ELECTIVE STUDY

HYPERTENSION IN PREGNANCY

NAME: CHRISTOPHER VINCENT

NIM: 1302005295

SEMESTER: II

PRODI: KU B

SUPERVISOR

Dr Desak Made Wihandani

FAKULTAS KEDOKTERAN

UNIVERSITAS UDAYANA

DENPASAR

2017

1
 PREFACE

I, Christopher Vincent, second semester medical student in Universitas Udayana

with NIM No of 1302005295 would like to express my prayers to Lord for
successfully completing my Special Studies on task on topic of Hypertension in
Pregnancy.

Firstly, I would like to express my heartiest thank you to my supervisor, Dr. Desak
Made Wihandani for assisting me in my paper work and also guiding me through
summary writing as well as developing a good understanding of the topic with
me. She has been helpful in providing assistance in finding journals for the
specified topic and leading me through the successful completion of my report.

Secondly, the benefit that I have gained through the whole journey of this report is
that I have chance to explore more about the field of the topic I have researched
on. In addition, I have learned how to take full responsibility of my own research
paper. Overall I have learnt many wonderful and important facts about this topic.

Thank You.

Denpasar, August 21, 2014

By,

---------------------------------

(CHRISTOPHER VINCENT)

NIM: 1302005295

2
 CONTENT

COVER---------------------------------------------------------------------------------------1

PREFACE------------------------------------------------------------------------------------2

CONTENT-----------------------------------------------------------------------------------3

CHAPTER 1 : INTRODUCTION
1.1 Background------------------------------------------------------------------------------4
1.2 Problem Identification------------------------------------------------------------------5
1.3 Aims--------------------------------------------------------------------------------------5
1.4 Benefits-----------------------------------------------------------------------------------5

CHAPTER 2 : LITERATURE REVIEW

2.1 Types of Hypertension in Pregnancy-------------------------------------------------7
2.2 Signs and Symptoms-------------------------------------------------------------------8
2.3 Pathophysiology-------------------------------------------------------------------------8
2.4 Risk Factors--------------------------------------------------------------------------9-10
2.5 Complications----------------------------------------------------------------------11-12
2.6 Diagnostic Methods---------------------------------------------------------------12-13
2.7 Management------------------------------------------------------------------------13-14
2.8 Drug Therapy----------------------------------------------------------------------14-15

CHAPTER 3 : CONCLUSION----------------------------------------------------------16

REFERENCES-----------------------------------------------------------------------------17

CHAPTER 1 : INTRODUCTION

3
1.1 Background

Blood pressure is the pressure of the blood against the blood vessel walls each
time the heart contracts to pump the blood through the body. High blood pressure
is also as called hypertension. A person's blood pressure is considered high when
the readings are greater than 140 mm Hg systolic or 90 mm Hg diastolic. In
general, high blood pressure, or hypertension, contributes to the development of
coronary heart disease, stroke, heart failure and kidney disease. [6]
Hypertension can lead to many health problems. Hypertension is one of the most
common medical complications of pregnancy. During pregnancy, severe or
uncontrolled hypertension can cause complications for the mother and the baby.
This condition significantly contributes to maternal and perinatal morbidity and
mortality. A relative paucity of investigative data, as well as the frequent difficulty
in making an etiological diagnosis by clinical criteria alone, may be among the
reasons why there are many conflicts about the management of hypertension
during pregnancy.
Hypertension is a sign of an underlying pathology, which may be pre-existing or
appears for the first time during pregnancy. The identification of this clinical
entity and effective management play a significant role in the outcome of
pregnancy, both for the mother and the baby. In the developing countries with
inadequately cared pregnancy, this entity on many occasions remains undetected
until major complications supervene. Although many pregnant women with high
blood pressure have healthy babies without serious problems, high blood pressure
can be dangerous for both the mother and the foetus. Women with pre-existing, or
chronic, high blood pressure are more likely to have certain complications during
pregnancy than those with normal blood pressure. However, some women develop
high blood pressure while they are pregnant (often called gestational
hypertension). [8]
The effects of high blood pressure range from mild to severe. High blood pressure
can harm the mother's kidneys and other organs, and it can cause low birth weight
and early delivery. In the most serious cases, the mother develops preeclampsia or

4
"toxaemia of pregnancy", which can threaten the lives of both the mother and the
foetus. [7]

1.2 Problem Identification

The problems that can be identified from background are as such:

1. What are the different types of hypertension conditions during pregnancy?

2. What are the clinical signs and symptoms?

3. What is the pathophysiology or etiology behind this condition?

4. What are the complications arise from this condition?

5. What are the diagnostic tools used to diagnose this condition?

6. How this condition managed and what is the drug therapy given?

1.3 Aims

1. To understand the different types of hypertension conditions during

pregnancy.
2. To understand and identify the different clinical signs and symptoms in
this condition.

3. To understand the pathophysiology and etiology behind this condition.

4. To understand the complications that can arise from this condition.

5. To know the different methods used to diagnose this condition.

6. To understand the different ways this condition is managed and the drugs
that can be given for treatment purpose.

1.3 Benefits

5
By reading this paper, we will understand the different types of hypertension
conditions during pregnancy. We will also know and identify the clinical signs and
symptoms that a pregnant mother will have if she has hypertension during
pregnancy. We will also understand the pathophysiology behind this condition,
hence helping us to recognise the different ways that can be applied to manage
this condition, including the drug therapy. We will be able to identify the different
diagnostic tools and methods used to correctly diagnose a woman with
hypertension during pregnancy and the type of hypertension condition she may
have.

6
 CHAPTER 2 : LITERATURE REVIEW

2.1 Types of hypertension in pregnancy

Sometimes high blood pressure is present before pregnancy. In other cases, high
blood pressure develops during pregnancy. For example:

2.1.1 Gestational hypertension

Women with gestational hypertension have high blood pressure that develops
after 20 weeks of pregnancy. There is no excess protein in the urine or other
signs of organ damage. Some women with gestational hypertension eventually
develop preeclampsia. [2]

2.1.2 Chronic hypertension

Chronic hypertension is high blood pressure that was present before pregnancy
or that occurs before 20 weeks of pregnancy. But because high blood pressure
usually doesn't have symptoms, it might be hard to determine when it began.

2.1.3 Chronic hypertension with superimposed pre-eclampsia

This condition occurs in women with chronic high blood pressure before
pregnancy, who then develop worsening high blood pressure and protein in the
urine or other health complications during pregnancy.

2.1.4 Pre-eclampsia
Sometimes chronic hypertension or gestational hypertension leads to
preeclampsia, a pregnancy complication characterized by high blood pressure
and signs of damage to another organ system, usually after 20 weeks of

7
 pregnancy. Left untreated, preeclampsia can lead to serious, even fatal,
complications for mother and baby. Previously, preeclampsia was only
diagnosed if a pregnant woman had high blood pressure and protein in her
urine. However, experts now know that it's possible to have preeclampsia, yet
never have protein in the urine. [9]

2.2 Signs and symptoms

All pregnant women should receive antenatal education. This is important so that
they are aware of the symptoms associated with hypertension during pregnancy,
its importance and the need to obtain medical advice. [5]

Such symptoms include:

1.1 Blood pressure >160 mm Hg systolic or >110 mm Hg diastolic.

1.2 Proteinuria of new onset at a rate of >2 g/24 h or >100 mg/dL (2+) in a
random urine.
1.3 Increasing serum creatinine levels (especially >177 jtmol/L [2 mg/dL], unless
known to be elevated previously).
1.4 Platelet count <10xl0'/L, evidence of microangiopathic hemolytic anemia
(eg, schistocytes and/or increased lactic acid dehydrogenase and direct
bilirubin levels).
1.5 Upper abdominal pain, especially epigastric and right upper quadrant pain.
1.6 Headache, visual disturbances, or other cerebral signs.
1.7 Cardiac decompensation (eg, pulmonary edema). Usually associated with
underlying heart pathology or chronic hypertension.
1.8 Retinal hemorrhages, exudates, or papilledema. (These are extremely rare in
the absence of other indicators of severity and when present almost always
indicate underlying chronic hypertension.)
1.9 Presence of intrauterine growth retardation and decreasing urine volume,
which require added vigilance.

2.3 Pathophysiology
Despite being the leading cause of maternal death and a major contributor of
maternal and perinatal morbidity, the mechanisms responsible for the

8
pathogenesis of Pregnancy Induced Hypertension(PIH) have not yet been fully
elucidated. Studies during the past decade, however, have provided a better
understanding of the potential mechanisms responsible for the pathogenesis of
PIH.
The initiating event in PIH appears to be reduced uteroplacental perfusion, as a
result of abnormal cytotrophoblast invasion of spiral arterioles. Placental ischemia
is thought to lead to widespread activation/dysfunction of the maternal vascular
endothelium that results in enhanced formation of endothelin and thromboxane,
increased vascular sensitivity to angiotensin II, and decreased formation of
vasodilators such as nitric oxide and prostacyclin. The quantitative importance of
the various endothelial and humoral factors in mediating the reduction in renal
hemodynamic and excretory function and elevation in arterial pressure during PIH
is still unclear.
Investigators are also attempting to elucidate the placental factors that are
responsible for mediating activation/dysfunction of the maternal vascular
endothelium. Microarray analysis of genes within the ischemic placenta should
provide new insights into the link between placental ischemia and hypertension.
More effective strategies for the prevention of preeclampsia should be
forthcoming once the underlying pathophysiologic mechanisms that are involved
in PIH are completely understood.

2.4 Risk factors

Preeclampsia is more common at the extremes of maternal age (< 18 y or >35 y).
The increased prevalence of chronic hypertension and other comorbid medical
illnesses in women older than 35 years may explain the increased frequency of
preeclampsia among older gravidas. In addition, black women have higher rates of
preeclampsia complicating their pregnancies compared with other racial groups,
mainly because they have a greater prevalence of underlying chronic
hypertension. Among women aged 30-39 years, chronic hypertension is present in
22.3% of black persons, 4.6% of non-Hispanic white persons, and 6.2% of

9
Mexican Americans. Hispanic women generally have blood pressure levels that
are the same as or lower than those of non-Hispanic white women.
Women who develop preeclampsia during pregnancy have an increased risk of
recurrent preeclampsia during subsequent pregnancies. The overall risk is about
18%. The risk is higher (50%) in women who develop severe early preeclampsia
(i.e. before 27 weeks' gestation). These women are also at increased risk for
cardiovascular disease later in life. Whether the preeclampsia increases
cardiovascular risk or the two conditions share a common underlying cause
remains unclear.

2.4.1 Maternal personal risk factors for preeclampsia

The following are maternal personal risk factors for preeclampsia:
1 First pregnancy
2 New partner/paternity
3 Age younger than 18 years or older than 35 years
4 History of preeclampsia
5 Family history of preeclampsia in a first-degree relative
6 Black race
7 Obesity (BMI 30)
8 Interpregnancy interval less than 2 years or longer than 10 years

2.4.2 Maternal medical risk factors for preeclampsia

The following are maternal medical risk factors for preeclampsia:
1 Chronic hypertension, especially when secondary to such disorders as
hypercortisolism, hyperaldosteronism, pheochromocytoma, or renal artery
stenosis
2 Preexisting diabetes ( type 1 or type 2), especially with microvascular disease
3 Renal disease
4 Systemic lupus erythematosus
5 Obesity
6 Thrombophilia
7 History of migraine

10
8 Use of selective serotonin uptake inhibitor antidepressants (SSRIs) beyond the
first trimester.
2.4.3 Placental/foetal risk factors for preeclampsia
The following are placental/foetal risk factors for preeclampsia:
1 Multiple gestations
2 Hydrops fetalis
3 Gestational trophoblastic disease
4 Triploidy

2.5 Complications

High blood pressure during pregnancy poses various risks, including:

2.5.1 Decreased blood flow to the placenta
If the placenta doesn't get enough blood, your baby might receive less
oxygen and fewer nutrients. This can lead to slow growth, low birth
weight or preterm birth. Prematurity can lead to breathing problems for the
baby.
2.5.2 Placental abruption
Preeclampsia increases your risk of placental abruption, in which the
placenta separates from the inner wall of your uterus before delivery.
Severe abruption can cause heavy bleeding and damage to the placenta,
which can be life-threatening for both you and your baby.

2.5.3 Premature delivery

Sometimes an early delivery is needed to prevent potentially life
threatening complications.

2.5.4 Future cardiovascular disease

Having preeclampsia increases your risk of future heart and blood vessel
(cardiovascular) diseases. The risk is even greater if you've had
preeclampsia more than once or you've had a premature birth. To minimize

11
 this risk, after delivery try to maintain your ideal weight, eat a variety of
fruits and vegetables, exercise regularly, and don't smoke.

2.6 Diagnostic Methods

Determining whether elevated blood pressure identified during pregnancy is due

to chronic hypertension or to preeclampsia is sometimes a challenge, especially if
no recorded blood pressures from the first half of the gestation are available.
Clinical characteristics obtained via history, physical examination, and certain
laboratory investigations may be used to help clarify the diagnosis. Foetal well-
being must also be considered with the workup of the mother. [4]

Preeclampsia is rare before the third trimester, and the diagnosis of severe
hypertension or preeclampsia in the first or early second trimester necessitates
exclusion of gestational trophoblastic disease and/or molar pregnancy. Mild lower
extremity oedema is common in normal pregnancy, but rapidly increasing or
nondependent oedema may be a signal of developing preeclampsia. However,
oedema is no longer included among the criteria for the diagnosis of preeclampsia.
New seizures in pregnancy suggest preeclampsia-eclampsia, but primary
neurologic disorders must be excluded.

Hyperaldosteronism and hypercortisolism are difficult to diagnose during

pregnancy due to the high levels of progesterone and the normal increase in
endogenous cortisol output.

2.6.1 Routine Tests

Laboratory testing to evaluate chronic hypertension (if not done previously or
recently) includes testing for target organ damage, potential secondary causes of
hypertension, and other risk factors. [1]

Blood tests to order when evaluating eclampsia include those suggested to

evaluate for preeclampsia. Such studies include: urinalysis; complete blood cell
(CBC) count; and serum sodium, potassium, creatinine, and glucose levels (the

12
presence of high levels of progesterone, an aldosterone antagonist, during a
normal pregnancy may mask the hypokalemia from hyperaldosteronism).
Other suggested tests include measurements of creatinine clearance, blood urea
nitrogen (BUN), albumin, 24-hour urinary protein, serum calcium, uric acid,
glycosylated hemoglobin, thyroid-stimulating hormone (TSH), liver enzymes and
bilirubin, and a urine dip for protein.

For a woman with chronic hypertension in her first trimester, obtain the following
laboratory studies (to serve as baseline values, to be referred to later in the
pregnancy if a concern regarding superimposed preeclampsia arises): CBC count,
electrolytes, BUN, creatinine, liver enzymes, and urine dip for protein and a 24-
hour urine collection for creatinine clearance and protein excretion.

A spot urine protein/creatinine ratio has been studied in pregnancy, and, because it
lacks sensitivity versus a 24-hour collection, it is not recommended as part of the
evaluation. In addition to the lack of recommendations from consensus
statements, the spot test can miss women with lower levels of proteinuria.
Serum lipids (i.e. total cholesterol, high-density lipoprotein [HDL], low-density
lipoprotein [LDL], triglycerides) predictably increase during pregnancy, so
measurement should be deferred until the postpartum period. In addition, the
increase in endogenous corticosteroid levels during normal pregnancy makes it
difficult to evaluate for secondary hypertension due to adrenal corticosteroid
excess. [6]

2.7 Management

When preeclampsia is suspected, consider hospitalization, an approach that

diminishes the likelihood of convulsions, reduces the consequence of diagnostic
error, and may improve foetal outcome. Near term, induction of labour should be
undertaken, but temporization can be considered when the foetus is very
immature. [3]

13
Delivery, however, is indicated regardless of gestational age if any of the
following are present:
1. severe hypertension resistant to 24 to 48 hours of therapy
2. thrombocytopenia,
3. the appearance of liver abnormalities
4. progressive renal dysfunction
5. premonitory signs of eclampsia
6. evidence of foetal jeopardy
7. general deteriorating state

Regulation of blood pressure:

The degree to which blood pressure should be decreased is disputed. The Working
Group's Consensus Report recommends maintaining levels between 90 and 105
mm Hg.

2.8 Drug therapy

(1) Hydralazine administered intravenously is the drug of choice. Start with low
doses (5 mg IV bolus), and then administer 5 to 10 mg every 20 to 30 minutes to
avoid precipitous decreases. Side effects include tachycardia and headache.
Neonatal thrombocytopenia has been reported.

(2) Diazoxide is recommended for the occasional patient whose hypertension is

refractory to hydralazine. Use 30-mg miniboluses because precipitous
hypotension may result with higher doses. Side effects include arrest of labor and
neonatal hypoglycaemia.
(3) Experience with labetalol is growing, and some use this agent instead of
diazoxide as a second-line drug.

(4) Favourable results have been reported with calcium channel blockers.
However, if magnesium sulphate is being infused, the magnesium ion may
potentiate the effect of the calcium channel blockers, resulting in precipitous and
severe hypotension.

14
(5) Refrain from using nitroprusside, because fetal cyanide poisoning has been
reported in animal models. However, in the final analysis, maternal well-being
will dictate therapy choice.

The Working Group retained parenteral magnesium sulphate as the drug of choice
for preventing impending eclamptic convulsions.

Therapy should be continued for 12 to 24 hours into the puerperium, because one
third of patients with eclampsia have their convulsion after childbirth.

15
CHAPTER III

CONCEPT

Based on my literature review, I have decided to investigate the relationship between

pregnant women with hypertension as a case, and pregnant women that do not
suffer from hypertension as a control. Aside from that, this study population is
conducted to pregnant women who visited the Reka Clinic, Seremban. By
conducting this studies we can get to know that how does pregnancy hypertension
affect and effect the daily lifestyle of a pregnant women and what cause
hypertension to occur.

16
CHAPTER IV

METHOD OF RESEARCH

4.1 Design of Research

The research method is using analytic research is research conducted with the
main objective to analyse a situation. The circumstances or the situation we
describe the design using "case control".

Factors of Positive Risk

Positive Hypertension

Factors of Negative Risk

Pregna
nt Lady

Factors of Positive Risk

Negative Hypertension

Factors of Negative Risk

Information:

Exposure: The risk factors of hypertension in pregnant women

Case: Pregnant women who suffer from hypertension

Control: Pregnant women who do not suffer from hypertension

4.2 Time and Place of Experiment

The survey would be conducted at 7th semester on given duration. The period of this
survey would be for two weeks. The survey will be given out in a Reka Clinic, Seremban,
Malaysia.

17
4.3 Population and Sample of Research

This study population is pregnant women who visited the Reka Clinic, Seremban.

The sample was pregnant women with hypertension as a case, and pregnant
women that do not suffer from hypertension as a control.

Sample size

The formula for the sample size is the same as the case-control study cohort
studies and experiments, namely:

(Po qo + P1 q1) (Z1-/2 + Z1-)2

=
(P1 - Po)2
By:
Po = the proportion of exposure in the population (control)

P1 = proportion of population exposure to illness (cases)

Po (OR)
=
1+Po (OR -
Is known:

OR = 0,155

Po = 0, 87

P1 = 0,509

q0 = 1-Po = 0, 13

q1 = 1-P1 = 0,491

Asked:

n (Number) samples

Answers:

(Per group) = (Po qo + P1 q1) (Z1-/2 + Z1-)2 n

(P1 - Po)2

n = (0,87 x 0,13 + 0,509 x 0,491) (1,96 + 0,84)2

(0,509 - 0,87)2

n = 21,838

18
From the above calculation can know the number of samples 21.838 respondents.
But researchers made up to 30 respondents, with a ratio of 1: 1, i.e. at 30 as cases
and 30 as a control, so that the total sample taken 60 samples.

Ways of sampling

How sampling of non-random sampling that sampling is not based on the

possibilities that can be taken into a count, but solely based on sheer practicality
by using Accidental Sampling is done by taking the case or the respondent who
happened to be.

With a sample of the following criteria:

Inclusion criteria:

1. Pregnant women with hypertension that is not the willing to become

respondents.

2. Capital as referred to in no. 1 which has the ability to answer questions both
verbally and in writing.

4.4 Instrument of Research

Primary data: data obtained through questionnaires distributed to respondents in

accordance with the inclusion criteria.

Secondary data: Medical Record

The research instrument:

Research tool used was a questionnaire, a list of questions about the factors that
influence hypertension, and medical record.

4.5 Variables

Is something that is used as a characteristic, the nature / size of owned / earned by

a researcher about a certain sense concept.

Dependent variable: Hypertension in pregnancy

Independent variable: Factors that influence hypertension

19
 REFERENCES

1. Carson Michael P, 2015, Hypertension and Pregnancy. Available at:

http://emedicine.medscape.com/article/261435-overview#showall

2. Dutta D.C., 2011, Textbook of Obstetrics 7th Edition, pp. 219-239

3. Granger JP, 2001, Pathophysiology of Pregnancy-Induced Hypertension.

Available at: http://www.ncbi.nlm.nih.gov/pubmed/11411754

4. Health and Pregnancy, 2014. Available at:

http://www.webmd.com/baby/tc/preeclampsia-and-high-blood-pressure-
during-pregnancy-topic-overview

5. High Blood Pressure in Pregnancy, 2012. Available at:

http://www.nhlbi.nih.gov/health/resources/heart/hbp-pregnancy

6. Hypertension in Pregnancy, 2015. Available at:

http://patient.info/doctor/hypertension-in-pregnancy

7. Lindheimer Marshall D, 1993, Hypertension in Pregnancy. Available at:

http://hyper.ahajournals.org/

8. Mayo Clinic Staffs, 2014, High Blood Pressure and Pregnancy: Know the
Facts. Available at: http://www.mayoclinic.org/healthy-
lifestyle/pregnancy-week-by-week/in-depth/pregnancy/art-20046098?
pg=1

9. Preeclampsia and High Blood Pressure during Pregnancy, 2014. Available

at: http://www.acog.org/Patients/FAQs/Preeclampsia-and-High-Blood-
Pressure-During-Pregnancy

20