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9-1-4
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Rationale
Causal Conditions
Key Objectives
Objectives
Applied Scientific Concepts

Version: November 2004

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PREGNANCY ASSOCIATED HYPERTENSION

-Rationale

Ten to 20 % of pregnancies are associated with hypertension. Chronic hypertension complicates<5%, preeclampsia occurs in slightly>6%, and gestational hypertension arises in 6% of pregnant women. Preeclampsia is potentially serious, but can be managed by treatment of hypertension and 'cured' by delivery of the fetus.

-Causal Conditions

Chronic hypertension (BP>140/90 mmHg antedates pregnancy, or<20 weeks gestation, or persists>12 weeks postpartum)

Preeclampsia-eclampsia (new hypertension and proteinuria after 20 weeks gestation)

Preeclampsia superimposed on chronic hypertension

Preeclampsia superimposed on chronic hypertension and proteinuria, both present before 20 weeks (severe exacerbation of blood pressure, systolic>180 mmHg, diastolic>110 mmHg, in last half of pregnancy)

Preeclampsia superimposed on gestational hypertension

Gestational hypertension (latter half of pregnancy, no proteinuria)

Transient hypertension of pregnancy (resolves by 12 weeks postpartum)

Masked chronic hypertension (persists beyond 12 weeks postpartum)

-Key Objectives

Describe normal changes in blood pressure during pregnancy and define hypertension in pregnancy with these changes in mind.

Outline the treatment of preeclampsia including considerations for early diagnosis, medical supervision and need for hospital admission, and timely delivery.

-Objectives

Through efficient, focused, data gathering:

List some risk factors for development of preeclampsia; perform rollover test in at risk patients.

Differentiate preeclampsia from pre-existing chronic hypertension and gestational hypertension; differentiate preeclampsia superimposed on pre-existing hypertension from primary preeclampsia.

Elicit symptoms and signs indicative of risk for convulsions (e.g., headache, epigastric pain, visual abnormalities, proteinuria, etc.); measure pressure (normotensive for 20 weeks then>140/90 mmHg).

List and interpret critical clinical and laboratory findings which were key in the processes of exclusion, differentiation, and diagnosis:

Select and interpret laboratory investigation useful to the diagnosis of preeclampsia (>300 mg/d protein, hyperuricemia) and HELLP syndrome (hemolysis, elevated liver enzymes, low platelets).

Conduct an effective plan of management for a patient with hypertension in pregnancy:

List the goals of management of hypertension in pregnancy (with respect to the safety of the mother and second, the delivery of a live infant not requiring intensive, prolonged neonatal care).

Discuss strategies for the prevention of pregnancy-induced hypertension in at risk patients.

List drugs indicated and contraindicated and pressure levels in the management of preeclampsia (systolic?160 mmHg, and diastolic?105 mmHg) and chronic hypertension (systolic?150 mmHg and diastolic?100 mmHg).

-Applied Scientific Concepts

Outline the changes in utero-placental circulation (impaired trophoblast invasion and placental ischemia) that occur in preeclampsia.

Outline later changes resulting from placental ischemia such as altered capillary permeability, intravascular inflammatory response, abnormal prostaglandin metabolism, and activation of endothelial cells and the coagulation system.

© The Medical Council of Canada, 2010