What is the appropriate next step in management for a pregnant patient with a blood pressure of 150/90 mm Hg and new‑onset lower‑extremity edema?

Management of Pregnant Patient with BP 150/90 and Lower Limb Edema

This patient requires admission for further evaluation and rule out preeclampsia (Option B). While edema occurs in up to 60% of normal pregnancies and is no longer diagnostic for preeclampsia, the combination of new-onset hypertension (BP 150/90 mmHg) after 20 weeks gestation mandates comprehensive evaluation to exclude preeclampsia and other hypertensive disorders of pregnancy 1.

Why Admission is Mandatory

All pregnant women with hypertension (≥140/90 mmHg) presenting with concerning features require hospitalization regardless of gestational age or severity to clarify the diagnosis and ensure maternal safety 2. This patient meets diagnostic criteria for gestational hypertension at minimum, which requires urgent evaluation to rule out preeclampsia—a potentially life-threatening condition 1.

Critical Diagnostic Considerations

• Edema alone is not diagnostic: While edema occurs in up to 60% of normal pregnancies and is no longer used to diagnose preeclampsia, it cannot be dismissed as "normal" when accompanied by hypertension 1

• Blood pressure threshold met: This patient's BP of 150/90 mmHg exceeds the diagnostic threshold of ≥140/90 mmHg for hypertension in pregnancy, measured on at least two occasions 1, 3

• Preeclampsia can present without proteinuria: The modern definition of preeclampsia includes gestational hypertension with either proteinuria OR evidence of maternal organ dysfunction OR uteroplacental dysfunction 1, 4

Immediate Evaluation Protocol Upon Admission

Maternal Assessment

• Proteinuria screening: Obtain urine albumin-to-creatinine ratio (ACR) in spot urine sample or 24-hour urine collection; significant proteinuria is defined as ≥30 mg/mmol ACR or ≥0.3 g/24 hours 1, 2

• Laboratory workup: Complete blood count, platelet count, liver transaminases (ALT/AST), serum creatinine, uric acid, LDH, and coagulation panel to assess for end-organ dysfunction 1, 2

• Blood pressure monitoring: Check BP every 4 hours or more frequently if unstable 2

• Symptom assessment: Evaluate for headache, visual changes, right upper quadrant pain, or epigastric pain—all warning signs of severe disease 1, 5, 6

Fetal Assessment

• Electronic fetal heart monitoring to assess fetal well-being 1

• Ultrasound evaluation for fetal growth and amniotic fluid volume if indicated 1

Management Based on Blood Pressure Level

For BP 140-149/90-95 mmHg (This Patient's Range)

• Close supervision required: European guidelines recommend non-pharmacological management may be considered for BP 140-149/90-95 mmHg, but this requires hospitalization for diagnosis confirmation, gestational age assessment, and evaluation of maternal/fetal risk factors 1

• Antihypertensive initiation threshold: Current European guidelines recommend initiating drug treatment for BP persistently ≥150/95 mmHg, or at ≥140/90 mmHg in the presence of gestational hypertension with proteinuria (preeclampsia), chronic kidney disease, or other high-risk conditions 1

If Severe Hypertension Develops (≥160/110 mmHg)

• Immediate treatment required: Severe-range hypertension requires treatment within 30-60 minutes to prevent maternal stroke 1, 2

• First-line agents: Oral immediate-release nifedipine 10-20 mg or intravenous labetalol 1, 2

• Target BP: Systolic 110-140 mmHg and diastolic 85 mmHg 2

Common Pitfalls to Avoid

• Do not dismiss edema as "normal": While edema alone is not diagnostic, when combined with hypertension it raises significant concern for preeclampsia and mandates evaluation 1

• Do not rely on proteinuria alone: Preeclampsia can present with hypertension and organ dysfunction without proteinuria 1, 4

• Do not delay evaluation: Hypertensive disorders in pregnancy can progress rapidly to severe complications including eclampsia, stroke, placental abruption, and HELLP syndrome 1, 4, 5

• Do not use outpatient management initially: Even "mild" hypertension requires initial hospitalization to establish diagnosis, rule out severe disease, and determine appropriate ongoing management 1, 2

Ongoing Management Strategy

• If preeclampsia is confirmed: Continue hospitalization with intensive monitoring; delivery timing depends on gestational age, disease severity, and maternal/fetal status 2, 7

• If gestational hypertension without preeclampsia: May consider outpatient management with close follow-up only after thorough inpatient evaluation excludes preeclampsia and severe features 1

• Aspirin prophylaxis: If not already initiated and gestational age <36 weeks, consider aspirin 100-150 mg daily, though benefit is limited when started after first trimester 2, 4