37 Week Gestation with Hypertension

A 35-year-old, gravida 2 para 1001 woman at 37.6 weeks of gestation presents for her antenatal check. She states that she has been having constant headaches for the last 2 days.

She tells you that she has gained 5 pounds in the last week. Upon examination, her blood pressure is 154/102 mm Hg. Urine drip reveals 2+ protein.

You repeat the blood pressure readings 20 minutes later, and her blood pressure reading is 158/98 mm Hg.

Which of the following is the most appropriate next step in this patient's treatment plan?

• Start her on antihypertensive medications and start laboratory work.
• Induce the patient.
• Perform amniocentesis for confirming fetal lung maturity.
• Give her steroids.

The Table below explains guidelines from the American College of Obstetricians and Gynecologists for inducing labor in patients who are newly diagnosed with pre-eclampsia.

Chronic Hypertension

For medically indicated early delivery of a neonate, there is no need to perform amniocentesis to determine fetal lung maturity. The patient will require amniocentesis for fetal lung maturity if the early delivery is being considered for reasons not medically indicated.

Acute-onset, severe hypertension that is accurately measured using standard techniques and is persistent for 15 minutes or more is considered a hypertensive emergency.

Severe-onset hypertension may occur in the second half of gestation in women not known to have chronic hypertension who develop sudden, severe hypertension (ie, with pre-eclampsia, gestational hypertension, or HELLP syndrome), but it can also occur among patients with chronic hypertension who are developing superimposed pre-eclampsia with acutely worsening, difficult-to-control, severe hypertension.

It is well known that severe hypertension can cause injury to the central nervous system. The degree of systolic hypertension (as opposed to the level of diastolic hypertension or relative increase or rate of increase of mean arterial pressure from baseline levels) may be the most important predictor of cerebral injury and infarction. In a case series of 28 women with severe pre-eclampsia and stroke, all but 1 woman had severe systolic hypertension prior to hemorrhagic stroke. A total of 54% died, whereas only 13% had severe diastolic hypertension in the hours preceding stroke. A similar relationship between severe systolic hypertension and risk of hemorrhagic stroke has been observed in nonpregnant adults. Thus, systolic blood pressure of 160 mm Hg or higher is included as part of the definition of severe hypertension in pregnant women or women in the postpartum period.

References:

Abdul Sultan A, West J, Tata LJ, et al. Risk of first venous thromboembolism in pregnant women in hospital: population based cohort study from England. BMJ. 2013;347:f6099.

American College of Obstetricians and Gynecologists. ACOG committee opinion no. 560: Medically indicated late-preterm and early-term deliveries. Obstet Gynecol. 2013;121(4):908-910.

Broekhuijsen K, van Baaren GJ, van Pampus MG, et al. Immediate delivery versus expectant monitoring for hypertensive disorders of pregnancy between 34 and 37 weeks of gestation (HYPITAT-II): an open-label, randomised controlled trial. Lancet. 2015;385:2492.

Crowther CA, Bouwmeester AM, Ashurst HM. Does admission to hospital for bed rest prevent disease progression or improve fetal outcome in pregnancy complicated by non-proteinuric hypertension? Br J Obstet Gynaecol. 1992;99:13.

Henderson JT, et al. Low-Dose Aspirin for the Prevention of Morbidity and Mortality From Preeclampsia: A Systematic Evidence Review for the U.S. Preventive Services Task Force. 2014.

Maloney KF, Heller D, Baergen RN. Types of maternal hypertensive disease and their association with pathologic lesions and clinical factors. Fetal Pediatr Pathol. 2012;31:319.

This question appears in Med-Challenger OBGYN Review with CME.

 

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