Hypertension in Pregnancy: Evaluation

EVALUATION

The history and physical examination are directed toward detection of pregnancy-associated hypertensive disease and its signs and symptoms. A review of current obstetric records, if available, is especially helpful to ascertain changes or progression in findings. Visual disturbances, es-pecially scotomata, or unusually severe or persistent headaches are indicative of vasospasm. Right-upper-quadrant pain mayindicate liver involvement, presumably involving disten-tion of the liver capsule. Any history of loss of conscious-ness or seizures, even in the patient with a known seizure disorder, may be significant.

The position of the patient influences blood pressure. It islowest with the patient lying in the lateral position, high-est when the patient is standing, and at an intermediate level when she is sitting. The choice of the correct-size blood pressure cuff also influences blood pressure readings, with falsely high measurements noted when normal-sized cuffs are used on large patients. Also, during the course of pregnancy, blood pressure typically declines slightly in the second trimester, increasing to prepregnant levels as gestation nears term (Fig. 16.2). If a patient has not been seen previously, there is no baseline blood pressure against which to compare new blood pressure determinations, thereby making the diagnosis of pregnancy-related hyper-tension more difficult.

The patient’s weight is compared with her pregravid weight and with previous weights during this pregnancy, with special attention to excessive or too-rapid weight gain. 

Peripheral edema is common in pregnancy, especially in the lower extremities.

However, persistent edema unresponsive to resting in the supine position is not normal, especially when it also involves the upper extremities, sacral region, and face.

Indeed, the puffy-faced, edematous, hypertensive preg-nant woman is the classic picture of preeclampsia. Careful blood pressure determination in the sitting and supine positions is necessary. Funduscopic examination may de-tect vasoconstriction of retinal blood vessels indicative of similar vasoconstriction of other small vessels. Tenderness over the liver, attributed partly to hepatic capsule disten-sion, may be associated with complaints of right-upper-quadrant pain. The patellar and Achilles’ deep tendon reflexes should be carefully elicited, and hyperreflexia noted. The demonstration of clonus at the ankle is espe-cially worrisome.

The maternal and fetal laboratory evaluations for pregnancy complicated by hypertension are presented in Table 16.1 and demonstrate, by the wide range of tests, the multisystem effects of hypertension in pregnancy. Maternal liver dysfunction, renal insufficiency, and coagulopathy are significant concerns and require serial evaluation. Evaluationof fetal well-being with ultrasonography, and a nonstress test and/or biophysical profile are important.