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Hypertension in Pregnancy
A 33-year-old African-American primigravid woman presents for prenatal care at 10 weeks
gestation by her last menstrual period. Her blood pressure taken in the office is 150/100.
QUESTIONS
How common is hypertension in pregnancy?
What is the most likely diagnosis?
DISCUSSION
Hypertensive disease occurs in about 12% to 22% of pregnancies. Hypertension during pregnancy is
considered to be either gestational hypertension-preeclampsia or chronic hypertension. Hypertension that
occurs before 20 weeks gestation, even in the absence of a history of hypertension, is defined as chronic
hypertension. The one exception is patients with gestational trophoblastic disease, who may develop
gestational hypertension-preeclampsia before 20 weeks gestation. The most likely diagnosis in this
patient is chronic hypertension, but gestational trophoblastic disease should be excluded by
ultrasonography.
Further questioning provides a history of essential hypertension since age 25. The patient reports
that she is currently not taking any treatment for her blood pressure. The remainder of her history
is noncontributory, and a routine gynecologic examination is remarkable only for a 10-weeksized
uterus.
QUESTIONS
Should the patient be on medication for her chronic hypertension?
The patients physical examination and laboratory evaluation are normal. Her pregnancy remains
uncomplicated until 35 weeks gestation, when she calls the physicians office with a complaint of a
headache.
QUESTIONS
What should the physician be concerned about?
The patient is seen on the labor floor, and her blood pressure is persistently 180/120. Urine protein
is noted to be +2 on straight cath. The patient complains of a persistent headache that is not
relieved by acetaminophen. Physical examination is unremarkable, and her cervix is noted to be 1
cm dilated and 90% effaced with the fetal vertex at minus 1 station. Fetal monitor demonstrates
irregular contractions and fetal heart rate in the 140s and reassuring.
QUESTIONS
What is the physicians diagnosis now?
What laboratory studies are indicated?
How should the patient be managed?
DISCUSSION
Based on the patients blood pressure and symptoms, the patient meets criteria for the diagnosis of
superimposed severe preeclampsia. Laboratory evaluation should include a complete blood count to
evaluate for hemoconcentration or hemolysis and thrombocytopenia, a serum creatinine and uric acid test
to identify renal dysfunction, and liver function tests to identify a transaminitis. Because of the diagnosis
of severe preeclampsia and the patients presentation, delivery is indicated to prevent both maternal and
fetal morbidity and mortality. Vaginal delivery is preferred. The decision to preform a cesarean delivery
needs to be individualized. The patient should also receive parenteral magnesium sulfate for seizure
prophylaxis and antihypertensive therapy.