Gestational hypertension and pre-eclampsia: progression, treatment and delivery
THE CONTEXT
Gestational hypertension (GH) can evolve into pre-eclampsia (PE). Disease progression may be rapid, so management depends on severe features and gestational age.
Progression and severity
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Gestational hypertension may enter a proteinuric phase and evolve into pre-eclampsia.
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Progression to severe pre-eclampsia, HELLP syndrome or eclampsia may be rapid and unpredictable. An apparently mild presentation can rapidly become severe, making severity classification potentially misleading.
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Women with gestational hypertension presenting with severe blood pressure elevation should be managed in the same manner as women with severe pre-eclampsia.
Underlying mechanisms
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The cause of pre-eclampsia remains unclear; placental and maternal vascular dysfunction are proposed contributors.
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Impaired remodeling of the uterine spiral arteries is thought to reduce placental perfusion.
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Increased inflammation and production of antiangiogenic factors lead to maternal endothelial cell damage, which manifests as the signs and symptoms of pre-eclampsia.
Medications and prophylaxis
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Antihypertensive medication is recommended for severe hypertension during pregnancy.
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Daily low-dose aspirin is given to high-risk women. The passage describes its use for pre-eclampsia prophylaxis from 16 weeks until delivery, while also stating that no proven method prevents pre-eclampsia.
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Magnesium sulfate is recommended in severe pre-eclampsia, eclampsia or HELLP syndrome. It is used to prevent and treat seizures in women with gestational hypertension or pre-eclampsia with severe features, or with eclampsia.
Delivery decisions
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Blood pressure management and decisions about delivery follow the same principles in gestational hypertension and pre-eclampsia.
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Women with gestational hypertension or pre-eclampsia without severe features should be delivered at more than 37 weeks.
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The decision to deliver should not be based on the severity of proteinuria.
Unusual timing of eclampsia
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Rare cases of eclampsia can develop before 20 weeks or more than 48 hours postpartum.