Gestational Hypertension / Pregnancy Induced Hypertension.

 

Gestational Hypertension (pregnancy induced hypertension)

Gestational hypertension also known as pregnancy induced hypertension is elevated blood pressure greater than or equal to 140/90 mmHg on two occasions at least 4hours a part after 20 weeks of gestation with no protein urea and it resolves after 6 to 12 weeks after birth.

Pathophysiology of gestational hypertension: results primarily from abnormal placental development and vascular dysfunction, leading to increased systemic vascular resistance.

1: Abnormal placenta implantation: in early pregnancy the placenta is supposed to embed deeply in to the uterine wall and remodel maternal spiral arteries so in gestational hypertension this remodeling is incomplete so the arteries remain narrow and high-resistance.

2:  Reduced uteroplacental blood flow:  as we know the spiral arteries stay narrow, and there is poor blood supply to the placenta and that causes placenta ischemia.

3: Release of antiangiogenic factors: the ischemic placenta releases toxins and antiangiogenic factors like (sFlt-1) in to the maternal blood and these block normal blood vessel development and damage the lining of blood vessels (endothelium).

4: Systemic endothelial dysfunction: lining of the blood vessels become inflamed and leaky and that leads to vasoconstriction, increased systemic vascular resistance, capillary leak causing edema and then hypertension.

Clinical features of PIH:

1: Headache: may indicate increased pressure in brain.

2: Edema: may signal fluid imbalance.

3: blurred vision: may indicate progression of preeclampsia.

4: sudden weight gain: may indicate fluid retention.

5: upper abdominal pain: usually under the rib on the right may indicate liver involvement.

6: decreased urine output: may indicate impaired kidney function due to high blood pressure.

Who is at risk developing PIH

Gestational hypertension or pregnancy induced hypertension is a common condition in pregnancy however not all pregnancy women are same risk.

1: First pregnancy.

2: Obesity.

3: Maternal age younger than 20 or older than 40.

4: Twins.

5: Diabetes.

6: chronic hypertension.

7: Hight blood pressure in previous pregnancy.

How to measure the blood pressure the right way:

1: Patient should be in a sitting position.

2: Resting first for atleast5minute or more.

3: Using the right side of the cuff.

4: 2 different occasions at 4hours a part.

Workout diagnosis of PIH:

1: primary diagnose is blood pressure measurement above or equal to 140/90 mmHg.

2 Urinalysis: no protein urea.

3: CBC w/smear: normal.

4: Bmp: normal.

5: LFT: normal.

5: PT/PTT: normal.

6: Fetal ultrasound (evaluate fetal weight and AFI).

Why does PIH put risk both mother and the baby.

The mother:

A: she has severe high blood pressure think about the brain she can develop eclampsia which seizure disorder and get stroke.

B: think about the lungs she could go in to fluid overload.

C: think about the heart may develop myocardial infraction or heart attack.

D: think about kidney failure.

The baby:

A: Growth restriction

B: Placenta separates from uterine wall.

C: Baby can pass away.

Complication of PIH:

A: preterm delivery: is known also know as preterm birth is when the fetus born before 37weeks of gestation.

B: intrauterine growth retardation (IUGR): is also known as intrauterine growth restriction it is when the fetus is smaller than expected for it is gestational age.

C: Small for gestational age: is when the fetus birth weight is below the 10^th percentile of it is gestational age.

D: Development of preeclampsia: is a serious pregnancy complication characterized by new-onset hypertension after 20weeks of gestational with or without protein urea.

E: placenta abruptio: is a serious obstetric condition where the placenta detaches partially or completely from uterine wall before delivery of the baby.

F: fetal demise: also called intrauterine fetal death or stillbirth is the death of fetus in the uterus after 20 weeks of gestation but before birth.

G: maternal malignant hypertension: is rapidly progressive from a hypertension during pregnancy which extremely high blood pressure equal or greater than 180/120 mmHg.

Management of PIH:

A: lifestyle modification:

Bed rest.

Reduce physical stress.

Maintain adequate hydration and nutrition.

B: Medication

Labetalol (PO or IV) is antihypertensive of choice in gestational hypertension.

Mild gestational hypertension less than 160/110mmHG monitor no meds unless persistent.

A: frequent blood pressure and urine monitoring.

B: rest and lifestyle modifications.

 Severe gestational hypertension above 160/110 mmHg:

A: antihypertensive therapy like (Labetalol, Nifedipine and Hydralazine.

B: consider early delivery depending on the gestational age.

N.B: ACE inhibitors, ARBs and direct renin inhibitors are contraindicated in pregnancy.

C: delivery plan:

1: less than 37 week of gestation and stable: expectant management (steroids if it is less than 32-34 weeks).

2: less than 37 weeks and indications for delivery consider inducing delivery (steroids <32-34 weeks)

3: more or equal to 37weeks of gestation consider inducing delivery.

Prognosis:

A: It usually resolves within 12 weeks postpartum

B: If hypertension persists beyond 12weeks evaluate for chronic hypertension.

Conclusion:

Pregnancy induced hypertension or gestational hypertension is a common condition in pregnancy women and in generally pregnancy women should be followed closely and their blood pressure under regular basis and continue their medication if they had chronic hypertension to make sure that the mother and fetus are healthy and save.