eMedicine Specialties > Obstetrics and Gynecology > Medical Problems in Pregnancy

Hypertension and Pregnancy: Follow-up

Author: Paul Gibson, MD,, Associate Professor, Departments of Medicine and Obstetrics and Gynecology, Divisions of General Internal Medicine and Maternal-Fetal Medicine, University of Calgary
Coauthor(s): Michael P Carson, MD, Clinical Associate Professor, Department of Medicine, Clinical Assistant Professor, Department of Obstetrics/Gynecology and Reproductive Sciences, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School; Director of Research/Outcomes, Department of Medicine, Jersey Shore University Medical Center
Contributor Information and Disclosures

Updated: Jul 30, 2009

Follow-up

Further Inpatient Care

  • When women have mild preeclampsia remote from term or labile blood pressures due to chronic hypertension and/or gestational hypertension, they often are admitted to hospital for bed rest and frequent fetal monitoring.
    • The severity of any abnormalities on admission dictates the frequency of blood work.
    • Daily examination should include a funduscopic examination for retinal spasm or edema, lung examination for signs of volume overload, cardiac examination for gallop rhythms, abdominal examination for hepatic tenderness, examination of extremities/sacrum for increasing edema, and neurologic examination for clonus.
    • Treating hypertension secondary to preeclampsia with medications may reassure the clinician falsely but does not slow progression of the process; therefore, if treatment with antihypertensives is undertaken, clinicians must remain vigilant for all other symptoms, signs, and laboratory evidence of worsening preeclampsia.
    • Other symptoms and signs of worsening preeclampsia must be sought routinely and delivery facilitated if the maternal or fetal condition worsens.
  • Hypertension due to preeclampsia may worsen or even present in the postpartum period.
    • After delivery, women with preeclampsia require ongoing close blood pressure monitoring. Blood pressure sustained greater than 160/110 mm Hg should be urgently treated with IV antihypertensives. Oral antihypertensive therapy should be undertaken for sustained pressures above 155/105 mm Hg.
    • Blood pressure changes due to preeclampsia usually resolve within days to weeks after delivery but may persist for 3 months. Persistent hypertension beyond this point probably represents chronic hypertension.

Further Outpatient Care

  • Women with preeclampsia require follow-up after hospital discharge to ensure normalization of blood pressure and any lab abnormalities noted. This follow-up may be undertaken via an internal medicine specialist (obstetric internist) and obstetrician or a family physician.
    • Women with persistent hypertension due to preeclampsia require ongoing reassessment of their blood pressure. As vasospasm resolves, these women may be weaned off their antihypertensive therapy.
    • Laboratory abnormalities related to preeclampsia (eg, proteinuria, thrombocytopenia, liver enzyme elevations) should be followed until the abnormalities return to the reference range. This is vital to ensure that no other underlying maternal medical disorder with potential long-term consequences is missed.

Inpatient & Outpatient Medications

  • Available data suggest that all studied agents are excreted into human breast milk, but most are excreted to a negligible degree. All antihypertensive medications are believed to be compatible with breastfeeding, but using medications with a well-established record is reasonable.
  • Atenolol, as well as the other beta-blocking agents nadolol and metoprolol, appear to be concentrated in breast milk. Labetalol and propranolol do not share this property and are preferred agents if a beta-blocker is indicated.

Transfer

Women with preeclampsia remote from term (ie, <34-36 weeks' gestation) should be promptly transferred to a facility with adequate resources to care for premature newborn infants. This is essential because worsening preeclampsia disease activity may require urgent delivery at any time.

Deterrence/Prevention

Multiple interventions to prevent preeclampsia have been investigated. Pharmacologic treatment and normalization of chronic hypertension does not reduce the risk of developing superimposed preeclampsia. Other therapies that have been tried include low-dose acetylsalicylic acid (ASA),12 supplemental calcium,13 salt restriction,14 supplemental magnesium,15 and fish oil therapy.16 While several large trials of ASA in high-risk populations showed minimal benefit in reducing the frequency of preeclampsia, a meta-analysis reported an approximate 15% reduction in preeclampsia among pregnant women taking low-dose ASA.17 This therapy appears very safe and might be considered in high-risk women. None of the other therapies have demonstrated any significant preventive benefit.

One trial demonstrated some preventive benefit to supplemental antioxidants (vitamins C and E), but a recent review found that the evidence does not support routine use of antioxidants for this purpose.18

Complications

  • Life-threatening complications in preeclampsia
    • Seizures
    • Cerebral hemorrhage
    • Pulmonary edema - Due to pulmonary capillary leak, excess IV fluid administration, or myocardial dysfunction
    • Acute renal failure - Due to renal vasospasm, ATN, or renal cortical necrosis
    • Disseminated intravascular coagulopathy
    • HELLP syndrome - Microangiopathic hemolysis, elevated liver enzymes, and thrombocytopenia (platelets [PLT] <100)
    • Hepatic infarction/rupture and subcapsular hematoma - May lead to massive internal hemorrhage and shock
  • Acute fatty liver of pregnancy: Although a distinct and rare disorder, acute fatty liver has some clinical features similar to, and often overlapping with, severe preeclampsia.
  • TTP and HUS: While unrelated to preeclampsia, consider these important disorders in the setting of presumed severe HELLP syndrome.

Prognosis

  • Women who develop preeclampsia during pregnancy have an increased risk of recurrent preeclampsia during subsequent pregnancies. The overall risk is about 18%. The risk is higher (50%) in women who develop severe early preeclampsia (ie, before 27 weeks' gestation).
  • Women who develop preeclampsia are at increased risk for cardiovascular disease later in life. Whether the preeclampsia increases cardiovascular risk or the 2 conditions share a common underlying cause remains unclear.19
  • Transient hypertension of pregnancy, ie, the development of isolated hypertension in a woman in late pregnancy without other manifestations of preeclampsia, is associated strongly with later development of chronic hypertension.

Patient Education

Miscellaneous

Medicolegal Pitfalls

Most internists do not have extensive exposure to diagnosing and treating medical disorders during pregnancy and therefore feel some discomfort doing so. Consult with an obstetric internist, maternal-fetal medicine specialist (perinatologist), and/or medical subspecialist. The experience of these experts allows them to assess quickly which treatments offer the best risk-benefit ratio. In most situations, the benefit of maximizing maternal well-being with the usual therapies outweighs potential adverse effects on the fetus.

Special Concerns

  • Pregnancy
    • Most patients enter pregnancy with the expectation that their pregnancy and delivery will involve nothing but happiness. When severe complications occur, patients often feel scared, angry, and helpless. The best approach is to discuss all issues with patients. Take all possible steps to help the patient and her family understand the complications and treatment. Begin the discussion by providing the diagnosis and reassure the pregnant woman that, in most cases, the complications are not due to her actions or failure to act. Follow with discussion of plans for evaluation and treatment, providing her an opportunity to ask questions. Empower the patient by involving her in the decision-making process.
    • Patients ask very important questions. Physicians should feel comfortable being honest and telling patients and families when they do not have all of the answers. Physicians should let patients know that they will work to find the answers. This honesty and thoroughness solidifies the physician's reputation as a caring and competent doctor. Consultation with experienced clinicians helps the physician care for the patient and reassure her that all avenues of treatment are being explored.
    • Many reference texts and articles are available regarding the treatment of medical disorders during pregnancy. Becoming educated about these topics helps physicians feel more comfortable treating and counseling patients.
 


More on Hypertension and Pregnancy

Overview: Hypertension and Pregnancy
Differential Diagnoses & Workup: Hypertension and Pregnancy
Treatment & Medication: Hypertension and Pregnancy
Follow-up: Hypertension and Pregnancy
Multimedia: Hypertension and Pregnancy
References
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References

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Further Reading

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Keywords

hypertension and pregnancy, pregnancy-induced hypertension, PIH, preeclampsia, hyperpiesis, hyperpiesia, high blood pressure, gestational hypertension, chronic hypertension, preeclampsia-eclampsia, preeclampsia superimposed on chronic hypertension, gestational hypertension, transient hypertension of pregnancy, chronic hypertension in the latter half of pregnancy

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Contributor Information and Disclosures

Author

Paul Gibson, MD,, Associate Professor, Departments of Medicine and Obstetrics and Gynecology, Divisions of General Internal Medicine and Maternal-Fetal Medicine, University of Calgary
Paul Gibson, MD, is a member of the following medical societies: Alberta Medical Association, Canadian Society of Internal Medicine, Royal College of Physicians and Surgeons of Canada, and Society of Obstetric Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Michael P Carson, MD, Clinical Associate Professor, Department of Medicine, Clinical Assistant Professor, Department of Obstetrics/Gynecology and Reproductive Sciences, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School; Director of Research/Outcomes, Department of Medicine, Jersey Shore University Medical Center
Michael P Carson, MD is a member of the following medical societies: American College of Physicians, Society of General Internal Medicine, and Society of Obstetric Medicine
Disclosure: Nothing to disclose.

Medical Editor

Gerard S Letterie, DO, Associate Clinical Professor, Medical Director of In-vitro Fertilization Lab, Department of Obstetrics and Gynecology, Virginia Mason Medical Center, University of Washington
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

CME Editor

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Hancock Medical Center
Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians
Disclosure: Nothing to disclose.

Chief Editor

Carl V Smith, MD, The Distinguished Chris J and Marie A Olson Chair of Obstetrics and Gynecology, Professor, Department of Obstetrics and Gynecology, University of Nebraska Medical Center
Carl V Smith, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, American Medical Association, Arkansas Medical Society, Association of Professors of Gynecology and Obstetrics, Central Association of Obstetricians and Gynecologists, Council of University Chairs of Obstetrics and Gynecology, Nebraska Medical Association, and Society for Maternal-Fetal Medicine
Disclosure: Nothing to disclose.

 
 
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