An article recently published with NPR details some shocking statistics concerning pregnancy-related hypertension, and it has been made apparent how little is known about pregnancy hypertension. The newborn is often watched and evaluated very closely, but not as much attention is focused on the Mother, especially postpartum. We also still have very little information on the causes of pregnancy related hypertension, especially conditions surrounding preeclampsia.
Some of the key statistics that emerged from the study were:
Pregnancy related hypertension is defined as a pre-existing or new hypertensive disorder complicating pregnancy. It is the most common medical complication of pregnancy. The types of pregnancy related hypertension include:
This is when hypertension predates pregnancy or is detected before 20 weeks of gestation. Reported in 5% of pregnant women and may appear in the postpartum period.
Hypertension without proteinuria developing after 20 weeks of gestation. This either progresses to preeclampsia or chronic hypertension or resolves and becomes transient hypertension.
When Hypertension (blood pressure above 140/90 mm Hg) and proteinuria (>300 mg/24 hours) are both detected after 20 weeks of gestation. If proteinuria isn’t present then diagnosis requires one of thrombocytopenia, impaired liver function, new renal insufficiency, pulmonary edema or new onset cerebral or visual disturbance. The most commonly affected are nulliparous women, or those with pregnancies complicated by multiple gestations, and the condition becomes more frequent in women nearing term.
This is a multi-system disorder and is seen as a complication of severe preeclampsia.
If preeclampsia isn’t detected and treated then eclampsia will develop which is catastrophic, and detected by new-onset grand mal seizures in patients of preeclampsia.
As well as the specific symptoms mentioned earlier regarding various types of pregnancy related hypertension, these symptoms should also be evaluated when assessing any hypertension concerns during pregnancy:
It is important to recognize these key symptoms and make an early diagnosis to allow the best possible outcome for both mother and baby. If you are unsure and have clinical doubt, using a differential diagnosis tool like Isabel could ensure that you have seen all relevant disorders and considered ‘don’t miss’ diagnoses.
Following your differential diagnosis, steps can be taken to confirm diagnosis. Monitor blood pressure and request general blood tests, including levels of creatinine, electrolytes, uric acid, liver enzymes and platelet count. Compare the results with baseline tests performed earlier in pregnancy. You can also request a urinalysis to detect proteinuria.
Mild preeclampsia can be treated with antihypertensives and regular checkups until delivery. Corticosteroids may also be used to improve liver and platelet function and prolong pregnancy if not post-partum.
Indications for hospitalization include severe hypertension or severe preeclampsia. If women with a history of preeclampsia develop severe gestational hypertension, fetal growth restriction, or recurrent preeclampsia, then they need to be hospitalized for the remainder of the pregnancy or until preeclampsia symptoms disappear.
Delivery is the only cure for preeclampsia, and often early delivery is the best option for patients with severe hypertension. Gestational age and health of mother and baby should be compared with each other to determine the course of action. Indications that delivery is the most sensible option are:
Severe preeclampsia will require delivery of the baby as soon as possible to stop development of eclampsia. Depending on the length of gestation, treatment can vary:
Eclampsia (generalized seizures) will develop if preeclampsia is not recognized and treated, which can be life-threatening. Eclamptic seizures may occur unexpectedly in patients with no apparent or minimally elevated blood pressure and no proteinuria. Eclampsia may be preceded by premonitory signs including headache, visual disturbances, epigastric pain, constriction sensation in thorax, apprehension, excitability and hyperreflexia so these symptoms should be taken very seriously in a pregnant woman. What is not often realised is eclampsia can develop antepartum, intrapartum or up to 48 hours postpartum. It is commonly misunderstood that once the baby is delivered then eclampsia cannot occur, and that is why it is important that maternal health postdelivery is monitored just as closely as it is prior to the baby being delivered, and urgent action taken if the mother develops more symptoms.
The NPR article states that every year in the US, 700 to 900 women die from pregnancy of childbirth-related causes and an additional 65,000 nearly die making it one of the worst records in the developed world. In the US, maternal deaths increased from 2000 to 2014 and in a recent CDC Foundation, nearly 60% of deaths were preventable. One of the reasons given by the authors of the article for this trend is confusion amongst caregivers on how to recognise worrisome symptoms in pregnant women and therefore how to recognize and treat obstetric emergencies. Using a differential diagnosis tool to research these worrisome symptoms and consider the red flagged don’t miss diagnoses in pregnant women and those in the postpartum period could help reduce these statistics and worrying trend. Adopting standardised care pathways across all states will also help reduce these figures and obtain positive results such as has been seen in the UK.
If you have clinical doubt during diagnosis of hypertension conditions, or any other diagnostic process, consider using the Isabel DDx Generator:
Mandy has worked for Isabel Healthcare since 2000. Prior to this, she was a Senior Staff Nurse on the Pediatric Infectious disease ward and high dependency unit at one of London's top hospitals, St Mary’s in Paddington which is part of Imperial College Healthcare NHS Trust. Her experience in the healthcare industry for the past 28 years in both the UK and USA means she's a vital resource for our organization. Mandy currently lives and works in Scottsdale, Arizona.