A 28-year-old multiparous woman at 28 weeks of gestation presents with blood pressure 150/95 mmHg, which is new-onset. She denies headache, visual disturbances, or epigastric pain. Urine dipstick is negative for protein. Full blood count, liver function tests, and serum creatinine are all normal. Fetal heart rate is 145 bpm with normal variability. What is the correct classification and next step in management?

Question

Accepted Answer

D. Gestational hypertension; start oral labetalol and arrange weekly clinic visits. ## Clinical Diagnosis: Gestational Hypertension

### Diagnostic Criteria

**Key Point:** Gestational hypertension is defined as:
- **New-onset hypertension** (SBP ≥140 mmHg or DBP ≥90 mmHg) after 20 weeks of gestation
- **Absence of proteinuria** and other signs of preeclampsia
- **Normal laboratory findings** (platelets, liver enzymes, creatinine)
- **No severe features**

This patient meets all criteria: new BP elevation at 28 weeks, no proteinuria, normal labs, no symptoms.

### Differential Diagnosis: Gestational vs. Chronic Hypertension

| Feature | Gestational Hypertension | Chronic Hypertension |
|---------|--------------------------|----------------------|
| **Onset** | After 20 weeks | Before pregnancy or before 20 weeks |
| **Proteinuria** | Absent | May be present |
| **Lab abnormalities** | None | May have renal/cardiac involvement |
| **Postpartum course** | BP normalizes within 12 weeks | Persists postpartum |
| **Diagnosis** | Clinical; confirmed if BP remains elevated at 12 weeks postpartum | Requires pre-pregnancy or early pregnancy BP documentation |

This patient's **new-onset hypertension at 28 weeks** with **no prior BP documentation** is classified as **gestational hypertension** unless she had documented hypertension before pregnancy (which is not mentioned).

## Management of Gestational Hypertension

```mermaid
flowchart TD
  A[Gestational hypertension at 28 weeks]:::outcome --> B{Severe features present?}:::decision
  B -->|No| C[Antihypertensive therapy if SBP ≥160 or DBP ≥110]:::action
  B -->|Yes| D[Admit; IV antihypertensives; plan delivery]:::urgent
  C --> E[Oral first-line: labetalol, nifedipine, methyldopa]:::action
  E --> F[Weekly antenatal visits + BP monitoring]:::action
  F --> G[Fetal monitoring: NST/USG as per protocol]:::action
  G --> H{Develops preeclampsia or reaches term?}:::decision
  H -->|Preeclampsia| I[Escalate to delivery planning]:::urgent
  H -->|Term/near-term| J[Vaginal delivery preferred]:::outcome
```

### Antihypertensive Therapy Indications

**High-Yield:** Antihypertensive treatment is recommended in gestational hypertension when:
- **SBP ≥160 mmHg or DBP ≥110 mmHg** (severe range) → treat immediately
- **SBP 140–159 mmHg or DBP 90–109 mmHg** (mild-to-moderate) → individualize; some guidelines recommend treatment to reduce maternal cardiovascular events

This patient has **SBP 150 mmHg (mild-to-moderate range)**, so antihypertensive therapy is reasonable.

### First-Line Antihypertensive Agents in Pregnancy

| Agent | Dose | Onset | Safety in Pregnancy |
|-------|------|-------|---------------------|
| **Labetalol** | 200–400 mg PO BD–TDS | 2–4 hours | Preferred; extensive safety data |
| **Nifedipine (extended-release)** | 10–20 mg PO BD | 30 min–2 hours | Preferred; safe in all trimesters |
| **Methyldopa** | 250–500 mg PO BD–TDS | 4–6 hours | Safe; slower onset, often second-line |
| **Hydralazine** | 10–25 mg PO TDS–QID | 1–2 hours | Safe; used for acute severe hypertension |

**Clinical Pearl:** Labetalol is often preferred as first-line because it is effective, well-tolerated, and has the longest safety record in pregnancy [cite:ACOG Practice Bulletin 202].

### Monitoring Plan

**Key Point:** Gestational hypertension requires:
1. **Weekly antenatal visits** with BP monitoring
2. **Repeat urinalysis** at each visit to detect proteinuria (development = preeclampsia)
3. **Fetal monitoring:** NST and ultrasound as per standard antenatal protocols
4. **Laboratory review:** Repeat FBC, LFTs, creatinine if any clinical change
5. **Delivery planning:** At 37 weeks (or earlier if preeclampsia develops)

### Why Not the Other Options?

**Option 1 (Preeclampsia without severe features):** Incorrect diagnosis; preeclampsia requires **proteinuria or other end-organ dysfunction**. This patient has neither.

**Option 2 (Chronic hypertension):** Incorrect classification; chronic hypertension is diagnosed when hypertension is present **before pregnancy or before 20 weeks**. This is new-onset at 28 weeks.

**Option 3 (Transient hypertension):** Premature and unsafe; transient hypertension is a **retrospective diagnosis** made postpartum when BP normalizes. At 28 weeks, we must assume gestational hypertension and treat accordingly to prevent progression to preeclampsia.

## Prognosis

**High-Yield:** Approximately **25–50% of women with gestational hypertension develop preeclampsia** during pregnancy or postpartum. Close monitoring is essential.

**Mnemonic: GASP** — **G**estational hypertension, **A**ntihypertensive therapy, **S**erial monitoring, **P**reeclampsia surveillance

Answer

A. Transient hypertension; reassure and discharge with self-monitoring of blood pressure at home

Answer

B. Preeclampsia without severe features; admit for 24-hour observation and antihypertensive therapy

Answer

C. Chronic hypertension; refer to internal medicine and continue pregnancy with close monitoring

Explanation

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