What is Pregnancy-Induced Hypertension (PIH)? Pregnancy-induced hypertension is also known as Gestational Hypertension, Pre-eclampsia, Pre-eclamptic toxemia, or Hypertensive disease of pregnancy.
But before going further let me tell you the minute differences between the above-mentioned terminologies. Hypertension in pregnancy can be one of the following three varieties;
1- Gestational Hypertension:
“Hypertension that occurs solely because of ongoing pregnancy is called Gestational Diabetes.”
” Hypertension occurring after 20 weeks of gestation but not accompanied by proteinuria is termed Gestational Hypertension.
This Gestational Hypertension is further described into the following 2 types;
i- Pregnancy Induced Hypertension (also known as PIH)
Pregnancy-induced hypertension vs Pre-eclampsia
i- Pregnancy Induced Hypertension (PIH):
” Gestational hypertension with raised blood pressure as the sole clinical feature is called Pregnancy Induced Hypertension (PIH) “.
” Gestational Hypertension which is characterized by raised blood pressure and at least one or more additional features especially proteinuria is called Pre-eclampsia “.
Pre-eclampsia is a serious condition that occurs during pregnancy when there is high blood pressure and increased protein in the urine. It cannot be diagnosed on +1 protein (urine test). At least protein should be +2 or above to label the patient Pre-eclamptic. Do rule out UTI (urinary tract infection).
Pregnancy Induced Hypertension (PIH) is the onset of hypertension after 20 weeks of gestation.
2- Chronic Hypertension:
The woman may be hypertensive from before the beginning of the pregnancy.
“Chronic hypertension includes essential hypertension when the cause of the rise in blood pressure is unidentifiable”.
This chronic hypertension is secondary to some recognizable underlying causes; for example pheochromocytoma, renal artery stenosis, coarctation of the aorta, and Cushing’s syndrome.
Gestational hypertension during the second half of pregnancy in patients with pre-existing chronic hypertension is called Superimposed hypertension.
3- Accidental diagnosis of chronic hypertension:
Chronic hypertension incidentally becomes apparent first time during pregnancy.
Types Of Pregnancy Induced Hypertension:
There are three (3) types of hypertension in pregnancy;
Mild Hypertension ( aka Mild PIH) = Blood pressure range: 140/90
Moderate Hypertension ( aka Moderate PIH) = Blood pressure range: 150/100
Severe Hypertension ( aka Severe PIH ) = Blood pressure range: 160/110
What are the signs and symptoms of pregnancy-induced hypertension:
“ PIH is a rise in diastolic blood pressure of at least 15 mmHg or the systolic of at least 30 mmHg over the previously known normal blood pressure.”
Pregnancy-induced hypertension signs and symptoms are;
- Blurring of vision
- fainting on changing posture
- Nausea, vomiting
- Epigastric pain
- Edema (swelling)
- Sudden weight gain
- Decreased urine output
How do you manage a case of pregnancy-induced hypertension?
If a patient comes to you with a Blood pressure of 140/90 mmHg and is not taking any medication then she is suffering from Mild PIH.
Ask the patient 7 basic questions;
- Any complaints of nausea and vomiting
- Usage of folic acid
- Any treatment patient is taking so far?
- Is any scanning or down testing at 16 weeks done or not?
- Review any treatment or tests done yet.
- Which treatment patient is taking so far? Is she taking any anti-hypertensives?
- When was her last visit to a physician?
To manage a case of pregnancy-induced hypertension, go for her PIH profiling including the tests like CBC, and RFTs to see the effect of the blood pressure on the organs.
Once the blood pressure is already controlled without medication, reassure the patient and discharge her on 2 weekly follow-ups and deliver the patient at 40 weeks.
If the patient is admitted with Moderate PIH, and blood pressure around 150/100 mmHg, control her blood pressure by starting Labetalol. Once the blood pressure is controlled i-e less than 140/90 mm Hg (which is the target b.p), then offer the patient PIH profile to see the effect on the organs.
The patient’s Assessment will include;
see for any headache, blurring of vision, or epigastric pain.
For Fetal assessment;
go for fetal heart rate, fetal growth, liquor, and estimated weight.
Once the Blood pressure is controlled, call the patient on a weekly or 2 weekly bases depending upon the control of blood pressure and gestational age.
Try to individualize the patient i.e. If the patient is at 35 weeks of gestation, call her on a weekly visit. If the patient is on 32 weeks, her Blood Pressure is well controlled, and the patient is compliant with medicine, then the patient is on good follow-up, and she can be called on 2 weekly bases.
Deliver the patient at 38 to 39 weeks of her gestation,
Pregnancy-induced hypertension treatment:
If a patient has Severe PIH i-e B.P is 150/110 mmHg is admitted, control her B.P with Intravenous Labetalol. Do her PIH profile to see the maternal and fetal assessment. Discharge the patient with a weekly follow-up along with maintenance of her blood pressure record and PIH profile. Deliver your patient as close to term as possible i-e usually at 38 to 39 weeks.
Care plan for pregnancy-induced hypertension:
At each follow-up visit, measure your patient’s blood pressure, and urine protein. Also check the compliance of the patient to drugs, any symptoms of headache, or blurring of vision. Do her abdominal examination to see fundal height, amount of liquor, and baby weight.
Access your patient again at 36 weeks for the timing and mode of delivery. Discuss the contraception importance of breastfeeding and delivering her.
The need for ultrasound always needs to be individualized. A patient who has mild PIH may not need repetition of ultrasounds because such patients have usually no underlying complication related to fetal growth.
If the patient has moderate to severe PIH, again individualize, as there is no hard and fast rule about weekly or 2 weekly scannings.
If your patient is fine, no severe PIH, and fundal height is corresponding with fetal height, then no fetal scan is required.
If the patient has severe PIH, and persistent hypertension, it means there is some underlying maternal condition that compromises the fetal condition. If liquor is not adequate, repeat the scan.
-What do you want to do in per abdominal examination?
- to estimate/measure symphysial-fundal height
- look for visceromegaly
-What are the 5 basic things to ask the patient?
- Nausea, vomiting
- Use of folic acid
- Any treatment patient is taking so far
- at 16 weeks, and scanning, down testing, done or not
- Review any treatment or tests done yet
- Which treatment patient is taking so far? Is she taking any hypertensives?
- When was her last visit to the physician?
-What are the criteria for pre-eclampsia diagnosis based on proteinuria?
Pre-eclampsia cannot be diagnosed on +1 protein. The protein level should be +2 or above to label the patient Pre-eclampsia
-In which week you will do a cesarian section of your patient?
After assessing feto-maternal conditions @ 37 weeks.
– Any specific precaution at the Cesarian section?
Do fetomaternal and B.p monitoring. Continue hypertensive. After delivery make sure that the baby is accessed by a pediatrician. early breastfeeding, B.p monitoring 2-4 times a day. If blood pressure is above normal, check the patient on alternate days. After 72 hours check her blood count. platelets, transaminases, and serum creatinine.
Pregnancy-Induced hypertension Case study:
A 32 years old patient with previous 2 cesarian sections one alive issue who develops pregnancy-induced hypertension presents with a blood pressure of 130/80 mmHg, Giving a history of stillbirth due to placental abruption at term. Currently, her blood pressure is 130/90 mmHg. Proteinuria +1. The patient is also a known Asthmatic. How will you manage the patient?
Hypertension in pregnancy history taking:
Ask the patient when she was diagnosed with hypertension.
What are the current complaints?
Any complaints of UTI (urinary tract infection) or retention of urine to rule out renal causes?
Any rash or joint pain due to SLE (systemic lupus erythematosus)?
Any pain or fainting on change of posture could be Pheochromocytoma.
Any chest pain or shortness of breath due to coarctation of the aorta?
Any palpitations or tremors due to thyroid disease?
See for any blood tests done so far, Review her medications to see if you need to stop any ACE inhibitors, any ARBs, or any diuretics, and offer her alternatives.
Your aim is to keep her BP (blood pressure) less than 140/90 mmHg. Ask her about any previous admission to the hospital, or last visit to the physician.
Ask the patient about contraception in pre-pregnancy. How’s her pregnancy going so far? If she is using folic acid?
Manage the patient considering at which week of gestation she is presenting to you.
At the 10th week:
Ask the patient, if she is taking folic acid, if any Ultrasound (USG) done, any complaints of nausea and vomiting.
At the 16th week:
Ask your patient if she used any folic acid. Any ultrasound is done for empty scans and nuchal-translucency. No need to ask for nausea, or vomiting at this stage (as it is of no importance at this stage). Ask for any scanning if done. Did she use any Aspirin?
Do ask her when she was diagnosed with hypertension during pregnancy. current medication. Your aim should be to keep blood pressure down. As her about any hospital admission during this pregnancy till yet and; last visit to a physician.
At the 20th week:
Ask the patient about nausea, vomiting, empty scanning (done or not), any medications (if she is using), folic acid intake, and anomaly scan (which is usually done between the 18th – 20th week).
Ask the patient for compliance with the visits, and growth scans as you proceed further weeks. Anomaly Scan at 20 weeks measurement. Insist the patient on frequent visits to the hospital.
Check the patient’s b.p at every visit. Do vigilant monitoring. Look for any signs and symptoms of headache, blurring of vision, or pain in the upper abdomen.
Ask the patient for Postoperative history. review any past obstetric history as the patient is having previous 2 cesarian sections and 1 live issue.
Ask her about previous births and deliveries, mode of delivery, recovery, children are alive. Any history of hypertension, Any ICU admission, Any blood transfusion, history of Eclampsia, Any ICU (intensive care unit) admission, and how was her recovery?
Ask her about the history of abruption. Inquire at which gestation that abruption occurs. Be vigilant about the patient,s vital especially blood pressure (as there is a chance that placental abruption occurred due to undiagnosed HTN in previous pregnancy).
At 36 weeks:
Access the patient for control of BP (blood pressure), patient’s biochemistry, and growth of the baby. Do USG (ultrasound) to see the growth of the fetus, amount of liquor, fetal biochemistry, and estimated baby weight, in line with the Obstetrician, Physician, pediatrician, and Anesthetist.
Ask her about any gynecological history, surgical history, allergies, drug and social history, and any personal history.
Taker the patient’s BMI, and check blood pressure and pulse for radio-femoral edema. Check her for any edema, and chest auscultation, and look for renal bruits in the renal area for Renal arterial stenosis. Look for her thyroid, if it’s enlarged (to look for any Thyroid disease).
Check the patient’s reflexes, and review the patient’s investigations; which include baseline investigations, CBC, blood group, blood sugar fasting, hepatitis B and hepatitis C profile,
Specific investigations in pregnancy-induced hypertension include RFt’s, urea, creatinine, serum uric acid, serum bilirubin, ALT, and AST. Review her Fundoscopy for hemorrhages, exudates, and papillar edema.
Review any ECG (echocardiogram) if available. Check her Blood Pressure (BP) record. A dating scan (if available) to confirm the Gestational Age.
The best management for Pregnancy Induced Hypertension:
How will you manage the patient? Arrange a multidisciplinary team, senior consultant, pediatrician, and anesthetist. Explain maternal risks with superimposed eclampsia, as well as fetal risks, CVA (cardiovascular disease), pulmonary edema, renal failure, and if it is all Maternal Mortality.
Also explain Fetal risks, which include IUGR (intrauterine growth retardation), stillbirth, Oligohydramnios, distress, and placental abruption.
How does pregnancy-induced hypertension and eclampsia is managed:
To manage Pregnancy induced hypertension (PIH), form a multidisciplinary team. Take consent from the patient and family. Review scans done, and arrange Down’s Syndrome testing. Review medications to see if there is any need to change at 140/90 mmHg blood pressure. Start anti-hypertensives.
Pregnancy-induced hypertension medication:
As the patient is a known Asthmatic, Labetalol in pregnancy-induced hypertension is not a suitable drug. So start Methyldopa in pregnancy-induced hypertension. The dosage of methyl dopa in pregnancy-induced hypertension is 250mg TDS (thrice a day). Start Aspirin for high b.p in pregnancy along with Calcium (Ca) and Vitamin D.
Counsel the patient to report to the hospital in case of such symptoms and monitor baby movements in pregnancy-induced hypertension. Even if the patient has good compliance with the doctor, access her control of symptoms and medication at every visit. Make the patient vigilant about the existing pregnancy that if during this time abruption occurs, if complaints of any episode of vaginal bleeding, pain in the abdomen, blurring of vision, or headache, report to the hospital.
The aim of pregnancy-induced hypertension is to deliver the patient at 38 weeks of Gestation.
As the patient id previous 2 ( means previous 2 cesarian sections), go for her elective C-section after anesthesia evaluation, and informed consent. Discuss the contraception methods with the patient. Inject the patient with Dexamethasone (part of prophylaxis to reduce respiratory distress) recommended by guidelines for any Cesarian-section.
Follow the surgical checklist. At delivery time, the baby should be handed over pediatrician and then post-op care. Do a Paediatric evaluation of the baby. Observe the patient for 28-48 hours. Review the medication again.
Aldomet will be stopped immediately after the delivery of the baby because it will cause post-natal depression. Encourage the patient for breastfeeding.
Discuss contraception but do tell the patient to avoid OCPs. Encourage the patient for lifestyle modification, and weight reduction. Arrange the patient’s 6 weekly visits to the hospital for B.P monitoring and
Complications of pregnancy-induced hypertension:
Pre-eclampsia or pregnancy-induced hypertension results in;
- damage to the heart
- damage to the lungs
- damage to the kidneys
- damage to the liver
- damage to eye
- May cause a brain injury or a stroke.
Do broad, individualized care, and then you need to deliver the patient according to the categories and guidelines explained/discussed above.