Differential Diagnosis for Hypertension in Pregnancy at 31 Weeks

Single Most Likely Diagnosis

• Gestational Hypertension: This condition is the most common cause of hypertension in pregnancy, typically presenting after 20 weeks of gestation without any pre-existing medical conditions. The blood pressure of 132/92 is consistent with the diagnosis of gestational hypertension, which is defined as a systolic blood pressure of 130 mmHg or higher, or a diastolic blood pressure of 80 mmHg or higher on two separate occasions at least 4 hours apart.

Other Likely Diagnoses

• Chronic Hypertension: This could be a pre-existing condition that was not previously diagnosed or was not well-controlled before pregnancy. The fact that the blood pressure is elevated at 31 weeks could indicate that the hypertension is not solely gestational.
• Preeclampsia: Although preeclampsia typically includes proteinuria in addition to hypertension, it's essential to consider this diagnosis, especially if there are other symptoms such as visual disturbances, severe headache, or abdominal pain. The absence of proteinuria does not rule out preeclampsia entirely, especially in cases of early or mild disease.

Do Not Miss Diagnoses

• Preeclampsia with Severe Features: This is a critical diagnosis to consider because it can lead to severe maternal and fetal complications if not promptly recognized and managed. Severe features include blood pressures of 160/110 mmHg or higher, thrombocytopenia, renal insufficiency, impaired liver function, pulmonary edema, and cerebral or visual disturbances.
• Chronic Hypertension with Superimposed Preeclampsia: This condition occurs when a woman with chronic hypertension develops new-onset proteinuria or worsening hypertension after 20 weeks of gestation. It's a significant concern because it can lead to more severe outcomes than either condition alone.

Rare Diagnoses

• Secondary Hypertension Due to Underlying Conditions: Such as renal disease, primary aldosteronism, pheochromocytoma, or sleep apnea. These conditions are less common but can have significant implications for both maternal and fetal health if not properly diagnosed and managed.
• Posterior Reversible Encephalopathy Syndrome (PRES): Although rare, PRES can occur in the context of severe preeclampsia or eclampsia and is characterized by neurological symptoms and specific findings on MRI. It's essential to consider this diagnosis in patients with severe hypertension and neurological symptoms.