How to manage a patient with gestational hypertension and decreasing hemoglobin and platelet counts on antihypertensive medication?

Management of Gestational Hypertension with Decreasing Hemoglobin and Platelet Counts

This patient with gestational hypertension showing decreasing hemoglobin (from 11.9/37.1 to 10.8/33.3) and platelets (from 286 to 251) requires immediate evaluation for possible progression to preeclampsia and medication adjustment. 1

Immediate Assessment

• Perform a complete evaluation for preeclampsia, as the decreasing hemoglobin and platelet counts may indicate progression from gestational hypertension to preeclampsia 1
• Check for other signs of organ dysfunction including:
  • Liver enzymes (AST, ALT, LDH) 1
  • Renal function (creatinine, electrolytes) 1
  • Uric acid levels (elevated levels associated with worse maternal and fetal outcomes) 1
  • Proteinuria (urine protein/creatinine ratio ≥30 mg/mmol or ≥0.3 mg/mg is abnormal) 1
• Assess for neurological symptoms (headache, visual disturbances) which may indicate severe preeclampsia 1

Management Algorithm

Step 1: Blood Pressure Control

• If BP ≥160/110 mmHg: Urgent treatment in a monitored setting with oral nifedipine or IV labetalol or hydralazine 1
• If BP consistently ≥140/90 mmHg: Initiate or adjust antihypertensive therapy targeting diastolic BP of 85 mmHg and systolic BP between 110-140 mmHg 1
• Preferred medications include methyldopa, labetalol, or nifedipine 1
• Reduce or discontinue antihypertensive drugs if diastolic BP falls below 80 mmHg 1

Step 2: Hospital Admission Decision

• Admit to hospital if any of the following are present:
  • Progressive decline in hemoglobin or platelet counts 1
  • Development of proteinuria (indicating progression to preeclampsia) 1
  • Severe hypertension (≥160/110 mmHg) despite treatment 1
  • Neurological symptoms (headache, visual changes) 1

Step 3: Monitoring Protocol

• Maternal monitoring:

  • BP monitoring at least twice daily 1
  • Blood tests twice weekly (hemoglobin, platelet count, liver enzymes, renal function, uric acid) 1
  • Clinical assessment for clonus and other neurological signs 1
  • Repeat proteinuria assessment if not already present 1

• Fetal monitoring:

  • Ultrasound assessment of fetal biometry and growth 1
  • Amniotic fluid assessment 1
  • Umbilical artery Doppler studies 1
  • More frequent monitoring if fetal growth restriction is present 1

Step 4: Delivery Considerations

• Deliver at 37 weeks' gestation if stable gestational hypertension 1
• Consider earlier delivery if any of the following develop:
  • Progressive thrombocytopenia 1
  • Progressive abnormal renal or liver function tests 1
  • Severe hypertension despite treatment with multiple agents 1
  • Abnormal neurological features 1
  • Non-reassuring fetal status 1

Medication Management

• For current antihypertensive medication:

  • Evaluate current medication type and dosage 1
  • If using methyldopa, monitor for potential hematologic effects as it can rarely cause hemolytic anemia 2
  • Consider switching to labetalol or nifedipine if hemoglobin continues to decrease 1
  • Avoid ACE inhibitors, ARBs, and direct renin inhibitors as they are contraindicated in pregnancy 1

• If preeclampsia develops:

  • Administer magnesium sulfate for seizure prophylaxis if severe features present 1
  • Consider antenatal corticosteroids if preterm delivery is anticipated (24-34 weeks) 1, 3

Post-Discharge Monitoring

• Implement home blood pressure monitoring with clear parameters for when to contact healthcare providers 4
• Schedule follow-up within 72 hours after discharge to reassess blood pressure and laboratory values 1, 4
• Continue monitoring for at least 6 weeks postpartum as hypertensive disorders can worsen or initially present after delivery 5, 4

Key Considerations and Pitfalls

• Gestational hypertension is not a benign condition - approximately 25% of cases will progress to preeclampsia 1
• The risk of complications is higher when gestational hypertension develops before 34 weeks 1
• Decreasing hemoglobin and platelet counts, even if still within normal range, may be early indicators of progression to preeclampsia and should never be ignored 1
• Do not attempt to distinguish between "mild" and "severe" preeclampsia clinically, as all cases can rapidly deteriorate 1
• Women with gestational hypertension have increased long-term cardiovascular risk and should receive appropriate follow-up after pregnancy 1, 5