GESTATIONAL

HYPERTENSION

Submitted by:
MARASIGAN, JAE C.
MARCO, ANNIE CLARESSE C.
BSN IV-9 GRP. A
Definition:

Gestational hypertension is high blood pressure that develops after

the twentieth week of pregnancy. It is clear that the condition affects blood
flow to organs such as the kidneys, placenta, brain, and liver. It occurs in
about 5 percent to 8 percent of all pregnancies. Another type of high blood
pressure is chronic hypertension - high blood pressure that is present
before pregnancy begins. There is no way of preventing this type of
hypertension, but regular prenatal care will usually catch it early, reducing
the chances of complications.
A major cause of maternal and perinatal morbidity and mortality in
developing countries-12% of maternal mortalities worldwide. WHO
estimates 15% of pregnant women would have some form of hypertensive
disorder in pregnancy, labour and puerperium.
Gestational hypertension can develop into preeclampsia. This
condition occurs most often in young women with a first pregnancy. It is
more common in twin pregnancies, in women over the age of 35, in women
with chronic hypertension, diabetes, African-American women, and in women
who had hypertension in a previous pregnancy. It is diagnosed when blood
pressure readings are higher than 140/90 mm Hg after 20 weeks of
pregnancy with normal blood pressure.

Preeclampsia (also known as toxemia) is diagnosed when a woman

with gestational hypertension also has increased protein in her urine.

Causes and Risk Factors:

The cause of gestational hypertension is unknown. Some conditions

may increase the risk of developing this, including the following:

• pre-existing hypertension (high blood pressure)

• kidney disease
• diabetes
• hypertension with a previous pregnancy
• mother's age younger than 20 or older than 40
• multiple fetuses (twins, triplets)
• African-American race
• Nulliparity
• twin pregnancies
• previous preeclampsia
• obesity
• hypertension
• multiparous women conceiving with a new partner
• extremes of age
• black women
• mother or sister with preeclampsia (suggests genetic factors)
 • renal disease
• obesity and insulin resistance
• polysystic ovarian syndrome (PCOS)
• DECREASED risk in smokers
• women who are pregnant for the first time
• women who are pregnant with twins or triplets
• women who have had gestational hypertension or preeclampsia
in a prior pregnancy
• women who are overweight before the pregnancy

Signs and symptoms:

The following are the most common symptoms of high blood pressure in
pregnancy. However, each woman may experience symptoms differently.
Symptoms may include:

• increased blood pressure

• headache
• thirst
• protein in the urine
• edema (swelling)
• sudden weight gain
• visual changes such as blurred or double vision
• nausea, vomiting
• right-sided upper abdominal pain or pain around the stomach
• urinating small amounts
• changes in liver or kidney function tests

Pathophysiology:

The symptoms of PIH affect almost all organs. The vasculature spasm
may be caused by increased cardiac output that injures the endothelial cells
of the arteries and the action prostaglandins (notably decreased prostacyclin
and thrombexane). In PIH there is a reduced responsiveness to blood
pressure changes. Vasoconstriction occurs and blood pressure increases
dramatically. With elevated blood pressure, the cardiac system becomes
overwhelmed and the heart is forced to pump against rising peripheral
resistance. This in turn reduces the blood supply to the organs, specifically to
the kidneys, pancreas, liver, brain and placenta. Poor placental perfusion
results to inadequate nutrient and oxygen supply to the fetus. Ischemia in
the pancreas may cause epigastric pain and an elevated amylase-creatinine
ratio. Spasm of the arteries in the retina leads to vision changes. And if
retinal hemorrhages occur, it can result to blindness.
 Vasospasm in the kidney increases blood flow resistance. Degenerative
changes develop in the kidney glomeruli because of back pressure. This
leads to increased permeability of the glomerular membrane, allowing the
serum protein to escape in the urine. The degenerative changes also result
in lowered glomerular filtration rate; in turn there is a decrease in urine
output and clearance of creatinine. And because of tubular reabsorption of
sodium along with fluid retention, subsequent edema develops. Which is
then further increased because as more protein is lost, the osmotic pressure
in the circulation drops and fluid diffuses from the circulatory system into the
denser interstitial spaces to equalize pressure. Extreme edema can lead to
cerebral and pulmonary edema and seizures (as seen in eclampsia).

Laboratory Examination:

• creatine, urea, uric acid (increased)

• hemoglobin (often elevated due to hemoconcentration)
• platelets (decreased)
• blood film for hemolysed cells
• PTT, INR, fibrinogen, D-dimer (increased)
• ALT, AST, bilirubin, LDH (increased)
• fragmented RBCs on smear

urine dipstick

• 2+ significant
• 3-4+ severe

24 hour urine collection or a protein/creatinine ratio

• >300mg/24hr
• >5g/24hr severe

Treatment:

The goal of treatment is to prevent the condition from becoming worse and
to prevent it from causing other complications. Treatment for gestational
hypertension may include:

• bedrest (either at home or in the hospital may be recommended)

• hospitalization (as specialized personnel and equipment may be
necessary)
• magnesium sulfate (or other antihypertensive medications for
gestational hypertension)
 • fetal monitoring (to check the health of the fetus when the mother has
gestational hypertension) may include:
o fetal movement counting - keeping track of fetal kicks and
movements. A change in the number or frequency may mean the
fetus is under stress.
o nonstress testing - a test that measures the fetal heart rate in
response to the fetus' movements.
o biophysical profile - a test that combines nonstress test with
ultrasound to observe the fetus.
o Doppler flow studies - type of ultrasound that uses sound waves
to measure the flow of blood through a blood vessel.
• continued laboratory testing of urine and blood (for changes that may
signal worsening of gestational hypertension)
• medications, called corticosteroids, that may help mature the lungs of
the fetus (lung immaturity is a major problem of premature babies)
• delivery of the baby (if treatments do not control gestational
hypertension or if the fetus or mother is in danger). Cesarean delivery
may be recommended, in some cases.

Medical Management:

Medications

• Always get repeat readings and assess the status of the baby before
instituting medication treatment.
• Hydralazine the drug of choice; other drugs include methyldopa,
labetolol, nitroprusside, nifedipine.
• Avoid diuretics and ACE inhibitors due decreased intravascular volume,
risk of uterine ischemia and teratogenicity for ACE.
• Magnesium sulfate (MgSO4) can be used for prevention of worsing
eclampsia. If seizures begin, continue to treat with magnesium bolus,
followed by continuous infusion.
• Do not give magnesium too quickly, as it can cause toxicity. This can
include loss of reflexes, flushing, somnolence, paralysis, respiratory
distress, and cardiac arrest. Calcium is the antidote.
• Further outpatient care and followup is important. Risk of seizures is
highest in first 24 hours postpartum, requiring continued MgSO4 for 12-
24 hours. Seizures can occur up to 30 days postpartum.