Background: A pregnant woman, 38-years–old, with a history of high blood pressure, presents at 10 weeks’ gestation for hypertension in pregnancy.

The patient is taking labetalol and nifedipine. She planned the pregnancy. Prior to conception, her hypertension was well-controlled. It now reads 158/108 mm Hg. Her body mass index is 35. This is her first pregnancy.

positive pregnancy test in a patient with hypertension in pregnancy — Positive pregnancy test in a patient with hypertension in pregnancy.

Multiple family members have a history of hypertension.

Please answer the following questions:

What is causing her elevated blood pressure?
* Preeclampsia
* Eclampsia
* Gestational hypertension
* Chronic hypertension
* Normal, expected physiologic changes in pregnancy

Chronic hypertension

Chronic hypertension in pregnancy is defined as a systolic blood pressure of 140 mm Hg or higher starting before pregnancy or before 20 weeks’ gestation.
A
True
B
False

A True

The American College of Obstetricians and Gynecologists now suggests using a blood pressure reading of 140/90 mm Hg as the point to start or adjust medical treatment for chronic hypertension during pregnancy. This is a change from the previous recommendation of 160/110 mm Hg.

In normal pregnancy, blood pressure typically rises during the first trimester.
A
True
B
False

B False

In pregnancy, the blood pressure typically decreases during the first trimester. The blood pressure reaches a bottom point in the second trimester. High blood pressure in the first trimester is inconsistent with normal pregnancy changes.

The American College of Obstetricians and Gynecologists (ACOG) recommends a blood pressure of 140/90 mm Hg as the threshold for treating chronic hypertension in pregnant patients. ACOG no longer recommends a threshold of 160/110 mm Hg.
A
True
B
False

A True

The previously recommended threshold for blood pressure was 160/110 mm Hg.
A
True
B
False

A True

Antihypertensive treatment has been shown to prevent preeclampsia.
A
True
B
False

B False

Blood pressure therapy can reduce the risk of severe hypertension by up to 50% compared to placebo; however, it does not prevent preeclampsia.

Which condition is associated with proteinuria: gestational hypertension or preeclampsia?

Preeclampsia occurs after 20 weeks of pregnancy. It is associated with proteinuria and new onset hypertension.

Gestational hypertension does not present with proteinuria.

Discussion:

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Hypertension in Pregnancy

Chronic Hypertension in Pregnancy

In pregnant patients, chronic hypertension is likely if hypertension in pregnancy is recognized before 20 weeks’ gestation. The American College of Obstetricians and Gynecologists (ACOG) defines chronic hypertension as a systolic blood pressure greater than or equal to 140 mm Hg or diastolic blood pressure greater than or equal to 90 mm Hg before pregnancy, before 20 weeks’ gestation, or persisting longer than 12 weeks postpartum.

Blood pressure typically decreases in the first trimester, reaches its lowest point in the second trimester, and gradually rises thereafter.

The American College of Obstetricians and Gynecologists (ACOG) recommends a blood pressure threshold of 140/90 mm Hg to start or adjust antihypertensive therapy for pregnant patients with chronic hypertension, down from the previous recommendation of 160/110 mm Hg.

Blood pressure treatment reduces severe hypertension risk by 50% but does not prevent preeclampsia, small size for gestational age, preterm birth, or infant mortality.

Risk Factors for Hypertensive Disease in Pregnancy

There are conditions that increase the risk of hypertensive disease in pregnancy. These conditions include pre-existing hypertension, kidney disease, diabetes mellitus, obstructive sleep apnea, thrombophilia, and autoimmune disease. Certain factors increase the risk of developing gestational hypertension and the progression to preeclampsia.

Risk factors for hypertensive disease in pregnancy include a history of preeclampsia, HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count), high body mass index, autoimmune disease, advanced maternal age, primiparity, or a family history of gestational hypertension.

Gestational Hypertension versus Preeclampsia

Gestational hypertension presents after 20 weeks without proteinuria or end-organ damage, resolving within 12 weeks post-delivery. Preeclampsia is characterized by new-onset hypertension and proteinuria after 20 weeks, along with end-organ involvement.

Preeclampsia requires proteinuria or new-onset end-organ damage, which is not present in this patient’s case. Our patient is only 10 weeks pregnant, which is too soon for preeclampsia to present. Our patient started the pregnancy with hypertension that was well-controlled.

Physiological Changes in Pregnancy

Normal pregnancy physiology involves decreased blood pressure in the first trimester, reaching a nadir in the second trimester. High blood pressure in the first trimester is inconsistent with normal pregnancy changes.

Inspiration: Hypertension In Pregnancy National Library of Medicine

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