Hypertension Review OSCE - Hypertension in Pregnancy

Case Overview

• Age/Sex: 26-year-old female
• Occupation: Primary school teacher
• Setting: Antenatal clinic / GP surgery
• Chief complaint: "I just came for a blood pressure check"

Patient Script

Who I Am

I'm 26, a primary school teacher, and this is my first pregnancy — I'm about halfway through.

What Brings Me In

The midwife said my blood pressure was a bit high at my last appointment, so I was asked to come back to have it checked properly.

My Story

I am currently 20 weeks and 5 days pregnant. At my routine midwife appointment 3 days ago she measured my blood pressure and said it was higher than usual, so she asked me to get it rechecked today. I haven't felt very unwell, but I've had a mild headache on and off for the last 48 hours that goes away with paracetamol. I have noticed a bit of swelling in my ankles this week, but my shoes still fit. I had some backache after gardening last weekend which I thought was just muscle strain. I measured my blood pressure at home once with my partner’s cuff last night; it read high (it said about 150/95) which made me worried.

I haven't had any severe headaches, no vomiting, no severe visual disturbance, and no pain under my ribs. I haven't had any vaginal bleeding or reduced fetal movements. This is my first baby; my pregnancy until now has been uncomplicated apart from some nausea in the first trimester.

My Medical Background

• Past medical history: No chronic illnesses; childhood asthma (infrequent, not using inhaler now)
• Previous pregnancies: None (primigravida)
• Medications: Folic acid and iron supplement; paracetamol occasionally for headaches
• Allergies: None known
• Social: Lives with partner, non-smoker, drinks coffee (1–2 cups/day), no recreational drugs
• Family history: Mother had "high blood pressure" in pregnancy; father treated for hypertension in his 50s

What I Think & Worry About

• I am worried this high blood pressure might harm my baby.
• I worry I might need medication or to be admitted to hospital.
• I am anxious because my mother also had high blood pressure in pregnancy and she was quite unwell.

If You Ask Me About Other Symptoms...

• Headaches: "Mild frontal headaches on and off for 2 days, better with paracetamol."
• Vision: "No blurring or flashing lights — vision is the same as before pregnancy."
• Urine: "I haven't had pain peeing; once I noticed my urine looked a little foamy yesterday but I thought it was because I was dehydrated."
• Swelling: "Mild swelling in both ankles today, not puffy hands or around my face."
• Chest symptoms: "No chest pain or breathlessness, just the usual tiredness.")
• Recent infections/meds: "I had a sore throat two weeks ago and took some over-the-counter cold medicine; otherwise nothing else."
• Home BP readings: "Only checked once last night — it read about 150/95 on my partner's cuff."

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Clinical Summary

Examination

• General: Alert, comfortable at rest
• Blood pressure: 150/95 mmHg (right arm, seated) — repeat after 15 minutes: 148/94 mmHg
• Heart rate: 86 beats per minute
• Respiratory rate: 16 breaths per minute
• Temperature: 36.7°C
• Oxygen saturation: 98% on air
• Weight/BMI: weight 78 kg, height 1.64 m → BMI 29.0 kg/m2
• Peripheral oedema: mild bilateral ankle swelling
• Abdominal / obstetric: Fundal height consistent with dates; fetal heart rate audible, regular
• Neurological/other: No focal neurology; reflexes normal

Investigations

• Urine dipstick: trace protein (1+) (interpretation: may be physiologic; needs quantification)
• Urine protein:creatinine ratio (PCR): 18 mg/mmol (interpretation: below threshold for significant proteinuria)
• Full blood count: Hb 120 g/L; platelets 230 x10^9/L (normal)
• Urea & electrolytes: Creatinine 62 μmol/L (normal)
• Liver function tests: ALT 20 U/L (normal)
• Urine culture: pending (no dysuria symptoms)
• Ultrasound (dating/growth scan): fetal growth and amniotic fluid within expected range for 20+5 weeks (planned if abnormal follow-up)

Diagnosis

Primary: Gestational hypertension (new-onset hypertension after 20 weeks' gestation without significant proteinuria or end-organ dysfunction). Evidence: persistent elevated BP readings ~150/95 mmHg after 20 weeks, urine PCR 18 mg/mmol (below threshold for pre-eclampsia), normal platelets/LFT/renal function, mild peripheral oedema only.

Differential diagnoses:

• Chronic (pre-existing) hypertension: less likely because there is no history of hypertension pre-pregnancy and BP was not raised earlier in pregnancy or at booking.
• Preeclampsia: less likely currently because there is no significant proteinuria (PCR low) and no maternal organ dysfunction (normal LFTs, creatinine, platelets); must remain under surveillance as it can develop.
• White coat hypertension: possible contributor (BP elevated in clinic) but home reading also suggested elevated BP, and repeat clinic BP remained high.

Management

• Confirm diagnosis with repeated clinic BP measurements and consider ambulatory/home BP monitoring.
• Quantify proteinuria (done: urine PCR 18 mg/mmol) and check labs (CBC, LFTs, renal function) — results currently reassuring.
• Initiate close follow-up in antenatal clinic with repeat BP checks (same arm, seated, rest for 5 min) and repeat urine PCR if BP remains elevated.
• Start antihypertensive therapy if persistent BP ≥150/95 mmHg (or per local protocol): oral labetalol as first-line (discuss dose starting and titration) or oral nifedipine MR if labetalol contraindicated; consider immediate therapy if symptomatic or sustained higher readings.
• Fetal surveillance: baseline fetal growth assessment and plan for serial growth scans and antenatal fetal monitoring as indicated.
• Advise on warning signs requiring urgent review: severe headache not relieved by paracetamol, visual disturbances, epigastric pain, vomiting, sudden swelling, reduced fetal movements.
• Avoid NSAIDs; review other medications; arrange obstetric review and shared care with hypertension/pregnancy clinic.
• Plan postpartum follow-up: recheck BP after 6 weeks postpartum as hypertension may persist and require long-term management.

Key Learning Points

• New hypertension after 20 weeks without proteinuria or organ dysfunction is gestational hypertension; it requires careful surveillance because preeclampsia can develop later.
• Diagnosis depends on accurate, repeated blood pressure measurement and objective quantification of proteinuria (urine PCR/24-hour protein) plus assessment for end-organ dysfunction.
• Management includes confirming persistently raised BP, deciding on antihypertensive treatment based on thresholds and symptoms, coordinating obstetric follow-up and fetal surveillance, and counseling about warning signs and postpartum follow-up.