Hypertension in Pregnancy: Part 2

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In Hypertension in Pregnancy Part 1, I reviewed the ACOG recommendations for the management of hypertension and preeclampsia in pregnancy. In Part 2, I will discuss what this might mean for you, the patient.

What is Hypertension?

Hypertension is also known as “high blood pressure”. This is diagnosed when the systolic (top number) reading is over 140 OR the diastolic (bottom number) is over 90. Only one of these readings need to be high for the blood pressure to be considered abnormal (eg a reading of 141/87 is still abnormal). There need to be at least two elevated blood pressures 4-6 hours apart to make the diagnosis. Blood pressure is considered severely elevated when the systolic pressure is over 160 or the diastolic pressure is over 110.

When the readings are elevated before 20 weeks of pregnancy, this is typically due to chronic hypertension (CHTN) that is either known (the patient was diagnosed years ago and is being managed medically) or that has not been previously diagnosed (the patient has had chronic hypertension but hasn’t been to the doctor in years and didn’t know she had it). When the blood pressure becomes elevated after 20 weeks of pregnancy where is had previously been normal, it is called either Gestational Hypertension (GHTN) or Preeclampsia (preE).

What are Gestational Hypertension and Preeclampsia?

PreE is a condition that is found in pregnancy and the postpartum period. No one knows for sure what causes preE, but it is thought to be due to the way the placenta implants in the uterus that causes changes in hormone levels and the way that blood vessels constrict. PreE can result in elevated blood pressure, seizures, kidney or liver problems, pulmonary edema (fluid in the lungs) , or even death. It can affect the baby by causing the placenta not to work as well so the baby becomes growth restricted, or rarely causing placental abruption (an emergency where the placenta to separates prematurely from the uterus that can result in hemorrhage or fetal death). Symptoms include headache, blurry vision or seeing spots, liver pain/epigastric pain in the middle or upper right side of the abdomen, difficulty breathing, or seizures. Many times, people do not feel ill until the disease is very severe. If you have any of these symptoms, you should notify your provider immediately.

Gestational hypertension is elevated blood pressure in  pregnancy without other symptoms or organ involvement. It may remain mild, or may progress to preE through the pregnancy.

How is Preeclampsia diagnosed?

Sometimes, patients have no symptoms but come to the clinic for a routine appointment and are found to have elevated blood pressure. Other times, people begin having symptoms before their blood pressure elevates. Many of the symptoms of preE can be caused by other reasons. For example, blurry vision and headache can be caused by eye strain, or diabetes. Right sided abdominal pain can be caused by gallstones, or appendicitis, or the baby laying in a certain spot. Because of this, labs will be ordered by your provider to determine if your symptoms are due to preE or another reason. If your blood pressure is also high then labs will check the severity of the disease. Labs ordered may include a CBC (to check for anemia and platelet levels), CMP (to check liver enzymes), and a urine test to check for protein in the urine. The urine test may either be a protein/creatinine ratio, a quick test that gives a snapshot of protein levels, or a 24 hour urine collection that measures levels over 24 hours. If you have elevated blood pressures and are found to have lab abnormalities, protein in your urine, or other symptoms like persistent headache, blurry vision, or epigastric pain, you may be diagnosed with preE. If you have elevated blood pressures, all labs are normal, and you have no other symptoms, you may be diagnosed with gestational hypertension. Either of these can make your pregnancy considered “high risk”.

What is the treatment for Gestational Hypertension or Preeclampsia?

There is NO TREATMENT for GHTN or preE other than delivery of the baby. After delivery, the disease resolves on its own over a period of days or weeks. For this reason, delivery of the baby is usually recommended at 37 weeks of pregnancy when baby is term and the risk of induction or early delivery is outweighed by the risk of complications due to the disease. If preE becomes severe before 37 weeks, delivery will usually be considered at that time because of the danger posed to the mother and baby. Occasionally, preE is not diagnosed until after delivery. In these women, blood pressure has been normal during pregnancy but they become symptomatic in the postpartum period.

What can you expect?

If preE is mild and you are under 37 weeks pregnant, you will likely get extra monitoring by your provider. This can include frequent blood work to check the progression of the disease. Because preE and GHTN can affect the growth of the baby, you will likely get growth ultrasounds every 3-4 weeks. They will also check “dopplers” to monitor blood flow to and from the baby with these ultrasounds. Once you are 32 weeks pregnant (sometimes earlier), you will also be recommended to have nonstress tests (NSTs) and biophysical profiles (BPPs). During an NST, you will have monitors placed on your abdomen to watch the baby’s heartbeat and to check for contractions, usually lasting about 20-40 minutes. You may also have a BPP, an ultrasound where the fluid around the baby is measured, as well as checking for certain movements, such a practice breathing motions. The NSTs and BPPs are usually done once or twice a week until delivery. Medications to lower blood pressure are not usually given for mild preE because it may mask the disease progressing to severe preE.

If preE becomes severe, you may be admitted to the hospital. If the baby is less than 34 weeks, you may be given steroid injections to help mature the baby’s lungs faster. You may be given a medicine called magnesium sulfate through the IV. This medicine does not treat the preE, but decreases the chances of you having a seizure. You may also be given medicine to lower your blood pressure.

You do not automatically need a c-section if you have preE. Typically, induction of labor will be recommended first. A c-section may be recommended if the baby does not tolerate labor or if your health is in danger (for example, you are having uncontrolled seizures). The magnesium can make the baby sleepy after delivery.

After delivery, you will usually stay on the magnesium sulfate for at least 24 hours and will stay in the hospital for at least 2-3 days to make sure the disease is resolving and blood pressures are controlled. Sometimes, patients are discharged home with blood pressure medication. You will also follow up sooner for your first postpartum appointment, usually within 7-10 days.

After delivery, if you develop new or worsening symptoms like headache, blurry vision, difficulty breathing, or epigastric pain, be sure to notify your provider right away.

Do You Have Options?

Of course! Any recommendations made by research, or by your provider, are just that: RECOMMENDATIONS. Research shows that following these recommendations leads to better outcomes. According to Preeclampsia.org, “Ten million women develop preeclampsia each year around the world. Worldwide about 76,000 pregnant women die each year from preeclampsia and related hypertensive disorders. And, the number of babies who die from these disorders is thought to be on the order of 500,000 per annum. In developing countries, a woman is seven times as likely to develop preeclampsia than a woman in a developed country. From 10-25% of these cases will result in maternal death.” These deaths have been decreased in the US because of medical and obstetric care available.  You should be aware of the risks of preE when making your decision. However, preterm delivery, induction of labor, or c-section have their own risks that should be discussed with your provider.

Whatever plan is chosen is YOUR DECISION. I had one patient who was induced in her prior pregnancy for preE. She was terrified of having another induction if she developed preE again in this pregnancy. I reminded her that while that probably would be the recommendation if she did indeed develop preE again, it was her choice to proceed or not. She said, “So, if I know the risks, and I’d rather have a seizure at home and possibly die than have an induction, I can?”. The answer is YES. You may be asked to sign a form saying you are going against medical advice and that your provider is not responsible, but you can not be forced to have an induction, or a c-section (or anything else, for that matter). I’m not advocating this, only reminding you that the ultimate decision is yours. Always talk to your provider about the plan, and if you are uncomfortable, speak up!

I hope this clarifies hypertension and preeclampsia for you, and gives you an idea of what might you might expect with the diagnosis. If you have any questions, please let me know!

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