What is the most important examination to perform on a pregnant female with hypertension at 35 weeks gestation (35 weeks of pregnancy)?

From the Guidelines

The most important examination for a female at 35 weeks gestation with hypertension is to check for signs of preeclampsia, which includes blood pressure measurement, urine protein assessment, and evaluation for maternal symptoms and fetal well-being. At this point, checking fetal position would be the most appropriate among the options provided, as determining fetal position is crucial because it helps assess if the baby is in the optimal vertex (head-down) position for delivery, which becomes increasingly important as the pregnancy approaches term, especially in a high-risk situation like maternal hypertension where early delivery might be necessary 1.

Key Considerations

• Checking fetal position provides information about potential complications during delivery and has more immediate implications for delivery planning in a hypertensive patient who might require expedited delivery if her condition worsens into preeclampsia or eclampsia.
• A complete evaluation would also include laboratory tests for preeclampsia markers, fetal heart rate monitoring, and ultrasound assessment of fetal growth and amniotic fluid volume.
• According to the most recent guidelines, women with preeclampsia should be assessed in hospital when first diagnosed, and fetal monitoring should include assessment of fetal biometry, amniotic fluid, and UA Doppler with ultrasound at first diagnosis and thereafter at 2 weekly intervals if the initial assessment was normal 1.

Management Recommendations

• Blood pressure should be controlled to levels of 110 to 140/85 mm Hg, and monitoring for development of preeclampsia is crucial 1.
• Fetal growth should be monitored, especially if maternal uric acid is elevated, and delivery can be delayed until 39+6 weeks provided BP can be controlled, fetal monitoring is reassuring, and preeclampsia has not developed 1.
• The decision to transfer a patient to the intensive care unit (ICU) should be made collectively by a team of specialists based on the stability of the patient, physical examination, vital signs, laboratory values, imaging, and expected care required 1.

Long-term Implications

• Women with gestational hypertension or pre-eclampsia are at increased risk of developing hypertension, stroke, ischaemic heart disease, and thrombo-embolic disease in later adult life, and cardiovascular risk assessment and lifestyle modifications are recommended to avoid complications in subsequent pregnancies and to reduce maternal cardiovascular risk in the future 1.

From the Research

Examination for Pregnant Females with Hypertension

To determine the most important examination for a pregnant female with hypertension at 35 weeks gestation, several factors and studies must be considered.

• The study 2 highlights the importance of early diagnosis of chronic hypertension in pregnancy to provide adequate follow-up and monitoring for placental complications.
• Another study 3 discusses the use of Doppler ultrasonography and biomarkers such as mean arterial pressure (MAP), uterine artery pulsatility index (UtA-PI), and serum pregnancy-associated plasma protein A (PAPP-A) for predicting preeclampsia.
• The research 4 emphasizes the relationship between blood pressure and maternal health in pregnancy, suggesting that placental syndromes are associated with an increased maternal risk of progression to hypertension and cardiovascular disease.
• A study 5 investigates the potential value of combining maternal factors with maternal cardiovascular parameters at 35-37 weeks' gestation in predicting pre-eclampsia and gestational hypertension.
• Furthermore, the study 6 examines the performance of screening for pre-eclampsia at 35-37 weeks' gestation by maternal factors and combinations of mean arterial pressure (MAP), uterine artery pulsatility index (UtA-PI), serum placental growth factor (PlGF), and serum soluble fms-like tyrosine kinase-1 (sFlt-1).

Key Findings

The key findings from these studies suggest that:

• Maternal cardiac function at 35-37 weeks' gestation can be used to predict pre-eclampsia and gestational hypertension 5.
• Screening for pre-eclampsia at 35-37 weeks' gestation using maternal factors and biomarkers can identify a high proportion of pregnancies that develop late pre-eclampsia 6.
• The performance of screening depends on the racial origin of the women 6.
• Chronic hypertension in pregnancy is associated with placenta-mediated complications, regardless of preeclampsia 2.

Important Examinations

Based on these findings, important examinations for a pregnant female with hypertension at 35 weeks gestation may include:

• Doppler ultrasonography to assess uterine artery pulsatility index (UtA-PI) and maternal cardiovascular parameters 3, 5, 6.
• Measurement of mean arterial pressure (MAP) to predict pre-eclampsia and gestational hypertension 5, 6.
• Assessment of serum biomarkers such as placental growth factor (PlGF) and soluble fms-like tyrosine kinase-1 (sFlt-1) to predict pre-eclampsia 6.
• Evaluation of maternal cardiac function to predict pre-eclampsia and gestational hypertension 5.