RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2013
Pregnancy-induced hypertension without significant proteinuria (O13), Pregnancy-induced hypertension with significant proteinuria (O14), Pre-existing hypertension with associated proteinuria (O11), Pre-existing hypertension complicating pregnancy, childbirth and the puerperium (O10), Eclampsia (O15)
general information
Short description
Approved
minutes of the meeting of the Expert Commission
on health development issues of the Ministry of Health of the Republic of Kazakhstan
Name:
Arterial hypertension in pregnant women- The criteria for diagnosing arterial hypertension in pregnant women are an increase in systolic blood pressure≥140 mmHg. Art. or diastolic blood pressure≥90 mm Hg. Art. Elevated blood pressure should be confirmed by two measurements using a mercury sphygmomanometer (V tone is used to record diastolic blood pressure) in a sitting position or an aneroid device. It is possible to measure blood pressure while lying on your left side. Only validated ambulatory blood pressure monitors and devices should be used (www.dableducational.org). Ambulatory BP monitoring results are more predictive of outcomes than office BP measurements.
Protocol code: 010
Abbreviations used in the protocol:
AH - arterial hypertension;
BP - blood pressure;
ACS - associated clinical conditions;
ALT - alanine aminotransferase;
AO - abdominal obesity;
AST - aspartate aminotransferase;
HC - hypertensive crises;
LVH - left ventricular hypertrophy;
DBP - diastolic blood pressure;
DLP - dyslipidemia;
LVMI - left ventricular myocardial mass index;
BMI - body mass index;
MAU - microalbuminuria;
MI - cerebral stroke;
INR - international normalized ratio;
MS - metabolic syndrome;
IGT - impaired glucose tolerance;
OT - waist circumference;
OXC - total cholesterol;
POM - target organ damage;
PTI - prothrombin index;
PE - preeclampsia;
SBP - systolic blood pressure;
DM - diabetes mellitus;
GFR - glomerular filtration rate;
ABPM - 24-hour blood pressure monitoring;
CVD - cardiovascular diseases;
TIA - transient ischemic attack;
TSH - glucose tolerance test;
USDG - Doppler ultrasound;
RF - risk factors;
CAH - chronic arterial hypertension;
HDL cholesterol - high density lipoprotein cholesterol;
LDL cholesterol - low density lipoprotein cholesterol
Date of protocol development- year 2013
Protocol users: cardiologists, therapists, obstetricians-gynecologists, GPs.
Disclosure of no conflict of interest: No
Classification
Clinical classification:
Hypertensive conditions during pregnancy are represented by a group of diseases:
Existing before pregnancy;
Developed directly in connection with pregnancy.
Classification of hypertension during pregnancy - Mild (140-159/90-109 mm Hg) and severe (≥160/110 mm Hg) hypertension are distinguished (in contrast to the recommendations of the European Society of Hypertension/European Society of Cardiology and others recommendations providing for the identification of different degrees of hypertension.
Arterial hypertension in pregnant women is a heterogeneous condition that includes the following forms:
2. Gestational hypertension
3. Arterial hypertension present before pregnancy and combined with gestational hypertension and proteinuria
4. Unclassified hypertension.
1. Arterial hypertension present before pregnancy
It is observed in 1-5% of pregnant women. The diagnostic criterion is an increase in blood pressure ≥140/90 mmHg. Art. before pregnancy or in the first 20 weeks. pregnancy. Hypertension usually persists for more than 42 days after delivery and may be accompanied by proteinuria.
In women with undiagnosed hypertension, blood pressure may be normal at the beginning of pregnancy due to its physiological decrease in the first trimester. In such cases, arterial hypertension detected on later pregnancy, can be mistakenly regarded as gestational, and the return of blood pressure to previous values as preeclampsia.
2. Gestational hypertension- Gestational hypertension, accompanied and not accompanied by proteinuria, is an increase in blood pressure associated with pregnancy itself. Complicates the course of pregnancy in 6-7% of cases. Preeclampsia is a pregnancy-specific syndrome that develops at 21 weeks of gestation. or more and is characterized by de novo arterial hypertension in combination with proteinuria ≥0.3 g/day. Preeclampsia is a systemic disease that causes changes in the body of both mother and fetus. Edema today is no longer considered a diagnostic criterion, since its frequency is normal course pregnancy rate reaches 60%. In general, preeclampsia complicates pregnancy in 5-7% of cases, but its frequency increases to 25% in women with pre-pregnancy arterial hypertension.
Preeclampsia is more common in first pregnancies, multiple pregnancies, hydatidiform moles, and diabetes mellitus. Preeclampsia is gestational hypertension that is accompanied by proteinuria (≥0.3 g/day in 24-hour urine or ≥30 mg/mmol creatinine in a single urine sample). Gestational hypertension develops from 21 weeks. gestation and in most cases resolves within 42 days after birth. It leads to deterioration of organ perfusion. It matches with
placental insufficiency, which often leads to poor fetal growth. Additionally, preeclampsia is one of the most common causes of prematurity. Its share in the structure of causes of birth of children with very low body weight (less than 1500 g) is 25%, and in the structure of causes of premature birth - 50%. Severe preeclampsia is the cause of intracranial hemorrhage and acute renal failure, which together account for up to 90% of the causes of all deaths during pregnancy with preeclampsia.
Symptoms of severe preeclampsia are:
Pain in the right hypochondrium or epigastric region due to liver edema + hemorrhages in the liver
Headache + visual disturbances (cerebral edema)
Blindness associated with lesions of the occipital lobe
Increased reflexes + clonus
Seizures (cerebral swelling)
HELLP syndrome: hemolysis, increased liver enzymes, decreased platelet count.
3. Arterial hypertension, existing before pregnancy and combined with gestational hypertension and proteinuria. If arterial hypertension, existing before pregnancy, is characterized by a further increase in blood pressure and the appearance of proteinuria ≥3 g/day from 21 weeks. gestation, then this condition is regarded as a combination of pre-pregnancy hypertension with gestational hypertension with proteinuria.
4. Unclassified hypertension. If blood pressure is measured for the first time at 21 weeks. pregnancy and hypertension is detected (with or without systemic manifestations), then it is regarded as unclassifiable. In such cases, it is necessary to continue monitoring blood pressure for 42 days after birth and beyond.
Chronic hypertension
When planning pregnancy, women with hypertension should undergo a comprehensive clinical and laboratory examination in accordance with generally accepted standards for the management of patients with hypertension in order to: - assess the functional state of target organs - ECG, echocardiography, examination of the fundus vessels, ultrasound of the kidneys, if necessary, ECG monitoring by Holter, stress tests; - determining the degree and risk group of hypertension (Tables 1 and 3); - if a woman takes antihypertensive drugs at the stage of pregnancy planning - correction of drug therapy: discontinuation of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers, adjustment of drug doses, achieving the target blood pressure level<140/90 мм рт.ст.
Maternal and fetal prognosis estimates. Allocate 3 tbsp. risk of developing pregnancy complications in women with CAH: stage I. risk - minimal, corresponds to hypertension 1-2 risk groups. Pregnancy is proceeding relatively satisfactorily and is acceptable. At the same time, 20% of pregnant women with CAH develop various complications: gestosis, abruption of a normally located placenta, 12% - premature birth. II Art. risk - pronounced, corresponds to hypertension of 3rd degree of risk. The frequency of pregnancy complications is increasing significantly - premature birth occurs in every fifth pregnant woman, and antenatal fetal death is observed in 20% of cases. Pregnancy is potentially dangerous for mother and fetus. III Art. risk - maximum, corresponds to hypertension of 4 risk degrees: pregnancy is contraindicated. Complications of pregnancy and childbirth occur in every second woman, perinatal mortality is 20%. 
Table 2. Risk stratification criteria for developing cardiovascular complications in chronic hypertension
| Risk factors | Target organ damage |
|
Smoking Dyslipidemia: 0XС>5.0 mmol/l (190 mg/dl) or LDL cholesterol>3.0 mmol/l (115 mg/dl) or HDL cholesterol< 1,2 ммоль/л (46 мг/дл) или ТГ >1.7 mmol/l (150 mg/dl) fasting plasma glucose 5.6-6.9 mmol/l (102 - 125 mg/dl) NTG family history of early CVD, DLP, DM; (among women< 65 лет) |
LVH ECG: Sokolov-Lyon sign > 38mm; Cornell product > 2440 mm x ms EchoCG: LVMI > 110 g/m2 |
|
Vessels Ultrasound signs of arterial wall thickening (IMT > 0.9 mm) or atherosclerotic plaques of the great vessels; pulse wave speed from the carotid to the femoral artery > 12 m/s; |
|
|
Kidneys slight increase in serum creatinine: 107 - 124 µmol/l (1.2 - 1.4 mg/dl); low GFR< 60 мл/мин/1,73м2 (MDRD формула) или низкий клиренс креатинина < 60 мл/мин (формула Кокрофта-Гаулта) MAU -30 - 300 mg/day; urine albumin/creatinine ratio ≥ 31 mg/g (3.5 mg/mmol) |
|
| Diabetes | Associated clinical conditions |
|
fasting plasma glucose > 7.0 mmol/L (126 mg/dL) with repeated measurements plasma glucose after a meal or 2 hours after taking 75 g of glucose > 11.0 mmol/l (198 mg/dl) |
Cerebrovascular diseases ischemic MI hemorrhagic MI TIA |
| Metabolic syndrome | |
|
The main criterion is AO (OT > 80 cm) Additional criteria: BP ≥ 140/90 mm Hg, LDL cholesterol > 3.0 mmol/l, HDL cholesterol< 1,2 ммоль/л, ТГ >1.7 mmol/l, fasting hyperglycemia ≥ 6.1 mmol/l, IGT - plasma glucose 2 hours after taking 75 g of glucose ≥ 7.8 and ≤ 11.1 mmol/l The combination of the main and 2 of the additional criteria indicates the presence of MS |
Heart diseases myocardial infarction angina pectoris coronary revascularization chronic heart failure |
|
Kidney diseases diabetic nephropathy renal failure: serum creatinine > 124 µmol/L (1.4 mg/dL) |
|
|
Peripheral artery diseases
dissecting aortic aneurysm symptomatic peripheral arterial disease |
|
|
Hypertensive retinopathy hemorrhages or exudates papilledema |
During pregnancy in women with arterial hypertension, it is recommended to assess the severity of hypertension in accordance with Table 4.
Table 4. Classification of the severity of hypertension during pregnancy 
This classification is used to characterize the degree of increase in blood pressure in any form of hypertension during pregnancy (chronic hypertension, gestational hypertension, PE).
Preeclampsia- pregnancy-specific syndrome, which occurs no earlier than the 21st week of gestation, is determined by the presence of hypertension and proteinuria (more than 300 mg of protein in daily urine). moderately expressed (Table 5); severe (Table 5); critical: eclampsia; swelling, hemorrhage and retinal detachment; acute fatty hepatosis; HELLP syndrome; acute renal failure; pulmonary edema, placental abruption.
Risk factors for preeclampsia: woman's age<18 лет или ≥ 40 лет, гипертензивные расстройства во время предыдущих беременностей, антифосфолипидные антитела или аутоиммунные состояния, АГ или ДАД ≥90 мм рт. ст.; заболевания почек или протеинурия; сахарный диабет, ожирение (ИМТ≥35 кг/м2), семейный анамнез преэклампсии (у матери, сестер), многоплодная беременность, первая беременность, интервал между беременностями ≥10 лет, САД ≥130 мм рт. ст., или ДАД ≥80 мм рт. ст. перед беременностью. При наличии факторов риска преэклампсии описаны положительные эффекты небольших доз аспирина (75-100 мг в сутки).
Eclampsia
The occurrence of seizures in women with hypertension and proteinuria (preeclampsia) that cannot be explained by other causes.
Risk of developing eclampsia: the appearance of neurological symptoms, an increase in headache, visual disturbances, pain in the epigastrium and in the right hypochondrium, periodically occurring cyanosis of the face, paresthesia of the lower extremities, pain in the abdomen and lower extremities without clear localization, fibrillation of muscles, mainly the facial group, shortness of breath, agitation or on the contrary, drowsiness, difficulty breathing through the nose, coughing, dry cough, drooling, chest pain.
Preeclampsia due to chronic hypertension
diagnosed in pregnant women with chronic hypertension in the following cases:
1) the first appearance of proteinuria (0.3 g of protein or more in daily urine) from the 21st week of gestation or a noticeable increase in previously existing proteinuria;
2) a sharp increase in blood pressure in those women whose hypertension was easily controlled before the 21st week of pregnancy;
3) the appearance of signs of multiple organ failure (oliguria, increased creatinine, thrombocytopenia, hemolysis, increased AST, ALT).
Examples of formulating the diagnosis of hypertension in a pregnant woman
1. Pregnancy 11 weeks. Chronic hypertension of moderate severity (in a patient who has not previously been examined, with SBP 140 - 159 mmHg and/or DBP 90 - 109 mmHg).
2. Pregnancy 12 weeks. Chronic hypertension of moderate severity (in a patient diagnosed before pregnancy with SBP 140 - 159 mmHg and/or DBP 90 - 109 mmHg, LVH).
3. Pregnancy 15 weeks. Chronic hypertension. Renovascular hypertension of severe severity (in a patient with renovascular secondary hypertension diagnosed before pregnancy or in its early stages with a blood pressure level > 160/110 mm Hg).
4. Pregnancy 22 weeks. Gestational hypertension, moderate severity (in a pregnant woman with newly developed hypertension after 20 weeks of gestation with a blood pressure level of 140-159/90-109 mm Hg).
5. Pregnancy 34 weeks. Preeclampsia, moderate severity (in a patient with a previously uncomplicated pregnancy with the appearance of hypertension with a blood pressure level not exceeding 160/110 mm Hg and proteinuria not more than 5 g/day).
6. Pregnancy 35 weeks. Preeclampsia against the background of chronic hypertension, moderate severity (in a patient with a previously established diagnosis of arterial hypertension, with blood pressure not higher than 160/110 mm Hg with newly developed proteinuria not exceeding 5 g/day).
7. Pregnancy 26 weeks. Preeclampsia, severe. Pulmonary edema. HELLP syndrome. Fetal growth restriction syndrome (in a patient with newly developed hypertension after 20 weeks of pregnancy, the level of blood pressure and proteinuria in this case may vary, due to clinical signs of pulmonary edema, laboratory manifestations of HELLP syndrome and ultrasound criteria for fetal growth restriction syndrome).
Clinical picture
Symptoms, course
Diagnostic criteria:
Complaints and anamnesis- Anamnesis collection - in the first trimester, the presence of chronic hypertension, identification of risk factors and symptoms,
Characteristic of secondary forms of hypertension. Signs of symptomatic hypertension: “acute” onset of hypertension with frequent crises or rapid stabilization of blood pressure at high levels, systolic-diastolic hypertension with diastolic pressure more than 110 mm Hg. Art., refractory to adequate antihypertensive therapy, no family history of hypertension (except for fibromuscular dysplasia of the renal artery), good tolerance of high blood pressure, but rapid development of complications (myocardial infarction, acute cerebrovascular accident, renal failure, hypertensive retinopathy).
Physical examination. Standard objective examination, incl. when examining the cardiovascular system, the size of the heart, the presence of pathological noises, signs of heart failure (wheezing in the lungs, liver size, swelling in the legs) are assessed. The state of the pulse in the peripheral arteries is examined, the presence of pathological noise in the projection of the renal arteries. Organ examination abdominal cavity, incl. palpation of the kidneys (polycystic disease, hydronephrosis), detection of systolic murmur in the projection of the renal arteries onto the anterior abdominal wall (renal artery stenosis).
Blood pressure measurement- after a 5-minute rest, a woman should not perform heavy physical activity during the previous hour. Blood pressure level is measured with the pregnant woman sitting, in a comfortable position, or lying on her left side. The cuff is placed on the arm so that its lower edge is 2 cm above the elbow, and the rubber part of the cuff covers at least 80% of the shoulder circumference (cuff width 12-13 cm, length 30-35 cm). For patients with a very large or very small upper arm circumference, it is necessary to have a large and a small cuff. Blood pressure levels are measured twice, with an interval of at least a minute, on both arms. The level of SBP is determined by phase I of Korotkoff sounds, DBP - by phase V (complete disappearance of sound signals). In 15% of pregnant women, phase V cannot be determined. In these cases, the DBP level is established according to phase IV, i.e. at the moment of significant weakening of tones. It is necessary to measure blood pressure in both arms and legs in order to identify symptoms of aortic coarctation and nonspecific aortoarteritis.
Measurement of waist circumference, height, weight, BMI assessment.
Diagnostics
Laboratory research
Basic:
clinical blood and urine tests every 2 weeks on an outpatient basis, in emergency cases, as often as the clinical situation requires;
biochemical blood test (for planned and emergency hospitalization), frequency of studies in accordance with the clinical situation:
Assessment of fasting blood glucose, TSH if necessary (Table 6);
- lipid metabolism (total cholesterol, HDL cholesterol, LDL cholesterol, triglycerides);
- assessment of liver function (bilirubin, ALT, AST);
- assessment of kidney function (determination of creatinine with calculation of glomerular filtration rate using the Cockcroft-Gault formula);
- potassium level; o uric acid;
assessment of the presence of albumin excretion in urine to detect microalbuminuria (test strip);
if available positive test for microalbuminuria, quantitative determination of protein content in daily urine (Table 7).
Assessment of general blood and urine analysis
1. Hemoglobin and hematocrit - an increase in the values of indicators due to hemoconcentration. Characteristic of PE and is an indicator of the severity of the process. If the course is unfavorable, the values may be reduced if hemolysis develops.
2. Leukocytes - neutrophilic leukocytosis - a criterion for preeclampsia.
3. Platelets - a level of less than 100 x 103 /l indicates the development of severe PE.
4. Peripheral blood smear - the presence of erythrocyte fragments (schizocytosis, spherocytosis) indicates the development of hemolysis in severe PE.
5. Microalbuminuria is a predictor of the development of proteinuria
6. Proteinuria - hypertension during pregnancy, accompanied by proteinuria, should be considered as PE.
Assessment of biochemical parameters
1. Serum creatinine - a level of more than 90 µmol/l, especially in combination with oliguria (less than 500 ml/day), indicates the presence of severe PE
2. Uric acid - increased with PE
3. AsAt, AlAt - increase indicates severe PE
4. Serum bilirubin - increases due to hemolysis or liver damage in PE
Specific laboratory tests according to indications (if signs of symptomatic hypertension are detected):
Signs of renoparenchymal hypertension:
Urine culture for bacterial flora
Primary hyperaldosteronism:
Tests with hypothiazide and veroshpiron
Determination of aldosterone levels and plasma renin activity
Cushing's syndrome or disease:
Determining the level of cortisol in the blood
Determination of the level of excretion of oxycorticosteroids in urine
Pheochromocytoma and other chromaffin tumors:
Determination of the level of catecholamines and their metabolites in the blood and urine
Thyroid diseases:
Determination of thyroid hormone levels, TSH
Instrumental studies:
Basic
1. ABPM or self-monitoring at home.
2. ECG.
3. EchoCG.
4. Examination of the vessels of the fundus. According to indications, perform:
5. Ultrasonography kidneys, adrenal glands, renal arteries to confirm or exclude secondary hypertension.
6. Doppler ultrasound of peripheral vessels.
7. Urine examination according to Zimnitsky and Nechiporenko, urine culture, determination of GFR.
8. Ultrasound and Dopplerography of the vessels of the fetoplacental complex.
9. Stress tests (VEM, treadmill), Holter ECG monitoring. X-ray and radioisotope research methods are contraindicated during pregnancy.
Indications for consultation with specialists:
1. obstetrician-gynecologist - joint management throughout the entire period of observation, with the determination of indications for the possibility of maintaining pregnancy, prolongation and termination, and method of delivery;
2. endocrinologist - presence of signs of symptomatic hypertension caused by endocrine pathology, diagnosis of disorders and treatment of glycemic disorders;
3. neurologist - presence of symptoms of brain damage (acute cerebrovascular accidents, transient cerebral circulatory disorders, chronic forms of vascular pathology of the brain, etc.);
4. ophthalmologist - presence of symptoms of retinopathy;
5. nephrologist - presence of signs of symptomatic hypertension caused by renoparenchymal pathology;
6. angiosurgeon - diagnosis and treatment of vasorenal arterial hypertension.
List of basic and additional diagnostic measures
Basic
1. Clinical blood and urine test every 2 weeks. If necessary according to the clinical situation
2. biochemical blood test (for planned and emergency hospitalization): - assessment of fasting glycemia - lipid metabolism (total cholesterol, HDL cholesterol, LDL cholesterol, triglycerides) - assessment of liver function (bilirubin, ALT, AST) - assessment of kidney function (determination of creatinine with calculation glomerular filtration rate according to the Cockcroft-Gault formula) - potassium level - uric acid
3. assessment of the presence of urinary albumin excretion to detect microalbuminuria (test strip)
4. in the presence of a positive test for microalbuminuria, quantitative determination of protein content in daily urine.
5. ABPM
6. ECG
7. EchoCG
8. Ultrasound examination of the kidneys and adrenal glands
9. Doppler ultrasound of peripheral vessels (brachiocephalic, renal arteries, etc.)
10. Ultrasound and Dopplerography of the vessels of the fetoplacental complex.
Additional
1. Glucose tolerance test
2. Urine culture for bacterial flora
3. Tests with hypothiazide and veroshpiron
4. Determination of aldosterone levels and plasma renin activity
5. Determining the level of cortisol in the blood
6. Determination of the level of excretion of oxycorticosteroids in urine
7. Test with dexamethasone
8. Determination of the level of catecholamines and their metabolites in the blood and urine
9. Determination of thyroid hormone levels
10. Fundus examination;
11. Determination of the ankle-brachial index;
12. Determination of pulse wave speed (an indicator of the rigidity of the main arteries);
Differential diagnosis
Differential diagnosis
Table 8. Differential diagnosis of hypertension during pregnancy
| Form AG | Symptoms | Diagnostic methods applicable during pregnancy |
| Renal hypertension | ||
| Renovascular hypertension | murmurs in the projection of the renal arteries | - Doppler study of blood flow in the renal vessels |
| Renoparenchymal hypertension: | ||
| Glomerulonephritis |
development of hypertension in at a young age, urinary syndrome, history of acute glomerulonephritis, decreased filtration with a moderate decrease in renal blood flow, bilateral, symmetrical, uniform damage to both kidneys |
Daily proteinuria; Kidney biopsy; |
| Chronic pyelonephritis | periods of low-grade fever, pain in the lumbar region, disorders of urination (polyuria, nocturia) and urination (dysuria, pollakiuria), an early decrease in the concentrating ability of the kidneys (hyposthenuria) is observed | - urine cultures |
| Endocrine hypertension | ||
|
Primary hyperaldosteronism (Conn syndrome) |
muscle weakness, paresthesia, convulsions, polyuria, nocturia, spontaneous hypokalemia (<3,5мэкв/л) |
Tests with dichlorothiazide and spironaloctone; Determination of aldosterone levels and plasma renin activity; Ultrasound of the adrenal glands |
| Cushing's syndrome or disease | Obesity, moon-shaped face with plethora, stretch marks more than 1 cm wide, usually white, pads of fat above the collarbones, impaired glucose tolerance, hypokalemia, acne, especially not on the face, hirsutism. |
Determining the level of cortisol in the blood; Determination of the level of excretion of oxycorticosteroids in urine Test with dexamethasone; Ultrasound of the adrenal glands |
| Pheochromocytoma and other chromophine tumors |
crisis nature of the course of hypertension, neurofibromatosis of the skin, severe headache, sweating and palpitations, difficult to control hypertension, unexplained sinus tachycardia, orthostatic hypotension, recurrent arrhythmias, café au lait stains |
Determination of the level of catecholamines and their metabolites in the blood and urine; Ultrasound of the adrenal glands |
| Thyroid diseases | systolic hypertension, paroxysms of atrial fibrillation (thyrotoxicosis) | Thyroid hormones (T3, T4, TSH), ultrasound of the thyroid gland |
| Hemodynamic hypertension: | ||
| Coarctation of the aorta | decreased pulsation in the legs and high blood pressure in the arms, cold feet and intermittent claudication, blood pressure in the arms is higher than in the legs, systolic murmur on the posterior surface of the chest on the left, rib usuration, deformation of the aortic arch | Doppler ultrasound examination of the great vessels. |
| Aortic valve insufficiency | Physical symptoms of aortic regurgitation | EchoCG |
| Chronic arterial hypertension (essential) - see. table 2. | ||
| Pregnancy-associated hypertension | ||
| Gestational hypertension | first detected increase in blood pressure after 20 weeks of pregnancy | Inpatient examination for timely diagnosis of PE (Table 9) |
| Preeclampsia | Hypertension and proteinuria | Severity rating (Table 5) |
| Eclampsia | Hypertension, proteinuria and seizures | Monitoring of clinical and laboratory parameters |
Table 9. Assessment of indicators for PE
| Laboratory indicators | Changes during the development of PE |
| Hemoglobin and hematocrit | Increased values of indicators due to hemoconcentration. Characteristic of PE and is an indicator of the severity of the process. If the course is unfavorable, the values may be reduced if hemolysis develops. |
| Leukocytes | Neutrophilic leukocytosis. |
| Platelets | A decrease, a level less than 100 x 103 /l, indicates the development of severe PE. |
| Peripheral blood smear | The presence of erythrocyte fragments (schizocytosis, spherocytosis) indicates the development of hemolysis in severe PE. |
| INR or PTI | Increased values in DIC syndrome |
| Fibrinogen | Decline. |
| Serum creatinine |
An increase, a level of more than 90 µmol/l, especially in combination with oliguria (less than 500 ml/day), indicates presence of severe PE. |
| Uric acid | Promotion. |
| AsAt, AlAt | An increase indicates severe PE. |
| LDH | Promotion. |
| Serum albumin | Decrease (indicates increased endothelial permeability, characteristic of PE). |
| Serum bilirubin | Increased due to hemolysis or liver damage |
| Microalbuminuria | Is a predictor of the development of proteinuria |
| Proteinuria | Hypertension during pregnancy, accompanied by proteinuria, should |
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Treatment
Treatment Goals- achieving target blood pressure levels, preventing the development of complications caused by high blood pressure levels, ensuring the preservation of pregnancy, the physiological development of the fetus and normal childbirth.
Treatment tactics:
non-drug treatment:
1. Differentiated limitation of physical activity: in most cases, with uncomplicated chronic and gestational hypertension, aerobic exercise, walks in the fresh air, sufficient 8-10 hours of sleep at night, preferably 1-2 hours of daytime sleep can be recommended.
2. Avoid stressful situations that increase blood pressure levels
3. In case of severe hypertension, gestational hypertension, bed rest on the left side is recommended.
4. For moderately severe PE, bed rest is not necessary.
5. A diet rich in vitamins, microelements, calcium, and proteins is recommended. Salt restriction during pregnancy is not indicated.
6. Smoking and drinking alcohol are strictly prohibited.
7. Reducing body weight during pregnancy is not recommended due to the risk of giving birth to low-weight children and subsequent slowdown in their growth.
drug treatment:
Management tactics for pregnant women depending on the severity of hypertension.
For moderate hypertension(BP 140-159/90-109 mm Hg) - differentiated treatment depending on the presence of target organ damage (Table 10).
For severe hypertension(BP 160/110 mm Hg and above):
-prevention, first of all, of cerebrovascular complications in the mother.
-antihypertensive therapy should begin immediately
- emergency hospitalization and monitoring of the condition of the pregnant woman and fetus are indicated, including using laboratory and instrumental research methods (Table 10).
An acceptable range of blood pressure levels for the treatment of hypertension in pregnant women should be considered systolic blood pressure values of 130-150 mm Hg. and diastolic blood pressure 80-95 mm Hg.
Antihypertensive drugs classified as class “A” (controlled studies in pregnant women have not revealed a risk to the fetus, the likelihood of fetal harm is unlikely) for the treatment of hypertension in pregnant women currently does not exist, and no drug is 100% safe in the early stages of pregnancy, and pharmacotherapy should be avoided during the first trimester if possible.
Most of the antihypertensive drugs used to treat hypertension in pregnant women belong to category “C” (experimental studies revealed a risk to the fetus (teratogenic, embryotoxic effects); there were no controlled studies in pregnant women; or experimental and clinical studies were not conducted. The drugs may prescribed when the expected therapeutic effect outweighs the potential risk to the fetus). Drugs in this category should only be used if the potential benefits of their use justify the risk of adverse effects on the fetus. The inclusion of a drug in this category shows that the risk to the fetus when using it cannot be underestimated. Data on the effectiveness and safety of the use of category C drugs during pregnancy are based on descriptions of clinical cases, the results of small studies and meta-analyses.
Food and Drug Administration Safety Criteria in Pregnancy (FDA, 2002).
A - studies in pregnant women have not revealed a risk to the fetus.
B - there is no information about the risk to the fetus in humans or there is no risk in the experiment; a risk has been detected in animals, but there are not enough studies in humans.
C - the risk to the fetus in humans has not been determined, side effects have been identified in animals, but there are insufficient studies in humans. The expected therapeutic effect of the drug may justify its use, despite the potential risk to the fetus.
D - a risk to the fetus has been proven in humans, but the expected benefit from its use for the expectant mother may outweigh the potential risk to the fetus.
X is a drug dangerous to the fetus, and the negative impact of this drug on the fetus exceeds the potential benefit for the expectant mother.
Basic drugs for the treatment of hypertension during pregnancy
1. Central α-agonist methyldopa - class B, first-line drug
2. Calcium antagonists (CA) - nifedipine, class C, first or second line drug
3. β-blockers (β-AB) - class C
4. α-β-adrenergic blocker - labetalol - class C
Additional means (use in exceptional cases)
1. some vasodilators (nitroglycerin). Dihydralazine, which has long been considered the “gold standard” for antihypertensive therapy in patients with preeclampsia, is currently not recommended for use due to the significant number of side effects from the side of the fetus.
2. diazoxide
3. clonidine - a third-line drug for refractory hypertension in the third trimester
Table 11. Drugs for rapid reduction of blood pressure in severe hypertension during pregnancy
| A drug | Doses, method of administration | Time of onset of the hypotensive effect | Note |
| Nifedipine | 10 mg tablet, orally | 30-45 minutes, repeat after 45 minutes. | Sublingual use is contraindicated |
| Labetalol | 20-50 mg, intravenous bolus administration | 5 minutes, repeat after 15-30 minutes. | Contraindicated in bronchial asthma and heart failure, may cause bradycardia in the fetus. |
| Diazoxide | 15-45 mg, max 300 mg, IV bolus | 3-5 minutes, repeat after 5 minutes. | Rarely used as a backup. May cause inhibition of labor, development of hyperglycemia, hyperuricemia, and water retention in the body. |
| Nitroglycerine | IV drip 10-20 mg in 100-200 ml of 5% glucose solution, injection rate 1-2 mg/hour, maximum 8-10 mg/hour | 1-2 min | It is the drug of choice for the development of pulmonary edema due to increased blood pressure. SBP should be maintained at a level of at least 100-110 mmHg. Use for more than 4 hours is not advisable due to the risk of negative effects on the fetus and the risk of developing cerebral edema in the mother. |
| Sodium nitroprusside | IV drip, in 250 ml of 5% glucose solution, start with 0.25 mcg/kg/min, up to a maximum of 5 mcg/kg/min | 2-5 min. | It is rarely used if there is no effect from the above remedies and/or there are signs of hypertensive encephalopathy. The effect of cyanide poisoning on the fetus may occur if used for more than 4 hours |
| Clonidine | 0.075 - 0.15 mg orally. Possible intravenous administration. | 2-15 min. | 0.075 mg 3 times a day, maximum single dose 0.15 mg, maximum daily dose 0.6 mg |
| Uradipil | The initial dose of 25 mg (5.0 ml) is administered intravenously over 2 minutes. Maintenance dose: intravenous syringe dispenser or through an intravenous drip system at a rate of 8-10 mg/hour (initial rate - 2 mg/hour - 0.4 ml/hour) to maintain a stable blood pressure level for 10- 12 hours. It is possible to dilute the drug with 0.9% sodium chloride solution in a minimum proportion of 4 mg of urapidil per 1 ml of solution. | 2-5 min. | The maximum dose for infusion or microjet intravenous administration is 20 mg/hour, the maximum daily dose is 480 mg |
Principles of antihypertensive therapy for rapid reduction of blood pressure in pregnant women:
1. One should be wary of an excessive decrease in blood pressure, which can cause impaired placental perfusion and deterioration of the fetus.
2. It is necessary to constantly monitor the functional indicators of the fetus.
3. In some cases, it may be useful to simultaneously administer 250 ml of saline solution with antihypertensive drugs to prevent a sharp drop in blood pressure.
4. Magnesium sulfate is not actually an antihypertensive drug. In severe PE, its administration is necessary for the prevention and treatment of convulsive syndrome.
5. Simultaneously with emergency care measures, planned antihypertensive therapy with long-acting drugs begins in order to prevent a re-increase in blood pressure.
Class I- reliable evidence and/or consensus of expert opinion that a given procedure or type of treatment is appropriate, useful and effective
Class II- conflicting evidence and/or differences in expert opinion about the benefits/efficacy of a procedure or treatment.
Class IIa- the preponderance of evidence/opinion to support benefit/effectiveness.
Class IIb- the benefit/efficacy is not sufficiently supported by evidence/expert opinion.
Class III credible evidence and/or consensus among experts that a given procedure or treatment is not beneficial/effective and, in some cases, may be harmful.
Level of evidence A. Data obtained from several randomized clinical trials or meta-analyses.
Level of evidence B. Data obtained from a single randomized trial or non-randomized trials.
Level of evidence C. Only expert consensus, case studies, or standard of care.
First-line drug for the treatment of hypertension in pregnant women
Methyldopa. During treatment with the drug, uteroplacental blood flow and fetal hemodynamics remain stable, and perinatal mortality decreases. Does not affect cardiac output and blood supply to the kidneys in the mother. The only antihypertensive drug used during pregnancy whose long-term effects on child development have been studied. Disadvantages - adverse reactions such as drowsiness, depression, orthostatic hypotension. The drug can be taken in the I, II, III trimesters of pregnancy.
Second line drugs
Calcium antagonists (CA). For the treatment of hypertension in pregnant women in cases where hypertension is refractory to methyldopa therapy. The most studied drug of the AK group is a representative of the dihydropyridine group - nifedipine. Sufficient clinical experience has been accumulated to consider it relatively safe for the fetus. Short-acting nifedipine (10 mg tablet) is recommended as a drug for the pharmacotherapy of severe hypertension in pregnant women. Extended-release tablets (20 mg), as well as modified/controlled-release tablets (30/40/60 mg) are used for long-term, planned basic therapy of hypertension during gestation. The hypotensive effect of nifedipine is quite stable, in
clinical studies did not report serious adverse events, in particular, the development of severe hypotension in the mother.
Short-acting nifedipine, when used sublingually, in some cases can provoke a sharp uncontrolled drop in blood pressure, which leads to a decrease in placental blood flow. In this regard, even in emergency situations, it is recommended to take the drug orally. Prolonged forms of nifedipine do not cause a pathological decrease in blood pressure levels, reflex activation of the sympathetic nervous system, and provide effective control over blood pressure levels throughout the day without a significant increase in blood pressure variability. The effectiveness and safety of the combination with magnesium sulfate has been demonstrated. Concerns have previously been raised about the combined use of nifedipine and magnesium sulfate. Cases of hypotension, suppression of myocardial contractility, myocardial infarction and neuromuscular blockade have been described when using this combination of drugs. However, the results of a number of subsequent studies did not confirm these concerns and demonstrated the effectiveness and safety of this combination. The use of AK is possible in the second and third trimesters of pregnancy. Side effects of AK treatment include: nausea, headache, dizziness; allergic reactions; hypotension, peripheral edema. When used simultaneously with magnesium sulfate, the antihypertensive effect may be enhanced.
β-blockers (β-blockers). It is advisable to give preference to cardioselective β-blockers with vasodilating properties, since this, first of all, avoids an increase in total peripheral vascular resistance and myometrial tone. Side effects of β-blockers include bradycardia, bronchospasm, weakness, drowsiness, dizziness, and rarely depression and anxiety. You should be aware of the possibility of developing “withdrawal syndrome”.
Third line drugs
Diuretics. Duretics should not be used for hypertension in pregnant women as first-line drugs, are not recommended for use in PE and are absolutely contraindicated in cases of impaired uteroplacental blood flow and fetal development retardation. However, drugs in this group can be used to control blood pressure in pregnant women with chronic hypertension. When using diuretics in the treatment of hypertension in a patient before pregnancy, they are not canceled.
Clonidine can be used in the third trimester of pregnancy as a third-line drug for refractory hypertension.
Table 13. Combinations of antihypertensive drugs used for hypertension in pregnant women
Table 14. Antihypertensive drugs contraindicated for use during pregnancy
| Angiotensin-converting enzyme inhibitors (ACEIs) and ATI receptor blockers (in the first trimester - C; II, III trimesters - D) | Although the use of ACE inhibitors in the first trimester is associated with an increase in the incidence of congenital malformations of the cardiovascular and central nervous system from 3% to 7% (analysis of data from 29,096 women, 209 of whom took ACEIs during the first trimester), this is not an indication for artificial termination of pregnancy. It is necessary to discontinue the drug (correction of antihypertensive therapy) and perform a fetal ultrasound as planned (at 19-22 weeks) with a detailed examination of the fetal structures, especially the heart. The use of these drugs in the II-III trimesters is associated with a decrease in blood supply to the kidneys in the fetus and the development of acute renal failure in the fetus/newborn; with the development of fetopathy, including renal dysgenesis, oligohydramnios as a result of oliguria in the fetus, bone dysplasia with impaired ossification of the cranial vault and contractures of the limbs, as well as pulmonary hypoplasia (with the subsequent development of respiratory distress syndrome of newborns); with a high risk of fetal development delay; death of the fetus or newborn. |
| Spironolactone (D) | Not recommended during pregnancy as it causes feminization of the male fetus. |
| Diltiazem (C) | Animal studies indicate a high risk to the fetus. Data on use for hypertension during pregnancy in humans are insufficient. There are isolated observations of the use of diltiazem in women. In one study, after use of diltiazem in the first trimester, 4 of 27 newborns (15%) had malformations, including 2 children with heart defects. |
Tactics for gestational hypertension
Gestational hypertension(first detected increase in blood pressure after 20 weeks of pregnancy) requires hospitalization of the patient for observation, clarification of the diagnosis, and exclusion of the possible development of PE. Antihypertensive therapy begins immediately. In case of absence
progression of the disease and with stable functional indicators of the fetus, moderate hypertension, effective antihypertensive therapy, further monitoring of the patient can be carried out on an outpatient basis with weekly monitoring of her condition. As with chronic hypertension, the goal of antihypertensive therapy for gestational hypertension is to prevent the progression of hypertensive syndrome, since there is no evidence that lowering blood pressure to any specific value can reduce the risk of developing PE.
Tactics for PE
Moderately severe PE without signs of fetal growth restriction and disturbances in blood flow parameters according to Doppler ultrasound as a result of careful monitoring, try to prolong pregnancy to 37 weeks.
Severe PE- immediate delivery is carried out regardless of gestational age. Delivery takes place as soon as the mother's condition stabilizes. The maternity ward should provide the possibility of round-the-clock surgical care (caesarean section).
Treatment of preeclampsia
Antihypertensive therapy (nifedipine, methyldopa per os, nitroglycerin, sodium nitroprusside or urapidil intravenous (IV) drip).
Blood pressure must be reduced gradually based on the value of the average (medial) blood pressure (BPmean = (SBP + 2DBP)/3, where, BPmean - BP average (medial) blood pressure), which should correspond to 25% of the initial level.
A sharp decrease in blood pressure can lead to the development of acute renal failure and deterioration of utero-fetal-placental blood flow.
In case of resistant hypertension, increasing renal and liver failure, symptoms of impending eclampsia (severe headache, blurred vision, hyperreflexia), urgent delivery is indicated.
Antihypertensive therapy for severe PE and eclampsia is symptomatic therapy, but it can reduce the risk of stroke, reduce the risk of eclampsia in severe PE, and prolong pregnancy for at least 1-2 days for corticosteroid preparation of the fetal lungs. Prevention of seizures - administration of magnesium sulfate 4-6 g intravenously in a stream for 15-20 minutes, then continued intravenous infusion at a rate of 1.5-2 g/h under the control of serum magnesium levels (maintain within 4.8 -9.6 mg%). Symptoms of magnesium intoxication: drowsiness, decreased knee reflex, respiratory depression.
Treatment of eclampsia
The most common causes of death in eclampsia are intracranial hemorrhage (rupture of a vascular aneurysm) and renal failure. Treatment:
Administration of magnesium sulfate 4-6 g intravenously in a stream over 15-30 minutes, then intravenous infusion at a rate of 1-2 g/hour for 24 hours. For repeated convulsive episodes, an additional 2 to 4 grams of the drug intravenously over 5 minutes.
- immediate delivery is the only pathogenetic method of treating eclampsia today.
Clinical monitoring when using magnesium sulfate - respiratory rate > 16 per minute, urine output greater than 25 ml per hour, knee reflex determination.
Relief of side effects of magnesium sulfate:
1. Respiratory arrest: intubation and immediate initiation of mechanical ventilation, stop administering the drug. Inject intravenously 1 g of calcium gluconate (antidote of magnesium ions). Ventilation should continue until adequate spontaneous breathing is restored.
2. Respiratory depression: oxygen inhalation through a mask, administer 1 g of calcium gluconate intravenously, stop administering magnesium sulfate. There should be a nurse next to the patient who should constantly monitor her.
3. Lack of knee reflex. If breathing is normal, stop administering magnesium sulfate until the reflex is restored. If it is necessary to resume administration of the drug, doses should be minimal to prevent seizures after the reflex is restored.
4. Diuresis less than 100 ml in 4 hours. If there are no other signs of drug toxicity, reduce the IM dose of magnesium sulfate to 2.5 g, or the IV infusion rate to 0.5 g/hour.
Absolute indications for emergency delivery, regardless of gestational age:
1. eclampsia (after an attack);
2. manifestation of neurological symptoms (developing eclampsia);
3. critical complications of preeclampsia; reversible (reverse) or undetectable (absent) end-diastolic blood flow in the umbilical artery according to Doppler ultrasound.
Delivery
The vast majority of births occur through the natural birth canal. If treatment is insufficiently effective, it is recommended to exclude pushing.
C-section should be carried out in the following cases:
. premature placental abruption;
Retinal detachments; . resistance to AHT in combination with severe fundus changes;
. development of heart failure, coronary or renal failure.
Surgical intervention for hypertension in pregnant women.
Such forms of hypertension as pheochromocytoma, primary aldosteronism, renovascular hypertension, coarctation of the aorta provide for surgical treatment methods, the possibility of using which during pregnancy should be discussed in each specific case.
Preventive actions:
1. screening of women of childbearing age to identify risk factors and early diagnosis AG;
2. training of women with hypertension planning pregnancy;
3. careful observation, non-drug and drug treatment of pregnant women with hypertension with monitoring of clinical, laboratory and instrumental parameters with the necessary frequency for the timely detection of complications, prodromal symptoms of pre-eclampsia and eclampsia;
4. planned hospitalization at critical times for pregnancy to determine the possibility of carrying a pregnancy, methods of delivery;
5. joint determination of tactics for managing pregnant women with hypertension with obstetricians-gynecologists at all stages of pregnancy.
Observation during the postpartum period
1. Observation for at least 48 hours (against the background of a physiological increase in blood volume, the risk of an increase in DBP of more than 100 mm Hg)
2. The optimal blood pressure level is below 150/95 mm Hg. Art.
3. In most cases, interruption of breastfeeding is not necessary; in most cases, it is possible to use those medications that were used before childbirth
4. Additional examination in order to identify the causes of the development of hypertension, assess the condition of target organs.
5. After 12 weeks after birth, the diagnosis of gestational hypertension with persistent hypertension should be changed to “Arterial hypertension”, indicating the degree and risk group or possible options diagnosis of secondary (symptomatic) hypertension.
6. In cases of spontaneous normalization of blood pressure levels up to 12 weeks after birth, a diagnosis of transient (transient) hypertension is retrospectively established.
7. The recovery period after childbirth in the majority of women who have suffered gestational hypertension and PE, regardless of the severity of hypertension,
lasts quite a long time.
Tactics of antihypertensive therapy after childbirth
1. Refusal of drug therapy with hypertension without POM, AC and blood pressure levels up to 150/95 mm Hg. Lactation is possible in this case.
2.Low-dose drug therapy with hypertension without POM, ACS and a blood pressure level of 150/95 - 179/109 mm Hg, which allows you to continue breastfeeding. In this situation, target blood pressure values will probably not be achieved, but overall cardiovascular risk will be reduced.
3. Antihypertensive therapy, including combined with achieving the target blood pressure level in patients from a high-risk group (with hypertension with POM and/or ACS, with a blood pressure level of 180/110 and above, diabetes mellitus, metabolic syndrome) In this situation, it is necessary to stop breastfeeding.
4. Lactation Breastfeeding does not cause an increase in blood pressure in a woman. Bromocriptine, which is used to suppress lactation, can cause hypertension. All antihypertensive drugs can be excreted in breast milk. Most of them are detected in breast milk at very low concentrations, with the exception of propranolol and nifedipine, whose levels are comparable to those in maternal plasma.
Table 15. Use of antihypertensive drugs during lactation
| Nifedipine | Use is potentially safe for infant. Excreted in breast milk in an amount less than 5% of the therapeutic dose. Possibly delayed breastfeeding for 3-4 hours after taking the drug, which allows you to sharply reduce the amount of the drug entering the milk. |
| Methyldopa | Excreted into breast milk in small quantities, its use is potentially safe for a nursing infant. |
| Labetalol* | Excreted into breast milk in small quantities. Peak concentrations of labetalol in milk occur 2-3 hours after administration. In only one case were detectable concentrations of labetalol found in the child's plasma. No adverse effects were observed in infants whose mothers received labetalol during lactation. |
| Captopril** | The concentration in breast milk is negligible, 1% of the level in maternal plasma. No adverse effects were observed in infants whose mothers received captopril during lactation. |
| Enalapril** | The concentration in breast milk is 1% of the level in maternal plasma. The amounts of enalapril and enalaprilat that could potentially reach the fetus are negligible and clinically insignificant. |
| Verapamil | Excreted into breast milk. With a daily dose of 240 mg, the level in milk is about 23%. Neither verapamil nor its metabolite are detected in the child's plasma. |
| Diltiazem | Excreted into breast milk. Concentrations of the drug in serum and milk change in parallel and are almost equal. |
| Hydrochlorothiazide*** | Excreted into breast milk in minimal quantities |
| Spironolactone *** | Indicated for hyperaldosteronism. |
|
Note: *Although there have been no reports of respiratory distress, bradycardia and hypoglycemia, in children whose mothers received beta blockers during lactation, it is necessary to monitor the child's condition for early diagnosis of a possible clinical picture caused by beta-adrenergic receptor blockade. The American Academy of Pediatricians classifies propranolol, timolol, nadolol, oxprenalol, labetalol as compatible with breastfeeding. Taking metoprolol is considered compatible with breastfeeding, although it accumulates in milk; Acebutalol and atenolol should not be used in nursing women. ** Prescription is possible for severe hypertension, in combination with diabetes mellitus, kidney disease. *** The use of diuretics (furosemide, hydrochlorothiazide and spironolactone) may cause a decrease in milk production. 3rd hospitalization - in 2-3 weeks. before the expected date of birth to monitor the functional state of target organs, adjust therapy, conduct prenatal preparation and determine labor management tactics.
difficulties in selecting drug therapy, refractory hypertension. 3. Severe hypertension (BP 160/110 mm Hg and above). 4. First detected increase in blood pressure after 20 weeks of pregnancy (gestational hypertension). 5. Clinical signs of the development of HELLP syndrome: repeated (persistent) attacks of epigastric pain. HELLP (Hemolysis, Elevated Liver enzymes and Low Platelets) - hemolysis, increased activity of liver enzymes and thrombocytopenia - is associated with an extremely severe form of preeclampsia and eclampsia. InformationSources and literature
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Treatment of arterial hypertension during pregnancy should be carried out under constant medical supervision. In this case, it is possible to avoid complications caused by increased blood pressure in the expectant mother.
The time of bearing a baby becomes a real test for the body of the expectant mother. Among the most common pathologies that doctors register in women is arterial hypertension during pregnancy. It causes dangerous conditions that affect both the health of the mother herself and the intrauterine development of the little person.
This is a pressing issue for obstetricians around the world. high pressure in female patients. This is not surprising. Even in countries where great attention is paid to health care, hypertension in pregnant women ranks first in the ranking of causes of death among women during or after childbirth.
The World Health Organization has introduced a definition of pathology. According to it, arterial hypertension during pregnancy is a condition in which the systolic pressure is 140 mmHg. Art. or higher. At the same time, the diastolic value is at a level of 90 mmHg or more. They also make a diagnosis of hypertension in pregnant women in cases where there is a stable increase in systolic blood pressure by 25 mmHg. Art. and diastolic pressure by 15 mm compared with measurements recorded before conception or during the first 12 weeks of gestation.
If pregnancy proceeds normally, the woman will have slightly low blood pressure until the last trimester. This is explained by the relaxation of the smooth muscles of the vascular walls, which occurs in response to hormonal changes. In the last three months before giving birth, blood pressure levels become the same as before pregnancy.
Classification of hypertension during pregnancy
Controversy continues in specialist circles regarding the concept of hypertension during pregnancy. There is no single generally accepted classification of this pathology in the world. Domestic doctors distinguish several forms of the disease.
Chronic arterial hypertension appears long before pregnancy or is detected in the first 20 weeks after conception. It occurs both independently and as a result of complications of somatic diseases. She is characterized by blood pressure readings of 140/90 and above, which persist even after childbirth.
Gestational hypertension is diagnosed after 20 weeks of gestation. The condition is not accompanied by disturbances in kidney function and the appearance of protein in the urine. As a rule, gestational hypertension improves over time, and blood pressure returns to normal within a month and a half after the birth of the baby. Observation must be carried out for three months.
Preeclampsia is a condition in which gestational hypertension is combined with proteinuria (the appearance of protein in the urine in an amount of 300 mg or more per day). The most severe and dangerous form of arterial hypertension in pregnant women is eclampsia. It is diagnosed after 20 weeks of gestation if the expectant mother, in addition to the listed symptoms, experiences seizures that are not caused by other reasons.
Chronic gestational hypertension is a pathology diagnosed before pregnancy and manifested with new strength after the 20th week. Accompanied by proteinuria.
Hypertension in pregnant women, which cannot be classified, is associated with an increase in blood pressure, which cannot be attributed to one or another subtype due to insufficient knowledge.
Causes of hypertension in pregnant women
Cardiologists believe that the main factor provoking the occurrence of pathology is stress. Hypertension in pregnant women appears as a result of emotional shocks, mental and mental overload. They lead to the occurrence of neurocirculatory dystonia (NCD).
The majority of cardiologists' patients have previously experienced increased blood pressure (episodically or systematically). Even if high blood pressure values were not recorded in the medical record, the doctor makes a conclusion about the existence of pathology based on the woman’s interview. In this case, arterial hypertension and pregnancy are phenomena not directly related to each other.
The presence of concomitant diseases, which sometimes are not even identified at the time of the first visits to the obstetrician-gynecologist, can also provoke the disease. Therefore, when a combination such as hypertension and pregnancy occurs, treatment is carried out taking into account concomitant diseases. Among such pathologies are disorders of the endocrine system (thyrotoxicosis, diabetes mellitus), problems with the kidneys, and respiratory system organs.
In addition, other factors that cause hypertension during pregnancy play an important role. As a result of the changes occurring in a woman’s body, the load on the circulatory system increases, which cannot always cope. Blood pressure rises due to the following reasons:
- insufficient increase in vascular volume;
- compression exerted by the growing uterus on the diaphragm;
- increased blood volume in a pregnant woman;
- the occurrence of placental circulation;
- changes in the position of the heart inside the chest;
- high levels of hormones;
- late gestosis.
Hypertension in pregnant women can also threaten if a woman decides to become a mother already in mature age– after 30-35 years – or when very young. Carrying several babies, large volume amniotic fluid can also cause high blood pressure.
Insufficient physical activity of a woman before and after the onset of an important period is not reflected in the best way on the body. Just like anxiety and depression, which many pregnant women are susceptible to. WITH psychological state manifestations are closely related to the expectant mother. In this condition, which is only conditionally considered a pathology, frequent pressure surges are possible.
Symptoms of hypertension in pregnant women
How pronounced the manifestations of hypertension in pregnant women are depends on many factors: the degree of pressure increase, individual characteristics of neuroendocrine regulation, and the state of the most important organs and systems.
Many women, who do not even suspect that pregnancy and hypertension are developing in parallel, when visiting a doctor, complain of attacks of severe weakness, excessive sweating and fever. Ladies tend to attribute dizziness, nausea and vomiting, and periodic headaches to their special situation.
In addition to the listed symptoms, if you feel them, it is worth measuring your blood pressure, there are other signs of hypertension:
- tachycardia, heart pain;
- nosebleeds;
- noise in ears;
- sleep problems;
- aching in the lower back;
- bouts of thirst;
- red spots appearing on the face.
In no case should you ignore the signals of trouble that appear from the organs of vision. Danger signs Associated with a hypertensive state are considered to be a decrease in acuity and flickering of spots before the eyes.
Attacks of sudden excitement or, conversely, depression, causeless anxiety should also alert you. When you next visit the doctor, you need to tell him about the unpleasant symptoms.
Diagnosis of hypertension in pregnant women
A doctor can suspect hypertension in a pregnant woman by carefully collecting anamnesis. There is a high probability of pathology if hypertension is detected during a previous pregnancy, as well as if the woman’s family has already had cases of early death associated with high blood pressure, or strokes at a young age.
Risks increase significantly when future mom who is carrying a child, smokes, or abuses caffeinated drinks or alcohol.
Physical methods
An important diagnostic criterion, in addition to the patient’s complaints, is her physical parameters. The presence of excess weight, disproportionate development of muscles in the legs and arms give the doctor reason to suspect a problem with blood pressure.
During the examination, the doctor must measure the pressure and pulse in both arms when the woman is lying down and then in a standing position. Comparison of the results obtained allows us to draw a conclusion about the chronic form or episodic hypertension.
Stenosis of the carotid arteries can be detected by auscultation and palpation. During a visit to the doctor, other diagnostic procedures are also performed:
- auscultation of heart sounds, lungs;
- palpation of the abdomen;
- determination of pulse, pressure in the lower extremities;
- detection of edema of the lower extremities.
Laboratory diagnostic methods
There is a mandatory set of tests that a pregnant woman with suspected hypertension has to undergo:
- daily diuresis, which allows you to detect protein, blood, glucose in the urine;
- blood biochemistry (liver tests, protein fractions, glucose, potassium, calcium, sodium);
- detailed (clinical) blood test;
- electrocardiogram.
Additional examinations may be necessary if therapy for such an unsafe condition as arterial hypertension during pregnancy is ineffective. Typically, women have to undergo the following tests:
- urine (according to the method of Nechiporenko, Zimnitsky, general, for bacteriuria);
- blood from a finger (common with the leukocyte formula, for glucose);
- biochemistry (determining serum concentrations of potassium, creatinine, urea,
- detection of cholesterol, high-density lipoproteins, triglycerides);
- determination of adrenocorticotropic hormone, 17-hydroxycorticosteroids.
Instrumental examination methods
The most accessible way to detect hypertension in a pregnant woman is to measure blood pressure. A patient with suspected pathology must be referred to ultrasound examination heart (as well as kidneys, adrenal glands), echocardiography and Dopplerography. The condition of the fundus is checked. Sometimes a chest x-ray is prescribed.
Treatment of pregnant women with hypertension
At the same time, you need to minimize the consumption of salt in any form, vegetable fats, and simple carbohydrates. You need to eat often and in small portions. This allows you to control your weight and avoid the accumulation of fluid in the body.
Treatment of hypertension in pregnant women involves moderate physical activity, alternating with proper rest (night and day). Light exercise and long walks in the fresh air are allowed.
Doctors prescribe treatment during pregnancy medications. Therapy is carried out with single-component agents in a minimal dosage. It is also possible to prescribe combined or long-acting medications.
All cases of arterial hypertension in pregnant women are determined exclusively by a specialist, taking into account the characteristics of the patient’s condition and the possible negative impact on the developing organism. To quickly reduce blood pressure, use the following drugs:
- nifedipine;
- labetalol;
- hydralazine.
For long-term treatment of a condition such as hypertension in pregnant women, calcium channel blockers, as well as beta-blockers, are well suited:
- pindolol;
- oxprenolol;
- nebivolol;
- labetalol.
If the attending physician prescribes combination drugs for hypertension, they are usually represented by beta-blockers along with thiazide diuretics or agents that interfere with the absorption of calcium ions.
What does hypertension cause in pregnant women?
The appearance of hypertension during pregnancy is a great danger for the woman’s body and the fetus in her womb. In the absence of therapy or its ineffectiveness, severe complications arise. It is possible to develop gestosis, and sometimes premature birth or miscarriage.
In the case of severe forms, hypertension and pregnancy become incompatible concepts. Children are extremely rarely born full-term, with normal weight. There is a high risk of stroke or death of the mother during the birth of the baby.
Naturally, pregnancy with hypertension should proceed under the constant supervision of specialists. To do this, a woman needs to seek the help of highly qualified doctors at the perinatal center as quickly as possible.
AH - increase in the absolute value of blood pressure to 140/90 mm Hg. Art. and higher or a rise in blood pressure compared to its values before pregnancy or in the 1st trimester: systolic blood pressure - by 25 mm Hg. Art. and more, diastolic - by 15 mm Hg. Art. or more from normal with 2 consecutive measurements with an interval of at least 4 hours or a single recorded diastolic blood pressure of more than 110 mm Hg. Art.
Synonyms: Arterial hypertension, hypertension (essential hypertension), neurocirculatory asthenia, symptomatic hypertension.
Stages of hypertension according to WHO classification
Stage 1 – blood pressure from 140/90 to 159/99 mm Hg. Art.
Stage 11 – blood pressure from 160/100 to 179/109
Stage 111 – blood pressure from 180/110 and above.
Causes of hypertension in pregnant women
Conditions leading to the formation of hypertension:
- hypertension - 90%,
- kidney diseases (pyelonephritis, glomerulonephritis, polycystic disease, etc.),
- endocrinopathies (hypercortisolism, Itsenko-Cushing disease, etc.),
- neurogenic disorders (hypothalamic syndrome),
- gestosis.
Pathogenesis
- hereditary predisposition,
- insufficient production of 17-hydroxyprogesterone in the placenta,
- vascular sensitivity to angiotensin 11,
- activity of the renin-angiotensin-aldosterone system,
- corticovisceral hypertension,
- endothelial dysfunction,
— immunological theory of hypertension in pregnant women.
Clinical variants of the course of hypertension during pregnancy
- Typical course: decrease in blood pressure in the 1st trimester and increase at the end of the 11th and 111th trimester,
- Atypical course:
a) with an increase in the 1st, or 11th, or 111th trimester of gestation,
b) with consistently high blood pressure throughout pregnancy,
c) with the addition of gestosis.
- Crisis course of GB.
Diagnostics
History: increased blood pressure before pregnancy, presence of risk factors (smoking, presence of EGP, heredity).
Complaints: fatigue, headaches, palpitations, sleep disturbances, blurred vision, tinnitus, cold extremities, paresthesia, nosebleeds, etc.
Physical examinations: the woman’s body mass index is more than 27 kg/m2, auscultation of hypertension, signs of left ventricular hypertrophy.
Laboratory tests: general urine analysis, according to Nechiporenko, according to Zimnitsky, examination of 24-hour urine for protein; biochemical blood test (total protein, liver enzymes, bilirubin, glucose, creatinine, urea, electrolytes); clinical blood test (hemoglobin, hematocrit, platelets, formula). ECG, 24-hour blood pressure monitoring, ultrasound of the kidneys and adrenal glands, fundus examination.
Complications of pregnancy
- miscarriage, abortion, premature birth,
- gestosis,
— IUGR of the fetus,
- fetal hypoxia,
- obstetric bleeding.
Risk levels of pregnancy and childbirth (Shekhtman M.M.):
1st grade minimal - complications of pregnancy occur in no more than 20% of women, pregnancy worsens the course of hypertension in less than 20% of patients,
Grade 2 severe – pregnancy complications occur in 50%,
3rd degree maximum - most women experience pregnancy complications, more than 50%, and pregnancy is dangerous to the woman’s health and life.
Obstetric tactics:
Pregnancy is contraindicated (order No. 736 dated December 3, 2007):
- GB 11B-111 stage,
- Hypertension in the absence of effect from adequate therapy (the adequacy of antihypertensive therapy is assessed by a council).
Management of pregnancy with hypertension:
- Identification into a risk group;
- Indications for hospitalization:
- Examination and decision on whether to continue pregnancy in the presence of stage 1-11A of the disease,
- Termination of pregnancy or treatment if a woman refuses to terminate a pregnancy at stage 11B or 111 of the disease,
- Lack of effect from outpatient treatment.
- Obstetric complications (fetal hypoxia, gestosis, etc.),
- Prenatal hospitalization at 37-38 weeks for examination and decision on the method of delivery.
- Treatment of hypertension;
- Prevention of obstetric complications.
Non-drug treatment:
Non-drug measures are indicated for all pregnant women with hypertension.
- elimination of emotional stress,
- change diet,
- reasonable physical activity,
— daytime rest mode “bed rest”,
— control of risk factors for progression of hypertension,
- limit salt to 5g per day,
- limiting fat overweight bodies.
Drug therapy:
1st line drugs.
- Alpha adrenergic agonists (methyldopa, also known as dopegit 500 mg 2-4 times a day, clodinine, less often clonidine with individual dose selection);
2nd line drugs.
- Selective beta-blockers (corvitol, atenolol, metoprolol 25-100 mg, nebilet);
- Slow calcium channel blockers (not earlier than 18 weeks of pregnancy): nifedipine 20-40 mg per day, amlodipine 2.5-10 mg per day, verapamil 120-240 mg;
3rd line drugs.
- Alpha – adrenergic agonists + 2nd line drugs.
Antihypertensive therapy is carried out depending on the type of hemodynamics:
For the hyperkinetic type - beta-blockers: corvitol, atenolol, metaprolol, nebilet.
For the eukinetic type - alpha adrenergic agonists: dopegit, clonidine; beta blockers: corvitol, atenolol; calcium antagonists: nifedipine, verapamil;
hypokinetic type – alpha – adrenergic agonists: dopegit, clonidine; calcium channel blockers: nifedipine, verapamil.
Indications for early delivery:
- hypertension refractory to therapy,
- complications from target organs: myocardial infarction, stroke, retinal detachment;
- severe forms of gestosis and their complications: preeclampsia, eclampsia, coma, acute renal failure, pulmonary edema, PONRP, HELLP syndrome;
— deterioration of the fetus’s condition: hypoxia, IUGR grade 3.
Childbirth through the birth canal is carried out in a high-risk hospital, together with an anesthesiologist, with the conclusion of a cardiologist and an ophthalmologist. In the active phase of labor (opening of the cervix by 3-4 cm) after the administration of antispasmodics, early amniotomy is indicated. During childbirth, step-by-step pain relief is carried out (antispasmodics, analgesics, epidural anesthesia), antihypoxants and agents that improve uteroplacental and fetoplacental blood flow are administered; according to indications, antihypertensive therapy. When blood pressure is above 160/100 mm Hg. Art. Controlled normotension (with ganglion blockers) is indicated; if ineffective, switch off the pushing period with obstetric forceps in case of cephalic presentation or extract the fetus by the pelvic end if conditions exist. Prevention of bleeding at the end of the 11th and 111th stages of labor, continue in the postpartum period (iv/drip oxytocin), monitor blood pressure and the condition of the postpartum woman every 15 minutes.
In the postpartum period, treatment for hypertension is continued. Upon discharge from the maternity hospital - individual selection of contraception, transfer of patronage to the antenatal clinic.
Arterial hypertension during pregnancy - an increase in the absolute value of blood pressure up to 140/90 mm Hg. and higher or a rise in blood pressure compared to its values before pregnancy or in the first trimester: systolic blood pressure - by 25 mm Hg. or more, diastolic blood pressure - by 15 mm Hg. or more from normal with 2 consecutive measurements with an interval of at least 4 hours or a single recorded diastolic blood pressure >110 mm Hg.
Synonyms
Arterial hypertension.
Hypertension (essential hypertension), neurocirculatory asthenia, symptomatic hypertension.
ICD-10 CODE
O10 Pre-existing hypertension complicating pregnancy, childbirth and the postpartum period.
O16 Maternal hypertension, unspecified.
EPIDEMIOLOGY
Hypertension occurs in 4–8% of pregnant women. This is the second (after embolism) cause of MS. According to WHO, MS in hypertension reaches 40%. PS indicators and the frequency of premature births (10–12%) in pregnant women with hypertension significantly exceed those in healthy pregnant women. Hypertension increases the risk of PONRP and can cause cerebrovascular accidents, retinal detachment, eclampsia, massive coagulopathic bleeding, FPN, and antenatal fetal death.
In various regions of Russia, the frequency of hypertensive conditions in pregnant women is 7–29%.
CLASSIFICATION OF ARTERIAL HYPERTENSION
In 2003, the European Society for the Study of Hypertension proposed to use it to refer to hypertension in pregnant women.
the following concepts:
- pre-existing hypertension - increased blood pressure diagnosed before pregnancy or during the first 20 weeks of gestation and persisting for at least 42 days after birth;
- gestational hypertension - hypertension registered after 20 weeks of pregnancy in women with initially normal blood pressure (in this case, blood pressure normalizes within 42 days after birth);
- preeclampsia - a combination of gestational hypertension and proteinuria (proteinuria - the presence of protein in the urine in an amount of >300 mg/l or >500 mg/day, or more than “++” when qualitatively determined in a single portion of urine);
- pre-existing hypertension with gestational hypertension and proteinuria - a condition in which hypertension is diagnosed before pregnancy, but after 20 weeks of pregnancy the severity of hypertension increases and proteinuria appears;
- unclassifiable hypertension - increased blood pressure, unclassified due to lack of information.
According to the WHO classification, it is customary to distinguish the following stages of arterial hypertension:
Stage I - increase in blood pressure from 140/90 to 159/99 mm Hg;
Stage II - increase in blood pressure from 160/100 to 179/109 mm Hg;
Stage III - increase in blood pressure from 180/110 mm Hg. and higher.
Highlight:
primary hypertension;
symptomatic hypertension.
Stages of hypertension.
● Stage I - no target organ damage.
● Stage II:
- left ventricular hypertrophy;
- local or generalized narrowing of retinal vessels;
- microalbuminuria, proteinuria, increased creatinine concentration in blood plasma;
- signs of atherosclerotic lesions of the aorta, coronary, carotid or femoral arteries.
● Stage III:
- from the heart: angina pectoris, myocardial infarction, heart failure;
- from the brain: transient cerebrovascular accident, stroke, hypertensive encephalopathy;
- from the kidneys: renal failure;
- from the vessels: dissecting aneurysm, symptoms of occlusive damage to peripheral arteries.
US Department of Health and Human Services classification (1990)
● Hypertension that is not specific to pregnancy.
● Transient (gestational, transient) hypertension.
● Pregnancy-specific hypertension: preeclampsia\eclampsia.
ETIOLOGY OF ARTERIAL HYPERTENSION IN PREGNANCY
In more than 80% of cases, hypertension that precedes pregnancy or manifests itself during the first 20 weeks of gestation is caused by hypertension. In 20% of cases, hypertension before pregnancy increases due to other reasons - symptomatic hypertension.
Causes of hypertension in pregnant women
● Conditions leading to systolic hypertension with high pulse pressure (arteriosclerosis, aortic valve insufficiency, thyrotoxicosis, fever, arteriovenous fistulas, patent ductus arteriosus).
● Conditions leading to the formation of systolic and diastolic hypertension:
- due to increased peripheral vascular resistance: chronic pyelonephritis, acute and chronic glomerulonephritis, polycystic kidney disease, renal vascular stenosis, renal infarction, nephrosclerosis, diabetic nephropathy, renin-producing tumors, endocrinopathies (hypercortisolism, Itsenko-Cushing disease, primary hyperaldosteronism, congenital adrenogenital syndromes, pheochromocytoma, hypothyroidism, acromegaly);
- mental and neurogenic disorders: psychogenic hypertension, hypothalamic syndrome, family autonomic dysfunction (Riley–Day syndrome);
- coarctation of the aorta;
- true polycythemia;
- polyarteritis nodosa;
- hypercalcemia;
- hypertension (more than 90% of all cases of hypertension);
- gestosis;
- acute intermittent porphyria, etc.
In domestic cardiology, the leading mechanism for the formation of hypertension is still considered neurogenic, emphasizing the uncertainty of its etiology.
At the initial stages of development, hypertension is a kind of neurosis that arose under the influence of stress factors, negative emotions, neuropsychic overstrain, leading to a breakdown of higher nervous activity. The combination of psycho-emotional stress with other predisposing factors is important. These include features of higher nervous activity, hereditary burden, and damage to the brain and kidneys suffered in the past. Excessive consumption of table salt, smoking, and alcohol may have a certain significance. It is believed that the formation and development of hypertension occurs as a result of dysfunction of the central nervous units that regulate blood pressure levels, as well as as a result of shifts in the function of humoral regulation systems. The implementation of violations of corticovisceral regulation occurs through the pressor (sympathoadrenal, renin-angiotensin-aldosterone) and depressor (kallikrein-kinin, vasodilator series of prostaglandins) systems, which are normally in a state of dynamic equilibrium. During the development of hypertension, both excessive activation of pressor factors and inhibition of vasodilator systems are possible, leading to the predominance of the vasopressor system.
The initial stages of the disease, as a rule, occur against the background of activation of pressor systems and increased levels of prostaglandins. In the early stages, depressor systems are able to compensate for the vasoconstrictor effects and hypertension is labile. Subsequent weakening of both pressor and depressor systems leads to a persistent increase in blood pressure.
PATHOGENESIS OF ARTERIAL HYPERTENSION IN PREGNANCY
During pregnancy, a hereditary predisposition to hypertension may occur; hypertension may be associated with insufficient production of 17-hydroxyprogesterone in the placenta, vascular sensitivity to angiotensin II, excessive activation of the renin-angiotensin-aldosterone system (at the same time, renal ischemia contributes to an increase in the production of renin and angiotensin II and vasopressin secretion), a corticovisceral model of the manifestation of hypertension in pregnant women is also possible. The immunological theory of hypertension in pregnant women is considered. Much attention is paid to endothelial dysfunction as a trigger for the development of hypertension.
The pathogenetic mechanisms of increased blood pressure, along with disorders in the central nervous system and the sympathetic part of the autonomic nervous system, are an increase in cardiac output and blood volume, an increase in peripheral vascular resistance, mainly at the level of arterioles. Further, electrolyte ratios are disrupted, sodium accumulates in the vascular wall, and the sensitivity of its smooth muscles to humoral pressor substances (angiotensin, catecholamines, etc.) increases. Due to swelling and thickening of the vascular wall, blood supply deteriorates (despite the increase in blood pressure) internal organs and over time, due to the development of arteriolosclerosis, the heart, kidneys, brain and other organs are affected. The heart, forced to overcome increased peripheral resistance, hypertrophies, and with a long course of the disease, dilates, which ultimately can contribute to the occurrence of heart failure.
Damage to the renal vessels contributes to ischemia, proliferation of the juxtaglomerular apparatus, further activation of the renin-angiotensin system and stabilization of blood pressure at a higher level. Over time, kidney damage manifests itself as a decrease in their filtration function and, in some cases, chronic renal failure may develop. Due to damage to the blood vessels of the brain, patients with hypertension experience hemorrhagic strokes, sometimes with a fatal outcome. A prolonged increase in blood pressure contributes to the development of atherosclerosis. Hypertension causes functional and morphological changes in blood vessels associated with a narrowing of their lumen.
Atherosclerotic damage to the coronary vessels leads to the occurrence of coronary heart disease, which occurs unfavorably in patients with hypertension. With cardiac hypertrophy, the number of capillaries does not increase, but the capillary-myocyte distance becomes greater. Atherosclerotic damage to cerebral vessels can increase the threat of stroke, and atherosclerotic changes in other vessels cause ever new clinical manifestations of damage to the relevant organs.
Thus, primary disorders in the central nervous system are realized through the second link, i.e. neuroendocrine system (increase in pressor substances, such as catecholamines, renin-angiotensin, aldosterone, as well as a decrease in depressor prostaglandins of group E, etc.), and are manifested by vasomotor disorders - tonic contraction of the arteries with increased blood pressure and subsequent ischemia and dysfunction of various organs .
Pathogenesis of gestational complications
Hypertension causes functional and morphological changes in blood vessels associated with a narrowing of their lumen. In this case, in the early stages of pregnancy, disturbances occur in the placental bed, which can subsequently lead to placental insufficiency, hypoxia and fetal malnutrition. Hypertension increases the risk of PONRP, the development of preeclampsia with characteristic complications for the fetus and the mother.
Preeclampsia varying degrees severity develops in 28–89.2% of pregnant women with hypertension and often appears early, at 24–26 weeks of pregnancy. Clinical manifestations of gestosis are very diverse and are caused by disturbances of microcirculation in vital organs, changes in the mineralocorticoid function of the adrenal glands, intravascular coagulation, etc. The hyperactivity of smooth muscle fibers observed during gestosis leads to an increase in peripheral, including renal, vascular resistance, which is ultimately accompanied by an increase in blood pressure. Preeclampsia, which develops against the background of hypertension, usually recurs in subsequent pregnancies, but is more severe.
The addition of gestosis to hypertension poses a danger to both the mother and the fetus; the risk of stillbirth, premature birth, PONRP, eclampsia, acute renal failure, and cerebrovascular accidents increases. Stroke, eclampsia and bleeding due to DIC caused by PONRP are the main causes of death in pregnant and postpartum women suffering from hypertension.
WITH early dates During pregnancy, hypertension develops morphological and functional changes in the placenta, which leads to dysfunction of the placenta. FPN develops. As a result, the exchange of gases, nutrients and excretory products in the placenta deteriorates, which contributes to malnutrition and even death of the fetus.
Microscopic examination of the placenta reveals: thrombosis of blood vessels and intervillous spaces; signs of sclerosis and obliteration, narrowing of the lumen, atheromatosis of the arteries; swelling of the villous stroma; necrotic changes in the placenta; predominance of chaotic sclerotic villi. The spiral vessels of the placental bed retain muscle and elastic layers either throughout the entire length of the vessel or in its individual sections.
CLINICAL PICTURE (SYMPTOMS) OF HIGH BLOOD PRESSURE DURING PREGNANCY
The clinical picture of hypertension is determined by the degree of increase in blood pressure, the functional state of the neuroendocrine system, various organs (primarily parenchymal), the state of hemodynamics (macro- and microcirculation) and blood rheology.
It is necessary to remember the depressive effect of pregnancy on blood pressure in the first trimester. It is known that at various stages of physiological pregnancy, blood pressure indicators undergo regular changes. During the first trimester of pregnancy, blood pressure (especially systolic) tends to decrease, and in the third trimester it gradually increases. In addition, during pregnancy and especially during childbirth, moderate tachycardia is observed, and immediately after childbirth, i.e. in the early postpartum period - bradycardia. It has been established that the blood pressure level reaches a maximum during pushing due to occlusion of the distal aorta.
Blood pressure in patients with hypertension during pregnancy is subject to fluctuations. Many researchers have noted its natural decrease and increase at different stages of pregnancy. The data from these observations do not always coincide. In some patients, the high level of blood pressure does not change significantly, in others it increases even more, and in others the blood pressure is normalized or even lower than normal. An increase in the level of previously elevated blood pressure is often caused by a combination of gestosis in pregnant women, and then edema and albuminuria appear. A temporary decrease in blood pressure in patients with hypertension is usually observed in the first or second trimester; in the third trimester and after childbirth, after eliminating the depressant effects, blood pressure rises again and may exceed the values set before pregnancy.
Typical complaints of patients are periodic increased fatigue, headaches, dizziness, palpitations, sleep disturbances, shortness of breath, pain in chest, blurred vision, tinnitus, cold extremities, paresthesia, sometimes thirst, nocturia, hematuria, unmotivated anxiety, less often nosebleeds. An increase in blood pressure, both systolic and diastolic, is considered the main symptom of the disease.
Initially, the increase in blood pressure is transient, not permanent, then it becomes permanent and its degree corresponds to the severity of the disease. In most cases, pregnant women with hypertension have anamnestic evidence of increased blood pressure even before pregnancy. With an insufficiently defined history, the presence of hypertension can be assumed if there is a hereditary burden for this disease, an early increase (up to 20 weeks of pregnancy) in blood pressure, not accompanied by edema and albuminuria, as well as the relatively middle age of the patient, retinal angiosclerosis, left ventricular hypertrophy, data on increased Blood pressure during previous pregnancies.
DIAGNOSIS OF HYPERTENSION DURING PREGNANCY
Anamnesis
Periodic increases in blood pressure in the past allow one to suspect hypertension. Pay attention to the presence of risk factors for hypertension such as smoking, diabetes, dyslipidemia, as well as cases of early death of relatives due to cardiovascular disorders. An indication of hypertension that occurred during a previous pregnancy is important. Secondary hypertension often develops before the age of 35 years.
You should also pay attention to previous kidney diseases, dysuric diseases in the past, abdominal injuries, heredity, data from past examinations, details of complaints with an emphasis on thirst, polyuria, nycturia, changes in the color of urine, lower back pain and their outcomes, use of medications (taking analgesics , contraceptives, corticosteroids, sympathomimetics), the relationship between blood pressure and pregnancy, the presence diabetes mellitus and tuberculosis in close relatives, etc.
Physical examination
It is necessary to clarify how long the complaints have been bothering you, whether they arose gradually or suddenly, and compare the time of their appearance with the duration of pregnancy.
A woman's body mass index >27 kg/m2 is a risk factor for the development of hypertension. Pay attention to the shape of the face, the presence, type and degree of obesity (suspicion of Cushing's syndrome), the proportionality of muscle development of the upper and lower extremities (impairment may indicate coarctation of the aorta). The values of blood pressure and pulse are compared in both upper extremities, and measurements taken in a horizontal position are compared with measurements in a standing position.
An increase in diastolic blood pressure during the transition from a horizontal to a vertical position is characteristic of hypertension, a decrease in blood pressure is characteristic of symptomatic hypertension. Palpation and auscultation of the carotid arteries allows you to detect signs of their stenosis. When examining the heart and lungs, pay attention to signs of left ventricular hypertrophy and decompensation of the heart (localization of the apical impulse, the presence of III and IV heart sounds, moist rales in the lungs). Palpation of the abdomen reveals an enlarged polycystic kidney. The pulse in the femoral arteries is examined; blood pressure in the lower extremities should be measured at least once. The limbs are examined to detect edema and assess its degree. The anterior surface of the neck is examined and the thyroid gland is palpated. Examine the urinary system. If neurological complaints are detected (headaches, dizziness), nystagmus and stability in the Romberg position are determined.
Laboratory research
All studies for hypertension are divided into mandatory (main studies) and additional. The latter are carried out if symptomatic hypertension is suspected and/or therapy for hypertension is not effective.
Basic Research
● examination of 24-hour urine for the presence of protein (the amount of protein or microalbuminuria), blood and glucose;
● biochemical blood test (total protein and its fractions, liver enzymes, electrolytes, glucose
blood);
● clinical blood test (Hb, Ht concentration and platelet count);
● ECG.
Additional Research
If kidney disease is suspected, a urine test is performed according to Nechiporenko, a microbiological examination of urine, filtration (clearance of endogenous creatinine) and concentration (urinalysis according to Zimnitsky) function is assessed, and an ultrasound of the kidneys is performed. The choice of other methods depends on the cause of symptomatic hypertension.
● General blood test.
● Urinalysis (general and Nechiporenko).
● Determination of glucose level in blood plasma (fasting).
● Serum content of potassium, uric acid, creatinine, total cholesterol, high-density lipoproteins, triglycerides.
● Determination of potassium, phosphorus, uric acid in blood serum.
● Determination of serum creatinine or urea nitrogen.
● Determination of aldosterone, renin, determination of the ratio of potassium and sodium in plasma.
● Determination of 17-ketosteroids in urine.
● Determination of 17-hydroxycorticosteroids and adrenocorticotropic hormone in the blood.
Instrumental studies
The main non-invasive method for diagnosing hypertension is auscultation of blood pressure according to N.S. Korotkov. For the correct method of measuring blood pressure, see
To correctly measure blood pressure for the purpose of classifying hypertension, it is necessary to comply with the conditions and methodology for measuring blood pressure: a quiet, calm environment, no earlier than 1–2 hours after meals, after rest (at least 10 minutes), before measuring blood pressure, exclude the intake of tea, coffee and adrenergic agonists . Blood pressure is measured in the sitting position, with the tonometer cuff placed at heart level. Additional measurements of blood pressure while standing to detect orthostatic hypotension are carried out 2 minutes after transition to a vertical position. It is advisable to measure blood pressure in orthostasis in the presence of diabetes mellitus, circulatory failure, vegetative-vascular dystonia, as well as in women receiving drugs with a vasodilating effect or with a history of episodes of orthostatic hypotension.
The pressure gauge must be checked and calibrated. The cuff is selected individually, taking into account the circumference of the shoulder (the latter is measured in its middle third): for AP<33 см используют манжету размером 12x23 см, при ОП=33– 41 см - 15x33 см, а при ОП >41 cm - 18x36 cm. Before measurement, it is necessary to evaluate systolic blood pressure by palpation (on the radial or brachial artery). When inflating air into the cuff, it is necessary to avoid causing pain to the patient. The rate of decrease in air pressure in the cuff should be 2–3 mmHg. per second. The appearance of the first tone corresponds to systolic blood pressure (the first phase of Korotkoff sounds). Diastolic blood pressure is determined by the 4th phase (the moment of sharp weakening of tones). If you suspect hypertension white coat"(occurs in 20–30% of pregnant women), 24-hour blood pressure monitoring is indicated. This method allows you to confirm hypertension, assess circadian rhythms of blood pressure and provide an individualized approach to the chronotherapy of hypertension. If congenital or acquired heart disease is suspected, echocardiography is performed to assess the characteristics of the central hemodynamics of a pregnant woman and resolve the issue of inversion of its types (during pregnancy or if drug therapy is ineffective). The condition of the vessels of the microvasculature is clarified using ophthalmoscopy. To assess the fetoplacental system, ultrasound and Dopplerography of the vessels of the fetoplacental complex are performed.
● ECG.
● Echocardiography.
● Fundus examination.
● Ambulatory 24-hour blood pressure monitoring.
● Ultrasound of the kidneys and adrenal glands.
● Chest X-ray.
● Urine bacteriuria.
Complications of pregnancy with arterial hypertension
Typical complications are gestosis, FPN, premature birth.
MM. Shekhtman identifies three degrees of risk for pregnancy and childbirth:
● I degree (minimal) - complications of pregnancy occur in no more than 20% of women, pregnancy worsens the course of the disease in less than 20% of patients.
● II degree (severe) - extragenital diseases often (in 20–50% of cases) cause pregnancy complications such as gestosis, spontaneous abortion, premature birth; Fetal malnutrition is often observed, PS is increased; the course of the disease may worsen during pregnancy or after childbirth in more than 20% of patients.
● III degree (maximum) - the majority of women suffering from extragenital diseases experience pregnancy complications (more than 50%), full-term children are rarely born and PS is high; pregnancy poses a danger to a woman’s health and life.
As the severity of the underlying disease increases, the frequency of pregnancy complications such as spontaneous abortion and premature birth increases. In the structure of complications of pregnancy with hypertension, the proportion of gestosis is highest. As a rule, gestosis is extremely difficult, difficult to treat and recurs in subsequent pregnancies. The high frequency of gestosis in hypertension is due to the common pathogenetic mechanisms of dysregulation of vascular tone and renal activity. One of the serious complications of pregnancy is PONRP.
Differential diagnosis
Differential diagnosis of hypertension in pregnant women is carried out based on the analysis of clinical and anamnestic data and the results of laboratory and instrumental examinations.
Differential diagnosis of hypertension is carried out with polycystic kidney disease, chronic pyelonephritis, diffuse diabetic glomerulosclerosis with renal failure and hypertension, renovascular hypertension, anomalies of kidney development, nodular periarthritis, coarctation of the aorta, pheochromocytoma, thyrotoxicosis, Itsenko-Cushing and Conn syndrome, acromegaly , encephalitis and brain tumors .
Screening
To screen for hypertension during pregnancy, blood pressure is measured at each appointment. Prevention of complications consists of normalizing blood pressure.
A pregnant woman suffering from arterial hypertension is hospitalized in a hospital three times during pregnancy.
The first hospitalization is before 12 weeks of pregnancy. If stage I of the disease is detected, pregnancy can be saved; stages II and III serve as an indication for termination of pregnancy.
The second hospitalization at 28–32 weeks is the period of greatest stress on the cardiovascular system. During this period, a thorough examination of the patient, correction of the therapy, and treatment of FPN are carried out.
The third hospitalization should be carried out 2-3 weeks before the expected birth to prepare women for delivery.
Indications for consultation with other specialists
To clarify the type of hypertension in a pregnant woman and correct drug therapy, a consultation is carried out with a therapist, cardiologist, ophthalmologist, urologist, nephrologist, endocrinologist.
An example of a diagnosis formulation
Pregnancy 30 weeks. AG.
TREATMENT OF HYPERTENSION DURING PREGNANCY
Treatment Goals
Reduce the risk of pregnancy complications and PS.
Indications for hospitalization
The absolute indication for hospitalization and initiation of parenteral antihypertensive therapy is an increase in blood pressure by more than 30 mm Hg. from the initial one and/or the appearance of pathological symptoms from the central nervous system. Relative indications: the need to clarify the cause of hypertension in a pregnant woman, the addition of signs of gestosis or a disorder of the fetoplacental system to previous hypertension, lack of effect from outpatient therapy for hypertension.
Non-drug treatment
Non-drug measures are indicated for all pregnant women with hypertension. With stable hypertension, when blood pressure does not exceed 140–
150/90–100 mm Hg. and there are no signs of damage to the kidneys, fundus and fetoplacental system in patients
with pre-existing hypertension, only non-drug interventions are possible:
- eliminating emotional stress;
- change in diet;
- reasonable physical activity;
- daytime rest mode (“bed rest”);
- control of risk factors for progression of hypertension;
- limiting table salt consumption to 5 g per day;
- limiting the intake of cholesterol and saturated fats if you are overweight.
An integral part of medical care for pregnant women with hypertension should be an increase in educational level
patients to ensure the patient’s conscious participation in the treatment and prophylactic process and increase it
efficiency.
- rational psychotherapy;
- reducing table salt consumption to 5 g/day;
- changing the diet with a decrease in the consumption of vegetable and animal fats, an increase in the diet of vegetables, fruits, grains and dairy products;
- staying in the fresh air for several hours a day;
- physiotherapeutic procedures (electrosleep, inductothermy of the feet and legs, diathermy of the perinephric region);
- Hyperbaric oxygen therapy has a good effect.
Drug therapy for hypertension during pregnancy
The main goal of hypertension therapy is to effectively reduce blood pressure.
Drug treatment is indicated for:
● blood pressure value more than 130/90–100 mm Hg;
● systolic blood pressure, more than 30 mm Hg. and/or diastolic blood pressure - more than 15 mm Hg. exceeding what is typical for a given woman;
● with signs of gestosis or damage to the fetoplacental system - regardless of the absolute numbers of blood pressure.
Principles of drug treatment of hypertension in pregnant women:
● carry out monotherapy with minimal doses;
● use chronotherapeutic approaches to treatment;
● preference is given to long-acting drugs;
● in some cases, combination therapy is used to achieve maximum hypotensive effect and minimize undesirable manifestations.
According to the recommendations of the European Society for the Study of Hypertension, pregnant women with hypertension try not to prescribe angiotensin-converting enzyme blockers, angiotensin receptor antagonists and diuretics. To quickly reduce blood pressure, use: nifedipine, labetalol, hydralazine. For long-term therapy of hypertension, β-adrenergic blockers are used: oxprenolol, pindolol, atenolol (taking the drug is associated with FGR), labetalol, nebivolol, methyldopa, slow calcium channel blockers - nifedipine (extended-release forms), isradipine.
The recommendations of the All-Russian Scientific Society of Cardiology (2006) declare a list of drugs for the treatment of hypertension of varying severity in pregnant women. For the treatment of grade 1–2 hypertension, the 1st line drug is methyldopa (500 mg 2–4 times a day), the 2nd line is labetalol (200 mg 2 times a day), pindolol (5–15 mg 2 times a day), oxprenolol ( 20–80 mg twice a day) and nifedipine (20–40 mg twice a day). For the treatment of stage 3 hypertension, first-line drugs of choice are hydralazine (5–10 mg IV bolus, if necessary, repeated administration after 20 minutes until a dose of 30 mg is reached or IV administration at a rate of 3–10 mg/h), labetalol ( 10–20 mg IV bolus, if necessary, repeated administration after 30 minutes or IV administration at a rate of 1–2 mg/hour), nifedipine (10 mg every 1–3 hours).
1st line drugs.
● α2-Adrenergic agonists (methyldopa 500 mg 2–4 times a day).
2nd line drugs.
● Selective β-blockers (atenolol 25–100 mg once daily; metoprolol 25–100 mg once daily).
● Slow calcium channel blockers (dangerous, but the benefits may outweigh the risks!): dihydropyridine derivatives - nifedipine 10–20 mg 2 times a day; amlodipine orally 2.5–10 mg 1–2 times a day; phenylalkylamine derivatives - verapamil orally 120–240 mg 1–2 times a day (up to 12 weeks during feeding); felodipine orally 2.5–20 mg 2 times a day.
3rd line drugs.
● Methyldopa + 2nd line drug.
To correct FPN, therapeutic and preventive measures have been developed, including, in addition to drugs that normalize vascular tone, drugs that affect metabolism in the placenta, microcirculation (pentoxifylline, aminophylline), protein biosynthesis (orciprenaline) and bioenergetics of the placenta.
To reduce the severity of the adverse effects of prescribed drugs and achieve a pronounced hypotensive effect, it is preferable to use combination therapy with low doses of two antihypertensive drugs (preferred combinations):
β-blockers + thiazide diuretics;
β-blockers + slow calcium channel blockers of the dihydropyridine series;
slow calcium channel blockers + thiazide diuretics.
Prevention and prediction of gestational complications
Pregnant women with hypertension should be identified as a high-risk group for both the fetus and the mother. Pregnant women are monitored by a therapist and must be examined by a therapist 2–3 times during pregnancy. During pregnancy there is a tendency for blood pressure to decrease; in some cases, you can do without antihypertensive drugs. With normal fetal development, pregnancy can continue until natural birth. There are three planned hospitalizations during pregnancy (see above).
Features of treatment of complications of gestation
Treatment of gestational complications by trimester
Treatment goals: reducing blood pressure to target levels with the minimum effective amount of prescribed therapy in order to minimize the risk of developing cardiovascular and obstetric complications in the pregnant woman and create optimal conditions for fetal development.
The treatment is carried out by a therapist.
In the first trimester, the minute volume of blood increases, and pregnancy is rarely complicated by fetal death and spontaneous miscarriage. Increased blood volume is a reflection of a compensatory reaction aimed at eliminating hypoxic changes. If there is a threat of miscarriage, sedative, anti-stress, antispasmodic and hormonal therapy is used. When an abortion begins, hemostatic agents are used to stop bleeding.
From the second trimester of pregnancy with hypertension, morphological and functional changes in the placenta develop, which leads to dysfunction of the placenta and the development of FPN. From the second half of pregnancy, when peripheral vascular resistance increases and minute blood volume decreases, the course of pregnancy worsens, fetal malnutrition and intrauterine asphyxia develop, and its death is possible. Combined forms of late gestosis develop from the early stages of pregnancy, sometimes up to 20 weeks.
Pharmacotherapy for gestosis should be comprehensive and include the following drugs: regulatory functions of the central nervous system; hypotensive; diuretics; to normalize rheological and coagulation parameters of blood; for infusion-transfusion and detoxification therapy; drugs that improve uteroplacental blood flow; antioxidants, membrane stabilizers, hepatoprotectors; immunomodulators.
With the development of FPN in the II and III trimester, therapy is prescribed aimed at normalizing the function of the central nervous system, improving uteroplacental blood flow, influencing the rheological properties of the blood, improving the trophic function of the placenta and normalizing metabolic processes.
If chronic fetal hypoxia occurs in the second and third trimester, therapy is aimed at improving uteroplacental blood flow, correction of metabolic acidosis, activation of metabolic processes in the placenta, improvement of oxygen utilization and reduction of the effect of hypoxia on the fetal central nervous system.
Treatment of complications during childbirth and the postpartum period Frequent obstetric pathology This group of pregnant women experience premature birth. Arterial hypertension is one of the main causes of premature abruption of a normally located placenta. Preeclampsia due to hypertension, no matter what the cause, can result in eclampsia if not adequately treated.
Stroke, eclampsia and bleeding due to DIC caused by placental abruption are the main causes of death in pregnant women and women in labor with arterial hypertension.
In the first and, especially, in the second stage of labor, a significant increase in blood pressure is noted, which is associated with psycho-emotional stress and the pain component during childbirth. Compensatory mechanisms are not able to provide an optimal level of blood pressure, there is a persistent increase in blood pressure, and cerebrovascular accidents are possible.
Childbirth is often accompanied by labor disturbances and often takes on a rapid and rapid course.
In the third stage of labor, against the background of a sharp drop in intra-abdominal pressure and a decrease in compression of the aorta, blood redistribution occurs, which contributes to a decrease in blood pressure compared to the first two periods.
Hypotonic bleeding often occurs during childbirth, often accompanied by vascular insufficiency.
Treatment of severe gestosis, including preeclampsia: hospitalization of patients has one purpose -
delivery during intensive care. Tactics for severe gestosis include the following:
- intensive therapy;
- abortion;
- delivery predominantly by CS;
- anesthetic protection from the moment of admission to the maternity hospital;
- full preparedness for possible massive coagulopathic bleeding during delivery;
- continuation of treatment of gestosis in the first 2–3 days after delivery;
- prevention of inflammatory and thrombotic complications in the postoperative (postpartum) period.
The main components of the treatment of pregnant women with severe gestosis:
- elimination of hypovolemia;
- administration of fresh frozen plasma;
- antihypertensive therapy;
- prescription of magnesium sulfate.
Timing and methods of delivery
Determined individually. If the pregnant woman’s blood pressure is well controlled, there is no obstetric history, the condition of the fetus is satisfactory - the pregnancy is prolonged to full term, programmed delivery is advisable through the vaginal birth canal with the provision of antihypertensive therapy, adequate analgesia of labor and monitoring of the woman’s blood pressure and the condition of the fetus.
Indications for early delivery:
● hypertension refractory to therapy;
● complications from target organs - myocardial infarction, stroke, retinal detachment;
● severe forms of gestosis and their complications - preeclampsia, eclampsia, posteclamptic coma, MODS, pulmonary edema, PONRP, HELLP syndrome;
● deterioration of the fetus' condition.
Most often, childbirth is carried out through the natural birth canal. In the first period, it is necessary to carefully monitor the dynamics of blood pressure in the first stage of labor, adequate pain relief, antihypertensive therapy, and early amniotomy. During the expulsion period, antihypertensive therapy is intensified with ganglion blockers. Depending on the condition of the mother and fetus, the second period is shortened by performing a perineotomy or applying obstetric forceps. In the third stage of labor, bleeding is prevented. Throughout labor, fetal hypoxia is prevented.
Evaluation of treatment effectiveness
Achieving target blood pressure in a pregnant woman while ensuring optimal perfusion of the placenta (reducing diastolic blood pressure to 90 mm Hg).
PREVENTION OF HYPERTENSION DURING PREGNANCY
Patients with hypertension before pregnancy are considered to be at high risk for the development of gestosis and FPN. To prevent them, it is recommended to take acetylsalicylic acid in a daily dose of 80–100 mg.
The advisability of using low molecular weight heparins and magnesium preparations has not been confirmed.
INFORMATION FOR THE PATIENT
● Hypertension worsens the prognosis of pregnancy and its outcomes.
● Blood pressure control should be achieved during pregnancy planning.
● Drug correction of hypertension prevents the progression of hypertension, but does not prevent the occurrence of preeclampsia.
● Hypertension requires regular medical supervision during pregnancy.
● All patients with hypertension are shown:
- elimination of emotional stress;
- changing the diet;
- regular dosed physical activity;
- daytime rest mode (“bed rest”).
● Antihypertensive therapy, individually prescribed and adjusted by a doctor, must be constant.
● If you have hypertension during pregnancy, it is necessary to undergo regular examinations and carry out prevention and treatment of disorders of the fetoplacental system.
Medical rehabilitation allows women to regain their health and reproductive function; 90% of women after rehabilitation successfully completed their second pregnancy.
FORECAST
It is determined by the genesis and severity of hypertension, the development of damage to target organs and the fetoplacental system, and the effectiveness of antihypertensive therapy.
In compensated stages, the prognosis is favorable.
Blood pressure (BP) in the body forces blood to move through the vessels and supply organs and tissues with nutrients. The force of pressure on the vessels is measured in millimeters of mercury (mmHg). Upper, or systolic, pressure is a condition in which the heart muscle is absolutely compressed to further pump blood through the vessels. The lower pressure, diastolic, is an indicator of complete relaxation of the heart muscle. Upper pressure readings from 90 to 120 mm Hg are considered normal. Art. Blood pressure up to 130/80-60 is allowed. But during pregnancy, these norms sometimes deviate. Arterial hypertension in pregnant women, just like diagnosed hypertension in pregnant women, occurs for several reasons.
During pregnancy, hormonal changes occur; with the growth of the fetus, one or more additional blood circulation circles in the placenta are formed in case of multiple pregnancy. This is necessary to provide nutrition for the unborn child. The load on the heart muscle increases sharply as the heart works harder. During this period, there is a high probability of arterial hypertension. If the difference between the normal working blood pressure does not exceed 10%, the health of the woman and the unborn child is not in danger. But indicators exceeding the norm by more than 15-20% indicate the occurrence of gestational hypertension, and in the case of persistent excess pressure, hypertension is suspected in the pregnant woman.
Hypertension during pregnancy occurs for the same reasons as everyone else, although there are specific factors that can attract the attention of the attending physician, namely:
- Heredity. The doctor finds out whether any of the relatives suffer from hypertension and the level of blood pressure before pregnancy.
- Woman's age. After 30-35 years of age, there is a greater chance that hypertension may develop during pregnancy.
- Order of pregnancy. The doctor analyzes the characteristics of previous pregnancies to get an overall picture.
- Interval between births. A period of two years is considered optimal. If the body has not had time to rest from a previous pregnancy, the likelihood that a woman will develop gestational hypertension or hypertension increases many times over.
- Multiple births. Hypertension in pregnant women with multiple pregnancies almost always occurs, but usually disappears immediately after birth. Exception: if the woman previously suffered from hypertension.
- The presence of mental, neurogenic disorders, depression.
- Physical activity, lifestyle, bad habits.
- Toxicosis.
Hypertension in pregnant women is often provoked by concomitant diseases:
- diabetes mellitus;
- anemia;
- hypothyroidism;
- obesity;
- cardiovascular diseases;
- renal failure.
Classifications of hypertension during pregnancy
Arterial hypertension during pregnancy is classified into the following types:
- Mild: blood pressure up to 150/90 mm Hg. Art. Swelling of the legs is observed, protein appears in the urine (up to 1 g).
- Average: blood pressure up to 170/110 mm Hg. Art.
- Severe: blood pressure above 180/120 mm Hg. Art.
In moderate to severe forms of the pregnant patient, hospitalization or bed rest, drug treatment to preserve the fetus are indicated.
This form is also called late toxicosis. The most dangerous is the combination of preeclampsia with chronic hypertension. The exact cause of preeclampsia has not been identified. It is believed that this is a genetically determined pathology.
If the diagnosis is made before 34 weeks, the patient is prescribed corticosteroids to accelerate lung development in the fetus, followed by premature delivery.
- Preeclampsia is an increase in blood pressure in the second and third trimesters of pregnancy. It is a complication resulting from the persistence of high blood pressure during pregnancy, characterized by the appearance of swelling and protein in the urine. Later, kidney failure, brain damage, and seizures like epilepsy appear. Doctors call the main cause of gestosis a large weight gain in pregnant women. That's why doctors regularly weigh expectant mothers during appointments. The danger is that the vessels of the placenta during gestosis are damaged due to the accumulation of excess fluid and edema, and the fetus does not receive enough oxygen and nutrition, the condition develops into the next form.
- Eclampsia. This form is extremely dangerous and is the leading cause of death among pregnant women. A pregnant woman experiences convulsions as in epilepsy and loses consciousness.
Symptoms of hypertension in pregnant women
Symptoms of high blood pressure in pregnant women are in many ways similar to the general manifestations of arterial hypertension, these are:
- severe pain in the head, upper peritoneum, dizziness;
- blurred vision, fear of light, tinnitus;
- sudden nausea turning into vomiting;
- increased heart rate - tachycardia;
- weight gain due to fluid retention;
- shortness of breath, weakness;
- nosebleeds;
- liver dysfunction, resulting in dark stool and yellowing of the skin;
- facial redness due to flushing;
- a decrease in the level of platelets in the blood due to poor clotting. Visible from blood test;
- mental disorders: the appearance of fear of death, anxiety.
Impaired vision or hearing with simultaneous headaches indicate incipient cerebral edema and a preconvulsive state. Shortness of breath sometimes occurs not only due to increased pressure, but also due to the growth of the abdomen.
When you inhale deeply, the chest rises slightly, and when you exhale forcefully, it contracts. In a pregnant woman, a growing belly does not allow the chest to contract normally, which causes an increase in blood pressure. The heart muscle has to work harder to deliver oxygen to all organs, including the placenta.
If at least one of the listed signs appears, you must immediately consult a doctor; late complications in pregnant women such as preeclampsia and eclampsia are difficult to correct. The danger of developing complications due to increased blood pressure is that the fetus, due to impaired blood supply to the placenta, experiences oxygen starvation, or hypoxia. As a result, intrauterine development is delayed or premature separation of the placenta occurs, leading to fetal death.
Diagnosis of pregnant women with high blood pressure
For a complete examination, pregnant women with arterial hypertension are prescribed:
- general examination with measurement of pulse and heart rate;
- Ultrasound of the heart, or echocardioscopy;
- identification of concomitant diseases;
- examination by an ophthalmologist of the fundus;
- examination by an endocrinologist;
- biochemical and general blood test;
- examination of urine for protein, the presence of blood in it, and the level of glomerular filtration.
Treatment and contraindications
Drug treatment in pregnant women is limited to adjusting antihypertensive therapy. Pregnant women cannot take the usual medications that lower blood pressure, so they are not prescribed ATP inhibitors: Captopril, Enalapril.
Also, during pregnancy, you should not take angiotensin II receptor blockers: Valsartan, Losartan, as their teratogenic properties cause pathologies and fetal deformities. For the same reason, due to its teratogenic effect, the drug Diltiazem is contraindicated.
“Reserpine” depresses the nervous system, circulates in the blood for a long time and is also not used in treatment during pregnancy.
Spironolactone, due to its antiandrogenic effect - a decrease in the level of male hormones - and the associated risk of developing abnormalities of the genitourinary system in the fetus, is also not used in the treatment of pregnant and lactating patients.
Drug treatment of pregnant women in case of emergency care with blood pressure levels from 140/90 mm Hg. Art.:
- "Nifedipine" (10 mg): under the tongue, one tablet. It is recommended to take up to three pieces per day. During administration, you must be in a supine position due to possible dizziness after taking the medicine.
- “Magnesia”, or magnesium sulfate, is given intravenously, sometimes after a rapid infusion a dropper is placed into a vein. Anticonvulsant with hypotensive effect. The dosage is prescribed only by a doctor.
- “Nitroglycerin” – intravenously, by dropper, by slow infusion. Rarely used if other medications do not help. A strong vasodilator with a hypotensive effect.
Non-drug treatment for pregnant women comes down to early registration: up to 12 weeks. By this time, the issue of maintaining or terminating the pregnancy is usually decided. With late calls, the issue of interruption becomes problematic. Subsequently, the patient has her blood pressure measured in both arms at each visit to the antenatal clinic. If a pregnant woman has arterial hypertension, it is recommended to keep a daily diary, where she should record her blood pressure and pulse in the morning and evening. When taking the medicine, it is necessary to count the number of daily urinations.
If there is a need for planned hospitalization of the patient, it is carried out in three stages.
Stage I of hospitalization: for up to 12 weeks. The patient is placed in the cardiology department and it is decided whether the pregnancy can be continued without a threat to the mother. If you have stage I hypertension (blood pressure up to 140/90 mm Hg), there are no contraindications to pregnancy.
In case of stage II hypertension (up to 160/95 mm Hg), pregnancy is left under the careful supervision of a specialist. But this is possible if there are no concomitant diseases: diabetes, heart rhythm disturbances, kidney diseases.
If stage II hypertension cannot be corrected or stage III develops, this is a reason to terminate the pregnancy.
The second stage of hospitalization is carried out at 28-32 weeks. A pregnant woman is placed in the cardiology department to assess compensatory cardiac activity. At this stage, the vascular bed is maximally loaded with fluid; in the case of an unstable state of the cardiovascular system, the issue of early birth is resolved.
The third stage of hospitalization occurs approximately two weeks before birth. At this time, the issue of the method of obstetric care is decided, and the risks for the mother and baby are assessed.
Unscheduled hospitalizations are carried out at any time according to indications.
Preventive actions
Pregnancy and concomitant hypertension is a serious test for a woman’s body. Ignoring symptoms and hoping that “everything will go away” is irresponsible.
As with any disease, with arterial hypertension or hypertension it is necessary to follow preventive measures:
- Eat right, excluding fatty, salty, canned foods. Monitor your own weight: the gain is no more than 15 kg during the entire pregnancy. It is useful to take at least one glass of cranberry juice, birch sap, and ¼ glass of beet juice every day before meals to lower blood pressure.
- Quit smoking and alcohol.
- Anti-infective and anti-inflammatory therapy is especially important before pregnancy.
- Moderate physical activity, walking outside.
- Avoid stressful situations, overload, observe work and rest schedules, and get enough sleep. Psychological support from loved ones helps a pregnant woman.
- Measure blood pressure regularly.
It is important to remember that self-medication of pregnant women with arterial hypertension or hypertension is strictly contraindicated. Improper use of medications leads to the development of complications: eclampsia, preeclampsia, which ranks first among the causes of death in pregnant women.
