Hypertension in pregnancy

Hypertension during pregnancy can lead to serious maternal and fetal complications if not properly managed. Here, we discuss different types of hypertension in pregnancy, along with their clinical features, management, and associated risks.

Types of Hypertension in Pregnancy

Gestational Hypertension
Preeclampsia
Eclampsia
HELLP Syndrome

1. Gestational Hypertension

Definition: Hypertension (BP > 140/90 mm Hg) occurs after the 20th week of gestation without pre-existing hypertension, proteinuria, or end-organ damage.
Treatment:
- Antihypertensive medications: Hydralazine, α-Methyldopa, Labetalol, Nifedipine
- Delivery is recommended at 37–39 weeks.
Mnemonic: Hypertensive Moms Love Nifedipine.

Feature	Details
Onset	After the 20th week of gestation
Blood Pressure	> 140/90 mm Hg
Proteinuria	Absent
End-Organ Damage	Absent
Medications	Hydralazine, α-Methyldopa, Labetalol, Nifedipine
Delivery Timing	37–39 weeks

2. Preeclampsia

Definition: New-onset hypertension after 20 weeks with either proteinuria or end-organ dysfunction.
Cause: Abnormal placental spiral arteries leading to endothelial dysfunction, vasoconstriction, and ischemia.
Increased Risk in Patients With:
- Pre-existing hypertension
- Diabetes
- Chronic kidney disease
- Autoimmune disorders (e.g., antiphospholipid antibody syndrome)
- Advanced maternal age (> 40 years)
Complications:
- Placental abruption
- Coagulopathy
- Renal failure
- Pulmonary edema
- Uteroplacental insufficiency
- May progress to eclampsia (seizures) and HELLP syndrome.
Treatment:
- Antihypertensive medications
- IV magnesium sulfate (for seizure prevention)
- Definitive treatment is the delivery of the fetus.

Feature	Details
Onset	After 20 weeks (< 20 weeks suggests molar pregnancy)
Proteinuria	Present
End-Organ Dysfunction	Possible (e.g., pulmonary edema)
Medications	Antihypertensives, IV magnesium sulfate
Definitive Treatment	Delivery

3. Eclampsia

Definition: Preeclampsia with the addition of maternal seizures.
Complications: Maternal mortality due to stroke, intracranial hemorrhage, or acute respiratory distress syndrome (ARDS).
Treatment:
- IV magnesium sulfate
- Antihypertensive medications
- Immediate delivery of the fetus

Feature	Details
Criteria	Preeclampsia + seizures
Complications	Stroke, intracranial hemorrhage, ARDS
Treatment	IV magnesium sulfate, antihypertensives, delivery

4. HELLP Syndrome

Definition: A severe form of preeclampsia characterized by:
- Hemolysis
- Elevated Liver enzymes
- Low Platelets
Clinical Features:
- The blood smear shows schistocytes.
- This can lead to disseminated intravascular coagulation (DIC) due to tissue factor release from the injured placenta.
- Potential for hepatic subcapsular hematomas, which can rupture and cause severe hypotension.
Treatment: Immediate delivery of the fetus.

Feature	Details
Hemolysis	Present (schistocytes on blood smear)
Elevated Liver Enzymes	Present
Low Platelets	Present
Complications	DIC, hepatic hematoma rupture, hypotension
Treatment	Immediate delivery

Points to Remember

Gestational Hypertension: Hypertension without proteinuria or end-organ damage, treated with specific antihypertensives and monitored closely.
Preeclampsia: Look for hypertension, proteinuria, and end-organ dysfunction; high risk in patients with certain pre-existing conditions.
Eclampsia: Preeclampsia with seizures—requires immediate intervention to prevent maternal mortality.
HELLP Syndrome: Hemolysis, liver involvement, and low platelets; emergency delivery is often necessary.

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