Pregnancy complicated by gestational hypertension is managed based on its severity, presence of preeclampsia, and gestational age. Preeclampsia cannot always be diagnosed definitively. hus, the Task Force (2013) recommends more frequent prenatal visits if preeclampsia is "suspected." Increases in systolic and diastolic blood pressure can be either normal physiological changes or signs of developing patholoy. Heightened surveillance permits more prompt recognition of ominous changes in blood pressure, critical laboratory findings, and clinical signs and symptoms (Macdonald-Wallis, 2015).
The basic management objectives for any pregnancy complicated by preeclampsia are: (1) termination of pregnancy with the least possible trauma to mother and fetus, (2) birth of a healthy newborn that subsequently thrives, and (3) complete restoration of health to the mother. In many women with preeclampsia, especially those at or near term, all three objectives are served equally well by induction of labor. One of the most important clinical questions or succesul management is precise knowledge of etal age.
• Early Diagnosis of Preeclampsia
Traditionally, the frequency of prenatal visits is increased during the third trimester, and this aids early detection of preeclampsia. Women without overt hypertension, but in whom eary developing preeclampsia is suspected during routine prenatal visits, are seen more frequenty. For many years at Parkland Hospital, women with new-onset diastolic blood pressures >80 mm Hg but <90 mm Hg or with sudden abnormal weight gain of more than 2 pounds per week have, at minimum, returned for visits at 7 -day intervals. Outpatient surveillance is continued unless overt hypertension, proteinuria, headache, visual disturbances, or epigastric pain supervenes.
Women with overt new-onset hypertension-either diastolic pressures �90 mm Hg or systolic pressures � 140 mm Hg-are admitted to determine if the increase is due to preeclampsia, and if so, to evaluate its severity.
With hospitalization, a systematic evaluation is instituted to include:
Detailed examination, which is coupled with daily scrutiny for clinical indings such as headache, visual disturbances, epigastric pain, and rapid weight gain
Quantification of proteinuria or urine protein:creatmme
Blood pressure readings with an appropriate-size cuf every 4 hours, except between 2400 and 0600 unless previous readings are elevated
Measurements of plasma or serum creatinine and hepatic transaminase levels and a hemogram that includes a platelet count. The frequency of testing is determined by hypertension severity. Although some recommend measurement of serum uric acid and lactate dehydrogenase levels and coagulation studies, their value has been questioned (CondeAgudelo, 2015; Thangaratinam, 2006).
Evaluation of fetal size and well-being and amnionic luid volume, by either physical examination or sonography.
Reduced physical activity throughout much of the day is likely beneficial, but as the 2013 Task Force concluded, absolute bed rest is not desirable. Ample protein and calories are included in the diet, and sodium and fluid intake are not limited or forced.
In sum, goals of evaluation include early identification of preeclampsia or worsening of the syndrome and development of a management plan for timely delivery. Fortunately, many cases are suiciently mild and near enough to term that they can be managed conservatively until labor commences spontaneously or until the cervix becomes favorable for labor induction. Complete abatement 0/ al signs and symptoms, however, is uncommon until ater delivery. If severe preeclampsia is diagnosed using the criteria in Table 40-2, further management is subsequently described.