| Preconception or first prenatal visit |
- Obtain baseline laboratory tests: Creatinine, urine protein to creatinine ratio (or 24-hour urine for total protein), and complete blood count should be obtained in all patients. Electrolytes are obtained in patients with renal dysfunction.
- Liver transaminases (AST/ALT) and platelet count are optional and useful if the patient exhibits symptoms of preeclampsia later in pregnancy. Obtain additional baseline testing, as appropriate, based on past medical history and comorbid conditions: Transthoracic echocardiogram or 12-lead ECG, testing for secondary causes of hypertension if high suspicion.
- Review and optimize antihypertensive and other medications. Angiotensin converting enzyme inhibitors and angiotensin receptor blockers should be discontinued before pregnancy since they have been associated with fetal malformations.
- Evaluate for other comorbidities (eg, diabetes testing, obesity, cigarette smoking) and manage as appropriate.
- Recommend home blood pressure monitoring.
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| Prenatal care |
- Determine estimated date of delivery; ultrasound estimation is generally superior to dating based on the menstrual history if uncertain.
- At 12 to 16 weeks of gestation, begin daily low-dose aspirin (if no contraindications) to reduce risk for developing preeclampsia.
- At each prenatal visit and at least monthly, measure blood pressure (perform more often if suboptimally controlled).
- After 20 weeks of gestation, discuss the signs and symptoms of preeclampsia and when to contact a health care provider.
- At 28 to 32 weeks of gestation, order ultrasound examination every 3 to 4 weeks to evaluate fetal growth.
- At 32 weeks of gestation, begin fetal testing with NSTs or BPPs.
- At 38+0 to 39+6 weeks of gestation, plan induction of labor in patients with well-controlled blood pressure without medications.
- At 37+0 to 39+0 weeks of gestation, plan induction of labor in patients with well-controlled blood pressure on medications; induction is performed sooner for patients with standard indications for induction (eg, superimposed preeclampsia).
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| Postpartum care |
- Evaluate blood pressure 3 to 10 days postpartum and more frequently if home blood pressures can be performed.
- Discuss blood pressure goals after delivery, signs and symptoms of postpartum preeclampsia and severe hypertension, and when to contact a health care provider.
- Encourage breastfeeding. If breastfeeding, prescribe medications with the best safety profile for the infant.
- Discuss contraception options.
- Discuss future pregnancy risks, importance of planned pregnancy, and long-term cardiovascular risks.
- Ask patient to follow up with her primary care provider for ongoing management of chronic hypertension.
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