Table 1.

Secondary causes of hypertension in pregnancy

AetiologyClinical assessment in pregnancyDiagnosis and management in pregnancy
CoarctationUpper limb hypertension
Radio-/brachiofemoral delay
Systolic murmur from associated bicuspid aortic valve
Turner’s syndrome phenotype
Echo/MRI
Chronic kidney diseaseSymptoms: oedema, arthralgia, rash, hair loss, visible haematuria, recurrent UTI and family history
Renal bruit
Urine dip
Quantification of proteinuria
Serum creatinine
Kidney ultrasound for morphology and symmetry
>2+ blood or protein on urine dip warrants further assessment
uACR >8 mg/mmol and uPCR >30 mg/mmol are abnormal in pregnancy
Creatinine >77 μmol/L is abnormal in pregnancy6
Imaging of renal vasculature usually delayed until postpartum, provided safe blood pressure control can be achieved
ACEi and ARB contraindicated due to fetotoxicity
Hyperaldosteronism / Conn’s syndromeHypokalaemia
Treatment resistance
Gestational increases in renin and aldosterone prevent accurate interpretation
Formal diagnosis usually delayed until postpartum, provided safe blood pressure control can be achieved
Spironolactone contraindicated due to anti-androgenic fetal effects
Limited data on the use of amiloride and eplerenone in pregnancy
Cushing’s syndromePhenotype: thin skin, bruising, striae, fat distribution, proximal weakness, elevated plasma glucose/early diagnosis of GDMPhenotype overlaps with normal pregnancy
Gestational increase in cortisol prevents accurate interpretation
Formal diagnosis usually delayed until postpartum, provided safe blood pressure control can be achieved
Phaeochromocytoma/paragangliomaHeadache, sweating, tachycardia, anxiety
Episodic hypertension
Urine and plasma metanephrine concentrations unaffected by pregnancy.
Non-contrast MRI
MIBG contraindicated due to placental transfer; maternal benefit of alpha-blockade outweighs risk; labetalol has insufficient alpha-blockade in isolation
HyperparathyroidismNausea/hyperemesis, constipation, low mood, polyuria
Serum calcium and PTH
Significant maternal (pancreatitis, kidney injury, nephrolithiasis, pre-eclampsia) and fetal (miscarriage, intrauterine death) risks warrant early diagnosis and support definitive surgical treatment in pregnancy
  • ACEi = angiotensin converting enzyme inhibitor; ARB = angiotensin receptor blocker; Echo = echocardiography; GDM = gestational diabetes mellitus; MIBG = radioactive iodine metaiodobenzylguanidine; MRI = magnetic resonance imaging; PTH = parathyroid hormone; uACR = urinary albumin:creatinine ratio; uPCR = urinary protein:creatinine ratio; UTI = urinary tract infection.