Gestational hypertension

New onset of hypertension :

systolic blood pressure ≥140 mmHg
and/or
diastolic blood pressure ≥90 mmHg
at ≥20 weeks of gestation
in the absence of
proteinuria or new signs of end-organ
dysfunction
• The blood pressure readings should be
documented on:
at least two occasions at least four hours apart.
• Gestational hypertension is severe when
systolic blood pressure is ≥160
mmHg and/or diastolic blood pressure is ≥110
mmHg.
 Criteria for the diagnosis of preeclampsia

Systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg on two occasions at least four hours apart after 20 weeks of gestation in a previously normotensive patient

If systolic blood pressure is ≥160 mmHg or diastolic blood pressure is ≥110 mmHg, confirmation within minutes is sufficient

and

Proteinuria ≥0.3 g in a 24-hour urine specimen or protein/creatinine ratio ≥0.3 (mg/mg) (30 mg/mmol)

Or dipstick ≥1+ if a quantitative measurement is unavailable

OR

Systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg on two occasions at least four hours apart after 20 weeks of gestation in a previously normotensive patient with the new
onset of any of the following (with or without proteinuria):

Platelet count <100,000/microL

Serum creatinine >1.1 mg/dL (97.2 micromol/L) or doubling of the creatinine concentration in the absence of other renal disease

Liver transaminases at least twice the upper limit of the normal concentrations for the local laboratory

Pulmonary edema

Cerebral or visual symptoms (eg, new-onset and persistent headaches not responding to usual doses of analgesics*; blurred vision, flashing lights or sparks, scotomata)
• Gestational hypertension is a temporary
diagnosis for hypertensive pregnant women
who do not meet criteria for preeclampsia or
chronic hypertension (hypertension first
detected before the 20th week of pregnancy)
• The diagnosis is changed to:
●Preeclampsia, if proteinuria or new signs of
end-organ dysfunction develop
●Chronic hypertension, if blood pressure
elevation persists ≥12 weeks postpartum.
• Normal blood pressure – Systolic <120 mmHg
and diastolic <80 mmHg
• Elevated blood pressure – Systolic 120 to 129
mmHg and diastolic <80 mmHg
• Hypertension:
-Stage 1 – Systolic 130 to 139 mmHg or
diastolic 80 to 89 mmHg
-Stage 2 – Systolic at least 140 mmHg or
diastolic at least 90 mmHg
• Transient hypertension of pregnancy, if blood
pressure returns to normal by 12 weeks
postpartum
• Thus, reassessment up to 12 weeks
postpartum is necessary to establish a final
diagnosis.
 RISK FACTORS
●A past history of preeclampsia
●Preexisting medical conditions:
Pregestational diabetes
Chronic hypertension

Systemic lupus erythematosus

Anti phospholipid syndrome
Prepregnancy body mass index >25
Chronic kidney disease (CKD)
●Multifetal pregnancy
●First pregnancy
 RISK FACTORS
• A family history of preeclampsia
• Prior pregnancy complications associated with
placental insufficiency
• Advanced maternal age ≥35
• Use of assisted reproductive technology
 DIAGNOSTIC EVALUATION
• distinguish gestational hypertension from
preeclampsia
• determine whether hypertension is severe
 DIAGNOSTIC EVALUATION
• Measure protein excretion

≥0.3 g in a 24-hour urine specimen or

protein/creatinine ratio ≥0.3 (mg/mg) (30
mg/mmol
 Signs and symptoms suggestive of
diagnosis of preeclampsia without
proteinuria rather than gestational
hypertension
Symptoms of central nervous system dysfunction:

•New-onset cerebral or visual disturbance, such as:Photopsia, scotomata, cortical blindness, retinal vasospasm
•Severe headache (ie, incapacitating, "the worst headache I've ever had") or headache that persists and progresses despite analgesic therapy
•Altered mental status
Hepatic abnormality:
Severe persistent right upper quadrant or epigastric pain unresponsive to medication and not accounted for by an alternative diagnosis or serum transaminase concentration ≥2 times the upper limit
of the normal range, or both
Thrombocytopenia:
<100,000 platelets/microL
Renal abnormality:

Progressive renal insufficiency (serum creatinine >1.1 mg/dL [97.2 micromol/L] or doubling of serum creatinine concentration in the absence of other renal disease)
 DIAGNOSTIC EVALUATION
• Evaluate for features of severe disease
visual disturbances
epigastric or right upper quadrant pain
chest auscultatIion for pulmonary edema
↓↓↓

preeclampsia
 DIAGNOSTIC EVALUATION
• Perform laboratory evaluation
thrombocytopenia
increase in creatinine to >1.1 mg/dL
doubling of hepatic transaminases
 DIAGNOSTIC EVALUATION
• Determine the severity of hypertension
systolic blood pressure is ≥160 mmHg
and/or diastolic blood pressure is ≥110 mmHg
 DIAGNOSTIC EVALUATION
• Assess fetal well-being
1. biophysical profile or nonstress test with
amniotic fluid estimation
2. sonographic estimation of fetal weight
3. umbilical artery Doppler velocimetry is
reserved for fetuses with growth restriction
 PROGRESSION TO PREECLAMPSIA
• 10 to 50 percent of women initially diagnosed
with gestational hypertension go on to
develop preeclampsia in 1 to five weeks, so
frequent maternal monitoring
for signs/symptoms of preeclampsia is
indicated
MANAGEMENT
Blood pressure less than 160/110 mmHg

• Site of care
weekly or twice weekly
antepartum visits to measure blood pressure
and protein excretion
• Patient education and counseling
report any symptoms suggestive ofpreeclampsia
signs suggestive of possible fetal impairment
Medical emergencies
 medical emergencies
• Heavy vaginal bleeding
• severe headache ("worse headache of my
life")
• stroke symptoms
• severe breathing problems
 MANAGEMENT
• Level of physical activity
bed rest???
• Low dose aspirin???
• Maternal blood pressure and laboratory
monitoring
monitoring blood pressure once or twice
weekly in the office and weekly assessment of
proteinuria, platelet count, and liver enzymes
 MANAGEMENT
• Fetal assessment
- monitor fetal movement daily
- nonstress test with sonographic
estimation of the amniotic fluid index or a
biophysical profile weekly
- serial ultrasound examinations to monitor
fetal growth every three to four weeks
 MANAGEMENT
• Antihypertensive therapy
We do not prescribe antihypertensive drugs for
antepartum treatment of gestational
hypertension
Unless
hypertension is severe or approaching the
severe range or the patient has preexisting end
organ dysfunction
 MANAGEMENT
• Antenatal corticosteroids
delivery within seven days and before 34
weeks of gestation
• Timing of delivery
• For uncomplicated pregnancies with only an
occasional blood pressure ≥140/90 mmHg
and <160/110 mmHg, we deliver at 38 to 39
weeks, since neonatal morbidity is lower than
at 37 to 38 weeks
• For pregnancies with frequent blood
pressures ≥140/90 mmHg and <160/110 mmHg,
comorbidities, or other risk factors for adverse
outcome, we deliver at 37 weeks.
 Blood pressure greater than 160/110
mmHg
• should be treated with antihypertensive drugs
to reduce the risk of stroke
• A reasonable blood pressure goal is 130 to 150
mmHg systolic and 80 to 100 mmHg diastolic.
• We suggest delivery for pregnancies ≥34
weeks of gestation.
 Drug Class Initial dose Usual effective dose range Maximum total daily dose

250 mg two to three times daily, 250 to 1000 mg in two to three

Methyldopa Centrally acting alpha-agonist 3000 mg
increase every two days as needed* divided doses

100 mg two times daily, increase by

Labetalol Combined alpha- and beta-blocker 100 mg twice daily every two to three 200 to 800 mg in two divided doses 2400 mg
days as needed

30 to 60 mg once daily as an
Nifedipine extended release• Calcium channel blocker extended release tablet, increase at 7 30 to 90 mg once daily 120 mg
to 14 day intervals

Hydralazine
NOTE: Due to reflex tachycardia,
Begin with 10 mg four times per day,
monotherapy with oral hydralazine is 50 to 100 mg in two to four divided
Peripheral vasodilator increase by 10 to 25 mg/dose every 2 200 mgΔ
not recommended; hydralazine may doses
to 5 days
be combined with methyldopa or
labetalol if needed as add-on therapy
• For pregnancies <34 weeks:
antenatal corticosteroids
frequent blood pressure,
laboratory
fetal monitoring
in the hospital
We administer magnesium sulfate for peripartum
seizure prophylaxis
 we offer women with a history of gestational
hypertension and blood
pressures ≥160/110 mmHg low dose aspirin in
future pregnancies to reduce their risk of
developing preeclampsia.