A 30-year-old woman, gravida 1 para 0, at 24 weeks gestation comes to the office for a prenatal visit. The patient feels well and has no vaginal bleeding, leakage of fluid, or contractions. She has had no headaches, changes in vision, or right upper quadrant pain. The patient has no chronic medical conditions and has had an uncomplicated pregnancy. She does not use tobacco, alcohol, or illicit drugs. Temperature is 37.2 C (99 F), blood pressure is 152/88 mm Hg, pulse is 72/min, and respirations are 14/min. Oxygen saturation is 99% on room air. Physical examination is normal. Fetal heart rate is 150/min on Doppler ultrasound. Laboratory results are as follows: A nonstress test is reactive. Repeat blood pressure is 154/86 mm Hg. Which of the following is the best next step in management of this patient's hypertension?

Question

A 30-year-old woman, gravida 1 para 0, at 24 weeks gestation comes to the office for a prenatal visit.  The patient feels well and has no vaginal bleeding, leakage of fluid, or contractions.  She has had no headaches, changes in vision, or right upper quadrant pain.  The patient has no chronic medical conditions and has had an uncomplicated pregnancy.  She does not use tobacco, alcohol, or illicit drugs.  Temperature is 37.2 C (99 F), blood pressure is 152/88 mm Hg, pulse is 72/min, and respirations are 14/min.  Oxygen saturation is 99% on room air.  Physical examination is normal.  Fetal heart rate is 150/min on Doppler ultrasound.  Laboratory results are as follows:  A nonstress test is reactive.  Repeat blood pressure is 154/86 mm Hg.  Which of the following is the best next step in management of this patient's hypertension?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d996_37de_bc81_eb5f0dfb0d8d_MD0003_00 New-onset hypertension at ≥20 weeks gestation (ie, systolic ≥140 or diastolic ≥90 mm Hg) represents a spectrum of disease, ranging from gestational hypertension to preeclampsia with or without severe features. Because of the potential complications associated with preeclampsia (eg, maternal end-organ damage, fetal growth restriction), all patients with hypertension at ≥20 weeks gestation require preeclampsia evaluation including: Blood pressure measurements Clinical signs of end-organ damage (eg, headache, visual changes, right upper quadrant pain) Laboratory signs of end-organ damage (ie, urinalysis, creatinine, transaminases, platelet count) Fetal well-being (eg, nonstress test) Although this patient has a normal laboratory evaluation, including urinalysis with only 1+ protein (≥2+ is diagnostic), the diagnosis of preeclampsia is not definitely excluded because urinalysis has a high rate of false negatives due to the small urine sample size compared to daily total urine output. Therefore, patients with new-onset hypertension and absent or minimal proteinuria on urinalysis or urine dipstick require a 24-hour urine collection for total protein (the gold standard) to definitively diagnose or exclude preeclampsia and establish a baseline measurement (Choice D). (Choice B) Delivery for hypertensive patients is based on disease severity (eg, uncontrolled blood pressure, end-organ damage, fetal growth restriction) and gestational age. Although patients with preeclampsia may require inpatient care and possible preterm delivery, this patient has no clinical features of end-organ damage or a definitive diagnosis of preeclampsia. (Choice C) Magnesium sulfate infusion is indicated in preeclampsia with severe features for maternal seizure prophylaxis; it is also indicated for imminent delivery at <32 weeks gestation for fetal neuroprotection. This patient has no clinical or laboratory signs of severe features (eg, headache, elevated creatinine) and no signs of imminent delivery (eg, increasing contractions); therefore, magnesium sulfate is not indicated. (Choice E) Although vigorous exercise is contraindicated in pregnant patients with hypertension (due to risk of further blood pressure elevation), normal physical activity is typically appropriate. In addition, outpatient bed rest does not prevent progression to preeclampsia but does increase the risk of venous thromboembolism. Educational objective: Patients with new-onset hypertension (ie, systolic ≥140 or diastolic ≥90 mm Hg) at ≥20 weeks gestation without signs of end-organ damage and absent/minimal proteinuria on urinalysis require a 24-hour urine collection for total protein to differentiate between gestational hypertension and preeclampsia. References: Hypertensive disorders of pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/26926408)

A 30-Year-Old Woman, Gravida 1 Para 0, at 24 Weeks