Table 9-1. Pregnancy Induced Hypertension (PIH)

	Mild PIH	Severe PIH	Eclampsia
Symptoms	None	Headache or	Unexplained convulsions
		epigastric pain or
		visual changes
Sustained	>140/90 mm Hg	At least >140/90 (if	At least >140/90 mm Hg
↑ blood pressure	<160/110 mm Hg	other findings) or
		>160/110 mm Hg
Laboratory tests	Hemoconcentration	Hemoconcentration	Hemoconcentration
	>300 mg proteinuria	> 5g proteinuria in	At least 1-2 +
	in 24 hrs	24 hrs or DIC, or	proteinuria
	No DIC, normal liver	↑ liver function tests
	function tests
Other findings	None	Pulmonary edema	May or may not be
		oliguria, cyanosis	present
Management	<36 wk: observe in	MgSO4: prevent or treat convulsions
	hospital, no MgSO4,	Lower diastolic BP to 90–100 mm Hg
	or blood pressure	Prompt delivery: not necessarily Cesarean
	meds
		section
	>36 wks: prompt
	delivery

OB Triad

 

CHRONIC HYPERTENSION WITH OR WITHOUT SUPERIMPOSED PREECLAMPSIA

 

A 35-year-old multigravida is seen in the outpatient prenatal clinic for her first prenatal visit. She is at 12 weeks’ gestation with a BP of 155/95. Chronic hypertension was diagnosed 5 years ago for which she has been treated with oral nifedipine. A spot urine dipstick protein is 2+. A recent 24-h urine collection showed

 

1.2 g of protein and a creatinine clearance of 85 ml/min. Serum creatinine is 1.2 mg/dl. She has no complaints of headache or visual changes.

 

Chronic HTN

 

• Pregnancy <20 wk or prepregnancy

• Sustained HTN (>140/90 mm Hg)

• +/– proteinuria

 

Risk Factors. Most chronic hypertension (HTN) is idiopathic without specific antecedents.Risk factors are obesity, advanced maternal age, positive family history, renal disease, diabetes, and systemic lupus erythematosus.

 

Etiology/Pathophysiology. Pathophysiology is vasospasm causing decreased end-organ perfu-sion, resulting in injury and damage. The acute problems arise from excessive systolic pressures,whereas the long-term problems arise from excessive diastolic pressures.

 

Diagnosis. The diagnosis of chronic HTN is made when BP≥140/90 mm Hg with onset beforethe pregnancy or before 20 weeks’ gestation.

 

 

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S2 OB-GYN.indb 81			7/8/13 6:35 PM

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USMLE Step 2 l Obstetrics

 

 

Pregnancy Prognosis with Chronic HTN:

• Good. Favorable maternal and neonatal outcome is found when BP 140/90–179/109 mm Hg and no evidence of end-organ damage.

 

• Poor. Pregnancy complications are more common in patients with severe HTN withthe following end-organ damage: cardiac, renal, and retinal.

 

– Renal disease. Pregnancy loss rates increase significantly if serum creatinine value are >1.4 mg/dL.

 

– Retinopathy. Longstanding HTN is associated with retinal vascular changes including hemorrhages, exudates, and narrowing.

 

– Left ventricular hypertrophy. This is seen mostly in women with prolonged BP values >180/110 mm Hg.

 

• Worst. Tenfold higher fetal loss rate if uncontrolled HTN (before conception or earlyin pregnancy) and chronic HTN with superimposed preeclampsia.

 

OB Triad

Chronic HTN with Superimposed Preeclampsia

• Chronic HTN

 

• Worsening BP

 

• Worsening proteinuria

Chronic HTN with Superimposed Preeclampsia:

 

• This complication occurs in 25% of patients with chronic HTN. Risk factors include renal insufficiency, HTN for previous 4+ years, and HTN in a previous pregnancy.

 

• Adverse pregnancy outcomes for both mother and baby are markedly increased.

 

Abruptio placenta incidence is markedly increased.

 

• The diagnosis is made on the basis of established chronic HTN along with any of the following: documented rising BP values; demonstrated worsening proteinuria; or evidence of maternal jeopardy (headache, epigastric pain, visual changes, thrombo-cytopenia [platelet count <100,000/mL], elevated liver enzymes, pulmonary edema, oliguria [<750 mL/24 h], or cyanosis). Edema may or may not be seen.

 

Laboratory Abnormalities. Chronic HTN patients have a spectrum of etiologies and diseaseseverity. Those with mild HTN and no end-organ involvement have normal laboratory tests, whereas those with renal disease may have evidence of decreased renal function including pro-teinuria, lowered creatinine clearance, and elevated BUN, creatinine, and uric acid.

 

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