Pregnancy Induced Hypertension

Copyright © 2015 Kumudha . This is an open access article distributed under the Creative Commons Att distribution, and reproduction in any medium, provided the original work is properly cited. INTRODUCTION Pregnancy induced hypertension is an unpredictable multiorgan disorder unique to human pregnancy. Toxemia of pregnancy has been a recognized pathophysiologic entity since the time of Hippocrates. In 1916, zweifel first termed ‘Toxemia’ (poison blood). It is also called as ‘Disease of Theories’ as the exact course of events that lead to the clinical syndrome have not been elucidated. It was soon recognized that they were also features of pregnancy toxemia. As soon as the sphygmomanometer was invented in 1896 arterial hypertension came to be acknowledged as an important features of eclampsia and that appearance usually pre-dated the actual occurrence of fits, from this background there gradually emerged the concept of pre-eclampsia, as a less severe degree of the same pregnancy toxemia, in which hypertension, fluid retension and albuminuria appeared in varying sequence and degree. Recent survey showed that toxemia of pregnancy is still an important cause of maternal deaths (ministry of heath, 1960). The hypertensive disorder occur in 7-10 percent of all late pregnancies and form one of the most important causes of maternal and perinatal deaths. According to the Indian registrar general’s figure, twenty-five years prior to 1963

MASTER CHART INTRODUCTION Pregnancy induced hypertension, is the commonest form of life threatening complications of pregnancy. Pregnancy is described as the only physiological state in which most physiological parameters are abnormal. The anatomical, physiological and biochemical adaptations that take place in a woman during the short span of human pregnancy are profound. Compared with normotensive gravidas, patients with elevated blood pressure have significantly greater maternal and fetal mortality and morbidity. The clinical and laboratory characteristics of hypertension associated with pregnancy are difficult to differentiate from those of hypertension independent of pregnancy.

Mail id:gomatimahalingam@soa.ac.in -------------------------------------------------------------------------------------------------------------------- Abstract Background:Pregnancy Induced Hypertension (PIH) is a life-threatening complication of pregnancy which adversely affects the maternal and perinatal outcome. Most of the deaths associated with PIH occur due to its adverse effects. Proper management of these complications can improve the perinatal outcome. The present study was aimed to find out the perinatal outcome associated with PIH.

MORPHOLOGICAL CHANGES IN PREGNANCY INDUCED HYPERTENSION KIDNEY: The characteristic lesion is glomerular endotheliosis which is well demonstrated by electron microscopy. There is deposition of osmophilic material between the basal membrane and the endothelial cells which leads to the narrowing of the capillary lumen and there is increase in the cytoplasm of endothelial cells and mesangial cells. There is no change in the epithelial cells or foot processes, no proliferation ofmesangial cells, and no alteration in the architecture of the renal medulla. The nature of the osmophilic deposits on immunofluorescent technique shows material that reacts with antibodies against fibrinogen and fibrin. [12],[13],[14],[15]

A STUDY ON FUNDUS FINDINGS IN PREGNANCY INDUCED HYPERTENSION ABSTRACT INTRODUCTION : Hypertensive disorders in pregnancy are considered the major cause of maternal morbidity and mortality in developing as well as developed countries. It is the most common medical problem in pregnancy, complicating 7–10% of all pregnancies. The biggest limitation clinicians face is differentiating pregnancy induced hypertension from hypertension independent of pregnancy. Pregnancy can affect anywhere in the visual pathway from anterior segment to the visual cortex. Ocular sequelae of 30 – 100% is seen in patients with HELLP syndrome. Retinal and cerebral vessels share a lot of anatomical and embryological characteristics. Hence they may show similar patterns of damage from diseases like hypertension. This also suggests that examination of ocular fundus would provide a noninvasive view of intracranial vascular pathology. Fundus changes also plays an important role in determining the termination of pregnancy. This study has been done to understand if fundus findings correlate with the severity of hypertension, grades of proteinuria and levels of blood urea and serum uric acid.

CERTIFICATE This is to certify that the Dissertation entitled “SERUM βHCG AS A PREDICTOR OF PREGNANCY INDUCED HYPERTENSION” submitted by Dr.Jayalakshmi, MBBS., to The Tamilnadu Dr.M.G.R. Medical University, Chennai, in partial fulfilment for the award of M.S (Obstetrics and Gynaecology) is a bonafide work carried out by her under my guidance and supervision during the academic year 2013-2017. This dissertation partially or fully has not been submitted for any other degree or diploma of this university or other.

The teaching faculty of the department of biochemistry, pathology, pharmacology, radiology, general medicine, anesthesia and obstetrics and gynecology and neonatal medicine provided a learning module in the web forum of university website for the final year medical undergraduate students. The students were able to comprehend pregnancy-induced hypertension (PIH) from its basics and decide on the relevant clinical implications. A case based discussion was done with the constellation of experts from all disciplines of medicine. This was followed with mind mapping of concepts developed. Pretest and posttest helped the teaching faculty to assess the impact of knowledge generated. Feedback was obtained to improvise the existing teaching method sand develop new teaching tools.

function, although the magnitude of proteinuria alone as a predictor of severity has been questioned. 5 Profound changes in the coagulation and fibrinolytic system occur during normal pregnancy causing a hypercoagulable state. There is a definite exaggeration of the hypercoagulable state of pregnancy during Pregnancy Induced Hypertension (PIH). Out of all the haematological abnormalities that occur in PIH, thrombocytopenia is the most common seen to occur in 11% to 29% of patients. 6 These pregnancies also are associated with qualitative changes suggesting increased platelet production and destruction. There is a shortened platelet life span, increased numbers of megakaryocytes in the bone marrow, and an increased number of immature platelets seen in the peripheral blood smear. 7 The frequency and intensity of maternal thrombocytopenia varies and is dependent on the intensity of the disease process and duration of PIH syndrome. 8 Overt thrombocytopenia, defined by a platelet count less than 100,000/L, indicates severe disease. 9 In general, the lower the platelet counts, the higher the maternal and fetal morbidity and mortality. In most cases, delivery is indicated because the platelet count continues to decrease. A variety of haematological abnormalities may occur in women with PIH of which thrombocytopenia is the most common. There is no screening test that would help in identifying which pregnancy will be associated with PIH or assess its severity. 10

Methods: A longitudinal cross-sectional study was conducted by 2,076 obstetric patients registered in the book of delivery emergency room BLUD RSUD Ende/ Ende hospital from September 1 st 2014 to August 31 st 2015. Pregnancy-induced hypertension was classified into gestational hypertension, preeclampsia, and severe preeclampsia. Categorical comparative chi-square continued by logistic regression analysis were performed to examine the effect of PIH to infants’ growth outcome.

Keywords: Eclampsia; Preeclampsia; Pregnancy-induced hypertension/therapy; Pregnancy; Therapeutics. RESUMO: Introdução: Estima-se que os distúrbios hipertensivos na gravidez afetam 6-8% das gestantes nos Estados Unidos e são considerados um dos principais fatores de mortalidade materna. No Brasil, de acordo com o DATASUS, se considerarmos as categorias O13 a O16 do CID-10, os distúrbios hipertensivos representaram cerca de 20,22% das mortes maternas no período de 2004 a 2014. Objetivos: O objetivo da revisão é demonstrar os tratamentos mais atuais para o tratamento de distúrbios hipertensivos durante a gravidez. Métodos: Foram consultadas as bases de dados Medline/Pubmed, LILACS/SciELO, Cochrane e Scopus, procurando artigos nacionais e internacionais publicados entre 2006 e 2016, em inglês e português, bem como os consensos estabelecidos pela Organização Mundial da Saúde e as estatísticas do DATASUS. Resultados: As medidas recomendadas para prevenir a pré-eclâmpsia (PE) foram a suplementação de cálcio para gestantes com baixa ingestão dietética e a administração de baixas doses de aspirina. Na PE, se acontecer no termo, o tratamento é induzir o parto, mas se ocorrer pré-termo, é monitorar, administrar sulfato de magnésio (SM), anti-hipertensivos e corticóide. Em caso de eclâmpsia, a SM é muito eficaz para reduzir as convulsões eclâmpticas. Os fármacos utilizados no tratamento da hipertensão crônica grave são metildopa em associação ou não, com nifedipina ou hidralazina. A crise hipertensiva aguda é tratada com fármacos de primeira linha, como nifedipina e hidralazina, e alternativamente com nitroprussiato de sódio. Conclusão: Os principais protocolos mundiais seguem basicamente a mesma orientação, mudando apenas detalhes específicos de conduta de acordo com os recursos do sistema de saúde de cada país. O controle da pressão arterial materna apresenta resultados satisfatórios para o binômio materno-fetal, pois reduz o risco de PE e eclâmpsia. O tratamento definitivo para PE e eclâmpsia é a indução de parto, sendo utilizado apenas medidas terapêuticas para controle, já que não têm cura.

Preeclampsia is defined as blood pressure 140/90 mm Hg or an increase of 30mmHg systolic or 15 mmHg diastolic over baseline values on at least two occasions > 6 hrs apart with proteinuria or generalized edema. The purpose of the present study is to correlate study of placenta in pregnancy induced hypertension cases and in normal pregnancy .

catalase was decreased significantly in women with pre- eclampia as compared to normotensive pregnant women which is in accordance with the previous reports. 26-28 However, some studies have depicted increased activity of catalase enzyme in hypertensive disorders. 29,30 Taken together the results show that lipid peroxidation plays a major role in the pathogenesis of pregnancy induced hypertension and to prevent further injury more of anti- oxidants are utilized and hence the levels of anti-oxidants decrease. Consequently, the enzymes of the first line of defense i.e SOD and Catalase decrease. A simultaneous decline in the activities of both SOD and Catalase was observed thereby damaging the important avenue of enzymatic anti-oxidant defense. These observations further confirm that pregnancy coupled with hypertension may lead to ineffective scavenging of reactive oxygen species resulting in oxidative damage and tissue injury.

Kurdiet et al (39) and Montenegro et al (40) observed that pulsatility index was higher in patients who developed Pregnancy induced hypertension and method is useful for the prediction of such complications. The profile of uterine artery floe velocity is studied. A wave with high systolic peak, a prominent prodiastolic notch and low end diastolic flow is a normal uterine artery profile during first half of the pregnancy. Because of the implantation and the development of placenta, uterine artery circulation changes from low flow with high resistance to high flow with low resistance.

Platelets in pregnancy induced hypertension Platelets play a crucial role in the pathophysiology of pre- eclampsia by promoting vascular damage and obstruction, leading to tissue ischaemia and further damage. 9 Thromboxane A2 the major product of arachidonic acid metabolism in platelets, is a potent vasoconstrictor and platelet- aggregating agent. As it has a short half-life it is normally measured as its stable hydration product, thromboxane B2. The effects of thromboxane A2 are normally counterbalanced by prostacyclin, a potent vasodilator and anti-platelet prostanoid which is the major product of arachidonic acid metabolism in vascular endothelium and which plays an important role in protecting the endothelium and limiting damage by inhibiting platelet aggregation and promoting vasodilatation. These two substances function as local hormones and are thought to be important in the control of the platelet-endothelium interaction. They oppose each other though the regulation of platelet adenylate cylase, which controls cAMP production and thereby platelet free calcium concentration; this links receptor occupancy with cellular response. Pro-aggregatory substances such as thromboxane A2 inhibit adenylate cyclase, allowing free intracellular cAMP, reducing free intracellular calcium and inhibiting platelet activation.

Pre-eclampsia and Eclampsia still remains a major problem in developing countries. Pregnancy induced hypertension is one of the most extensively researched subjects in obstetrics. Still the etiology remains an enigma to us. Though the incidence of pre-eclampsia and eclampsia is on the decline, still it remains the major contributor to poor maternal and foetal outcome. The fact that pre-eclampsia, eclampsia is largely a preventable disease is established by the negligible incidence of pre- eclampsia and eclampsia with proper antenatal care and prompt treatment of pre-eclampsia. In pre-eclampsia and eclampsia, pathology should be understood and that it involves multiorgan dysfunction should be taken into account. The early use of antihypertensive drugs, optimum timing of delivery and strict fluid balance, anticonvulsants in cases of eclampsia will help to achieve successful outcome. Early transfer to specialist centre is important and the referral the referral centers should be well equipped to treat such critically ill patients.

It is well observed that maternal and perinatal outcome are adverse with preeclampsia due to end organ damage as compared to pregnancy induced hypertension, at the same time there are insufficient comparative studies to support the same. 3 Hence this study is contemplated to be carried out in women with pregnancy induced hypertension and preeclampsia in the background of local ethnicity. Study of the role of proteinuria in predicting maternal and perinatal complications will aid in clinical management by identifying the high risk women who may need aggressive management and the low risk women in whom unnecessary interventions may be avoided.

Introduction Pregnancy-induced hypertension (PIH) is one of the most common causes of maternal mortality around the world whereby it contributed up to 8% of all maternal deaths 1 . Pregnancy induced hypertension here is defined as a diastolic blood pressure of equivalent or more than 90 mm Hg on two or more consecutive occasions 4 hours apart; or a diastolic blood pressure of equivalent or more than 110 mm Hg on any one occasion beginning at 20 weeks of gestation or more 2 . The aetiology of PIH is still unclear; however, various theories relating to dietary factor, immune system, vascular system and genetics have been tied with the formulation of the condition in a pregnant mother.

Fig 15:- ANC wise frequency of PIH V. DISCUSSION The retrospective study was conducted to assess prevalence of pregnancy induced hypertension. Generally, this problem is more common in developing countries, and the prevalence of PIH in, our study was found to be 26.2%.In our study, prevalence of PIH was found higher in the age group of 26 -30 years. We found that there is significant association between age and PIH and the risk in the subjects above age 25 is2.3 folds greater when compared with the women whose age is below 25 with p value of (0.0314) * . This is in accordance with the study by parazzini et.al. who concluded that the risk of PIH in women age more than 25 is 3.2 times greater than age below 25. Bharthi Mehtha et.al 5 also found similar higher prevalence among women greater than 25years (9.9%).

Abstract Gestational hypertension (GH) or pregnancy induced hypertension (PIH) is a condition characterised by high blood pressure during pregnancy. PIH can lead to serious condition called Pre-Eclampsia or Toxemia. The condition prevents placenta from getting enough blood resulting in low birth weight. Present study is a prospective case control study elucidating the effect of various demographic, clinicopathological and obstetric parameters on PIH. A total of 120 females with PIH and 150 normotensive pregnant females were included in the study. The survey was conducted using an interviewer administered questionnaire. The mean systolic and diastolic Blood Pressure (BP) of subjects with PIH was found to be 148.2 ± 5.5 and 96.2 ± 5.8 respectively. PIH was found to be statistically associated with occupation, socio-economic status, history of PIH, previous miscarriage, family history of hypertension and diabetes (P≤0.05). The results of the present study clearly pinpoint the cluster of factors that are associated with gestational hypertension. Identifying these factors may provide a window to clinicians and help them to recognize mothers who have higher chances to develop hypertensive disorders.

Pre-eclampsia is the elevated blood pressure and excess protein in the urine after 20 weeks of pregnancy in a woman who previously had normal blood pressure, a major cause of preterm birth and an early marker for future cardiovascular and metabolic diseases. The objective of study is to identify the level of awareness regarding pre-eclampsia (pregnancy induced hypertension or gestational hypertension) and its relation with increasing maternal and fetal mortality rate. The questionnaire based survey was conducted including both close & open ended questions and compared with the retrospective data among 160 respondents, in which our target was to investigate women of varying socioeconomic status & the duration of our research is almost 20 days. Statistically we found an overall poor awareness of pre-eclampsia with 26% of women surveyed having heard of it and remaining 74% were unknown to pre-eclampsia, 39% faced pre-eclampsia with its severe consequences and fetal mortality rate data showed 42% deaths stating pre-eclampsia as the major cause of it, in addition to that higher rate of maternal death i.e. 57% occurs due to pre-eclampsia subsiding other reasons as key reasons of maternal mortality. Hence it is concluded that Pre-eclampsia is a disorder of pregnancy with unknown etiology so awareness level is too low to decrease its incident & this lack of awareness translates to worse health outcomes proving pre-eclampsia as a major cause of maternal and fetal mortality and its lack of awareness increasing this risk day by day and making it a hidden threat to pregnancy.