## Clinical Diagnosis: Gestational Hypertension (Preeclampsia without Severe Features) **Key Point:** This patient has new-onset hypertension at 28 weeks without proteinuria (< 0.3 g/24 h), normal platelet count, normal renal function, and no symptoms or signs of end-organ dysfunction. This is **gestational hypertension** or **preeclampsia without severe features**, which can be managed expectantly in the outpatient setting with close monitoring. ### Rationale for Correct Answer **High-Yield:** The 2013 ACOG Task Force and current guidelines recommend: 1. **Outpatient management** for preeclampsia without severe features at < 37 weeks if maternal and fetal conditions are reassuring 2. **Antihypertensive therapy** is **NOT routinely indicated** for mild-to-moderate hypertension (BP 140–159/90–109 mmHg) in pregnancy; treatment is reserved for severe hypertension (≥ 160/110 mmHg) to prevent maternal cardiovascular complications 3. **Weekly antenatal visits** with BP monitoring, symptom assessment, and fetal surveillance 4. **Home BP monitoring** to detect progression 5. **Delivery at 37 weeks** if preeclampsia without severe features is confirmed; earlier delivery (34–37 weeks) only if severe features develop **Clinical Pearl:** The traditional teaching of "treat all hypertension in pregnancy" is **outdated**. Current evidence shows that treating mild-to-moderate hypertension does not improve maternal or neonatal outcomes and may reduce fetal growth. Antihypertensives are reserved for severe hypertension (≥ 160/110 mmHg) to prevent maternal stroke and other cardiovascular events. ### Diagnostic Criteria Comparison | Feature | Gestational HTN | Preeclampsia (No Severe Features) | Preeclampsia (Severe Features) | |---------|-----------------|-----------------------------------|-------------------------------| | **BP** | ≥ 140/90 | ≥ 140/90 | ≥ 160/110 OR symptoms | | **Proteinuria** | None | < 0.3 g/24 h OR 1+ dipstick | ≥ 0.3 g/24 h OR 2+ dipstick | | **Platelets** | Normal | ≥ 100,000/μL | < 100,000/μL | | **Creatinine** | Normal | ≤ 1.1 mg/dL | > 1.1 mg/dL | | **Liver enzymes** | Normal | Normal | Elevated | | **Symptoms** | None | None | Headache, RUQ pain, visual changes | | **Management** | Outpatient ± antihypertensives | Outpatient, antihypertensives only if BP ≥ 160/110 | Inpatient, antihypertensives, delivery in 24–48 h | | **Delivery timing** | 37 weeks | 37 weeks | 34–37 weeks (if stable) or immediate (if unstable) | **Mnemonic: MILD HTN in Pregnancy** — **M**oderate BP (140–159/90–109), **I**ncidental finding, **L**ow risk, **D**o not treat routinely → **H**ome monitoring, **T**herapy only if BP ≥ 160/110, **N**ormal delivery at term ### Management Algorithm ```mermaid flowchart TD A[New Hypertension in Pregnancy]:::outcome --> B{BP ≥ 160/110 or Symptoms?}:::decision B -->|Yes| C[Severe Features Present]:::urgent B -->|No| D[Assess Proteinuria & Labs]:::action C --> E[Inpatient Admission + Antihypertensives]:::action D --> F{Proteinuria or End-Organ Dysfunction?}:::decision F -->|Yes| G[Preeclampsia without Severe Features]:::outcome F -->|No| H[Gestational Hypertension]:::outcome G --> I[Outpatient Management]:::action H --> I I --> J[Weekly Visits + Home BP Monitoring]:::action J --> K{Progression to Severe Features?}:::decision K -->|Yes| L[Admit + Antihypertensives + Delivery Plan]:::urgent K -->|No| M[Deliver at 37 weeks]:::action ``` **High-Yield Fact:** The CHIPS trial (2015) showed that treating mild-to-moderate hypertension in pregnancy (target BP < 140/90) did NOT reduce preeclampsia or improve neonatal outcomes; it only increased maternal side effects. Thus, antihypertensives are reserved for **severe hypertension (≥ 160/110 mmHg)** to prevent maternal complications. [cite:ACOG Practice Bulletin 202, Cunningham & Leveno 25e Ch 40]
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