Postpartum subarachnoid hemorrhage – questions on gestational hypertension diagnosis and treatment threshold: A case report

Hypertensive disorders of pregnancy (HDP) are a leading cause of morbidity and mortality for pregnant patients, but how aggressively to address non-severe hypertension in pregnancy remains controversial. The American College of Obstetrics and Gynecology (ACOG) currently recommends a blood pressure treatment threshold of 140/90 mmHg during pregnancy. However, 2017 American College of Cardiology/American Heart Association (ACC-AHA) guidelines define stage 1 hypertension by blood pressures of >130/80 mmHg within the general population. There is now an understudied population of pregnant patients considered to have stage 1 hypertension by ACC-AHA guidelines but who do not meet the treatment threshold by ACOG's standards. This article presents a patient who met ACC-AHA-defined stage 1 hypertension throughout her pregnancy and went on to develop severe hypertension and a postpartum subarachnoid hemorrhage (SAH) secondary to venous hemorrhage. She presented to the emergency department 17 days postpartum complaining of an extreme headache and with a blood pressure of 230/125 mmHg. Magnetic resonance imaging showed SAH in the parietal region adjacent to the superior sagittal sinus. Magnesium and labetalol were administered followed by a clevidipine drip. The patient was continued on antihypertensives and made a full recovery. This article's objective is to draw attention to the urgent need for increased clarity of practice guidelines, consensus between societies, and further study of peripartum health outcomes for pregnant patients defined as having stage 1 hypertension by 2017 ACC-AHA criteria.