Hypertension in Pregnancy

Hypertension is the most common medical problem of pregnancy, affecting 10% of all pregnant women. The condition can lead to devastating outcomes with significantly increased risks of placental abruption, disseminated intravascular coagulation (disseminated intravascular coagulopathy), cerebral hemorrhage, hepatic failure, and acute renal failure. Hypertensive disorders of pregnancy are a significant cause of maternal and perinatal morbidity and mortality, and therefore require accurate diagnosis and proper medical management. CAM treatments for hypertensive disorders during pregnancy should always accompany proper medical management in conjunction with the care of an obstetrician.

Hypertensive disorders of pregnancy are divided into four categories according to the National High Blood Pressure Education Program (NHBPEP) 2000 Working Group:

1. Preeclampsia-eclampsia

2. Chronic hypertension

3. Preeclampsia superimposed on chronic hypertension

4. Gestational (transient) hypertension Hypertension itself is defined as a sustained increase in blood pressure > 140 / 90. Elevated blood pressure should be documented on at least two consecutive occasions greater than 6 hours apart, using the appropriate-size blood pressure cuff, to make a diagnosis of hypertension. Diastolic pressure should be considered the number at which the Phase V Korotkoff sound is auscultated. Patients should be told to avoid tobacco and caffeine for at least 30 minutes prior to a blood pressure reading, and should be encouraged to relax for 10 minutes prior to evaluation. The definition of hypertension as a 30 mm Hg systolic and / or 15 mm Hg rise over baseline is now considered invalid, as it is recognized that up to 73% of all women in their first pregnancies experience a dia-stolic rise of this magnitude at some point in the pregnancy with no subsequent development of pathology. Nonetheless, close observation of these women is recommended. Each type of hypertensive disorder of pregnancy has specific diagnostic criteria (Box Diagnosis of Hypertensive Disorders Complicating Pregnancy).

Diagnosis of Hypertensive Disorders Complicating Pregnancy

Preeclampsia

Minimum Criteria:

• BP = 140 / 90 mm Hg after 20 weeks gestation

• Proteinuria = 300 mg / 24 hours or = 1+ dipstick Increased certainty of preeclampsia:

• BP = 160 / 110 mm Hg

• Proteinuria 2.0 g / 24 hours or = 2 + dipstick

• Serum creatinine > 1.2 mg / dL unless known to be previously elevated

• Platelets < 100,000 mm

• Microangiopathic hemolysis (increased LDH)

• Elevated ALT or AST

• Persistent headache or other cerebral or visual disturbance

• Persistent epigastric pain Eclampsia

• Seizures that cannot be attributed to other causes in a woman with preeclampsia. THIS IS A MEDICAL EMERGENCY!

Chronic Hypertension

• BP = 140 / 90 mm Hg before pregnancy or diagnosed before 20 weeks gestation

Or

Hypertension first diagnosed after 20 weeks gestation and persistent after 12 weeks postpartum

Preeclampsia Superimposed on Chronic Hypertension

• New-onset proteinuria = 300 mg / 24 hours in hypertensive women but no proteinuria before 20 weeks gestation

• Sudden increase in proteinuria or blood pressure or platelet count <100.000 / mm in women with hypertension and proteinuria before 20 weeks gestation

Gestational Hypertension (Transient Hypertension)

• BP = 140 / 90 mm Hg for first time during pregnancy

• No proteinuria

• BP return to normal <12 weeks postpartum

• Final diagnosis made only postpartum

• May have other signs of preeclampsia, for example, epigastric discomfort or thrombocytopenia

• 15% to 25% of women will go on to develop preeclampsia; gestational age at diagnosis of transient hypertension is inversely related to likelihood of developing preeclampsia

Note that edema is no longer considered a diagnostic criterion of preeclampsia as it is found in many normal pregnancies and is not a reliable indicator.

Descriptions of Hypertensive Disorders of Pregnancy

Botanical Treatment Of Hypertension In Pregnancy

Additional Therapies

Nutritional Considerations

A diet rich in calcium, magnesium, and potassium may lessen cardiovascular risk. A diet rich in fruits, vegetables, whole grains, legumes, nuts, good-quality oils, and low-fat foods is associated with decreased hypertension and may be especially beneficial for women with chronic hypertension. Essential fatty acids may be beneficial in the prevention of pregnancy hypertension. Vascular sensitivity to angiotensin II was determined in the midtrime-ster of pregnancy in women after taking a diet with supplemented essential fatty acids and vitamins. The essential fatty acids linoleic and dihomo-gamma-linolenic acid were administered as evening primrose oil capsules (Efamol) for 1 week prior to the study. Vascular sensitivity was then determined in response to 4, 8, and 16 ng kg-1 min-1 angiotensin II. Vitamin supplements (Efavit) were given with the Efamol capsules. Seven women have been studied, and their vascular sensitivity compared with controls on normal diet. The vascular sensitivity was significantly reduced in all the patients on essential fatty acid supplements, and all values fell below the mean of the control group.

Exercise and Stress Management

Exercise and relaxation practices have generally been shown to be beneficial in the reduction of hypertension as part of therapeutic lifestyle choices. Although the role of exercise and stress management in the prevention of preeclampsia is not established, it is certainly beneficial in the management of chronic hypertension. Regular walking, yoga, meditation, biofeedback, and other gentle techniques are safe during normal pregnancy.