampsia
  • The patient will have seizures regardless of the BP
  • No history of epilepsy 
  • Management 
    • Magnesium sulphate administration to stop the seizure
      • Have to check for toxicity 
      • Decreased deep tendon reflexes is a sign 
        • Can lead to decreased respiratory drive 
      • Administer calcium gluconate to reverse toxicity 
    • Go through with delivery 
      • C-section - not much time available 
• HELLP syndrome - a type of preeclampsia with severe features
  • Hemolysis, Elevated Liver enzymes and Low Platelets 
  • Patients can have severe features 
    • Decreased platelets 
    • Transaminitis 
    • RUQ abdominal pain due to decreased blood flow 
    • Creatinine can be elevated 
      • Normal Cr in pregnancy is decreased (35-70 umol/L)
      • Cr >97 or doubling of Cr in the absence of renal disease = abnormal 
      • Consider pre-eclampsia
    • Vasoconstriction 
      • Pulmonary edema
      • Chest pain 
      • Headaches 
      • Vision changes 
  • Management - same way as eclampsia 
    • Magnesium sulphate administration to stop the seizure
      • 
      • Have to check for toxicity 
      • Decreased deep tendon reflexes is a sign 
        • Can lead to decreased respiratory drive 
      • Administer calcium gluconate to reverse toxicity 
    • Go through with delivery 
      • C-section - not much time available