Hypertensive disease of pregnancy

Last updated
Hypertensive disease of pregnancy
Other namesMaternal hypertensive disorder
Specialty Obstetrics
Frequency20.7 million (2015) [1]
Deaths46,900 (2015) [2]

Hypertensive disease of pregnancy, also known as maternal hypertensive disorder, is a group of high blood pressure disorders that include preeclampsia, preeclampsia superimposed on chronic hypertension, gestational hypertension, and chronic hypertension. [3]

Contents

Maternal hypertensive disorders occurred in about 20.7 million women in 2013. [1] About 10% of pregnancies globally are complicated by hypertensive diseases. [4] In the United States, hypertensive disease of pregnancy affects about 8% to 13% of pregnancies. [3] Rates have increased in the developing world. [3] They resulted in 29,000 deaths in 2013 down from 37,000 deaths in 1990. [5] They are one of the three major causes of death in pregnancy (16%) along with post partum bleeding (13%) and puerperal infections (2%). [6]

Signs and symptoms

Although many pregnant women with high blood pressure have healthy babies without serious problems, high blood pressure can be dangerous for both the mother and baby. Women with pre-existing, or chronic, high blood pressure are more likely to have certain complications during pregnancy than those with normal blood pressure. However, some women develop high blood pressure while they are pregnant (often called gestational hypertension). [7]

Chronic poorly-controlled high blood pressure before and during pregnancy puts a pregnant woman and her baby at risk for problems. It is associated with an increased risk for maternal complications such as preeclampsia, placental abruption (when the placenta separates from the wall of the uterus), and gestational diabetes. These women also face a higher risk for poor birth outcomes such as preterm delivery, having an infant small for his/her gestational age, and infant death. [8]

Risk factors

Some women have a greater risk of developing hypertension during pregnancy. These are:

Diagnosis

There is no single test to predict or diagnose preeclampsia. Key signs are increased blood pressure and protein in the urine (proteinuria). Other symptoms that seem to occur with preeclampsia include persistent headaches, blurred vision or sensitivity to light, and abdominal pain. [7]

All of these sensations can be caused by other disorders; they can also occur in healthy pregnancies. Regular visits are scheduled to track blood pressure and level of protein in urine, to order and analyze blood tests that detect signs of preeclampsia, and to monitor fetal development more closely. [7]

Classification

A classification of hypertensive disorders of pregnancy uses 4 categories as recommended by the U.S. National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy: [10]

  1. Chronic hypertension;
  2. Preeclampsia-eclampsia;
  3. Preeclampsia superimposed on chronic hypertension;
  4. Gestational hypertension (transient hypertension of pregnancy or chronic hypertension identified in the latter half of pregnancy).

This terminology is preferred over the older but widely used term pregnancy-induced hypertension (PIH) because it is more precise. [10] The newer terminology reflects simply relation of pregnancy with either the onset or first detection of hypertension; the question of causation, while pathogenetically interesting, is not the important point for most health care purposes. This classification treats HELLP syndrome as a type of preeclampsia rather than a parallel entity. [10]

Chronic hypertension

Chronic hypertension is a type of high blood pressure in a pregnant woman that is pre-existing before conception, diagnosed early in pregnancy, or persists significantly after the end of pregnancy. It affects about 5% of all pregnancies and can be a primary disorder of essential hypertension or secondary to another condition; it is not caused by pregnancy itself. [10]

The diagnostic criteria for chronic hypertension are typically considered to be at least two separate blood pressure readings taken at least four hours apart with systolic blood pressure ≥ 140mmHg, diastolic blood pressure ≥90 mmHg, or both, identified before pregnancy, before 20 weeks gestation, or persisting at least 12 weeks after giving birth. [10] However, there is some controversy over the utility of adopting lower thresholds for diagnosis of chronic hypertension, which is more consistent with recent recommendations from the American College of Cardiology and the American Heart Association for the diagnosis of hypertension in adults. [11] Chronic hypertension in pregnancy is now considered mild if blood pressures do not exceed 159 mmHg systolic and 109 mmHg diastolic and severe if pressures are ≥ 160 mmHg systolic or 110 mmHg diastolic, although controversy also exists as to the most appropriate cutoffs for this definition. [11]

Because chronic hypertension can progress to more severe forms of disease, it is important to accurately diagnose the condition early, ideally prior to pregnancy, and initiate management to control parental blood pressure. [12] This is often difficult, as many reproductive individuals may not regularly visit the doctor and, when pregnant, may initially present for prenatal care in the second trimester. [12]

Pre-eclampsia and eclampsia

Preeclampsia is a medical condition which usually develops after 20 weeks of gestation and traditionally involves both newly increased blood pressure (blood pressure > 140/90 mmHg) and proteinuria. [13]

Preeclampsia is a leading cause of fetal complications, which include low birth weight, preterm birth, and stillbirth. Women with preeclampsia are encouraged to deliver the child after 37 weeks of gestation to minimize the risks of the severe complications. [13]

Preeclampsia can also be diagnosed if a woman has both increased blood pressure and 1 or more signs of significant organ damage. Signs of significant organ damage include: [13]

If a woman with preeclampsia has any of these signs of significant organ damage, then her condition is classified as preeclampsia with severe features. [13] This diagnosis can be made even if the patient does not have proteinuria. Women with preeclampsia with severe features are encouraged to deliver the child after 34 weeks of gestation to minimize the risks of the severe complications. [13]

Preeclampsia can also present with seizures in the pregnant mother. [14] In this case, the patient would be diagnosed with eclampsia.[ citation needed ]

There is no proven way to prevent preeclampsia/eclampsia. [13] Most women who develop signs of preeclampsia, however, are closely monitored to lessen or avoid related problems. [13] The only way to "cure" preeclampsia/eclampsia is to deliver or abort the baby. [13]

Eclampsia

Eclampsia is one particularly concerning form of preeclampsia in which a pregnant woman who previously presented with signs of newly increased blood pressure begins to experience new generalized seizures or coma. [13] Up to 70% of patients with eclampsia experience complications associated with pregnancy. [15] These complications can include HELLP syndrome, acute kidney injury, and disseminated intravascular coagulation among others. [15]

HELLP Syndrome

HELLP Syndrome is a type of preeclampsia with severe features that involves increased hemolysis, increased liver enzymes, and low platelet levels. [16] While most women with HELLP syndrome have high blood pressure and proteinuria, up to 20% of HELLP syndrome cases do not present with these classical signs of preeclampsia. [17] However, like pre-eclampsia, HELLP syndrome can also lead to low birth weight and premature birth of the fetus/neonate. [18] HELLP syndrome has a fetal/neonatal mortality rate of 7-20%. [18]

Preeclampsia superimposed on chronic hypertension

Preeclampsia superimposed on chronic hypertension occurs when a pregnant woman with chronic hypertension develops signs of pre-eclampsia, typically defined as new onset of proteinuria ≥30 mg/dL (1+ in the dipstick) in at least 2 random urine specimens that were collected ≥4 h apart (but within a 7-day interval) or 0.3 g in a 24-h period. [19] Like ordinary pre-eclampsia, superimposed pre-eclampsia can also occur with severe features, which are defined as: systolic blood pressure ≥160 mmHg or diastolic blood pressure ≥110 mmHg despite escalation of antihypertensive therapy; thrombocytopenia (platelet count <100,000/microL); impaired liver function; new-onset or worsening renal insufficiency; pulmonary edema; or persistent cerebral or visual disturbances. As a result, superimposed pre-eclampsia can be diagnosed without proteinuria when a sudden increase in previously well-controlled blood pressure is accompanied by severe features of pre-eclampsia. [19]

Gestational hypertension

Gestational hypertension is a provisional diagnosis that involves newly increased blood pressure in a pregnant woman that usually develops after 20 weeks of gestation, but does not currently show any signs of proteinuria or other features associated with preeclampsia. [13] Up to 50% of gestational hypertension patients go on to develop some form of preeclampsia. [13]

Gestational hypertension will normally resolve by 12 weeks postpartum. [13] In this case, the diagnosis of gestational hypertension will be updated to be transient hypertension of pregnancy. [13] If the increased blood pressure does not resolve by 12 weeks postpartum, then the diagnosis of gestational hypertension will be updated to be chronic hypertension . [13]

Prevention

Blood pressure control can be accomplished before pregnancy. Medications can control blood pressure. Certain medications may not be ideal for blood pressure control during pregnancy such as angiotensin-converting enzyme (ACE) inhibitors and angiotensin II (AII) receptor antagonists. [7] Controlling weight gain during pregnancy can help reduce the risk of hypertension during pregnancy. [20]

There is limited evidence to suggest that calcium supplementation may reduce the risk of pre-eclampsia or stillbirth but it is unclear if it has other benefits. [21]

Management

The only way to definitively treat a hypertensive disease of pregnancy (i.e. preeclampsia/eclampsia, gestational hypertension, etc. ) is to deliver the fetus. [13] This prevents further development of complications related to the disorder in both the mother and the fetus. [13] Therefore, the first line approach to management of these conditions is to consider induction of preterm labor. The exact timing of when to induce labor is dependent on the severity of symptoms related to the hypertensive disease, as well as the medical condition of both the mother and the fetus. Generally, in mothers with preeclampsia, labor is induced once the gestational age is >37 weeks. [13] In patients with preeclampsia with severe features or eclampsia, labor is induced once the gestational age is >34 weeks. [13] In patients with gestational hypertension and no other signs of severe disease, labor is generally induced at term. [13]

In cases where the fetus has not yet reached a safe gestational age to be delivered, management is focused on managing symptoms to give the fetus more time to mature. [22] In women with gestational hypertension, some studies have found that usage of baby aspirin can prevent the progression of the condition to preeclampsia/eclampsia and reduce the risk of complications associated with hypertensive disorders of pregnancy. [22]

Pregnant women with chronic hypertension diagnosed before or early in pregnancy should be evaluated to identify the underlying cause of hypertension as well as possible existing end-organ damage caused by hypertension, such as cardiac and kidney injury. [12] Although most cases of chronic hypertension are primary, and thus classified as essential hypertension, secondary causes such as renal, vascular, and endocrine disorders must also be considered, especially in patients with chronic hypertension presenting abnormally, for instance at a young age or refractory to first-line treatment. [12] If end-organ damage or an underlying cause of hypertension is identified, these conditions must also be treated. [12] Women with chronic hypertension in pregnancy must be closely monitored because they are five times as likely as those with normal blood pressure to develop pre-eclampsia, which is a much more severe condition with serious risks for the mother and fetus. [11]

For all hypertensive disorders of pregnancy, a major component of care is management of the associated hypertension. [13] This involves use of antihypertensive medication as well as restricting activity to lower blood pressure to reduce the risk of stroke. [23] In women with preeclampsia or eclampsia, magnesium sulfate is often prescribed to prevent the occurrence of seizures in the gestational parent. [13] Treatment should be continued from the time of diagnosis to several weeks postpartum given the increased risk of medical complications immediately following delivery of the fetus. [24] A recent systematic review found that postpartum home blood pressure monitoring likely improves the determination of blood pressure measures and overall patient of these conditions. [25]

Prognosis

The effects of high blood pressure during pregnancy vary depending on the disorder and other factors. Preeclampsia does not in general increase a woman's risk for developing chronic hypertension or other heart-related problems. Women with normal blood pressure who develop preeclampsia after the 20th week of their first pregnancy, short-term complications, including increased blood pressure, usually go away within about six weeks after delivery. [7]

Women who have chronic hypertension before their pregnancy are at increased risk of complications such as premature birth, low birthweight or stillbirth. [26] Women who have high blood pressure and had complications in their pregnancy have three times the risk of developing cardiovascular disease compared to women with normal blood pressure who had no complications in pregnancy. Monitoring pregnant women's blood pressure can help prevent both complications and future cardiovascular diseases. [27] [28]

Even though high blood pressure and related disorders during pregnancy can be serious, most women with high blood pressure and those who develop preeclampsia have successful pregnancies. Obtaining early and regular prenatal care for pregnant women is important to identify and treat blood pressure disorders. [7]

Epidemiology

High blood pressure problems occur in six percent to eight percent of all pregnancies in the U.S., about 70 percent of which are first-time pregnancies. In 1998, more than 146,320 cases of preeclampsia alone were diagnosed. [7]

Although the proportion of pregnancies with gestational hypertension and eclampsia has remained about the same in the U.S. over the past decade, the rate of preeclampsia has increased by nearly one-third. This increase is due in part to a rise in the numbers of older mothers and of multiple births, where preeclampsia occurs more frequently. For example, in 1998 birth rates among women ages 30 to 44 and the number of births to women ages 45 and older were at the highest levels in three decades, according to the National Center for Health Statistics. Furthermore, between 1980 and 1998, rates of twin births increased about 50 percent overall and 1,000 percent among women ages 45 to 49; rates of triplet and other higher-order multiple births jumped more than 400 percent overall, and 1,000 percent among women in their 40s. [7]

Related Research Articles

Obstetrics is the field of study concentrated on pregnancy, childbirth and the postpartum period. As a medical specialty, obstetrics is combined with gynecology under the discipline known as obstetrics and gynecology (OB/GYN), which is a surgical field.

<span class="mw-page-title-main">Eclampsia</span> Pre-eclampsia characterized by the presence of seizures

Eclampsia is the onset of seizures (convulsions) in a woman with pre-eclampsia. Pre-eclampsia is a hypertensive disorder of pregnancy that presents with three main features: new onset of high blood pressure, large amounts of protein in the urine or other organ dysfunction, and edema. If left untreated, pre-eclampsia can result in long-term consequences for the mother, namely increased risk of cardiovascular diseases and associated complications. In more severe cases, it may be fatal for both the mother and the fetus.

<span class="mw-page-title-main">Pre-eclampsia</span> Hypertension occurring during pregnancy

Pre-eclampsia is a multi-system disorder specific to pregnancy, characterized by the onset of high blood pressure and often a significant amount of protein in the urine. When it arises, the condition begins after 20 weeks of pregnancy. In severe cases of the disease there may be red blood cell breakdown, a low blood platelet count, impaired liver function, kidney dysfunction, swelling, shortness of breath due to fluid in the lungs, or visual disturbances. Pre-eclampsia increases the risk of undesirable as well as lethal outcomes for both the mother and the fetus including preterm labor. If left untreated, it may result in seizures at which point it is known as eclampsia.

Fetal distress, also known as non-reassuring fetal status, is a condition during pregnancy or labor in which the fetus shows signs of inadequate oxygenation. Due to its imprecision, the term "fetal distress" has fallen out of use in American obstetrics. The term "non-reassuring fetal status" has largely replaced it. It is characterized by changes in fetal movement, growth, heart rate, and presence of meconium stained fluid.

HELLP syndrome is a complication of pregnancy; the acronym stands for hemolysis, elevated liver enzymes, and low platelet count. It usually begins during the last three months of pregnancy or shortly after childbirth. Symptoms may include feeling tired, retaining fluid, headache, nausea, upper right abdominal pain, blurry vision, nosebleeds, and seizures. Complications may include disseminated intravascular coagulation, placental abruption, and kidney failure.

<span class="mw-page-title-main">Gestational hypertension</span> Medical condition

Gestational hypertension or pregnancy-induced hypertension (PIH) is the development of new hypertension in a pregnant woman after 20 weeks' gestation without the presence of protein in the urine or other signs of pre-eclampsia. Gestational hypertension is defined as having a blood pressure greater than 140/90 on two occasions at least 6 hours apart.

<span class="mw-page-title-main">Placental abruption</span> Medical condition

Placental abruption is when the placenta separates early from the uterus, in other words separates before childbirth. It occurs most commonly around 25 weeks of pregnancy. Symptoms may include vaginal bleeding, lower abdominal pain, and dangerously low blood pressure. Complications for the mother can include disseminated intravascular coagulopathy and kidney failure. Complications for the baby can include fetal distress, low birthweight, preterm delivery, and stillbirth.

<span class="mw-page-title-main">Complications of pregnancy</span> Medical condition

Complications of pregnancy are health problems that are related to, or arise during pregnancy. Complications that occur primarily during childbirth are termed obstetric labor complications, and problems that occur primarily after childbirth are termed puerperal disorders. While some complications improve or are fully resolved after pregnancy, some may lead to lasting effects, morbidity, or in the most severe cases, maternal or fetal mortality.

Soluble fms-like tyrosine kinase-1 is a tyrosine kinase protein with antiangiogenic properties. A non-membrane associated splice variant of VEGF receptor 1 (Flt-1), sFlt-1 binds the angiogenic factors VEGF and PlGF, reducing blood vessel growth through reduction of free VEGF and PlGF concentrations. In humans, sFlt-1 is important in the regulation of blood vessel formation in diverse tissues, including the kidneys, cornea, and uterus. Abnormally high levels of sFlt-1 have been implicated in the pathogenesis of preeclampsia.

<span class="mw-page-title-main">Hypertensive emergency</span> Very high blood pressure and signs of organ damage

A hypertensive emergency is very high blood pressure with potentially life-threatening symptoms and signs of acute damage to one or more organ systems. It is different from a hypertensive urgency by this additional evidence for impending irreversible hypertension-mediated organ damage (HMOD). Blood pressure is often above 200/120 mmHg, however there are no universally accepted cutoff values.

<span class="mw-page-title-main">Intrauterine hypoxia</span> Medical condition when the fetus is deprived of sufficient oxygen

Intrauterine hypoxia occurs when the fetus is deprived of an adequate supply of oxygen. It may be due to a variety of reasons such as prolapse or occlusion of the umbilical cord, placental infarction, maternal diabetes and maternal smoking. Intrauterine growth restriction may cause or be the result of hypoxia. Intrauterine hypoxia can cause cellular damage that occurs within the central nervous system. This results in an increased mortality rate, including an increased risk of sudden infant death syndrome (SIDS). Oxygen deprivation in the fetus and neonate have been implicated as either a primary or as a contributing risk factor in numerous neurological and neuropsychiatric disorders such as epilepsy, attention deficit hyperactivity disorder, eating disorders and cerebral palsy.

Maternal health is the health of women during pregnancy, childbirth, and the postpartum period. In most cases, maternal health encompasses the health care dimensions of family planning, preconception, prenatal, and postnatal care in order to ensure a positive and fulfilling experience. In other cases, maternal health can reduce maternal morbidity and mortality. Maternal health revolves around the health and wellness of pregnant women, particularly when they are pregnant, at the time they give birth, and during child-raising. WHO has indicated that even though motherhood has been considered as a fulfilling natural experience that is emotional to the mother, a high percentage of women develop health problems and sometimes even die. Because of this, there is a need to invest in the health of women. The investment can be achieved in different ways, among the main ones being subsidizing the healthcare cost, education on maternal health, encouraging effective family planning, and ensuring progressive check up on the health of women with children. Maternal morbidity and mortality particularly affects women of color and women living in low and lower-middle income countries.

<span class="mw-page-title-main">Maternal–fetal medicine</span> Branch of medicine

Maternal–fetal medicine (MFM), also known as perinatology, is a branch of medicine that focuses on managing health concerns of the mother and fetus prior to, during, and shortly after pregnancy.

<span class="mw-page-title-main">Circumvallate placenta</span> Medical condition

Circumvallate placenta is a rare condition affecting about 1-2% of pregnancies, in which the amnion and chorion fetal membranes essentially "double back" on the fetal side around the edges of the placenta. After delivery, a circumvallate placenta has a thick ring of membranes on its fetal surface. Circumvallate placenta is a placental morphological abnormality associated with increased fetal morbidity and mortality due to the restricted availability of nutrients and oxygen to the developing fetus.

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<span class="mw-page-title-main">High-risk pregnancy</span> Medical condition

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A pre-existing disease in pregnancy is a disease that is not directly caused by the pregnancy, in contrast to various complications of pregnancy, but which may become worse or be a potential risk to the pregnancy. A major component of this risk can result from necessary use of drugs in pregnancy to manage the disease.

Obstetric medicine, similar to maternal medicine, is a sub-specialty of general internal medicine and obstetrics that specializes in process of prevention, diagnosing, and treating medical disorders in with pregnant humans. It is closely related to the specialty of maternal-fetal medicine, although obstetric medicine does not directly care for the fetus. The practice of obstetric medicine, or previously known as "obstetric intervention," primarily consisted of the extraction of the baby during instances of duress, such as obstructed labor or if the baby was positioned in breech.

Chaniece Wallace, a black woman and physician, died at 30 years of age from complications of pregnancy two days after the birth of her daughter. Her death is seen as preventable and is viewed in the context of high rates of maternal mortality in the United States, particularly among the African American population. It is cited as an example in medical and scholarly publications to call for improved health outcomes in the black U.S. population. Wallace died despite several factors seen as protective: she was "highly educated, employed as a health care practitioner, had access to health care, and had a supportive family." Wallace was a fourth year pediatric chief resident at the Indiana University School of Medicine and was working at Riley Children's Health Hospital at the time of her death.

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References

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