Gestational hypertension, preeclampsia, eclampsia, and HELLP: Clinical sciences

Hypertension in pregnancy is not one disorder, but actually a spectrum. This spectrum begins with gestational hypertension, where a patient only has elevated blood pressure.If you add proteinuria to hypertension, then we’re talking about preeclampsia without severe features. Now, progression to preeclampsia with severe features occurs if any of the following are observed; severely elevated blood pressures; labs indicating end-organ damage like thrombocytopenia, elevated liver enzymes, or renal insufficiency; or worrisome symptoms like new onset headache, visual changes, right upper quadrant pain, or epigastric pain.

Next, HELLP syndrome occurs when a patient presents with Hemolysis, Elevated Liver enzymes, and Low Platelets. These conditions have significant maternal and fetal risks, such as stroke, pulmonary edema, renal failure, and placental abruption. Finally, if the patient had a seizure, that’s eclampsia. Most hypertensive disorders resolve by 12 weeks postpartum, and they all increase a patient's risk of developing chronic hypertension in the future.

Your first step in evaluating a pregnant patient who presents with a chief concern suggesting a hypertensive disorder in pregnancy is to perform a CABCDE assessment and conduct a primary obstetric survey.

If the patient is unstable, check for uncontrolled bleeding and control any hemorrhage, as severely elevated blood pressure may cause a placental abruption. Next, stabilize their airway, breathing, and circulation and consider intubation when appropriate. Obtain IV access and continuously monitor maternal vital signs. Perform your primary obstetric survey, which includes monitoring the fetal heart rate; possibly testing for rupture of amniotic membranes; and consider checking cervical dilation.

Alright, let’s talk about stable patients. Your first step is to obtain a focused history and physical exam. Ask about any history of hypertension, which is a big risk factor. Additional risk factors include obesity, diabetes, kidney disease, age greater than 35, nulliparity, multifetal gestation, or a history of preeclampsia.

Then, measure their blood pressure. In patients who are more than 20 weeks pregnant, a hypertensive disorder of pregnancy is suspected if they have newly elevated blood pressures of at least 140 systolic, or at least 90 diastolic, or both, on two separate occasions more than 4 hours apart.

Okay, once you suspect a hypertensive disorder in pregnancy, it’s time to check labs. Obtain a CBC, CMP, LDH, and a urine protein-to-creatinine ratio; and possibly a 24-hour urine collection to measure total protein.

Alright, if your patient has normal labs and has no symptoms of preeclampsia, you can confirm the diagnosis of gestational hypertension. Antepartum management includes monitoring blood pressure and starting an antihypertensive medication like labetalol or nifedipine, if blood pressure is persistently above 140 systolic, 90 diastolic, or both. Antenatal fetal surveillance with non-stress tests and serial ultrasounds to assess fetal growth are recommended.

Additionally, monitor for disease progression by assessing blood pressure, serial labs, and asking about symptoms of preeclampsia with severe features. If maternal and fetal status are reassuring, you can wait until 37 weeks to deliver the fetus. Vaginal delivery is appropriate unless there are contraindications like fetal malpresentation or prior classical C-section.

While intrapartum, closely monitor maternal and fetal status for evidence of severe features, as they require additional interventions. In the postpartum period, schedule a short-interval blood pressure check, and discuss return precautions if they experience signs and symptoms of preeclampsia with severe features. Half of all patients with gestational hypertension will eventually develop preeclampsia, with those diagnosed prior to 32 weeks at highest risk. This is why close monitoring for disease progression is so important!

Now let’s talk about patients who have proteinuria. Patients with new-onset hypertension after 20 weeks gestation plus proteinuria meet the diagnosis of preeclampsia. Proteinuria is defined as a urine protein-to-creatinine ratio greater than or equal to 0.3, or a 24-hour urine collection with at least 300 mg of protein.

Once you’ve diagnosed preeclampsia, next assess for severe features. These include blood pressures of at least 160 systolic or 110 diastolic on two occasions at least 4 hours apart; laboratory abnormalities like thrombocytopenia with a platelet count of less than 100,000, renal insufficiency with a creatinine greater than 1.1, elevated liver function tests greater than two times the upper limit of normal; and signs or symptoms such as pulmonary edema, new-onset headache that does not improve with medication, visual symptoms like spots or blurry vision, severe, persistent right upper quadrant abdominal pain, or epigastric pain.

Here’s a clinical pearl! While blood pressure should be measured on two separate occasions at least 4 hours apart, in an acute setting with severely elevated blood pressures the diagnosis can be made within minutes to allow for timely intervention!

Patients with preeclampsia without severe features should be monitored closely in the outpatient setting. Consider starting an antihypertensive if blood pressure is persistently above 140 systolic, 90 diastolic, or both. Initiate antenatal fetal surveillance with non-stress tests and serial ultrasounds, and monitor for severe features with serial labs and symptomatology. As long as they remain asymptomatic for severe features with reassuring blood pressure, fetal status, and labs, vaginal delivery at 37 weeks is recommended.