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Hypertensive pregnancy disorders

Last updated: January 15, 2021

Summary

Hypertensive pregnancy disorders are the most common medical complication during pregnancy. There are four major types of hypertensive pregnancy disorders. The most common is gestational hypertension, also referred to as pregnancy-induced hypertension (PIH), which occurs after 20 weeks' gestation. Preeclampsia is a form of hypertensive pregnancy disorder with multiorgan involvement. It is characterized by new-onset hypertension and proteinuria after 20 weeks' gestation. Risk factors include nulliparity, a positive family history, and African-American ethnicity. Eclampsia is a severe form of preeclampsia, characterized by new-onset of eclamptic seizures (grand mal seizures). Preeclampsia may also progress to the life-threatening HELLP syndrome, which is characterized by hemolysis, elevated liver enzymes, and low platelet count.

Hypertensive pregnancy disorders are usually diagnosed in the course of regular prenatal care, which includes regular surveillance of blood pressure, weight, and urine tests. Initial treatment for all hypertensive pregnancy disorders consists of maternal and fetal monitoring until delivery is feasible. Antihypertensive treatment (e.g., labetalol, hydralazine) is indicated in severe hypertension. Magnesium sulfate is important to prevent seizures in severe preeclampsia and eclampsia. Patients with eclampsia and HELLP syndrome require immediate stabilization followed by delivery if the pregnancy is ≥ 34 weeks' gestation. Delivery is the only curative option for preeclampsia and eclampsia, which are both associated with increased maternal and fetal morbidity and mortality. HELLP syndrome has a poor fetal prognosis.

Definition

These disorders are on a spectrum from less to more severe and occur after 20 weeks' gestation.

Gestational hypertension can only be diagnosed if the patient was normotensive prior to 20 weeks' gestation. Otherwise, high blood pressure during pregnancy is classified as chronic hypertension.

The three primary features of PREeclampsia are Proteinuria, Rising blood pressure (hypertension), and End-organ dysfunction.

Epidemiology

Epidemiological data refers to the US, unless otherwise specified.

Etiology

Smoking actually decreases the risk of developing preeclampsia. [9]

Pathophysiology

Systemic effects of hypertensive pregnancy disorders
Organ Pathomechanism Disorder Occurrence [10]
Kidney
Lung
Liver
CNS
Blood

Clinical features

Gestational hypertension

Preeclampsia [6]

  • Onset: ∼ 90% occur after 34 weeks' of gestation.

Preeclampsia without severe features

Preeclampsia with severe features [12]

HELLP syndrome [13]

Eclampsia

Deterioration with headaches, RUQ pain, hyperreflexia, and visual changes are warning signs of a potential eclamptic seizure.

Diagnostics

Prenatal screening for hypertensive pregnancy disorders

Early detection to prevent maternal and fetal complications.

Initial workup [14]

Diagnostic criteria for hypertensive pregnancy disorders
Disorder Diagnostic criteria
Gestational hypertension
Preeclampsia Preeclampsia without severe features
Preeclampsia with severe features
HELLP syndrome
  • The following features must be present:
    • H = Hemolysis
    • EL = Elevated Liver enzymes
    • LP = Low Platelets
Eclampsia
Chronic hypertension

Fetal assessment

Differential diagnoses

Differential diagnosis of eclampsia

Seizure disorders during pregnancy

Differential diagnosis of HELLP syndrome

Causes of thrombocytopenia and liver impairment during pregnancy

Acute fatty liver of pregnancy

Intrahepatic cholestasis of pregnancy

Early initiation of therapy with ursodeoxycholic acid reduces the risk of preterm birth and stillbirth.

The differential diagnoses listed here are not exhaustive.

Treatment

Gestational hypertension and preeclampsia without severe features [5]

ACE inhibitors and angiotensin-receptor blockers (ARB) are contraindicated during pregnancy due to their teratogenic effect.

Preeclampsia without severe features can progress to preeclampsia with severe features within days, and thus should be closely monitored.

Hypertensive Moms Need Love: Hydralazine, Methyldopa, Nifedipine, Labetalol

Preeclampsia with severe features

Indications for delivery

Delivery is the only cure for preeclampsia.

Expectant management

Indicated if pregnancy < 34 weeks and mother and fetus are stable

Eclampsia

Delivery is the only cure for eclampsia.

HELLP syndrome [21]

Complications

Ischemic stroke, cerebral hemorrhage, and ARDS are the most common causes of death in patients with preeclampsia.

References:[26]

We list the most important complications. The selection is not exhaustive.

Prognosis

The prognosis of hypertensive pregnancy disorders depends on the severity of the condition and the complications that occur. In the majority of cases, the conditions resolve within hours or days after delivery.

Prevention

Prophylactic low-dose ASA PO from 12–14 weeks' gestation for patients with a high risk of developing preeclampsia [32]

References

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