Hypertensive pregnancy disorders

Last updated: August 19, 2022

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Hypertensive pregnancy disorders are among the most common complications during pregnancy and the early postpartum period. There are four major types of hypertensive pregnancy disorders: chronic hypertension, gestational hypertension, preeclampsia, and eclampsia. The most common type is gestational hypertension, also referred to as pregnancy-induced hypertension, which is hypertension that occurs after 20 weeks' gestation. Chronic hypertension describes hypertension that is diagnosed prior to pregnancy or in early pregnancy. Preeclampsia is a condition in which preexisting or new-onset hypertension is complicated by proteinuria and/or other features of end-organ dysfunction after 20 weeks' gestation. Preeclampsia may also progress to the life-threatening HELLP syndrome, which is characterized by hemolysis, elevated liver enzymes, and low platelet count. Eclampsia is a severe convulsive manifestation of hypertensive pregnancy disorders that is characterized by new-onset eclamptic seizures (tonic-clonic, focal, or multifocal).

These disorders are usually diagnosed during regular prenatal care, which includes routine surveillance of blood pressure, weight, and urine tests. Management depends on the severity of the condition. Nonurgent hypertensive pregnancy disorders (chronic hypertension, gestational hypertension, or preeclampsia without severe features) are generally managed with careful monitoring, possibly antihypertensive medications in chronic hypertension, and delivery at 37 weeks if there is no progression to severe preeclampsia. Patients with urgent hypertensive pregnancy disorders (preeclampsia with severe features, eclampsia, or HELLP), which are associated with increased maternal and fetal morbidity and mortality, require urgent maternal stabilization, magnesium sulfate for seizure prophylaxis, and expedited delivery of the fetus. Delivery is the only curative option for urgent hypertensive pregnancy disorders.

Gestational hypertension can only be diagnosed if the patient was normotensive prior to 20 weeks' gestation. Otherwise, high blood pressure during pregnancy is classified as chronic hypertension.

The three primary features of PREeclampsia are Proteinuria, Rising blood pressure (hypertension), and End-organ dysfunction.

Epidemiological data refers to the US, unless otherwise specified.

Systemic effects of hypertensive pregnancy disorders
Organ Pathomechanism Disorder Occurrence [12]
Kidney
Lung
Liver
CNS
Blood

Gestational hypertension

Preeclampsia [7]

  • Onset
    • ∼ 90% occur after 34 weeks' of gestation.
    • In approx. 5% of individuals with preeclampsia, the condition is not diagnosed during pregnancy and symptoms only develop postpartum (postpartum preeclampsia). [14]

Preeclampsia without severe features

Preeclampsia with severe features [15]

HELLP syndrome [16]

Hypertension and proteinuria may be mild or even absent in patients with HELLP syndrome. Patients may present primarily with nonspecific symptoms. [17]

Eclampsia

Deterioration with headaches, RUQ pain, hyperreflexia, and visual changes are warning signs of a potential eclamptic seizure.

Approach [1][18][19]

In patients with chronic hypertension, conduct baseline 24-hour urine protein, serum liver, and renal function tests at the initial prenatal care visit; an upward trend may indicate superimposed preeclampsia. [1]

Diagnostic workup [1][20]

The initial workup for all suspected hypertensive pregnancy disorders is the same.

Serial blood pressure measurement [1]

Ensure that an appropriately sized blood pressure cuff is used and that the patient has not used tobacco or caffeine within 30 minutes of the readings, as these may lead to inaccurate values. [22]

Hypertension should not be diagnosed on the basis of a single abnormal value; repeat blood pressure readings at least once, 4 hours apart (may be reduced to 15 minutes in severe hypertension requiring urgent treatment). [1]

Urine studies [1][19]

Any of the following may be used to assess for proteinuria.

Blood tests [1][18]

Routine studies

Perform the following in all patients to assess for end-organ dysfunction.

Additional studies (selected patients)

Diagnostic criteria [1][18]

Diagnostic criteria for hypertensive pregnancy disorders
Disorder Diagnostic criteria

Chronic hypertension [18]

Gestational hypertension [1]
Preeclampsia Preeclampsia without severe features [1]
Preeclampsia with severe features [1]
HELLP syndrome [1][17]
Chronic hypertension with superimposed preeclampsia [18][23]
Eclampsia [18]

RUQ pain is the most common symptom in HELLP. In 15% of cases, hypertension and proteinuria are not present. [1]

Proteinuria is not required to diagnose severe preeclampsia! [1][19]

Fetal assessment [1][24]

Fetal evaluation should be conducted in parallel with maternal workup.

Ultrasound and CTG parameters may be used to calculate a biophysical profile score to help guide decisions regarding preterm delivery. [27]

Differential diagnoses of altered liver chemistries [28][29]

See “Pregnancy-associated liver diseases” for details.

Differential diagnoses of eclampsia

Seizure disorders during pregnancy can be caused by any of the following:

Differential diagnoses of HELLP syndrome

The differential diagnoses listed here are not exhaustive.

Antihypertensives in pregnancy

Specific indications for these agents are detailed in the relevant sections below. Generally, parenteral antihypertensives are used in acute-onset severe hypertension and urgent hypertensive pregnancy disorders, and oral antihypertensives are used, as clinically indicated, during expectant management. [1]

Antihypertensives for urgent blood pressure control in pregnancy [1]

Antihypertensives should be given within 30–60 minutes of diagnosis in urgent hypertensive pregnancy disorders. [1]

Common oral antihypertensives in pregnancy [18] [1][31]

The following can be used alone or in combination.

Avoid ACE inhibitors and angiotensin receptor blockers during pregnancy (especially during the 1st trimester) because of their teratogenic effect. [18]

Antihypertensives used in pregnancy can be remembered with the mnemonic “Hypertensive Moms Need Love”: Hydralazine, Methyldopa, Nifedipine, or Labetalol

Magnesium sulfate for seizure prophylaxis [1][31][32]

Continue magnesium sulfate infusion for 24 hours after delivery or last seizure. [1]

All patients receiving magnesium need close monitoring (including continuous telemetry) for signs of hypermagnesemia.

Preeclampsia prophylaxis

Assess all patients with chronic hypertension and gestational hypertension for risk factors for preeclampsia.

Risk factors for preeclampsia [1][10][18]
High-risk factors Moderate-risk factors

Aspirin for preeclampsia prophylaxis [1][10][18]

Educate at-risk patients on the symptoms of preeclampsia. If preeclampsia does develop, management depends on the severity.

Corticosteroids for fetal lung maturity

Do not delay delivery for glucocorticoid administration if immediate delivery is indicated (e.g., eclampsia, DIC, pulmonary edema, intractable severe hypertension, placental abruption). [1][17][33]

Administer glucocorticoids immediately in stable patients if preterm delivery is anticipated. Even a single dose of antenatal glucocorticoids reduces neonatal mortality and morbidity. [1][33]

Patients with preeclampsia with severe features, HELLP, or eclampsia require immediate control of hypertension and management of complications (ideally in a tertiary care center) to minimize maternal and fetal mortality and morbidity. See “Hypertensive crises“ for general information.

Approach [1][17]

Administer antihypertensives within 30–60 minutes of diagnosis of an urgent hypertensive pregnancy disorder, if feasible. [1]

Aggressive fluid therapy can precipitate pulmonary edema in patients with preeclampsia; use fluid judiciously and monitor urine output!

Delivery is the only cure for preeclampsia, eclampsia, and HELLP syndrome. [17]

Indications for expedited delivery in hypertensive pregnancy disorders

Immediate delivery [1][17][32]

Assess frequently for indications for immediate delivery regardless of gestational age. The presence of any of the following is an indication for immediate delivery after maternal stabilization:

Do not delay delivery to administer corticosteroids if immediate delivery is indicated. [1][17]

Urgent delivery [1][17]

Delivery should be expedited after administration of corticosteroids for fetal lung maturity if any of the following are present:

Previously, fetal growth restriction was considered an indication for expedited delivery. However, according to the 2020 ACOG guidelines, expectant management may be continued in the absence of other abnormalities (e.g., Doppler findings, amniotic fluid volume). [1]

Continuously monitor maternal and fetal status. If there is any sign of deterioration, immediately expedite delivery without completing the corticosteroid course. [1][17]

Medical management [1][17]

Obstetric management [1][17]

Vaginal delivery is preferred, but often cesarean delivery is needed in the case of younger gestational age, immature cervix, or poor maternal or fetal condition.

Medical management [1][17]

Managing the airway in pregnancy can be challenging; consult anesthesia early.

Obstetric management [1][17]

Fetal distress often occurs during eclamptic seizures. However, delivery should occur only after maternal stabilization, as fetal status typically returns to normal once seizures have been controlled. [1][17]

Medical management [1][17]

Patients with HELLP syndrome are at increased risk of DIC, pulmonary edema, ARDS, and acute renal failure and therefore close monitoring is essential. [1]

Obstetric management [1][17]

Urgent cesarean delivery is recommended for patients who develop DIC to prevent disease progression. [17]

This checklist is applicable for patients with preeclampsia with severe features, HELLP, or eclampsia. [1][17]

Initial maternal and fetal management

Fetal management

Intrapartum and postpartum management

This section provides an overview of the management of chronic hypertension, gestational hypertension, or preeclampsia without severe features. See relevant subsections for details. [1][18]

Management of hypertension [18]

Management of chronic hypertension in pregnancy [18]
Blood pressure Management
≥ 140/90 mm Hg (mild hypertension) [34][35]

Systolic pressure ≥ 160 mm Hg

And/or diastolic pressure ≥ 110 mm Hg lasting ≥ 15 minutes (severe hypertension) [18]

Prophylaxis against superimposed preeclampsia [10][18]

Patients with chronic hypertension are at high risk of developing preeclampsia. [23]

If superimposed preeclampsia develops, it should be managed based on severity. See “Preeclampsia without severe features” or “Preeclampsia with severe features” as needed.

Obstetric management [18]

Prenatal care

Timing of delivery

Intrapartum management

Approach [1]

Patients with systolic BP ≥ 160 mm Hg and/or diastolic BP ≥ 110 mm Hg) should be diagnosed with preeclampsia with severe features and managed accordingly. [1]

Hospitalization and delivery [1][32]

If feasible, administer corticosteroids for fetal lung maturation if delivery of a viable fetus between 24 and 34 weeks' gestation is indicated. [1]

Outpatient management [1][36]

Patients at ≤ 36 6/7 weeks' gestation with gestational hypertension or preeclampsia without severe features can be managed in an ambulatory setting.

Maternal and fetal monitoring [1]

Weekly in-clinic or hospital visits are recommended for maternal and fetal evaluation and should include the following:

Follow proper techniques for blood pressure measurement (e.g., use of appropriate cuff sizes, resting for 10 minutes before measurement, and avoiding caffeine and tobacco use 30 minutes before measurement) to ensure accurate results. [1]

Preeclampsia without severe features can progress to preeclampsia with severe features within days and, therefore, should be closely monitored. [1]

Antihypertensives [1][31]

Preeclampsia prophylaxis [1]

Obstetric management [1][36]

In patients who develop gestational hypertension or preeclampsia without severe features at term, delivery within 24 hours of diagnosis is recommended. [32]

Inpatient management [1]

Eclampsia can manifest for the first time in the postpartum period! [1][36]

Discharge planning [36]

While symptoms usually resolve within 3 months of delivery for the majority of patients, approximately one-third of patients with preeclampsia remain hypertensive a year after delivery. [39][40][41]

Ischemic stroke, cerebral hemorrhage, and ARDS are the most common causes of death in patients with preeclampsia.

References:[44]

We list the most important complications. The selection is not exhaustive.

The prognosis of hypertensive pregnancy disorders depends on the severity of the condition and the complications that occur. In the majority of cases, the conditions resolve within hours or days after delivery.

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