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HTN in Pregnancy: DDx
Last updated: 09/24/2021
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
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