HTN in Pregnancy: DDx

Hypertensive disorders are one of the leading causes of maternal mortality worldwide. Blood pressure typically falls early in pregnancy and reaches nadir between 16-20 weeks gestational age. Later in pregnancy, the blood pressure will return to baseline. There are multiple categories of elevated blood pressure in pregnancy; management varies depending on the classification.

– Chronic hypertension: occurs in 0.9-1.5%of pregnant women

– SBP≥140mmHg or DBP ≥90mmHg existing before pregnancy or diagnosed before 20-weeks gestation

– patient is diagnosed with hypertension during pregnancy but persists ≥12 weeks after delivery

– As with hypertension in non-pregnant population, can be primary or secondary hypertension attributable to other causes

– Gestational Hypertension

– New onset SBP ≥140mmHg or DBP ≥90mmHg on at least 2 occurrences 4 hours apart after 20 weeks of gestation in previously normotensive female

– No proteinuria or severe features of pre-eclampsia

– 10-25% will develop signs/symptoms of pre-eclampsia later in pregnancy

– Typically resolve within 12 weeks after delivery (otherwise considered chronic, as above)

– Pre-eclampsia/Eclampsia/HELLP syndrome

– Pre-eclampsia:

– New onset SBP≥140mmHg or DBP ≥ 90mmHg on at least 2 occasions 4 hours apart after 20-weeks gestation (i.e. patient was normotensive prior to pregnancy) OR SBP ≥160mmHg or DBP≥110mmHg

– AND

– Proteinuria ≥300mg per 24hour urine collection, OR protein:creatinine ratio ≥0.3

– OR

– If no proteinuria, new-onset hypertension with new onset of one or more of the following (severe features):

– Thrombocytopenia (platelet count <100,000)

– Renal insufficiency (Cr >1.1 or doubling from baseline in absence of other disease)

– Impaired liver function (LFTs 2x upper limit of normal)

– Pulmonary edema

– Cerebral or visual symptoms (new onset headache not responsive to Tylenol)

– Pre-eclampsia CAN develop post-partum

– Risk factors for pre-eclampsia:

– High risk factors: prior pregnancy with pre-e, multifetal gestation, renal disease, autoimmune disease (SLE, antiphospholipid antibody syndrome), diabetes, chronic hypertension)

– Moderate risk factors: nulliparas/first pregnancy, advanced maternal age, BMI >30, family history

– Patients are started on ASA 81mg/day for pre-eclampsia prophylaxis

– Pre-eclampsia with severe features

– SBP ≥160mmHg or DBP≥110mmHg on 2 occasions at least 4 hours apart

– Thrombocytopenia (plt <100,000)

– Impaired liver function (LFTs 2x upper limit of normal)

– Pulmonary edema

– Cerebral or visual symptoms (new onset headache not responsive to Tylenol)

– Eclampsia:

– Seizures occurring in patient with pre-eclampsia without alternate cause for seizure (no other neurologic conditions, drug use, etc.)

– HELLP Syndrome:

– Hypertension + elevated liver enzymes + low platelets

– Potentially subtype of pre-eclampsia; patients do not have to have hypertension (~15% lack hypertension or proteinuria), though majority do

– Main presenting symptom is often RUQ pain and malaise, may have nausea/vomiting

– Associated with higher rates of morbidity/mortality

– Typically occurs in 3rd trimester, but can occur postpartum

– Pre-eclampsia superimposed on chronic hypertension

– In patient with chronic hypertension as above, new sudden increase in blood pressure in patient on previously stable anti-hypertensive regimen or elevated BP resistant to treatment OR new development of proteinuria or increase in proteinuria (if present before/early in pregnancy)

– Can be with severe features as well