From the Guidelines
For a 35-week pregnant patient with hypertension, focus your history and physical on distinguishing between chronic hypertension and pregnancy-specific hypertensive disorders like preeclampsia, as recommended by the most recent guidelines 1.
Key Components of History and Physical
- Obtain a detailed blood pressure history, including pre-pregnancy values, medication use, and when hypertension was first diagnosed.
- Ask about symptoms of preeclampsia such as headaches, visual changes, right upper quadrant pain, and edema.
- Review systems should cover cardiovascular, renal, and neurological symptoms.
- During the physical exam, measure blood pressure in both arms while the patient is seated, check for edema (especially facial or non-dependent), assess deep tendon reflexes for hyperreflexia, and examine the lungs and heart.
Laboratory Tests and Fetal Assessment
- Order laboratory tests including complete blood count, comprehensive metabolic panel, liver function tests, urine protein (spot protein/creatinine ratio or 24-hour collection), and uric acid levels.
- Fetal assessment should include ultrasound for growth, amniotic fluid volume, and a non-stress test, as suggested by the ISSHP classification, diagnosis, and management recommendations for international practice 1.
Management Considerations
- Management of hypertension in pregnancy involves balancing the risks of uncontrolled hypertension with the potential risks of antihypertensive therapy to the fetus, as outlined in the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1.
- The decision to initiate antihypertensive therapy should be based on the severity of hypertension and the presence of symptoms or end-organ damage, with consideration of the most recent position paper of the ESC Council on Hypertension and the European Society of Hypertension 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Approach to History and Physical
When approaching a patient with hypertension who is 35 weeks pregnant, it's essential to consider the following key points:
- Take a thorough medical history, including the patient's prior pregnancy history, to identify any potential risk factors for complications 2
- Assess the patient's current symptoms, such as headache, vision changes, or chest pain, which could indicate severe hypertension or preeclampsia 3
- Measure blood pressure accurately, using a validated device, to determine the severity of hypertension 4
- Perform a physical examination, including a fetal assessment, to evaluate for any signs of fetal distress or complications 5
Management of Hypertension
The management of hypertension in pregnancy involves:
- Identifying the severity of hypertension, using guidelines such as those from the European Society of Hypertension, which recommend initiating treatment at a blood pressure ≥ 150/95 mmHg 3
- Selecting an appropriate antihypertensive medication, such as methyldopa, labetalol, or nifedipine, based on the patient's specific needs and the expected time of delivery 4, 6
- Monitoring the patient's response to treatment, including regular blood pressure checks and fetal assessments, to adjust the treatment plan as needed 2, 5
Considerations for Severe Hypertension
In cases of severe hypertension, defined as a systolic blood pressure ≥ 170 mmHg or diastolic blood pressure ≥ 110 mmHg, hospitalization is often indicated 3
- Oral nifedipine, labetalol, and hydralazine are commonly used to treat severe hypertension in pregnancy, with nifedipine 50 mg showing promise as an effective and safe option 6
- The choice of medication and dosage regimen should be individualized based on the patient's specific needs and medical history 4, 5