Unspecified maternal hypertension, first trimester
ICD-10 O16.1 is a billable code used to indicate a diagnosis of unspecified maternal hypertension, first trimester.
Unspecified maternal hypertension in the first trimester refers to elevated blood pressure readings in pregnant women during the initial 13 weeks of gestation. This condition is characterized by systolic blood pressure readings of 140 mmHg or higher and/or diastolic readings of 90 mmHg or higher, without a clear diagnosis of gestational hypertension or pre-existing hypertension. The first trimester is a critical period for maternal and fetal health, and hypertension can lead to complications such as preeclampsia, placental abruption, and fetal growth restriction. Diagnostic workup typically includes a thorough medical history, physical examination, and monitoring of blood pressure over time. Additional tests may include urinalysis to check for proteinuria, blood tests to assess kidney function, and fetal monitoring to ensure the well-being of the fetus. Proper management and monitoring are essential to mitigate risks associated with hypertension during pregnancy.
Documentation must include detailed blood pressure readings, maternal history, and any symptoms related to hypertension.
Initial prenatal visits where hypertension is identified, follow-up visits for monitoring blood pressure.
Consideration of lifestyle factors, medication history, and family history of hypertension.
High-risk pregnancy documentation must include comprehensive assessments of maternal and fetal health, including ultrasound findings.
Management of hypertensive disorders in high-risk pregnancies, coordination of care with specialists.
Increased surveillance for complications and detailed documentation of interventions.
Used during initial prenatal visits where hypertension is identified.
Document blood pressure readings, maternal history, and any relevant symptoms.
Obstetricians should ensure thorough documentation to support the diagnosis.
Document all blood pressure readings, any symptoms experienced by the patient, and a detailed medical history that includes any previous hypertension or related conditions.
