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ob.gestational-hypertension.v1

Gestational Hypertension (without severe features)

obstetricssubacutechronicadultpregnancyoutpatientinpatient
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PLANNED dossier — no manifest, atoms, package, or design brief on disk yet. Drug regimen captures CHAP (target <140/90) + ACOG 767 (severe HTN within 30–60 min) + USPSTF 2021 aspirin prophylaxis + safe-pregnancy agents (labetalol, nifedipine ER, methyldopa) and explicitly forbids ACEi/ARB/renin inhibitors. Branches cleanly to ob.pre-eclampsia.core.v1 if proteinuria UPCR ≥0.3 OR any severe feature emerges; ~25–50% progression rate from GHTN to PE. Action plan covers home BP, severe headache/visual changes, decreased fetal movement, RUQ pain, sudden swelling. GAPS — no RxCUIs (validate via npm run research:rxnav:validate); no GHTN-specific registry workup adapter (uses workup.preeclampsia + standard panels); no test_files; LOINC list partial; aspirin prescription start window (12 vs 16 wk) deliberately conservative — verify against latest USPSTF/ACOG update before promotion. Deepened 2026-05-14 (shard-5-obped-id depth-pass-1): added co-located _briefs/ob.gestational-hypertension.v1.depth.md companion (alongside existing 2026-04-27 brief) + _research-bundles/ob.gestational-hypertension.v1.md. Phenotype matrix surfaced via depth brief: 8-axis cross-product (gestational timing early <34 wk / late ≥34 wk × severity mild / severe ≥160/110 × proteinuria status × severe-features status × pre-existing comorbidity (none / chronic HTN CHAP-eligible / DM / CKD) × parity × fetal load × superimposed-PE risk profile). First-class TS field for phenotype matrix remains schema-blocked. Refined outpatient setting playbook: added 3-day home BP self-monitoring at GHTN diagnosis, ambulatory BP monitoring (ABPM ≥135/85 per ISSHP 2024) for white-coat HTN rule-out, sFlt-1/PlGF ratio at diagnosis per local protocol (PROGNOSIS 2016 cutoff ≤38 NPV 99.3% / PARROT 2019), antihypertensive titration to labetalol 600 mg TID OR nifedipine ER 120 mg/d OR methyldopa 1.5 g TID, ASPRE-criterion aspirin if not already on (USPSTF 2021), postpartum BP self-monitoring × 6-12 wk (daily × 1 wk → weekly), 6-week postpartum visit, 6-month CV-risk screening (BP/lipids/glucose/BMI/UACR per AHA 2021), lifelong CV-disease counseling, next-pregnancy aspirin counselling at 6-week postpartum visit. Added 6 severity triggers: bp_sustained_above_160_110 (severe — sustained ≥160/110 → IV antihypertensive within 30-60 min + admit for severe-feature workup; PE-engine routing on positive workup), severe_features_emergence (severe — any single severe feature → reclassify to PE with severe features, carryover handoff to ob.pre-eclampsia.core.v1, magnesium 4-6 g IV load per Magpie 2002), magnesium_prophylaxis_required (severe — severe features OR eclampsia → 4-6 g IV load + 1-2 g/h × 24 h post-delivery; calcium gluconate for Mg toxicity reversal), fetal_growth_restriction (severe — EFW <10th + AC <10th + abnormal umbilical artery Doppler → MFM consult + weekly growth US with Doppler/MCA + delivery timing per ACOG/SMFM), postpartum_severe_hypertension (severe — BP ≥160/110 within 6 wk postpartum → ED for IV antihypertensive + consider magnesium prophylaxis; routes to cardio.htn.core.v1 if BP persists >12 wk postpartum), chap_eligible_chronic_htn_overlap (severe — chronic HTN diagnosed pre-pregnancy or in first 20 wks → start antihypertensive at sustained ≥140/90 per CHAP 2022; aspirin 81 mg from 12 wk per USPSTF 2021; superimposed PE risk ≈18-25% absent prophylaxis). Appended 7 canonical PMIDs (CHIPS canonical 25602002 alongside legacy 25629739, ASPRE 28657417, HYPITAT-II 25841731, PARROT 30995940, PROGNOSIS 26735990, USPSTF 34581729, Magpie 12057549) bringing evidence.pmids from 7 to 14. Updated primary_guideline to cite ACOG 222 (reaff 2024) + ACOG 767 (2019) + ACOG 203 + ISSHP 2024 (supersedes 2021) + CHAP + CHIPS + USPSTF 2021 + ASPRE + HYPITAT-II + PARROT + PROGNOSIS + Magpie + NICE NG133 (2023) + AHA 2021. Bayesian linkage (documented in co-located _briefs/ob.gestational-hypertension.v1.depth.md): sFlt-1/PlGF ratio ≤ 38 NPV ~99.3% at GHTN diagnosis as T_test rule-out (PROGNOSIS 2016 + PARROT 2019); ratio > 38 LR+ ≈ 7-9 for PE delivery within 1 wk → intensified surveillance + admit-low-threshold; ASPRE 2017 first-trimester screening derives the pre-test priors; T_treat = PO antihypertensive at sustained BP ≥140/90 per CHAP NEJM 2022 (18% relative risk reduction in adverse pregnancy outcomes, NNT ~14-15); cross-dossier routing to ob.pre-eclampsia.core.v1 (proteinuria or severe-feature emergence), cardio.htn.core.v1 (chronic HTN emerging postpartum >12 wk OR CHAP-eligible chronic HTN overlay), ob.postpartum-hemorrhage.core.v1 (delivery complications — avoid methylergonovine for PPH due to HTN; use carboprost or oxytocin), endo.gestational-diabetes.chronic.v1 (GDM overlay increases PE risk via inflammatory/endothelial overlap). Prehospital recognition encoded via outpatient → ED escalation triggers (sustained_severe_htn_160_110_in_ghtn + bp_sustained_above_160_110 + progression_to_pe_severe_features); a first-class "prehospital" DossierSetting value is schema-blocked. CRADLE-3 Lancet 2019 (PMID 30638537) anchors the low-resource / prehospital vital-sign-monitoring evidence base for the parallel pre-eclampsia engine — applies indirectly to GHTN via outpatient self-monitoring framework. Fluids field intentionally NOT encoded (GHTN management is fluid-neutral; PE-restrictive 80 mL/h pattern only emerges if reclassified to PE). Removed 2026-05-26: DELIVER 36027571 / POINT 29766750 / REDUCE 23900119 PMIDs were copy-paste-template carryover from 2026-04-27 baseline, off-domain for GHTN (DELIVER=HF SGLT2i, POINT=stroke antiplatelet, REDUCE=Swaziland biomass-anaemia) — removed from evidence.pmids per the orchestrator-gated removal pass (docs/superpowers/notes/2026-05-26-citation-deep-audit.md). ProMISe 25776532 retained.

Entry points (4)

  • vital_abnormality
    New BP ≥140/90 after 20 weeks (no prior chronic HTN)
    new_bp_140_90_after_20w
  • vital_abnormality
    BP ≥160/110 in pregnancy (route urgently — severe HTN)
    isolated_severe_htn_pregnancy
  • history
    Prior pre-eclampsia or gestational HTN — high-risk surveillance
    prior_pe_or_ghtn
  • demographic
    Risk profile triggers aspirin prophylaxis (chronic HTN, T1/T2DM, CKD, autoimmune, multiples)
    high_risk_for_pe

Required inputs (15)

  • gestational_agerequired
    demographic • used at CONTEXT
    GHTN defined as new HTN AFTER 20 weeks; drives delivery timing (≥37+0)
  • sbprequired
    vital • used at RED_FLAGS
    Severity stratification: 140–159 vs ≥160; ACOG 767 trigger
  • dbprequired
    vital • used at RED_FLAGS
    90–109 non-severe vs ≥110 severe
  • urine_proteinrequired
    lab • used at INITIAL_WORKUP
    UPCR or 24-h urine — distinguishes GHTN from pre-eclampsia
  • plateletsrequired
    lab • used at INITIAL_WORKUP
    <100K = severe feature → reclassify to PE
  • creatininerequired
    lab • used at INITIAL_WORKUP
    Cr ≥1.1 or doubling = severe feature
  • ast_altrequired
    lab • used at INITIAL_WORKUP
    AST/ALT ≥2× ULN = severe feature
  • severe_headacherequired
    symptom • used at CONTEXT
    Severe-feature symptom = reclassification trigger
  • visual_disturbancerequired
    symptom • used at CONTEXT
    Severe-feature symptom (scotomata, blurred vision)
  • epigastric_ruq_painrequired
    symptom • used at CONTEXT
    Severe-feature symptom (HELLP / liver capsule stretch)
  • decreased_fetal_movementrequired
    symptom • used at CONTEXT
    Fetal compromise — triggers NST/BPP and possible delivery
  • chronic_htnrequired
    history • used at CONTEXT
    Distinguishes GHTN from chronic / superimposed
  • prior_pre_eclampsiarequired
    history • used at CONTEXT
    Recurrence ≥20%; aspirin indication
  • current_meds
    medication • used at CONTEXT
    ACEi/ARB teratogen check; aspirin status; CCB choice
  • fetal_growth_us
    imaging • used at MONITORING
    Serial growth scans for FGR (gestational HTN doubles FGR risk)

12-phase flow (12)

  1. 1FRAME
    Confirm gestational HTN (new HTN ≥140/90 after 20 wk, NO proteinuria, NO severe features) vs chronic HTN vs pre-eclampsia vs superimposed — ACOG 2020 (PB 222); ISSHP 2021
    inputs: gestational_age, sbp, dbp, chronic_htn
    advance: classification assigned
  2. 2ENTRY
    Capture trigger (new HTN reading, prenatal screen, prior PE history, aspirin candidacy) — ACOG 2020 (PB 222); USPSTF 2021
    inputs: gestational_age
    advance: trigger documented
  3. 3CONTEXT
    Severe-feature symptom screen, baseline BP, prior PE history, aspirin status, fetal status — ACOG 2020 (PB 222); ISSHP 2021
    inputs: severe_headache, visual_disturbance, epigastric_ruq_pain, decreased_fetal_movement, chronic_htn, prior_pre_eclampsia, current_meds
    advance: severe-feature screen + fetal status documented
  4. 4RED_FLAGS
    BP ≥160/110 sustained × 15 min → IV antihypertensive within 30–60 min (ACOG 767); any severe feature → reclassify to ob.pre-eclampsia.core.v1
    inputs: sbp, dbp
    advance: severe HTN treated AND severe features ruled out (or branched)
  5. 5INITIAL_WORKUP
    CBC, CMP (Cr, AST/ALT), LDH, UPCR or 24-h urine, uric acid; fetal monitoring (NST); growth US — ACOG 2020 (PB 222)
    inputs: platelets, creatinine, ast_alt, urine_protein
    actions: panel.cbc, panel.lft, panel.renal, panel.ua
    advance: PE labs negative; UPCR <0.3; no severe features
  6. 6BRANCHING_WORKUP
    If proteinuria positive OR any severe feature → branch to ob.pre-eclampsia.core.v1; if FGR on US → MFM consult — ACOG 2020 (PB 222); ISSHP 2021
    actions: workup.preeclampsia
    advance: branch decision made
  7. 7DIFFERENTIAL
    Phenotype: gestational HTN, transient HTN of pregnancy, masked/white-coat HTN, chronic HTN missed pre-pregnancy, pre-eclampsia, superimposed PE — ISSHP 2021; ACOG 2020 (PB 222)
    advance: phenotype assigned
  8. 8RISK_STRATIFICATION
    Severity tier (non-severe 140–159/90–109 vs severe ≥160/110) — ACOG 2020 (PB 222); progression risk to PE (~25–50%) — ISSHP 2021; FGR risk; delivery timing (target 37+0) — ACOG 2020 (PB 222)
    inputs: sbp, dbp, gestational_age
    actions: calc.map
    advance: severity + delivery timing decided
  9. 9TREATMENT
    CHAP target <140/90 with PO labetalol or nifedipine ER (or methyldopa second-line); IV labetalol/hydralazine/PO nifedipine IR for sustained ≥160/110; aspirin 81 mg daily 12–28 wk for high-risk (USPSTF 2021); deliver at 37+0 if non-severe stable; AVOID ACEi/ARB/renin inhibitors
    inputs: sbp, dbp, gestational_age
    advance: BP at goal + medication initiated + delivery plan made
  10. 10DISPOSITION
    Outpatient surveillance for non-severe stable; antepartum admission for hard-to-control or near term; L&D for severe HTN unresponsive or any severe feature — ACOG 2020 (PB 222)
    advance: level of care assigned
  11. 11MONITORING
    BP twice weekly (or daily home BP) — CHAP (Tita NEJM 2022); UPCR weekly; CBC/LFT/Cr q1–2 wk; fetal kick counts daily; NST/BPP q1 wk after 32 wk; growth scan q3–4 wk — ACOG 2020 (PB 222)
    inputs: sbp, dbp, urine_protein, platelets
    actions: panel.cbc, panel.lft, panel.renal
    advance: no progression to PE; mother + fetus stable
  12. 12FOLLOWUP
    Postpartum BP at 3–7 d, 1–2 wk, 4–6 wk (HTN often persists 6–12 wk); aspirin from 12 wk in next pregnancy; lifelong CV risk follow-up (GHTN doubles future CV risk per AHA 2021)
    advance: postpartum BP normalized OR transitioned to chronic HTN management