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Hyperaldosteronism, pheochromocytoma, or hyperthyroidism might be quiescent during pregnancy but flare in the postpartum period.
How should one approach a pregnant patient with hypertension?
Preeclampsia might be diagnosed before fetal viability (approximately 24 weeks gestation), although the vast majority of cases occur near term.
Risks of premature delivery must be balanced with the risks of progressively severe manifestations for the mother and fetus.
Preeclampsia’s pathogenesis is attributed to abnormal placental implantation with abnormal maternal immune adaptation, altered angiogenic factors with increased systemic vascular resistance and endothelial dysfunction leading to the clinically apparent maternal syndrome.11Severe preeclampsia criteria include any of the following: eclampsia, HELLP syndrome (platelets less than 100,000/mm³, transaminases more than twice the upper limit of normal, and/or epigastric pain), SBP ≥160 mm Hg, DBP ≥110 mm Hg, proteinuria ≥5 grams per day, oliguria, pulmonary edema, placental abruption, or fetal manifestations such as intrauterine growth restriction (≤10th percentile of expected fetal weight based on gestational age), decreased amniotic fluid index, or fetal demise.2,5,12Maternal symptoms might include headache, visual disturbances, epigastric or right upper quadrant (RUQ) pain, rapid weight gain, and severe edema. Preeclampsia can rapidly progress from “less severe” to severe.
Maternal symptoms and abnormal lab findings are more predictive of adverse pregnancy outcomes than the degree of hypertension and/or proteinuria.1It is always in the mother’s interest to deliver when preeclampsia is diagnosed, because preeclampsia will not resolve until after delivery, with hypertension and lab abnormalities sometimes persisting for months postpartum.