HYPERTENSION AND PREGNANCY

Prepared and Presented by :-

DR.V.JAGANNATHAN

I was a medical consultant and Physician to a maternity Hospital and have had lot of opportunities to handle so many cases of Hypertension complicating Pregnancy and GDM apart from many other medical conditions complicating Pregnancy.

This is my small contribution on Hypertension and pregnancy.I am sure that our OG collegues will be more well versed and will be able to enrich more on my presentation.

I expect and request all our OG specialists and for that matter all our classmates who are all doing Obstetrics practice to contribute and enrich my presentation

JAGANNATHAN

Hypertension, can be a serious problem for anyone if left untreated. In pregnancy, hypertension can lead to life-threatening complications.

Between 8% and 16% of all pregnant women experience high blood pressure during their pregnancy. Hypertension in pregnancy can occur up to 6 weeks after delivery. The condition can negatively impact both a mother’s and her baby’s health during and after pregnancy, putting the mother at risk for a range of complications, including heart disease, seizures, and coma, and the baby at risk for premature birth and even death.

Anyhow hypertension during pregnancy can be managed with blood pressure medication and other treatments. However, for more serious related conditions, such as preeclampsia/eclampsia, women may need to be hospitalized or closely monitored

HYPERTENSION IN PREGNANCY

Hypertension in pregnancy is diagnosed when a pregnant person has a blood pressure reading that is 140/90 or higher on two different occasions. Readings of 140/90 or higher are considered mild Hypertension and  those over 160/110 are considered severe Hypertension.

Types of hypertension during pregnancy

There are several different types of hypertension that occur during pregnancy. If left untreated, some types may lead to more serious complications. These conditions include:

Chronic hypertension, which is simply another name for high blood pressure that was present before a person became pregnant or if the condition developed in the first half of her pregnancy (before 20 weeks).

Gestational hypertension, when a pregnant person develops high blood pressure during the second half of her pregnancy (after 20 weeks).

Preeclampsia, when high blood pressure develops after 20 weeks of pregnancy. One common sign of preeclampsia is a finding of protein in the mother’s urine. Preeclampsia puts stress on the heart and other organs and can cause serious complications, such as restricting the blood supply to the placenta, damaging the liver and kidneys, or causing fluid to accumulate in the lungs. The presence of protein in urine is a sign of kidney dysfunction. Preeclampsia can be mild or severe, but even mild preeclampsia can quickly progress to more severe complications. Preeclampsia often requires early delivery.

Eclampsia, a rare but serious, life-threatening complication of preeclampsia that occurs when a pregnant woman has seizures because of untreated or undertreated preeclampsia; this requires emergency medical attention.

HELLP syndrome (preeclampsia with Hemolysis, Elevated Liver enzyme levels, and Low Platelet levels), a very rare type of preeclampsia. This is a serious condition that causes liver damage and destroys red blood cells and platelets Most women with HELLP syndrome will need to deliver their baby earlier than expected.

Eclampsia and HELLP syndrome are both medical emergencies. Preeclampsia can also be a medical emergency, depending on how severe it is. They may be life-threatening to a pregnant woman and her baby if they aren’t treated immediately.

It’s important to note that because chronic or gestational hypertension can develop into preeclampsia/eclampsia, a pregnant woman’s blood pressure will be monitored at every prenatal appointment and her urine will be checked often for protein.

PATHOPHYSIOLOGY OF PIH

The mechanism responsible for the pathogenesis of pregnancy induced hypertension has not been fully understood. The initiating event appears to be a reduction in the placental perfusion as a result of cytotrophoblast invasion into the spiral arteries. Placental ischemia is considered to be responsible for a widespread activation and dysfunction of the maternal vascular endothelium causing enhanced formation of endocrine and thrombaxane, increased vascular sensitivity to Angiotensin-ii and decreased formation of vasodialators like nitric oxide and prostacycline.

These factors are considered to be responsible fot the increase in BP during Pregnancy.But still lots of reasearch are going on in this field.

Complications are associated with high blood pressure during pregnancy.

A woman with hypertension during pregnancy is at greater risk of:

Placental abruption (Premature separationl)

Delivering prematurely (before 37 weeks)

Having to have a Cesarean section

Having a low-birthweight baby

Having her baby admitted to the neonatal intensive care unit

Having a stillborn baby (fetal death)

Having her baby die within the first week of life

Having a stroke

Developing heart disease shortly after delivering the baby

Developing heart disease, diabetes, or high cholesterol levels later in life

In most cases, delivering a baby will improve symptoms of preeclampsia/eclampsia and HELLP syndrome. However, some women experience complications of preeclampsia/eclampsia in the days after delivering a baby, or they may even develop the condition up to 6 weeks after childbirth.

Causes and Risk Factors of hypertension during pregnancy

Certain risk factors increase the likelihood that a woman will develop high blood pressure during pregnancy, including:

Obesity

Diabetes

Chronic hypertension prior to pregnancy

Certain pre-existing medical conditions, like autoimmune diseases

Advanced age (35 or older)

Being pregnant for the first time Primi

Multiple gestation (twins or more)

High cholesterol levels

A personal or family history of high blood pressure during pregnancy

In some cases we don’t know why some pregnant women develop preeclampsia/eclampsia or HELLP syndrome.

Lowering the risk of preeclampsia before pregnancy

If the patient has one of the conditions listed above, she may be at higher risk for developing preeclampsia.

There are certain things that can be done before pregnancy to lower the chance of preeclampsia.

A pre-conception visit with an experienced medical team is an opportunity to understand how to best manage existing conditions and risks during pregnancy.

Providing drugs safe for and during Pregnancy. Frequent monitoring of BP. Recommend losing weight and regular exercise before pregnancy.

 

Symptoms of high blood pressure during pregnancy

Many pregnant people with high blood pressure don’t experience symptoms. However, some warning symptoms can be present with preeclampsia:

 Headaches

Pedal oedema

Swollen face or hands

Blurring of  vision

Temporary blindness

Light sensitivity and some times photophobia

Pain in the upper right hypochondrium

Haemeturea

Severe abd. pain

Dyspnoea

Pregnant women with preeclampsia or eclampsia may experience:

• Seizures
• Stroke
• Coma

Pregnant women with HELLP syndrome may experience:

• A feeling of malaise or of being unwell
• Pain in the upper right hypochondrium (from swelling of the liver or bleeding in the liver)
• Vomiting

DIAGNOSIS

A pregnant woman is diagnosed with hypertension if her blood pressure readings are higher than 140 systolic or 90 diastolic on two separate occasions, typically during her visit with her Ob/Gyn provider. If the reading is 160/110 or higher, the woman is diagnosed with severe high blood pressure.

Medical history is important. to know, for instance, whether the patient  had high blood pressure before becoming pregnant or

 If a family member was diagnosed with high blood pressure, preeclampsia/eclampsia, or HELLP syndrome during a previous pregnancy.

Tests may include:

Blood tests, which may show that the liver or kidneys are not functioning normally, a sign of preeclampsia or HELLP syndrome. Tests can also show that red blood cells have hemolysed and have leaked hemoglobin into the blood, a sign of HELLP syndrome. These tests may need to be checked frequently.

A urine test, which looks for protein in the urine. High levels of protein can indicate preeclampsia, although not all pregnant people with preeclampsia will have protein in their urine.

TREATMENT

Low-dose aspirin (81 mg) is recommended for pregnant people at higher risk for preeclampsia. This is usually started at 12-14 weeks and continued until the last month of pregnancy.

Pregnant women with mild gestational or chronic hypertension may not be kept under observation by monitoring  their blood pressure and urine to ensure the condition doesn’t advance to severe hypertension, preeclampsia/eclampsia, or HELLP syndrome.

In some cases, pregnant women with chronic hypertension who took blood pressure medications before becoming pregnant may continue to take them during their pregnancy.

 However, certain drugs, including ACE inhibitors and ARBs, are unsafe and contra indicated during pregnancy as they are considered to be teratogenic to the foetus

Instead anti hypertensives  that are safe for pregnancy have to be prescribed. Some examples are

A beta blocker like labetalol,

A calcium channel blocker like nifedipine,

A vasodialator like hydralazine, and

A diuretic like thiazide .

Treatment of chronic hypertension in pregnancy is important and may prevent preeclampsia.

For women with preeclampsia, delivering the baby when the fetus is mature (between 34 and 37 weeks) is the most common and effective way to improve symptoms. For many women, preeclampsia disappears within 6 weeks after delivery.

Doctors may monitor A pregnant woman with preeclampsia may be monItored at  home or admitted  to the hospital for evaluation and treatment that may include:

• Monitoring  blood pressure and urine frequently
• Monitoring  liver health and platelet counts to see if HELLP syndrome has developed
• Monitoring the fetus’s growth
• Prescribing anti hypertensive drugs, which may be delivered intravenously or by mouth in the hospital
• Prescribing anti-seizure medication (magnesium sulfate), which may prevent or treat eclampsia
• Giving steroid injections to help a baby’s lungs develop more quickly, since early delivery may become necessary

For women with HELLP syndrome, the treatment may include

Taking medications to reduce blood pressure.                                                         In certain cases, a blood transfusion may be necessary.                                            Ultimately, however, the only way to manage HELLP is to deliver the baby, which may be earlier than expected.                                                                              Most women experience symptom improvement within three days of delivery

Opinion and enrichment suggestion are welcome from the Experts in the field of OG and other specialists

JAGANNATHAN