Complications: High Blood Pressure (Hypertension) in Pregnancy
Hypertension during pregnancy is one of the leading causes of death for the mother. The pregnant woman with high blood pressure requires close monitoring throughout her pregnancy.
Hypertension in pregnancy occurs in four forms:
- Severe Preeclampsia. The initial report of the “National High Blood Pressure Education Program Working Group Report on High Blood Pressure in Pregnancy” defines Preeclampsia as severe if one or more of the following conditions are present:
- A systolic blood pressure of 160 or higher and diastolic of 110 or higher twice, taken at least 6 hours apart
- At least 5 grams of protein in the urine in a 24-hour period, or at least 3+ protein in two random urine samples that were tested at least 4 hours apart
- The mother’s urine output is less than 500 cc in a 24-hour period
- Headaches or changes in vision are present
- Pulmonary edema (fluid in the lungs) or cyanosis
- Pain in the right upper portion of the abdomen
- Lab values that show abnormal liver function
- The baby is not growing inside of the uterus
- Chronic Hypertension. Chronic hypertension is defined as a blood pressure of 140/90 or higher before the 20th week of pregnancy, or high blood pressure that continues six weeks after delivery. Management includes close monitoring of her blood pressure, as well as close monitoring of her baby.
- Preeclampsia. Preeclampsia is a serious condition that affects approximately 3 to 6% of pregnancies. It is defined as high blood pressure plus abnormally high levels of protein in the mother’s urine (300mg or more in a 24-hour period, or greater than 1+ protein on a urine dipstick in two separate urine samples). Preeclampsia may progress to eclampsia, where the mother has a seizure. She may also develop HELLP Syndrome. Preeclampsia is caused by the interaction between the mother’s body and the placenta. There are still factors that are unclear regarding the exact mechanism behind this disorder.
- HELLP Syndrome. The mother is diagnosed with HELLP Syndrome based on lab values that show hemolysis, abnormally high liver enzymes, and a low platelet count. This syndrome can occur in circumstances other than pregnancy. It is usually identified by1:
- Eclampsia. A woman is diagnosed as having eclampsia if she experiences a grand mal seizure.
- Preeclampsia Superimposed on Chronic High Blood Pressure. When a pregnant woman that may or may not have high blood pressure develops abnormally high levels of protein in her urine, or when her blood pressure suddenly rises, or has an increase in urine protein, she may have preeclampsia that is superimposed (added to) chronic high blood pressure. Her lab values may also show the presence of thrombocytopenia, or abnormally high liver enzymes.
- Gestational Hypertension. A woman who develops high blood pressure during her pregnancy, who may or may not have other signs of preeclampsia, is diagnosed with gestational hypertension.
Monitoring you and your baby
Because of the fact that the only known cure for gestational hypertension or preeclampsia is the delivery of the baby (specifically the placenta), careful monitoring of you and your baby must be done.
Mothers diagnosed with gestational hypertension who do not have protein in their urine and have normal lab values may receive, depending on how far you are into your pregnancy:
- An ultrasound where your baby’s estimated weight and volume of amniotic fluid will be measured. If the results are within normal limits, the tests do not have to be repeated unless there is a change in your condition.
- A non-stress test should also be performed at the time you are diagnosed. If the non-stress test is non-reactive, a biophysical profile should be done. If the biophysical profile is normal (a score of 8 out of 8). If the non-stress test was reactive, or the biophysical profile was normal, the tests do not need to be repeated unless there is a change in your condition.
For mothers diagnosed with mild preeclampsia (mildly-elevated blood pressure), with normal lab values (liver enzymes and platelet count), and no other symptoms (headaches, vision problems, or pain in the upper right portion of your abdomen), doctors may order:
- An ultrasound that measures your baby’s growth and amount of amniotic fluid should be performed at the time you are diagnosed. If the results are normal, an ultrasound should be repeated in 3 weeks. If the ultrasound reveals that your baby’s estimated weight is less than the 10th percentile for his gestational age, or if there is less than the normal amount of amniotic fluid, the tests should be done twice a week.
- A non-stress test or biophysical profile (or both) should be performed at the time you are diagnosed. If the non-stress test is within normal limits (reactive) and/or your baby receives a biophysical profile score of 8 out of 8, the tests should be repeated on a weekly basis. If you develop any new or worsening symptoms, the tests should be performed immediately.
Medical treatment for preeclampsia
Medications are used to control your blood pressure in severe hypertension and preeclampsia until you are far enough into your pregnancy that will give your baby the best chance of survival and the best possible adjustment to life outside of the uterus. The medications include Hydralazine, Labetalol, Nifedipine, and Sodium Nitroprusside.
Magnesium sulfate is a mineral that may be given to mothers diagnosed with preeclampsia. This medication has a neuroprotective benefit to the baby, and may help reduce the risk of cerebral palsy that is associated with early preterm birth. In preeclampsia, it reduces the mother’s risk of having a seizure. It is given intravenously (through the IV). Preeclampsia has progressed to eclampsia when the mother has a seizure. Seizure activity may be controlled with higher doses of magnesium sulfate. The mother will need to remain on the magnesium sulfate drip for at least 24 hours after delivery.
If you are diagnosed with preeclampsia during or after your 24th week of pregnancy, or before your 34th week of pregnancy, you should be given steroid injections to speed up the up your baby’s lung development. Betamethasone (Celestone) is usually given in two injections, 24 hours apart. The steroids also decrease the baby’s risk of developing an intravascular hemorrhage (bleeding within the brain), as well as bowel problems. The best benefit to your baby occurs 48 hours after the second injection. Sometimes, the baby may need to be delivered before 48 hours after the last injection. Although the full benefit of the steroids may have not been achieved, any benefit to the baby is important.
Because preeclampsia and eclampsia are life-threatening conditions for the mother, there are instances where the baby must be delivered regardless of his gestational age. If the baby is not delivered, both the mother and fetus may not survive.
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- Myatt, L., & Webster, R. (2009). Vascular biology of preeclampsia. Journal of Thrombosis and Haemostasis, 7(3), 375-384. doi: 10.1111/j.1538-7836.2008.03259.x