Hypertensive disorders in pregnancy

Table 1 Selected renal disorders during pregnancy

Renal disease by trimester
1st trimester	Hyperemesis gravidarum	Worsening of preexisting renal disease
Week 1-12	Cortical necrosis due to septic abortion	↓
	Preeclampsia (> after 20 wk)	↓
	AFLP	↓
2nd trimester	Preeclampsia	↓
Week 13-28	HELLP syndrome	↓
	TTP	↓
3rd trimester	Preeclampsia	↓
Week 29-40	Polyhydramnios	↓
	Extraureteral obstructive hydronephrosis	↓
Post-partum	Post-partum hemolytic uremic syndrome	↓
	Preeclampsia	↓

AFLP: Acute fatty liver of pregnancy; TTP: Thrombotic thrombocytopenic purpura; HELLP: Hemolysis, elevated liver enzymes, and low platelets.

Table 2 Renal disorders and associated maternal and fetal health risks

Maternal and fetal risk by degree of renal impairment
Stage	Pregnancy/fetal outcomes	Renal/maternal outcomes
Early CKD I-II sCr < 1.4 mg/dL eGFR < 70 mL/min Normal BP Minimal proteinuria	Higher risk than general population for preeclampsia, SGA, preterm delivery Counseling: May need specialized care Generally good outcomes	Lower risks for accelerated progression
Moderate CKD II-III sCr 1.4-2.4 mg/dL eGFR 40-70 mL/min	With more advanced CKD and higher proteinuria: Higher risks of caesarian section, preterm delivery, SGA, and need for NICU	Increased risk of progression during pregnancy and within 6 wk postpartum Counseling: Pregnancy termination doesn’t reliably reduce risks for progression
Severe CKD III-IV sCr > 2.4 mg/dL eGFR < 40 mL/min	With more advanced CKD and higher proteinuria: Higher risks of caesarian section, preterm delivery, SGA, and need for NICU care	Increased risk of progression during pregnancy and within 6 wk postpartum
ESRD	Decreased fertility and high fetal mortality except with more intensive hemodialysis Higher risks of preeclampsia, SGA, cervical incompetence, and need for NICU care persist	Increased need for transfusion, worsening hypertension
Post-transplant	± increased risk of fetal loss Increased risk of low birth weight and preterm delivery Significantly increased risk of preeclampsia if hypertensive	Blunted renal physiologic adaptations No anticipated decrease in graft survival but may be associated with decreased maternal life span Increased risk of diabetes, urinary tract infection (due to anatomy, insulin resistance, and immunosuppression)

SGA: Small for gestational age; NICU: Neonatal intensive care unit; CKD: Chronic kidney disease; ESRD: End-stage renal disease.

Table 3 Definition of preeclampsia

Updated definition	Supportive clinical signs
2 blood pressure readings	Edema
≥ 140/90	±
Taken ≥ 4-6 h apart	Uric acid level ≥ 7.8 mg/dL
After 20 wk gestation	±
+	Proteinuria (severe ≥ 5 g/g)
Patient not previously known to be
hypertensive	Thrombocytopenia
	Elevated serum aminotransferase levels
	Acute kidney injury
	Pulmonary edema
	Cerebral/visual disturbances (new onset)