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Essential Hypertension and Pregnancy

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Essential Hypertension and Pregnancy Essential hypertension and pregnancy ROBERT A. BEAR, MD, FRCP[C], FACP; NORMAN ERENRICH, MD Approximately 10/0 of pregnancies are Ces medicaments doivent .tre choisis Hypertension complicated during pregnancy: by essential hypertension. avec soin afin d'eviter toute toxicit6 differential diagnosis During pregnancy the blood pressure foetale ou maternelle, et les diur6tiques often stabilizes or improves. In ainsi que les r6gimes hyposodes patients with sustained hypertension, devraient .tre evites durant Ia It is difficult to make a diagnosis prospective controlled studies have grossesse. Chez 20/a a 110/a des patientes of essential hypertension in a woman demonstrated enhanced fetal survival souffrant d'hypartension essentielle whose elevated blood pressure is when the blood pressure was controlled le probleme s'accentue tard durant Ia being evaluated for the first time with antihypertensive medication. Such grossesse; cette accel6ration peut .tre during pregnancy. The diagnosis can medication must be chosen carefully predite par Ia d6termination, chez Ia be made most confidently to avoid fetal and maternal when the toxicity, mere, des pressions art6rielles et des hypertension has been noted prior and diuretics and salt restriction during volumes intravasculaires moyens, t6t pregnancy should be avoided. Among to pregnancy and its genesis has been durant Ia grossesse. Le traitement determined. patients with essential hypertension de l'hypertension acc6l.r6e est identique In persons first noted to the problem accelerates late in a celui d'une pr6-eclampsie s6v.re. be hypertensive during pregnancy, m- pregnancy in 20/o to l10/o; the La perte foetale est considerable mais vestigation must be undertaken to acceleration may be predicted by elle peut .tre diminu6e par une separate those with underlying es- determination of maternal mean arterial surveillance foetale et maternelle suivie sential hypertension from those with pressures and intravascular volumes et un accouchement precoce contr6le. pre-existent chronic renal disease, early in pregnancy. The treatment of Pour Ia plupart des patientes souffrant pre-eclampsia or secondary hyper- accelerated hypertension is identical d'hypertension essentielle les risques to that of severe pre-eclampsia. Fetal tension. Edema and proteinuria are de Ia grossesse sont faibles, et more common pregnant loss is considerable but can be lessened l'hypertension essentielle n'est pas in women by careful fetal and maternal uniformement une contreindication a with any of these disorders, and since monitoring and early controlled delivery. Ia grossesse. investigative procedures must be lim- The risks of pregnancy in most patients ited during pregnancy accurate diag- with essential hypertension are small, Hypertension, the commonest med- nosis often must await radiologic and and essential hypartension is not a ical complication of pregnancy, may biopsy procedures uniform performed post contraindication to pregnancy. occur in association with a number partum. In such cases it is helpful of underlying disorders. In most to obtain prior medical histories and Environ lOb des grossesses sont series 70% of hypertensive preg- compliquees d'hypertenslon essentielle. summaries of previous medical as- Durant Ia grossesse Ia tension art6rielle nant women have pre-eclampsia or sessments. This information, along souvent se stabilise ou s'am6liore. eclampsia, 25% have essential hy- with the current clinical history and Chez des patientes souffrant d'hyper. pertension and 5% have underlying the results of physical examination, tension persistante, des 6tudes chronic renal disease.1" Looked at microscopic examination and culture prospectives contr8l6es ont d.montre another way, 3% to 4% of all preg- of the urine, and determination of une survie foetale am6llor.e lorsque nancies are complicated by hyper- serum concentrations of creatinine, Ia tension art6rielle a 6te contr8l6e tension due to pre-eclampsia or par une m6dication antihypertensive. electrolytes and uric acid (the last eclampsia, while 1% are complicated being normal or increased in eclamp- From the division of nephrology, by essential hypertension.' Essential tic syndromes) and 24-hour urine department of medicine, St. Michael's hypertension therefore is a not un- excretion of protein, often leads to Hospital and the University of Toronto common cause of elevated blood an accurate clinical diagnosis. In Reprint requests to: Dr. Robert A. Bear, pressure in pregnancy. In this article addition, 24-hour urine excretion of Division of nephrology, Department of the diagnosis, clinical course and vanillylmandelic acid, metanephrine medicine, St. Michael's Hospital, 30 medical management of this disorder normetanephrine Bond St., Toronto, Ont. M5B and should be 1W8 are reviewed. measured in women with previously 936 CMA JOURNAL/APRIL 22, 1978/VOL. 118 unevaluated severe hypertension, as hypertension develops late in preg- a number of new and interesting pheochromocytoma during pregnan- nancy, some women whose blood studies other investigators have dem- cy, though rare, is associated with pressure has been maintained at nor- onstrated that severe hypertension in extremely high maternal and fetal mal levels throughout early pregnan- pregnancy (essential hypertension, mortality.3 cy experience this complication.11'1' essential hypertension with acceler- Pregnant women with pre-existent Patients with essential hyperten- ated hypertension, or an eclamptic renal disease (except for patients with sion in whom accelerated hyperten- syndrome) is often accompanied by lupus nephritis4) are best managed sion develops late in pregnancy are clinical or laboratory evidence, or on the basis of the serum creatinine universally described as having su- both, of decreased intravascular vol- value before pregnancy or at the perimposed pre-eclampsia; however. ume.' Furthermore, there is evidence time of the first consultation during precise data (for example, from renal that in women with hypertension of pregnancy.' Women with even mild biopsy) to support this diagnosis are any type in whom the blood volume pre-eclampsia should be admitted to scanty.13 Examination of the placenta falls to expand normally early in hospital for careful monitoring, while in such cases reveals decreased pla- pregnancy the fetal outcome is poor." those with severe pre-eclampsia (hy- cental size and ischemic vascular Bletka and collaborators" have pertension, edema, proteinuria, oligu- changes compatible with either hy- demonstrated that normotensive na, hyperreflexia and abdominal pertension or pre-eclampsia.'4 How- women in whom pre-eclampsia pain) require hospitalization, seda- ever, the changes in clotting factors eventually develops have substantial tion, bed rest in the lateral decubitus that occur in women with pre- decreases in circulating plasma vol- position, adequate sodium adminis- eclampsia have not been demon- ume early in pregnancy. These tration, blood pressure monitoring strated in pregnant women with es- studies suggest that decreased intra- and control, constant and multifacet- sential hypertension." Until more vascular volume may lead to hor- ted fetal monitoring and early de- definitive information accumulates, monal and hemodynamic changes de- livery.6 Secondary hypertension dur- therefore, these patients are best de- signed to increase blood pressure and ing pregnancy is relatively rare and, scribed as having accelerated hyper- thereby preserve uteroplacental per- with the exception of pheochromo- tension, the pathophysiologic features fusion. Decreased intravascular vol- cytoma and sometimes coarctation of of which remain undetermined. ume therefore may be paradoxically the aorta, is best dealt with defini- In general, maternal mortality in associated with striking increases in tively post partum.7 Because it is the essential hypertension is low; how- blood pressure. In the future it may purpose of this review to discuss es- ever, maternal risk is increased by be possible to predict the patients sential hypertension in pregnancy, advanced maternal age, by long- with essential hypertension in whom the management of pregnancy in standing hypertension with hyperten- accelerated hypertension is likely to women with pre-existent renal dis- sion-mediated end-organ damage and develop by monitoring factors such ease, an eclamptic syndrome or sec- by the development of accelerated as the mean arterial pressure during ondary 'hypertension will not be de- hypertension. Infant birth weights the 2nd trimester and the degree to tailed further. and the incidence of fetal loss do which the intravascular volume ex- not differ substantially from normal pands in the early stages of preg- when the blood pressure of women nancy. Essential hypertension with mild essential hypertension de- creases or remains normal through- Management during pregnancy Pathophysiologic considerations out pregnancy.'6 However, in women It is clear that in pregnant women and course during pregnancy with persistent hypertension during with underlying essential hyperten- pregnancy, control of the hyperten- sion the outcome of pregnancy will In women with essential hyperten- sion with antihypertensive agents is be determined to a certain extent by sion the blood pressure may remaln of unequivocal value in terms of fetal the degree to which the blood pres- stable in early pregnancy or may survival.""7 When accelerated hyper- sure is adequately controlled. Avail- even fall (generating a false sense of tension develops the incidence
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