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HEALTHY MAGAZINE
-------------------------------ADVISOR CLIENT CONTENT
HYPERTENSION In Pregnancy
P
erhaps you’ve wondered why at each prenatal visit your doctor always has you get your blood pressure taken and then pee in a cup. The reason is that he or she is looking for evidence of “preeclampsia.” Preeclampsia and other hypertensive disorders of pregnancy are among the most dangerous and deadly of diseases that you can have while carrying your unborn child. In my mind there are 4 sub-types of hypertension in pregnancy. They are: 1) Chronic Hypertension, 2) PIH or Pregnancy Induced Hypertension, 3) Preeclampsia (either mild or severe), and 4) Eclampsia. Chronic hypertension is defined as hypertension that is present even before pregnancy occurs, or, is present prior to 20 weeks gestational age. It usually occurs in the setting of obesity or diabetes prior to conception. It may also be “essential hypertension without a known etiology.” Chronic hypertension may co-exist with preeclampsia, which clinically can be a challenge to distinguish. People with chronic hypertension are usually on blood pressure medication prior to or soon after being diagnosed as pregnant. Because diabetes, obesity, and chronic hypertension often co-exist, these patients are at risk for end organ damage such as kidney disease and can be difficult to manage. Pregnancy Induced Hypertension (PIH) is hypertension that is newly onset with pregnancy
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after 20 weeks, but is not associated with proteinuria, abnormal liver or kidney function, or other neurological signs. Patients with pure PIH do not have to be delivered immediately, unless their blood pressures start to cause neurological symptoms or if in excess of 160/110. However, there is no definite agreed upon management. Preeclampsia is classically sub-divided into mild and severe disease. In the past, mild preeclampsia was defined as a blood pressure (BP) over 140/90 taken at least 6 hours apart on two occasions, associated with proteinuria of 300 mg/24hours. (About 10 years ago, the need for edema was removed from the definition.) Severe preeclampsia was defined as blood pressures above 160/110 and/or proteinuria of 5000 mg in a 24-hour urine collection. The addition of headaches, RUQ abdominal pain, mid-epigastric pain, visual disturbances, or other neurological symptoms would be classified as severe and might warrant intervention and early delivery. Very recently, just in the past couple of weeks, the American College of Obstetricians and Gynecologists (ACOG) “Task Force Report On Hypertension In Pregnancy” was released and stated that “Proteinuria, or elevated protein in the urine, should no longer be considered the signature criterion beside new onset hypertension in diagnosing preeclampsia.” They further state, “equal weight should be given to reduced platelet counts, renal insufficiency, severe headache, heart-lung compromise, and impaired liver function. Any of these concurrent with new onset hypertension at 20 weeks of pregnancy or beyond is enough to establish preeclampsia, even in the absence of proteinuria.” Also, proteinuria should no longer be used to classify the disease as mild or severe,
but the new guidelines stress the need for experience and clinical judgment in making the decision for delivery. One thing the panel of experts did agree on however was the need to deliver even mild cases of preeclampsia at 37 weeks. Keep in mind that one or two very mildly elevated BP’s do not, in and of themselves, define preeclampsia. Other factors mentioned above must be taken into consideration. The worst-case scenario is full blown eclampsia. This is when a patient has a seizure associated with hypertension. It is usually wise to allow the seizure to resolve, and then soon, within an hour or two after the patient is stabilized, to move directly to early delivery. Eclamptic seizures can be associated with permanent neurological damage or permanent brain injuries, though most commonly they will resolve fully upon delivery of the infant. This, I personally have only seen a handful of times in my 20 years of obstetrics, but it is a condition much better avoided whenever possible. This article is intended only as a very brief synopsis of a very dangerous and much studied disorder of pregnancy. For more information on preeclampsia you may visit ACOG’s website, or please feel free to contact Dr. Mark T. Saunders at 801-692-1429 or visit our website atdrsaundersobgyn.com.
ABOUT THE AUTHOR
Mark Saunders, MD Obstetrics & Gynecology Personal Care 801-692-1429 drsaundersobgyn.com
Dr. Mark Saunders is a wellrespected board certified obstetrician and gynecologist that has been practicing in the American Fork area for over 18 years.
HEALTHY UTAH JANUARY 2014
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