A 38-year-old woman, gravida 1 para 0, comes to the office for her first prenatal visit. Her last menstrual period was 14 weeks ago. The patient has had nausea and vomiting occasionally over the past few weeks but no other symptoms. She has not seen a health care provider in years but has no known medical conditions. Her only daily medication is a prenatal vitamin. The patient does not use tobacco, alcohol, or illicit drugs. Supine blood pressure is 142/96 mm Hg and pulse is 92/min. Repeat measurement 15 minutes later is 138/92 mm Hg and pulse is 88/min. Cardiopulmonary examination is normal. Pelvic examination shows an enlarged uterus consistent with 14 weeks gestation. There is mild bilateral ankle edema. Doppler ultrasound shows a fetal heart rate of 160/min. Urinalysis is negative for protein and glucose.
Which of the following is the most likely cause of this patient's hypertension?

Question

A 38-year-old woman, gravida 1 para 0, comes to the office for her first prenatal visit.  Her last menstrual period was 14 weeks ago.  The patient has had nausea and vomiting occasionally over the past few weeks but no other symptoms.  She has not seen a health care provider in years but has no known medical conditions.  Her only daily medication is a prenatal vitamin.  The patient does not use tobacco, alcohol, or illicit drugs.  Supine blood pressure is 142/96 mm Hg and pulse is 92/min.  Repeat measurement 15 minutes later is 138/92 mm Hg and pulse is 88/min.  Cardiopulmonary examination is normal.  Pelvic examination shows an enlarged uterus consistent with 14 weeks gestation.  There is mild bilateral ankle edema.  Doppler ultrasound shows a fetal heart rate of 160/min.  Urinalysis is negative for protein and glucose.
Which of the following is the most likely cause of this patient's hypertension?

Quizplus · Accepted Answer

Explanation: 11ec25c8_da80_9778_bc81_3342b2c71321_MD0003_00 Hypertensive disorders of pregnancy (defined during pregnancy as systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg) represent a spectrum of diseases that are diagnosed based on the timing/onset of hypertension and associated clinical features (eg, proteinuria, signs of end-organ damage). The initial differentiating factor between diagnoses is the timing/onset of hypertension, which is categorized by presentation before or after 20 weeks gestation. Chronic hypertension is defined as either prepregnancy hypertension or hypertension recognized at <20 weeks gestation, such as in this patient who may have had undiagnosed hypertension prepregnancy due to lack of routine medical care. In contrast, pregnancy-induced hypertension is thought to occur due to placental dysfunction, which typically does not manifest with hypertension until after 20 weeks gestation. Therefore, new-onset hypertension at ≥20 weeks gestation is more likely due to: placental dysfunction Gestational hypertension, which has no associated proteinuria or signs of end-organ damage (Choice C)OR Preeclampsia without severe features, which requires proteinuria and/or signs of end-organ dysfunction for diagnosis (Choice E) Differentiating between the various hypertensive disorders of pregnancy helps guide obstetric management (eg, delivery timing) and evaluation for additional complications. (Choice B) A complete molar pregnancy (hydatidiform mole), the abnormal proliferation of hyperplastic chorionic villi, can present with preeclampsia, particularly at unusually early gestational ages (eg, <20 weeks gestation). However, preeclampsia requires hypertension plus either proteinuria or signs of end-organ damage for diagnosis. This patient has no proteinuria. In addition, patients with a complete molar pregnancy typically have an abnormally enlarged uterus (ie, uterine size > gestational age); this patient's uterine size is equivalent to gestational age. (Choice D) Pregnancy causes increased release of peripheral vasodilators (eg, nitric oxide, prostacyclin) and decreased vascular sensitivity to vasoconstrictors (eg, norepinephrine, angiotensin II), resulting in marked systemic vasodilation and a decrease in overall blood pressure by 5-10 mm Hg from baseline. This effect is most pronounced between 12 and 20 weeks gestation and is followed by a gradual return to prepregnancy blood pressure levels in the third trimester. Educational objective: Chronic hypertension in pregnancy is diagnosed in patients with prepregnancy hypertension and those with hypertension recognized at <20 weeks gestation. References: Chronic hypertension and pregnancy outcomes: systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/24735917) Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/24150027)

A 38-Year-Old Woman, Gravida 1 Para 0, Comes to the Office