KEY POINTS
- All gravidas are at risk for hypertension and preeclampsia in the antepartum, intrapartum, and postpartum periods.
- In a patient who was previously normotensive, the diagnosis of hypertension should be based on blood-pressure criteria rather than threshold-increase criteria, since a gradual increase in blood pressure from the first to third trimesters is seen in 67% to 75% of normotensive pregnancies.
- The ultimate goals of therapy for hypertensive disorders must always be safety of the mother first and then delivery of a live, mature infant who requires no intensive and prolonged neonatal care.
- Antihypertensive medications should not be used to control blood pressure on an outpatient basis in women with preeclampsia.
- Common themes in medicolegal claims are the assumption by health-care providers that a patient’s proteinuria resulted from sample contamination or urinary tract infection, and a failure to appreciate the clinical significance of patient complaints during telephone calls.
- Complications related to HELLP syndrome are a major cause of litigation claiming failure to diagnose preeclampsia or failure to diagnose syndromes that can mimic preeclampsia.
Hypertensive disorders are the most common medical complications of pregnancy, with a reported incidence in the United States of 6% to 8%.1,2 These disorders are associated with an increased risk of maternal and perinatal mortality and morbidity (TABLE 1).3 Not surprisingly, they are a major cause of litigation against physicians and hospitals, most of it alleging misdiagnosis and/or mistreatment. In this article, I outline precautions that can reduce or prevent the risk of medicolegal claims involving hypertension in pregnancy. Among the issues covered are terminology, diagnosis, management, and complications of the disorders, based on the literature, a review of legal claims, and personal experience.
TABLE 1
Adverse outcomes in hypertensive disorders of pregnancy
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| IUGR=intrauterine growth restriction |
Definitions and terminology
Hypertension in pregnancy is the term typically used to describe a wide spectrum of patients whose disorders range from mild elevations in blood pressure (BP) to severe hypertension and organ dysfunction. Hypertension may be present before pregnancy, or it may become evident before 20 weeks’ gestation, in the second trimester, at term, during labor and delivery, or in the immediate (48 hours or less after delivery) or late (3 to 28 days after delivery) postpartum period.
Unfortunately, the terminology used to describe these disorders is confusing and inconsistent. For example, “pregnancyinduced hypertension” is vague and broad and should not be employed in clinical practice. In the medical record, it is more advisable to describe exactly what the findings are, e.g., chronic hypertension, gestational hypertension (new-onset hypertension after 20 weeks’ gestation), new-onset proteinuria (1+ or greater on at least 2 occasions), or a combination of findings.
The physician also should document whether the hypertension is mild or severe, as well as the presence or absence of associated symptoms such as persistent headache, visual changes, mental changes, epigastric or right upper quadrant (RUQ) pain, shortness of breath, or vaginal bleeding. The term “preeclampsia” should be used only to describe patients who have persistent hypertension and new-onset proteinuria or associated symptoms. The term “HELLP syndrome” (hemolysis, elevated liver proteins, and low platelets) should be used only when a woman with suspected or confirmed preeclampsia has documented evidence of hemolysis (elevated lactate dehydrogenase [LDH] or bilirubin) plus elevated liver enzymes (aspartate aminotransferase [AST] or alanine aminotransferase [ALT]) and thrombocytopenia (platelet count below 100,000).
Unless all of these elements are present, the medical record should describe only preeclampsia with either elevated liver enzymes or thrombocytopenia.
Diagnosing hypertension
Hypertension is the hallmark of these disorders. In a woman who was previously normotensive, its diagnosis should be based on BP criteria, e.g., at least 140 mm Hg systolic and/or 90 mm Hg diastolic. Because the hypertensive readings must be present on 2 occasions at least 6 hours apart, it is important to obtain and record BP at each visit during pregnancy.
The threshold-increase criteria (i.e., relative hypertension) are inadequate to diagnose gestational hypertension or preeclampsia, since a gradual increase in BP from the first to third trimesters is seen in 67% to 75% of normotensive pregnancies.4 However, these criteria signal the need for close observation of the patient, particularly when they are accompanied by generalized edema, proteinuria, and other symptoms such as headaches, blurred vision, or epigastric pain. In fact, the presence of these symptoms has a greater bearing on pregnancy outcome than the absolute level of blood pressure.