From the Guidelines
The next step in managing this 32-year-old woman at 31 weeks gestation with elevated blood pressure and proteinuria but no symptoms of preeclampsia is to control her blood pressure to levels of 110 to 140/85 mm Hg and monitor for development of preeclampsia, as recommended by the ISSHP classification, diagnosis, and management recommendations for international practice 1.
Key Principles of Management
- Control blood pressure to prevent maternal complications
- Monitor for development of preeclampsia
- Monitor fetal growth, especially if maternal uric acid is elevated
- Delivery can be delayed until 39+6 weeks provided blood pressure can be controlled, fetal monitoring is reassuring, and preeclampsia has not developed
Monitoring and Management
- Monitor blood pressure regularly to maintain levels between 110 to 140/85 mm Hg
- Perform urinalysis at each visit to monitor for proteinuria
- Conduct blood tests (Hb, platelet count, liver transaminases, uric acid, and creatinine) at 28 and 34 weeks as a minimum
- Assess fetal well-being with ultrasound from 26 weeks’ gestation and thereafter at 2 to 4 weekly intervals if fetal biometry is normal
- Educate the patient about preeclampsia warning signs, including headache, visual changes, right upper quadrant pain, and decreased fetal movement
Indications for Delivery
- Similar to those of preeclampsia
- Delivery at 39 weeks seems optimum if no indication arises This approach is based on the most recent and highest quality study available, which prioritizes controlling blood pressure and monitoring for preeclampsia to prevent maternal and fetal complications 1.
From the Research
Management of Hypertension in Pregnancy
The patient is a 32-year-old woman at 31 weeks gestation with elevated blood pressure (132/93 mmHg) and proteinuria (2+ on dipstick), but no symptoms of preeclampsia, and a history of high blood pressure in pregnancy. The next steps in management are:
- Assessment of Blood Pressure: According to 2, pregnancy-induced hypertension (PIH) is defined as systolic blood pressure (SBP) >140 mmHg and diastolic blood pressure (DBP) >90 mmHg. The patient's blood pressure is elevated, but not severely so.
- Classification of Hypertension: The patient's hypertension can be classified as mild to moderate, based on the blood pressure readings 2.
- Risk Assessment: The patient is at risk of developing preeclampsia, given her history of high blood pressure in pregnancy and the presence of proteinuria 2, 3.
- Monitoring: Close monitoring of the patient's blood pressure, proteinuria, and fetal well-being is essential 2, 3, 4.
- Treatment: According to 2 and 3, antihypertensive treatment is recommended in pregnancy when blood pressure levels are ≥ 150/95 mmHg. However, initiation of antihypertensive treatment at values ≥ 140/90 mmHg is recommended in women with gestational hypertension, with or without proteinuria. Methyldopa, labetalol, and nifedipine are commonly used antihypertensive agents in pregnancy 2, 5.
- Fetal Monitoring: Regular ultrasound and cardiotocography (CTG) monitoring are recommended to assess fetal well-being 6.
Key Considerations
- The patient's proteinuria and history of high blood pressure in pregnancy increase her risk of developing preeclampsia 2, 3.
- Close monitoring of the patient's blood pressure and fetal well-being is essential to prevent complications 2, 3, 4.
- Antihypertensive treatment should be individualized, based on the patient's blood pressure levels and risk factors 2, 3.