Hypertension in Pregnancy

Definitions

• Chronic hypertension – hypertension before pregnancy or identified before 20 weeks gestation
• Gestational Hypertension – >140 systolic or >90 diastolic diagnosed after 20 weeks of gestation
• Preeclampsia -  is characterized classically by the triad of hypertension (>140 systolic or >90 diastolic), proteinuria (1+ on dip or >300mg/24hr), and edema although edema is no longer included in the diagnosis. Proteinuria does not always have to be present and preeclampsia is highly suspect if in addition to hypertension, there are symptoms of headache, blurred vision, or abdominal pain. Maternal blood pressures with systolic >160 or diastolic > 110 denotes severe disease.
• Eclampsia -  seizures in a woman with preeclampsia not due to another cause – can occur up to 6 weeks postpartum (pay attention new momma flopping like fish is not cool). Signs of  a pending eclampic seizure are nausea/vomiting, headache and visual disturbance.
• HELLP – hemolysis, elevated liver enzymes and low platelets

Work up and treatment:

Labs – CBC, Complete metabolic panel (liver function tests), mg, coags, urine, uric acid

Preeclampsia

• If you have hypertension after 20 weeks gestation with no prior work up for preeclampsia then a work up should be started and close follow arranged or admit
• In the third trimester or postpartum patient with severe blood pressure or warning signs of eclampsia start prophylactic magnesium and reduce the blood pressure

Eclampsia (seizure)

• IV magnesium sulfate in a dose of 4-6grams; phenytoin and benzodiazipines work as well to break the seizure although magnesium needs to be given and a mg drip started
• Dont forget other causes of seizure like hypoglycemia or tox
• Correct blood pressure (diastolic <105)- hydralazine (first-line) and labetalol are commonly used
• If seizures are not controlled with magnesium, patient does not carry the diagnosis of preeclampsia or neuro abnormalities consider a head CT looking for bleed or cerebral venous thrombosis
• Monitor DTRs for loss of reflex first sign of dangerous levels of mg (next step is paralysis of the diaphragm). Can be reversed if needed with calcium
• Do not bolus fluids lower urine outputs are ok
• Definitive treatment for eclampsia is delivery of the fetus – consult OB
• If HELLP is present – correct the coagulopathy

Rosens 7th ed., ch 176

Hypertension and Pregnancy. http://emedicine.medscape.com/article/261435

Stead. Seizures in Pregnancy/Eclampsia. Emergency Medicine Clinics of North America – Volume 29, Issue 1 (February 2011)

Steegers EA, von Dadelszen P, Duvekot JJ, Pijnenborg R. Pre-eclampsia. Lancet. 2010 Aug 21;376(9741):631-44. Epub 2010 Jul 2.