ANSWER 64
This woman has accelerated hypertension, defined by the retinal papilloedema (grade IV
retinopathy), and renal failure. At this stage it is not clear whether the renal failure is chronic,
acute, or a mixture of acute on chronic.
Accelerated hypertension can occur as the initial phase of hypertension or as a develop-
ment in chronic hypertension, and can be a feature of either primary (essential) or sec-
ondary hypertension. In this case it may have been superimposed on hypertension after
the birth of her third baby, but the information is not available.
The immediate management is to:- lower the blood pressure at a gradual rate over 24 h. Rapid reduction to normal
figures can be extremely dangerous as the sudden change can precipitate arterial
thrombosis and infarction in the brain, heart and kidneys and occasionally other
organs. The details of the treatment will vary; either oral or intravenous
antihypertensive drugs may be used. - control the fluid intake according to fluid loss (urine plus insensible losses) and
observe closely for the development of pulmonary oedema. Should that develop
then dialysis will be urgently required as she will not respond to diuretics owing to
the renal failure.
! Management
The important question with regard to the renal failure is whether this is developing in kid-
neys chronically damaged by hypertension or some other undiagnosed renal disease, and
how much of it is reversible. Renal ultrasound, which is swift and non-invasive, will give
an accurate assessment of kidney size. In this case they were reduced at 8 cm, and end-
stage renal failure followed. The impaired visual acuity recovered completely. It is possible
that a window of opportunity to treat her hypertension at an earlier stage was lost when
she presented with the headaches but her blood pressure was not measured; accelerated
hypertension can destroy kidney function in a matter of days or weeks.
Accelerated hypertension was previously called malignant hypertension because before the
development of effective antihypertensive drugs its mortality approached 100 per cent. This
is no longer the case, and, furthermore, it gives patients the unfortunate and false impres-
sion that they have a form of cancer. The term should therefore no longer be used.
- Intrapartum hypertension must be followed up as it may indicate underlying renal dis-
ease and the beginning of chronic hypertension, primary or secondary. - Patients with headache must always have their blood pressure checked.
- Avoid the term ‘malignant hypertension’.