hypertension in pregnancy diagnosis and treatment

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1. Hypertension in pregnancy: Diagnosis and treatment.................................................................................. 1

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Abstrak: Hypertension affects 10% of pregnancies in the United States and remains a leading cause of bothmaternal and fetal morbidity and mortality. Hypertension in pregnancy includes a spectrum of conditions, mostnotably preeclampsia, a form of hypertension unique to pregnancy that occurs de novo or superimposed onchronic hypertension. Risks to the fetus include premature delivery, growth retardation, and death. The onlydefinitive treatment of preeclampsia is delivery. Treatment of severe hypertension is necessary to preventcerebrovascular, cardiac, and renal complications in the mother. The 2 other forms of hypertension, chronic andtransient hypertension, usually have more benign courses. Optimal treatment of high blood pressure inpregnancy requires consideration of several aspects unique to gestational cardiovascular physiology. The majorgoal is to prevent maternal complications without compromising uteroplacental perfusion and fetal circulation.Before an antihypertensive agent is prescribed, the potential risk to the fetus from intrauterine drug exposureshould be carefully reviewed.

Teks lengkap: Headnote Hypertension affects 10% of pregnancies in the United States and remains a leading cause of both maternaland fetal morbidity and mortality. Hypertension in pregnancy includes a spectrum of conditions, most notablypreeclampsia, a form of hypertension unique to pregnancy that occurs de novo or superimposed on chronichypertension. Risks to the fetus include premature delivery, growth retardation, and death. The only definitivetreatment of preeclampsia is delivery. Treatment of severe hypertension is necessary to preventcerebrovascular, cardiac, and renal complications in the mother. The 2 other forms of hypertension, chronic andtransient hypertension, usually have more benign courses. Optimal treatment of high blood pressure inpregnancy requires consideration of several aspects unique to gestational cardiovascular physiology. The majorgoal is to prevent maternal complications without compromising uteroplacental perfusion and fetal circulation.Before an antihypertensive agent is prescribed, the potential risk to the fetus from intrauterine drug exposureshould be carefully reviewed. Mayo Clin Proc. 2000;75:1071-1076 ACE = angiotensin-converting enzyme; DBP = diastolic blood pressure; HELLP = hemolysis, elevated liverenzymes, low platelet count; NHBPEP = National High Blood Pressure Education Program; SBP = systolicblood pressure Normal pregnancy is characterized by increases in cardiac output and blood volume, generalizedvasodilatation, a decrease in blood pressure, and resistance to pressor agents such as norepinephrine andangiotensin 11.1 Blood pressure achieves a nadir by midpregnancy, then returns to prepregnancy levels atterm. Systolic blood pressure (SBP) is less affected than diastolic blood pressure (DBP) because of theincreased cardiac output that offsets the vasodilatation. Further decline is noted during sleep, which follows thepattern of normal circadian rhythms observed in nonpregnant women. DEFINITION AND CLASSIFICATION Hypertension in pregnancy is defined as a blood pressure of 140/90 mm Hg or higher. Korotkoff phase V(disappearance) rather than Korotkoff phase IV (muffling of sounds) is used for the determination of DBP.2 Inthe outpatient setting, blood pressure should be measured in the sitting position, after a period of rest in a quietenvironment. For hospitalized patients, the lateral recumbent position eliminates the effect of compression ofthe inferior vena cava by the enlarged uterus that impairs venous return and causes a decline in blood pressure.Regardless of posture, special care should be taken to ensure that the patient's arms are kept at the heart level;positioning the arms above the heart can spuriously reduce the blood pressure readings. In pregnancy, the

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lowest blood pressures are obtained by using the right arm while the patient is resting in the left lateralposition.3 These blood pressure readings might merely reflect the changes in hydrostatic pressure caused bykeeping the right arm above the heart. Therefore, the increases in blood pressure with a change from a lateralto a supine position may simply represent a postural phenomenon rather than positive results on a rollover test,once considered a predictor of preeclampsia.4 The Working Group of the National High Blood Pressure Education Program (NHBPEP) recently published asecond report revising the classification of hypertensive disorders in pregnancy.2 The term transienthypertension was replaced by gestational hypertension, which is used only during pregnancy for a group ofwomen who develop high blood pressure for the first time after 20 weeks' gestation in the absence ofproteinuria. The rest of the classification remains unchanged (Table 1). Preeclampsia Preeclampsia is a multisystemic disease characterized by hypertension and proteinuria, a protein level of 300mg or greater in a 24-hour urine specimen that roughly correlates with a qualitative measurement of 1+ (30mg/dL) on dipstick urinalysis in the absence of urinary tract infection. Because of disagreement betweenrandom and 24-hour urinary protein determinations, the latter is recommended for diagnostic purposes. If this isnot feasible, a timed urinary collection corrected for creatinine excretion is an acceptable alternative. Thediagnosis of hypertension is supported by recording elevated blood pressure on 2 determinations performed 6hours apart. An important feature of preeclampsia is its unpredictable clinical course; women with mild hypertension Andminimal proteinuria can have rapid progression to the convulsive form of eclampsia. Thus, distinguishingbetween "mild" and "severe" forms is discouraged because it can be clinically misleading.5 However, certainsymptoms and signs are considered markers of severe disease and necessitate close monitoring and,frequently, urgent delivery. These include an SBP of 160 mm Hg or higher and a DBP of 110 mm Hg or higher,nephrotic range proteinuria (protein level >3.5 g/24 h), renal functional impairment (serum creatinine level >1.2mg/dL), thrombocytopenia (platelet count

If preeclampsia develops at less than 32 weeks' gestation, when the fetus is still immature, consideration shouldbe given to postponing delivery.7 This is a reasonable approach when hypertension is mild, and no renal, liver,or coagulation abnormalities are evident. Patients should be hospitalized and closely monitored for signs of fetaldistress and symptoms of headache, visual disturbances, and right upper quadrant pain that may heraldprogression to more severe forms, including eclampsia. The threshold for initiation of antihypertensive therapyis the same as for severe preeclampsia, ie, DBP of 100 mm Hg or higher. An oral agent is preferred if delivery isnot expected within 48 hours.5 Outpatient management can be considered for asymptomatic patients withtreatment-responsive hypertension in the absence of marked proteinuria (protein level

their pregnancies while their renal function is relatively preserved (serum creatinine level

channel blockers for seizure prophylaxis. In pregnancy, calcium channel blockers are increasingly used forsevere hypertension refractory to other drugs. Nifedipine has been studied most extensively and has beenshown to decrease blood pressure and improve renal function without affecting blood flow in the umbilicalartery. 17 As in other settings, the availability of long-acting preparations has mitigated the risk of precipitousblood pressure decreases that can potentially compromise uteroplacental blood flow and fetal well-being. According to the Working Group report of the NHBPEP, diuretics can be continued during pregnancy if initiatedbefore conception, especially in women with salt-sensitive chronic hypertension.2 Other indications for diuretictherapy are hypertension in the setting of renal failure and congestive heart failure. Possible adverse effectsinclude electrolyte abnormalities such as hyponatremia, hypokalemia, and hyperuricemia. Diuretics canaggravate volume depletion and promote reactive vasoconstriction and should be avoided in women withpreeclampsia. ACE inhibitors are contraindicated in pregnancy. They adversely affect the fetal renal system, causing anuriaand oligohydramnios. Complications reported in newborns after in utero exposure during the second and thirdtrimester include fetal limb abnormalities, lung hypoplasia, craniofacial deformities, and renal dysplasia.18Angiotensin II receptor blockers exert a similar hemodynamic effect on fetal renal circulation and can potentiallycause similar fetal malformations. Fetuses of women who take ACE inhibitors or angiotensin II receptor blockersduring the first trimester are not considered at a higher risk for these malformations, and women exposed tosuch agents during this time do not need to terminate their pregnancy. Finally, direct vasodilators, other than hydralazine, may need to be considered for the rare patient with severerefractory hypertension. Direct vasodilators can cause severe complications, such as excessive hypotension(both sodium nitroprusside and diazoxide) and cyanide intoxication (sodium nitroprusside only), making themthe agents of last resort." Nonpharmacological treatment consists mainly of bed rest, which has been shown not only to lower bloodpressure but also to promote diuresis and reduce premature labor.19 However, pregnant women with sodium-sensitive chronic hypertension should continue salt restriction during pregnancy. Salt restriction is notrecommended for routine treatment of women with preeclampsia, who frequently are volume contracted. Prevention of preeclampsia has been attempted by using several strategies. Some have proved to beunsuccessful, such as salt restriction,20 magnesium,21 and fish oil supplementation22; others are potentiallydangerous (diuretics). The role of low-dose aspirin has been studied in several large trials, including themulticenter Collaborative Lowdose Aspirin Study in Pregnancy (CLASP)23 trial that failed to show a beneficialeffect of aspirin in the prevention of preeclampsia. Although the study was designed to include women with ahigher risk, the incidence of preeclampsia in the placebo group was only 7.6%, similar to that in the generalpopulation. Therefore, the issue of the role of aspirin in high-risk groups remained unclear. In 1998, the NationalInstitutes of Health published the results of a double-blind, randomized, placebo-controlled trial of the role oflow-dose aspirin in the prevention of preeclampsia in 2539 women at higher risk (history of chronichypertension, insulin-treated diabetes mellitus, multifetal gestations, and preeclampsia in previouspregnancy).24 The demonstrated benefit was too small to justify routine prophylaxis: 38 women would need tobe treated to prevent 1 case of preeclampsia. Similarly, low-dose aspirin did not improve perinatal outcomes inthese women. Calcium supplementation, beyond the daily recommended level, also proved of no benefit in alarge National Institutes of Health trial of 4589 healthy nulliparous women. 25 The potential benefit ofantioxidants, vitamins C and E, was recently investigated in women at increased risk.26 When initiated at 16 to22 weeks' gestation at doses of 1000 mg and 400 IU daily, respectively, a reduction in plasma markers ofendothelial injury and a decreased incidence were observed in the treated group compared with the placebogroup. While the investigators recognized the need for multicenter trials to assess the effects in low-risk andhigh-risk patients from different populations, these studies should also address the issues of safety, particularlyfor the fetus, of vitamins C and E at the recommended doses.


CONCLUSION The ultimate goal of treatment of hypertension in pregnancy is delivery of a healthy newborn withoutcompromising maternal health. Early diagnosis and subsequent close monitoring of both mother and fetus arecrucial. Elevated blood pressure without proteinuria usually has a benign course and can be managed on anoutpatient basis. Antihypertensive medications should be used judiciously, and fetal risks from intrauterineexposure must be carefully evaluated. Severe preeclampsia (both pure and superimposed) represents anobstetrical emergency, with potential fatal outcomes for both fetus and mother. Optimally, such women shouldbe hospitalized and treated with bed rest, antihypertensive medications, and magnesium sulfate for seizureprophylaxis. The definitive treatment of preeclampsia is delivery. For mild forms remote from term, postponingdelivery is desirable and, if possible, can improve neonatal prognosis by decreasing prematurity. Questions About Hypertension in Pregnancy 1. Which one of the following can help distinguish superimposed preeclampsia from chronic hypertension? a. Severe hypertension with blood pressure greater than 180/100 mm Hg b. Onset of proteinuria in the third trimester c. Onset of hypertension in the third trimester d. Normal renal function e. Edema 2. Which one of the following is correct concerning ACE inhibitors in pregnancy? a. They are contraindicated b. They are always an indication for therapeutic abortion c. They should be replaced by angiotensin II receptor blockers d. They have peak teratogenic potential during the first trimester e. They are less harmful later in pregnancy 3. Which one of the following antihypertensive drugs has been proved to be safe in pregnancy based on follow-up studies of children exposed in utero? a. Nifedipine b. Hydralazine c. Methyldopa d. Labetalol e. Hydrochlorothiazide 4. Which one of the following is the most effective agent for the prevention of eclamptic seizures? a. Methyldopa b. Phenytoin c. Diazepam d. Magnesium sulfate e. Calcium gluconate 5. A 32-year-old multigravida presents with increasing leg edema at 34 weeks' gestation. Physical examinationfindings are unremarkable except for 2+ pretibial edema and a blood pressure of 155/95 mm Hg. The serumcreatinine level, uric acid value, liver function test results, and findings on dipstick urinalysis are normal. Duringa pregnancy 4 years ago, she had an elevated blood pressure that quickly normalized after spontaneousvaginal delivery. She has taken no antihypertensive drugs. Which one of the following is the most likelydiagnosis? a. Recurrent "pure" preeclampsia b. Preeclampsia superimposed on chronic hypertension c. Chronic hypertension


d. Gestational hypertension e. Normal pregnancy Correct answers: 1. b, 2. a, 3. c, 4. d, 5. d Sidebar Table 1. Classification of Hypertensive Disorders in Pregnancy2 Preeclampsia-eclampsia Preeclampsia superimposed on chronic hypertension Chronic hypertension Gestational hypertension References REFERENCES 1. McLaughlin MK, Roberts JM. Hemodynamic changes. In: Lindheimer MD, Roberts JM, Cunningham FG, eds. Chesley's Hypertensive Disorders in Pregnancy. 2nd ed.Stamford, Conn: Appleton &Lange; 1999:69-102. 2. National High Blood Pressure Education Program Working Group Report on High Blood Pressure inPregnancy. Report of the National High Blood Pressure Education Program Working Group on High BloodPressure in Pregnancy. Am J Obstet Gynecol. 2000; 183(l, suppl):51-522. 3. Van Dongen PW, Eskes TK, Martin CB, Van 't Hof MA. Postural blood pressure differences in pregnancy: aprospective study of blood pressure differences between supine and left lateral position as measured byultrasound. Am J Obstet GynecoL 1980;138:15. References 4. Lindheimer MD, Roberts JM, Cunningham FG, Chesley L. Introduction, history, controversies, and definitions.In: Lindheimer MD, Roberts JM, Cunningham FG, eds. Chesley's Hypertensive Disorders in Pregnancy. 2nd ed.Stamford, Conn: Appleton &Lange; 1999:3-41. 5. August P. Preeclampsia: new thoughts on an ancient problem. J Clin Hypertens. 2000;2:115-123. 6. Visser W, Wallenburg HC. Central hemodynamic observations in untreated preeclamptic patients.Hypertension. 1991;17:10721077. References 7. Sibai BM, Mercer BM, Schiff E, Friedman SA. Aggressive versus expectant management of severepreeclampsia at 28 to 32 weeks' gestation: a randomized controlled trial. Am J Obstet GynecoL 1994;171:818-822. 8. Cunningham FG, Lindheimer MD. Hypertension in pregnancy. N Engl J Med. 1992;326:927-932. 9. Sibai BM, Anderson GD. Pregnancy outcome of intensive therapy in severe hypertension in first trimester.Obstet GynecoL 1986;67: 517-522. References 10. Sibai BM, Abdella TN, Anderson GD. Pregnancy outcome in 211 patients with mild chronic hypertension.Obstet GynecoL 1983;61: 571-576. 11. Sibai BM. Treatment of hypertension in pregnant women. NEngl J Med. 1996;335:257-265. 12. Weitz C, Khouzam V, Maxwell K, Johnson JW. Treatment of hypertension in pregnancy with methyldopa: arandomized double blind study. Int J Gynaecol Obstet. 1987;25:35-40. 13. Chesley LC, Sibai BM. Clinical significance of elevated mean arterial pressure in the second trimester. Am JObstet Gynecol. 1988;159:275-279. 14. Cockburn J, Moar VA, Ounsted M, Redman CW. Final report of study on hypertension during pregnancy:the effects of specific treatment on the growth and development of the children. Lancet. 1982;1:647-649. 15. Umans JG, Lindheimer MD. Anti hypertensive treatment. In: Lindheimer MD, Roberts JM, Cunningham FG,eds. Chesley's Hypertensive Disorders in Pregnancy. 2nd ed. Stamford, Conn: Appleton &Lange; 1999:581-


604. 16. Butters L, Kennedy S, Rubin PC. Atenolol in essential hypertension during pregnancy. BMJ. 1990;301:587-589. 17. Ismail AA, Medhat I, Tawfic TA, Kholeif A. Evaluation of calcium-antagonist (Nifedipine) in the treatment ofpre-eclampsia. Int J Gynaecol Obstet. 1993;40:39-43. 18. Pryde PG, Sedman AB, Nugent CE, Barr M Jr. Angiotensin-converting enzyme inhibitor fetopathy. J Am SocNephrol. 1993;3: 1575-1582. References 19. Papiernik E, Kaminski M. Multifactorial study of the risk of prematurity at 32 weeks of gestation, I: a study ofthe frequency of 30 predictive characteristics. J Perinat Med. 1974;2:30-36. 20. Steegers EA, Eskes TK, Jongsma HW, Hein PR. Dietary sodium restriction during pregnancy: a historicalreview. Eur J Obstet Gynecol Reprod Biol. 1991;40:83-90. 21. Spading L, Spading G. Magnesium supplementation in pregnancy: a double-blind study. BrJ ObstetGynaecol. 1988;95:120-125. 22. Salvig JD, Olsen SF, Secher NJ. Effects of fish oil supplementation in late pregnancy on blood pressure: arandomised controlled trial. Br J Obstet Gynaecol. 1996;103:529-533. 23. CLASP (Collaborative Low-dose Aspirin Study in Pregnancy) Collaborative Group. CLASP: a randomisedtrial of low-dose aspirin for the prevention and treatment of pre-eclampsia among 9364 pregnant women.Lancet. 1994;343:619-629. 24. Caritis S, Sibai B, Hauth J, et al. Low-dose aspirin to prevent preeclampsia in women at high risk. N EnglJMed. 1998;338:701-705. 25. Levine RJ, Hauth JC, Curet LB, et al, National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units. Trial of calcium to preventpreeclampsia. N Engl J Med. 1997;337:69-76. 26. Chappell LC, Seed PT, Briley AL, et al. Effect of antioxidants on the occurrence of pre-eclampsia in womenat increased risk: a randomised trial. Lancet. 1999;354:810-816. AuthorAffiliation VESNA D. GAROVIC, MD AuthorAffiliation From the Divisions of Hypertension and Nephrology, Department of Internal Medicine, and Pregnancy-RelatedHypertension and Kidney Disease Clinic, Mayo Clinic, Rochester, Minn. Address reprint requests and correspondence to Vesna D. Garovic, MD, Division of Hypertension, Mayo Clinic,200 First St SW, Rochester, MN 55905.

MeSH: Antihypertensive Agents -- therapeutic use, Chronic Disease, Female, Fetal Viability -- physiology,Humans, Hypertension -- drug therapy, Hypertension -- physiopathology, Maternal-Fetal Exchange, PlacentalCirculation -- physiology, Pre-Eclampsia -- diagnosis, Pre-Eclampsia -- drug therapy, Pregnancy, PregnancyComplications, Cardiovascular -- drug therapy, Pregnancy Complications, Cardiovascular -- physiopathology,Risk Factors, Hypertension -- diagnosis (utama), Pregnancy Complications, Cardiovascular -- diagnosis (utama)

Substansi: Antihypertensive Agents;

Judul: Hypertension in pregnancy: Diagnosis and treatment

Pengarang: Garovic, Vesna D

Judul publikasi: Mayo Clinic Proceedings

Volume: 75

Edisi: 10


Halaman: 1071-6

Jumlah halaman: 6

Tahun publikasi: 2000

Tanggal publikasi: Oct 2000

Tahun: 2000

Penerbit: Mayo Foundation for Medical Education and Research

Tempat publikasi: Rochester

Negara publikasi: United States

Subjek publikasi: Medical Sciences

ISSN: 00256196

CODEN: MACPAJ

Jenis sumber: Scholarly Journals

Bahasa publikasi: English

Jenis dokumen: Journal Article

Nomor aksesi: 11040855

ID dokumen ProQuest: 216873268

URL Dokumen: http://search.proquest.com/docview/216873268?accountid=25704

Hak cipta: Copyright Mayo Foundation for Medical Education and Research Oct 2000

Terakhir diperbarui: 2014-01-15

Basis data: ProQuest Public Health

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Hypertension in pregnancy: Diagnosis and treatment

hypertension in pregnancy diagnosis and treatment

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