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Case 4

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-week–sized
uterus.

QUESTIONS
Should the patient be on medication for her chronic hypertension?

How else should she be evaluated?
DISCUSSION
The National High Blood Pressure Education Program Working Group on High Blood Pressure in
Pregnancy suggests that therapy could be increased or reinstituted for women with blood pressures
exceeding 150 to 160 mmHg systolic or 100 to 110 mmHg diastolic. If the patient’s blood pressure is
persistently 150/100, she should be treated to prevent maternal morbidity. The antihypertensives of choice
in pregnancy are α-methyldopa and labetalol. Angiotensin-converting enzyme inhibitors are
contraindicated in pregnancy. The patient should be evaluated for end-organ disease. The evaluation
consists of a complete physical examination including cardiac and funduscopic evaluation. Laboratory
evaluation should include a serum creatinine, blood urea nitrogen, and 24-hour urine test for total protein
and creatinine clearance. An electrocardiogram, echocardiography, and ophthalmologic evaluation should
also be considered. An ultrasound should be performed to confirm the patient’s dates and exclude a
hydatidiform mole.
The patient should be monitored closely. Serial sonography to monitor fetal growth is indicated.
Once the patient is in the third trimester, fetal surveillance is suggested. The clinician should be alert to
signs and symptoms of placental abruption and superimposed gestational hypertension-preeclampsia,
which can occur in pregnant women with chronic hypertension.

The patient’s physical examination and laboratory evaluation are normal. Her pregnancy remains
uncomplicated until 35 weeks’ gestation, when she calls the physician’s office with a complaint of a
headache.

QUESTIONS
What should the physician be concerned about?

What should the physician do next?
DISCUSSION
The patient should be instructed to come in immediately for evaluation. Symptoms such as headache,
visual disturbances, and epigastric pain may indicate preeclampsia in any pregnant patient. Patients with
chronic hypertension are at risk for superimposed gestational hypertension-preeclampsia.

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 physician’s diagnosis now?
What laboratory studies are indicated?
How should the patient be managed?
DISCUSSION
Based on the patient’s 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 patient’s 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.