Clinical Signs and Symptoms
Hypertension (high blood pressure) complicates almost 10 percent of pregnancies. Pregnancy may induce hypertension or aggravate a woman's pre-existing hypertensive condition. When a woman develops pregnancy-induced or aggravated hypertension, the pregnancy may continue to term. However, the risk of maternal or fetal death or injury increases in pregnancies complicated by hypertensive conditions. The condition may be lead to fetal growth retardation, prematurity, and uteroplacental insufficiency, which can diminish the flow of oxygen and nutrients to the fetus and cause fetal distress.
An obstetrician may respond to these potential complications by checking the mother's blood pressure at more frequent intervals, hospitalizing the mother for testing and observation, initiating drug therapy, ordering laboratory tests, or terminating the pregnancy.
Hypertensive conditions of pregnancy are classified by when the hypertension is diagnosed and what other clinical findings accompany it. For example, when the patient develops high blood pressure before becoming pregnant, or is diagnosed before the 20th week, the condition is called chronic hypertension. This may be mild or severe, depending on the blood pressure measurement. Patients who have chronic hypertension are at increased risk for developing more serious complications at a later stage of the pregnancy.
If the patient develops hypertension after the 20th week, the condition is called pregnancy-induced hypertension. If hypertension is accompanied by proteinuria (excess protein in the urine), or edema (fluid retention), or both, obstetricians refer to it as preeclampsia. Proteinuria is usually detected by a dipstick reading at the prenatal visit. Although it is not routinely done, a 24-hour total protein urine test can be performed when the obstetrician desires a more reliable indicator of the problem. The obstetrician need not rely only on the dipstick result, when time permits further evaluation.
Edema is the least significant indicator of a worsening hypertensive condition, because it is a normal finding in many pregnancies. However, edema of the hands and face is significant when hypertension is present and accompanied by excessive weight gain.
The signs of elevated blood pressure, proteinuria, and edema are important not only in diagnosing preeclampsia, but also in determining the severity of the disease. Therefore, the patient's blood pressure, urine, and weight gain should be checked at each prenatal visit. Other clinical findings that indicate a rapidly worsening situation are visual disturbances, ranging from slight blurring to partial or complete blindness; severe headaches; and right upper abdominal pain.
Preeclampsia is life-threatening when several factors combine to produce a condition known as the HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count). Another life-threatening complication, called eclampsia, arises when preeclampsia is accompanied by convulsions. Either of these may require the prompt delivery of the baby, regardless of the stage of pregnancy, to protect the mother.
There is no cure for preeclampsia other than terminating the pregnancy. However, even though adverse maternal consequences usually can be avoided by an early delivery, the baby may be compromised. The obstetrician must balance the benefits to the baby of treating the preeclampsia and prolonging the pregnancy against the risks of growth retardation and asphyxia, as well as the risks to the mother. Therefore, to implement a successful management plan, the doctor must accurately determine the age of the fetus.
Obstetricians may consider using antihypertensive drugs to control the underlying condition and to improve maternal and perinatal outcome. Appropriate management of a hypertensive condition should include more frequent evaluations of maternal and fetal well-being. The obstetrician must instruct the patient to report immediately any of the well-known symptoms. The critical questions for a lawyer investigating a birth trauma case, will be whether the doctor ignored or failed to properly interpret the clinical data, failed to properly monitor the mother's condition, failed to hospitalize the mother when necessary to determine the severity of the disease, failed to assess fetal well-being before her condition or the baby's became life-threatening, and failed to properly consider other relevant clinical information.
This web site is not intended as legal advice on cerebral palsy, and is not a substitute for obtaining guidance from your own legal counsel about cerebral palsy litigation. It provides general educational information about the standards of care and causation issues that can arise in obstetrical malpractice and cerebral palsy litigation. Readers of the articles contained within this web site should not act upon the cerebral palsy information without first consulting with a lawyer who is experienced in evaluating and litigating cerebral palsy and obstetrical malpractice cases. Mr. Apfel is admitted to practice law in Maryland and the District of Columbia. When Mr. Apfel is asked to participate in cerebral palsy
litigation filed in other states, he will associate with, and act as co-counsel with, an attorney licensed in that state who is familiar with the local laws and procedures.