[Hypertension in pregnancy]

Josip Delmis
Lijec̆nic̆ki Vjesnik 2006, 128 (11-12): 357-68
Pregnancy in hypertension is not a single entity, and currently several classifications exist. Most often used is the updated classification of the American College of Obstetricians and Gynecologists, which classifies hypertension into chronic hypertension, preeclampsia-eclampsia, preeclampsia superposed on chronic hypertension, and gestational hypertension. Preeclampsia occurs in about 7% of pregnant women. Primigravida have increased risk for preeclampsia. Preeclampsia frequency in sisters was 37%, in daughters 26%, in granddaughters 16%, an in daughters in law only 6%, which points to the strong hereditary association. Although basic clinical changes in preeclampsia appear in the second part of pregnancy, some haemodynamic and biochemical abnormalities may be observed earlier. Besides haemodynamic abnormalities in the mother, one of the main characteristics of preeclampsia is uteroplacental circulation insufficiency, and consequent intrauterine growth restriction. Basic alterations in preeclampsia occur due to inadequate trophoblast migration and lack of spiral artery physiologic transformation. In preeclampsia, musculoelastic layer of spiral arterioles is preserved, therefore their lumen stays narrow during the entire pregnancy, ad their wall sensitive to vasoconstrictive factors. Currently, the most convincing and most comprehensive is the hypothesis on generalized endothelial dysfunction as the underlying pathophysiological mechanisms. Preeclampsia is an illness that develops due to vasoconstriction and reduced perfusion, particularly in essential organs. HELLP syndrome is a multiple system disease whose pathogenesis has not yet been completely explained. In HELLP syndrome endothelial vascular cells are damaged, resulting in intravascular platelet activation. Frequency of HELLP syndrome is about 0.2-0.6% of all pregnancies, and 4-12% of those with preeclampsia. HELLP syndrome is an acronym for H = haemolysis, EL = elevated liver enzymes and LP = low platelet count. Risk factors are multiple pregnancy, mother' age over 25 years, white race, and poor perinatal outcome in previous pregnancies. Preeclampsia treatment is a great challenge for every physician, but also the subject of numerous discussion because there is no consensus on which drug would be the best for the treatment and prevention of preeclampsia. Generally accepted opinion is that the cut-off blood pressure level, when antihypertensive therapy should be initiated, is diastolic blood pressure over 110 mmHg. However, it should not be decreased below 90-100 mmHg in order not to jeopardize uteroplacental circulation, which is in preeclampsia and eclampsia already significantly reduced. Termination of pregnancy is the definitive treatment for preeclampsia and eclampsia.

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