Should borderline hypertension be worked up for preeclampsia?

Borderline Blood Pressure Should Be Worked Up for Preeclampsia

Yes, borderline hypertension in pregnancy should be thoroughly evaluated for preeclampsia, as it represents a significant risk factor for developing this potentially life-threatening condition. 1, 2

Rationale for Evaluation

• Borderline hypertension (prehypertension) during pregnancy is associated with approximately 20% chance of developing preeclampsia 1
• Women with borderline or hypertensive first trimester BP have a significantly higher risk of preeclampsia compared to normotensive women (pooled OR 3.23,95% CI 1.99-5.26) 3
• Transient gestational hypertension is not a benign disorder and requires extra monitoring throughout pregnancy 1
• Even mild elevations in blood pressure can lead to significant symptomatology in previously normotensive women 1

Recommended Evaluation Protocol

Initial Assessment

• Complete blood count with platelet count 1, 2
• Liver enzymes (AST, ALT, LDH) and function tests (INR, bilirubin, albumin) 1, 2
• Renal function tests (serum creatinine, electrolytes, uric acid) 1, 2
• Urinalysis with protein/creatinine ratio or albumin:creatinine ratio (≥30 mg/mmol considered abnormal) 1, 2
• Renal ultrasound if serum creatinine or urine testing is abnormal 1

Monitoring Recommendations

• Home blood pressure monitoring with proper technique and appropriate cuff size 2
• More frequent antenatal visits for blood pressure checks 1, 2
• Regular urine dipstick testing at each visit 2
• Fetal assessment including growth monitoring and amniotic fluid volume assessment 2
• Doppler studies if growth restriction is suspected 2

Diagnostic Criteria to Consider

Preeclampsia is defined as gestational hypertension accompanied by ≥1 of the following new-onset conditions at or after 20 weeks' gestation 1:

• Proteinuria
• Maternal organ dysfunction including:
  • Renal insufficiency
  • Liver involvement
  • Neurological complications
  • Hematological complications (thrombocytopenia, hemolysis)
  • Uteroplacental dysfunction (fetal growth restriction)

Important Clinical Considerations

• Proteinuria is present in approximately 75% of preeclampsia cases but is not required for diagnosis 1
• In the presence of hypertension, a new headache should be considered part of preeclampsia until proven otherwise 1
• HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) represents a more serious part of the preeclampsia spectrum 1
• Fetal growth restriction in the context of new-onset gestational hypertension should be considered as preeclampsia 1

Pitfalls to Avoid

1. Underestimating borderline hypertension: Even mild elevations in blood pressure can indicate developing preeclampsia 1
2. Relying solely on proteinuria: Preeclampsia can occur without proteinuria 1
3. Delaying evaluation: Early identification allows for closer monitoring and timely intervention 2
4. Missing atypical presentations: Preeclampsia can present with various organ dysfunctions beyond hypertension and proteinuria 1
5. Inadequate follow-up: Women with borderline hypertension require extra monitoring throughout pregnancy 1

By following this evaluation protocol for borderline hypertension in pregnancy, clinicians can identify preeclampsia early, implement appropriate monitoring, and potentially reduce maternal and fetal morbidity and mortality.