Intended for healthcare professionals

Endgames Case Review

Hypertensive disorder of pregnancy

BMJ 2017; 356 doi: (Published 02 February 2017) Cite this as: BMJ 2017;356:j285
  1. Robert Charles, ST5 anaesthetics,
  2. Christopher Swales, foundation year 2,
  3. Tess Bonnett, consultant, obstetrics and gynaecology,
  4. Phil Bonnett, consultant, anaesthetics
  1. Sheffield Teaching Hospitals Foundation Trust, Herries Road, Sheffield, South Yorkshire, UK
  1. Correspondence to R Charles robcharles{at}

A 41 year old woman (gravida 1 para 0) presented to the antenatal day unit at 32 weeks’ gestation with a blood pressure of 157/93 mm Hg. Her first recorded BMI in pregnancy was 32. She was a non-smoker and had no known drug allergies. Her history included a thoracic spine fracture and two lumbar disc protrusions that had been asymptomatic since 2002. Earlier in the day, she had a headache that was relieved by paracetamol. Urinalysis showed 1+protein and a urinary protein creatinine ratio of 19 mg/mmol. Further measurements found a blood pressure of 163/96 mm Hg. The patient was admitted to the antenatal ward and started on an antihypertensive. Once her blood pressure was stable she was discharged with regular follow-up.

At 34 weeks’ gestation she presented to labour ward triage with a blood pressure of 158/98 m Hg despite antihypertensive treatment. She was admitted to the antenatal ward, her antihypertensive therapy was increased, and a second line agent was started. Urinary protein creatinine ratio was 39 mg/mmol; 24 hour urine collection showed 540 mg/24 hour of protein. An ultrasound scan for growth, liquor volume, and umbilical cord dopplers was normal. Induction of labour was arranged at 37 weeks’ gestation.


  • 1. What is the most likely diagnosis and what are the risk factors in this case?

  • 2. What is the pathophysiology of this condition?

  • 3. How is this condition managed?


1. What is the most likely diagnosis and what are the risk factors in this case?

Short answer

Gestational hypertension developing into pre-eclampsia. Risk factors include nulliparity, maternal age >40 years, and body mass index >25.


Hypertension can be graded according to severity (box 1).1 The National Institute for Health and Care Excellence (NICE) classifies hypertensive disorder of pregnancy as chronic hypertension, gestational hypertension, or pre-eclampsia.1 Chronic hypertension is defined as pre-existing hypertension or hypertension diagnosed before 20 weeks’ gestation. Gestational hypertension is new …

View Full Text

Log in

Log in through your institution


* For online subscription