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Hypertensive disease complicates 6-8% of all pregnancies in the United States and is one of the major causes of maternal death. Hypertensive disease also significantly increases perinatal morbidity and mortality. Two distinct entities are commonly encountered in pregnant women: chronic hypertension and PIH. These two conditions may coexist; in fact, the risk of developing PIH is significantly increased in women.
Pregnancy-induced hypertension is a multiorgan disease process that may involve much more than elevated blood pressure. Several clinical subsets are recognized, depending on end-organ effects. Some such subsets have traditionally been given distinct labels, for example, preeclampsia when renal involvement leads to proteinuria, eclampsia when central nervous system involvement leads to seizures, and more recently.
Hypertension is defined as a sustained blood pressure increase to levels of 140 mm Hg systolic or 90 mm Hg diastolic. Blood pressure may depend greatly on patient position; ideally, measurements should be taken in a uniform manner at each prenatal visit; the proper cuff size should be used and the patient should be sitting.
Ordinarily, PIH has its onset after 20 weeks of gestation, and chronic is defined as devel oping before 20 weeks of gestation. Patients with gestational trophoblastic disease are an exception; they can develop classic features of PIH.
Symptoms suggesting significant end-organ involvement: headache, visual disturbances, or epigastric or right-upper-quadrant pain.
The etiology of PIH is unknown. However, it is well established that the disease process occurs most often in women who are pregnant for the first time, women with multiple gestation, and women with certain vascular disorders such as those seen with insulin-dependent diabetes, lupus erythematosus, renal disease, and chronic.
The increased sensitivity of the maternal vascular tree to angiotensin II precedes the development of by several weeks and results in alterations in regional perfusion and the hematologic system. The most frequently cited hematologic consequence of PIH is constriction of plasma volume, resulting in decreased perfusion of certain specific organs.
Thrombocytopenia is the most frequent abnormality in coagulation observed in patients with PIH. The development of disseminated intravascular coagulation, however, is rare in women with PIH, but the development of hemolytic anemia accompanied by bizarre erythrocyte morphology and consumption of platelets and other coagulation factors occurs more commonly.
Delivery is always an appropriate option in the term patient with. However, in the patient with an unfavorable cervix who exhibits only mild blood pressure elevations, minimal proteinuria, and no evidence of either maternal end-organ involvement or fetal compromise, it may be appropriate to delay delivery in an effort to obtain a more favorable cervix before induction. In most cases, should not be allowed to extend beyond 40 weeks of gestation in such patients.
Delivery should be considered in women who have signs and symptoms of severe PIH at 32-34 weeks of gestation.In some cases, the condition of women who initially manifest signs and symptoms of severe PIH will improve after observation and treatment with magnesium sulfate and various antihypertensive agents such as labetalol. In such women, continued observation is
Management of severe PIH at less than 28 weeks of gestation poses a difficult clinical dilemma because it is often unsuccessful and may be hazardous. Attempts at conservative management in women with severe PIH at 18-27 weeks of gestation have been associated with significant morbidity,
In women who develop PIH before 34 weeks of gestation, consideration should be given to screening for the presence of antiphospholipid antibodies. Such antibodies portend an increased risk of adverse outcome and of recurrent disease in subsequent pregnancies.
For the preterm patient with mild PIH, conservative management is generally indicated. For any patient with PIH who is not undergoing delivery, it is essential to closely monitor blood pressure and proteinuria and evaluate renal and hepatic function and platelet count. Serial sonography
Several antihypertensive agents have been used to control maternal blood pressure during labor to reduce the risk of cerebral accident. When blood pressure exceeds 110 mm Hg diastolic or 180 mm Hg systolic, consideration should be given to lowering the blood pressure. One widely used agent is hydralazine hydrochloride given intravenously. Intravenous labetalol is an
Delivery is indicated for any patient with persistent severe oliguria. If treatment is required before or after delivery, a fluid challenge may be given. If severe oliguria is unresponsive to a fluid