History

Fact Explanation
Past history of hypertension [1] Chronic hypertension complicates between 1% and 5% of pregnancies [6] It increases the risk of preterm delivery and intrauterine growth restriction [4] Chronic hypertension is defined as a blood pressure measurement of 140/90 mm Hg or more on two occasions before 20 weeks of gestation or persisting beyond 12 weeks postpartum [1]
Headache [1] Due to high blood pressure.Blood pressure elevations are severe (greater than 160/110 mm Hg) in superimposed pre eclampsia [2]
History of increased blood pressure in a previous gestation, especially before week 34 or when the patient is multiparous Pregestational diabetes Collagen vascular disease Underlying renal vascular or renal parenchymal disease Multi-fetus pregnancy [2]` Factors which make the patient high risk of developing pre eclampsia [2]
Family history of hypertension [1] There may be a family history of hypertension in chronic hypertensive patients [2]
Abdominal pain [3] Severe abdominal pain can occur due to placental abruption which is a complications of Chronic Hypertension in Pregnancy. Right upper quadrant tenderness may be present in affected women with HELLP syndrome. The three chief abnormalities found in HELLP syndrome are hemolysis, elevated liver enzyme levels and a low platelet count [3]
Swelling of hands and face [5] Due to superimposed Preeclampsia which is characterized by the development of proteinuria ( more than 2,000 mg per 24 hours [2 g per day] ). Edema occurs due to imbalances of the starling forces caused by protein loss [2]
References
  1. LEEMAN L, FONTAINE P. Hypertensive disorders of pregnancy. Am Fam Physician [online] 2008 Jul 1, 78(1):93-100 [viewed 20 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18649616
  2. ZAMORSKI MA, GREEN LA. NHBPEP report on high blood pressure in pregnancy: a summary for family physicians. Am Fam Physician [online] 2001 Jul 15, 64(2):263-70, 216 [viewed 20 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11476271
  3. SEELY E. W., MAXWELL C.. Chronic Hypertension in Pregnancy. Circulation [online] 2007 February, 115(7):e188-e190 [viewed 20 August 2014] Available from: doi:10.1161/​CIRCULATIONAHA.106.636472
  4. GUEDES-MARTINS L, GRAçA H, SARAIVA JP, GUEDES L, GAIO R, CERDEIRA AS, MACEDO F, ALMEIDA H. The effects of spinal anaesthesia for elective caesarean section on uterine and umbilical arterial pulsatility indexes in normotensive and chronic hypertensive pregnant women: a prospective, longitudinal study. BMC Pregnancy Childbirth [online] 2014 Aug 28:291 [viewed 18 October 2014] Available from: doi:10.1186/1471-2393-14-291
  5. YE C, RUAN Y, ZOU L, LI G, LI C, CHEN Y, JIA C, MEGSON IL, WEI J, ZHANG W. The 2011 survey on hypertensive disorders of pregnancy (HDP) in China: prevalence, risk factors, complications, pregnancy and perinatal outcomes. PLoS One [online] 2014, 9(6):e100180 [viewed 18 October 2014] Available from: doi:10.1371/journal.pone.0100180
  6. BRAMHAM K, PARNELL B, NELSON-PIERCY C, SEED PT, POSTON L, CHAPPELL LC. Chronic hypertension and pregnancy outcomes: systematic review and meta-analysis. BMJ [online] 2014 Apr 15:g2301 [viewed 18 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24735917

Examination

Fact Explanation
High blood pressure [1] Chronic hypertension is defined as a blood pressure measurement of 140/90 mm Hg or more on two occasions before 20 weeks of gestation or persisting beyond 12 weeks postpartum [1] Blood pressure elevations are severe (>160/110 mmHg) in superimposed pre eclampsia [2]
Edema of face and hands [3] Due to superimposed Preeclampsia which is characterized by the development of proteinuria ( more than 2,000 mg per 24 hours [2 g per day] ). Edema occurs due to imbalances of the starling forces caused by protein loss [2]
Abdominal examination [3] Severe abdominal pain can occur due to placental abruption which is a complications of Chronic Hypertension in Pregnancy. Right upper quadrant tenderness may be present in affected women with HELLP syndrome. The three chief abnormalities found in HELLP syndrome are hemolysis, elevated levels of liver enzyme and a low platelet count. Symphysio fundal height can be reduced due to intra uterine growth restriction which is a fetal complications of Hypertension in Pregnancy[3]
Hyper reflexia [1] Occur due to multi system failure in super imposed pre eclampsia [2]
References
  1. LEEMAN L, FONTAINE P. Hypertensive disorders of pregnancy. Am Fam Physician [online] 2008 Jul 1, 78(1):93-100 [viewed 20 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18649616
  2. ZAMORSKI MA, GREEN LA. NHBPEP report on high blood pressure in pregnancy: a summary for family physicians. Am Fam Physician [online] 2001 Jul 15, 64(2):263-70, 216 [viewed 20 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11476271
  3. SEELY E. W., MAXWELL C.. Chronic Hypertension in Pregnancy. Circulation [online] 2007 February, 115(7):e188-e190 [viewed 20 August 2014] Available from: doi:10.1161/​CIRCULATIONAHA.106.636472

Differential Diagnoses

Fact Explanation
Pregnancy induced hyprtension [1] Blood pressure higher than 140/90 measured on two separate occasions, more than 6 hours apart, diagnosed after 20 weeks of gestation [1]
References
  1. LEEMAN L, FONTAINE P. Hypertensive disorders of pregnancy. Am Fam Physician [online] 2008 Jul 1, 78(1):93-100 [viewed 20 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18649616

Investigations - for Diagnosis

Fact Explanation
Blood pressure [1] Chronic hypertension is defined as a blood pressure measurement of 140/90 mm Hg or more on two occasions before 20 weeks of gestation or persisting beyond 12 weeks postpartum [1] Blood pressure elevations are severe (greater than 160/110 mm Hg) in superimposed pre eclampsia [2]
Urinary proteins [3] proteinuria ( more than 2,000 mg per 24 hours [2 g per day] ) in super imposed pre eclampsia [2]
References
  1. LEEMAN L, FONTAINE P. Hypertensive disorders of pregnancy. Am Fam Physician [online] 2008 Jul 1, 78(1):93-100 [viewed 20 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18649616
  2. ZAMORSKI MA, GREEN LA. NHBPEP report on high blood pressure in pregnancy: a summary for family physicians. Am Fam Physician [online] 2001 Jul 15, 64(2):263-70, 216 [viewed 20 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11476271
  3. YE C, RUAN Y, ZOU L, LI G, LI C, CHEN Y, JIA C, MEGSON IL, WEI J, ZHANG W. The 2011 survey on hypertensive disorders of pregnancy (HDP) in China: prevalence, risk factors, complications, pregnancy and perinatal outcomes. PLoS One [online] 2014, 9(6):e100180 [viewed 18 October 2014] Available from: doi:10.1371/journal.pone.0100180

Investigations - Fitness for Management

Fact Explanation
Serum creatinine [1] There may be a pre existing renal impairment due to chronic hypertension. Also renal functions can get deteriorated due to super imposed pre eclampsia - serum creatinine increases to more than 1.2 mg per dL (110 μmol per L) [1]
Liver function tests [1] Can be abnormal due to multi organ impairment in pre eclampsia [1]
References
  1. ZAMORSKI MA, GREEN LA. NHBPEP report on high blood pressure in pregnancy: a summary for family physicians. Am Fam Physician [online] 2001 Jul 15, 64(2):263-70, 216 [viewed 20 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11476271

Investigations - Followup

Fact Explanation
Trans vaginal / abdominal ultra sound scans [1] Initial sonography should be performed at 18 to 20 weeks' gestation. Further fetal growth can usually be monitored by using fundal height measurements, but if maternal obesity or other factors render this measurement inaccurate, repeat sonograms should be obtained monthly starting at 28 to 32 weeks' gestation. Ultra sound scan is important to identify fetal complications due to hypertension such as, Prematurity,Placental insufficiency, Intrauterine growth restriction, Placental abruption [1]
References
  1. ZAMORSKI MA, GREEN LA. NHBPEP report on high blood pressure in pregnancy: a summary for family physicians. Am Fam Physician [online] 2001 Jul 15, 64(2):263-70, 216 [viewed 20 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11476271

Investigations - Screening/Staging

Fact Explanation
Urinary proteins [1] proteinuria ( more than 2,000 mg per 24 hours [2 g per day] ) in super imposed pre eclampsia [1]
References
  1. ZAMORSKI MA, GREEN LA. NHBPEP report on high blood pressure in pregnancy: a summary for family physicians. Am Fam Physician [online] 2001 Jul 15, 64(2):263-70, 216 [viewed 20 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11476271

Management - General Measures

Fact Explanation
Pre pregnancy counseling [2] Blood pressure should be well controlled.Because target organ damage, especially renal disease, can progress during pregnancy, assessment for ventricular hypertrophy, retinopathy and renal disease should be considered in women with a history of hypertension for more than several years. Women should be informed of the sizable (25 percent) risk of superimposed preeclampsia and its attendant risks, particularly preterm delivery. Tell women who take angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers or thiazides: That there is an increased risk of congenital abnormalities if these drugs are taken during pregnancy, to discuss other antihypertensive treatment with the healthcare professional responsible for managing their hypertension, if they are planning pregnancy, Stop antihypertensive treatment in women taking ACE inhibitors or ARBs or thiazides if they become pregnant and offer alternatives.[1]
Recognition of super imposed pre eclampsia [1] superimposition should be suspected when any one of the following is present: (1) blood pressure elevations are severe (greater than 160/110 mm Hg); (2) heavy proteinuria (more than 2,000 mg per 24 hours [2 g per day]) develops or proteinuria abruptly worsens; (3) blood pressure suddenly increases after a period of good control; or (4) serum creatinine increases to more than 1.2 mg per dL (110 μmol per L) [1]
Timing of delivery [1] Do not offer birth to women with chronic hypertension whose blood pressure is lower than 160/110 mmHg, with or without antihypertensive treatment, before 37 weeks. For women with chronic hypertension whose blood pressure is lower than 160/110 mmHg after 37 weeks, with or without antihypertensive treatment, timing of birth and maternal and fetal indications for birth should be agreed between the woman and the senior obstetrician. But delivery is the only cure for preeclampsia. Decisions regarding the timing and mode of delivery are based on a combination of maternal and fetal factors. Fetal factors include gestational age, evidence of lung maturity, and signs of fetal compromise on antenatal assessment. Patients with treatment-resistant severe hypertension or other signs of maternal or fetal deterioration should be delivered within 24 hours, irrespective of gestational age or fetal lung maturity. Fetuses older than 34 weeks, or those with documented lung maturity, are also delivered without delay [1]
Bed rest [1] Women with high blood pressure during pregnancy have often been advised to rest in bed, either at home or in hospital [1]
References
  1. ZAMORSKI MA, GREEN LA. NHBPEP report on high blood pressure in pregnancy: a summary for family physicians. Am Fam Physician [online] 2001 Jul 15, 64(2):263-70, 216 [viewed 20 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11476271
  2. MITTAL P, DANDEKAR A, HESSLER D. Use of a modified reproductive life plan to improve awareness of preconception health in women with chronic disease. Perm J [online] 2014 Spring, 18(2):28-32 [viewed 18 October 2014] Available from: doi:10.7812/TPP/13-146

Management - Specific Treatments

Fact Explanation
Antihypertensive drugs [3] In pregnant women with uncomplicated chronic hypertension aim to keep blood pressure lower than 150/100 mmHg because excessively lowering blood pressure may result in decreased placental perfusion and adverse perinatal outcomes. But offer antihypertensive drugs for pregnant women with target-organ damage secondary to chronic hypertension (for example, kidney disease), with the aim of keeping blood pressure lower than 140/90 mmHg [1] Alpha-methyldopa, Labetalol, Calcium channel blockers are commonly used and considered to be safe during the pregnancy. Methy dopa - 250mg-1.5g orally twice daily. It is a centrally acting α2-adrenergic agonist prodrug, which is metabolized to α-methyl norepinephrine and then replaces norepinephrine in the neurosecretory vesicles of adrenergic nerve terminals. Labetalol- 100-1200mg orally twice daily.a nonselective β-blocker with vascular α1-receptor blocking capabilities, has gained wide acceptance in pregnancy. When administered orally to women with chronic hypertension, it seems as safe and effective as methyldopa, although neonatal hypoglycemia with higher doses has been reported. Nifedipine- 30-120mg orally once daily.Calcium channel antagonists.Long acting drugs are used [2]
Post natal management [2] In women with chronic hypertension who have given birth, measure blood pressure: daily for the first 2 days after birth, at least once between day 3 and day 5 after birth, as clinically indicated if antihypertensive treatment is changed after birth. aims to keep blood pressure lower than 140/90 mmHg. Breast-feeding should be encouraged in women with chronic hypertension, including those requiring medication. Although most antihypertensive agents can be detected in breast milk, levels are generally lower than those in maternal plasma. continue antenatal antihypertensive , treatment and review long-term antihypertensive treatment 2 weeks after the birth [2]
Prevention of pre eclampsia [2] Although few studies have shown to be effective, most studies have shown no significant reduction in the risk of preeclampsia associated with the use of low-dose aspirin, calcium supplementation, or antioxidant supplementation with vitamins C and E [2]
References
  1. LEEMAN L, FONTAINE P. Hypertensive disorders of pregnancy. Am Fam Physician [online] 2008 Jul 1, 78(1):93-100 [viewed 20 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18649616
  2. SEELY ELLEN W., ECKER JEFFREY. Chronic Hypertension in Pregnancy. N Engl J Med [online] 2011 August, 365(5):439-446 [viewed 20 August 2014] Available from: doi:10.1056/NEJMcp0804872
  3. HAGE FG, MANSUR SJ, XING D, OPARIL S. Hypertension in women. Kidney Int Suppl (2011) [online] 2013 Dec, 3(4):352-356 [viewed 18 October 2014] Available from: doi:10.1038/kisup.2013.76