Cardiac disease in pregnancy and hypertension: Difference between revisions
No edit summary |
|||
| Line 1: | Line 1: | ||
{{Pregnancy and heart disease}} | {{Pregnancy and heart disease}} | ||
{{CMG}}; '''Associate | {{CMG}}; '''Associate Editors-In-Chief:''' {{AC}} Stacie Zelman, M.D. [mailto:szelman@wfumbc.edu] | ||
==Overview== | ==Overview== | ||
| Line 24: | Line 24: | ||
Pregnancy-induced hypertension (PIH) (or gestational hypertension) is defined as the development of new arterial hypertension in a pregnant woman after 20 weeks gestation. There is no specific treatment, but is monitored closely to rapidly identify [[pre-eclampsia]] and its life-threatening complications (HELLP syndrome and [[eclampsia]]). Treatment options are limited, as many antihypertensives may negatively affect the fetus; methyldopa and labetalol are most commonly used for severe pregnancy hypertension. | Pregnancy-induced hypertension (PIH) (or gestational hypertension) is defined as the development of new arterial hypertension in a pregnant woman after 20 weeks gestation. There is no specific treatment, but is monitored closely to rapidly identify [[pre-eclampsia]] and its life-threatening complications (HELLP syndrome and [[eclampsia]]). Treatment options are limited, as many antihypertensives may negatively affect the fetus; methyldopa and labetalol are most commonly used for severe pregnancy hypertension. | ||
==Pre-Eclampsia | ==[[Pre-Eclampsia]]== | ||
'''Pre-eclampsia''' (US: '''preeclampsia''') is a [[medical condition]] where [[hypertension]] arises in pregnancy ([[pregnancy-induced hypertension]]) in association with significant protein in the urine. Its cause remains unclear, although the principal cause appears to be a substance or substances from the [[placenta]] causing [[endothelial dysfunction]] in the maternal blood vessels.<ref name=DrifeMagowan>Drife JO, Magowan (eds). ''Clinical Obstetrics and Gynaecology'', chapter 39, pp 367-370. ISBN 0-7020-1775-2.</ref> While [[blood pressure]] elevation is the most visible sign of the disease, it involves generalized damage to the maternal endothelium and kidneys and liver, with the release of vasopressive factors only secondary to the original damage. | |||
Pre-eclampsia may develop at varying times within pregnancy and its progress differs among patients; most cases are diagnosed pre-term. It has no known cure apart from ending the pregnancy (induction of labor or abortion). It may also occur up to six weeks post-partum. Of dangerous pregnancy complications, it is the most common; it may affect both the mother and the fetus.<ref name=DrifeMagowan/> | |||
For a more detailed discussion of pre-eclampsia, click [[Pre-eclampsia|here]]. | |||
==[[Eclampsia]]== | |||
'''Eclampsia''', an acute and life-threatening complication of [[pregnancy]], is characterized by the appearance of [[tonic-clonic seizure]]s in a patient who had developed [[preeclampsia]]; rarely does eclampsia occur without preceding preeclamptic symptoms. ''Hypertensive disorder of pregnancy'' and ''toxemia of pregnancy'' are terms used to encompass both preeclampsia and eclampsia. Seizures and coma that happen during pregnancy but are due to preexisting or organic brain disorders are not eclampsia. | |||
The term is derived from the Greek and refers to a flash, a term used by [[Hippocrates]] to designate a fever of sudden onset. <ref name=Chesley>{{cite book| author=Chesley LC| title=Hypertensive Disorders in Pregnancy, in Williams Obstetrics, 14th Edition| publisher=Appleton Century Crofts, New York (1971), page 700}}</ref> | |||
==Prevalence== | |||
Eclampsia is a leading cause of maternal and perinatal mortality. The prevalence of eclampsia is reported to be 0.56 per 1,000 births (US data from 1979-86) versus 26 per 1,000 births for pre-eclampsia.<ref>{{cite journal |journal= Am J Obstet Gynecol. 1990 Aug;163(2): 460-5. | title=Epidemiology of preeclampsia and eclampsia in the United States, 1979-1986. |author=Saftlas AF, Olson DR, Franks AL, Atrash HK, Pokras R. |pmid=2396132}}</ref> While mortality can be kept low when antenatal care and [[maternal-fetal medicine| maternal-fetal services]] are provided, mortality rates are substantial in challenging settings. Thus in a setting in India , [[maternal mortality]] and [[perinatal mortality]] were reported to be 32% and 39%, respectively, in 1993.<ref> {{cite journal |author= Swain S, Ojha KN, Prakash A, Bhatia BD.| title=Maternal and perinatal mortality due to eclampsia. |journal=Indian Pediatr. 1993 Jun;30(6):771-3}}</ref> | |||
Eclamptic convulsions may appear in the last trimester (rarely before), during [[childbirth|labour]], and in the first two days [[postpartum]]; it would be highly unusual to see eclampsia later than 48 hours after delivery. <ref>Chesley, ibid p.701</ref> | |||
Typically patients show signs of [[pregnancy-induced hypertension]] and [[proteinuria]] prior to the onset of the hallmark of eclampsia, the eclamptic convulsion. Other cerebral signs may precede the convulsion such as nausea, vomiting, headaches, and cortical blindness. In addition, with the advancement of the pathophysiological process, other organ symptoms may be present including abdominal pain, liver failure, signs of the [[HELLP syndrome]], [[pulmonary edema]], and [[oliguria]]. The fetus may have been already compromised by [[intrauterine growth retardation]], and with the toxemic changes during eclampsia may suffer [[fetal distress]]. Placental bleeding and [[placental abruption]] may occur. | |||
===The eclamptic seizure=== | |||
Chesley distinguishes these four stages of an eclamptic event: In the ''stage of invasion'' facial twitching can be observed around the mouth. In the ''stage of contraction'' tonic contractions render the body rigid; this stage may last about 15 to 20 seconds. The next stage is the ''stage of convulsion'' when involuntary and forceful muscular movements occur, the tongue may be bitten, foam appears at the mouth. The patient stops breathing and becomes [[cyanosis|cyanotic]]; this stage lasts about one minute. The final stage is a more or less prolonged ''[[coma]]''. When the patient awakens, she is unlikely to remember the event.<ref>Chesley, ibid. page 702</ref> In some rare cases there are no convulsions and the patient falls directly into a coma. Some patients when they awake from the coma may have temporary blindness. | |||
The treatment of eclampsia requires prompt intervention and aims to prevent further convulsions, control the elevated blood pressure and deliver the fetus. | |||
For a more detailed discussion of eclampsia, click [[eclampsia|here]]. | |||
==References== | ==References== | ||
Revision as of 15:55, 25 October 2011
|
Cardiac disease in pregnancy Microchapters |
|
Diagnosis |
|---|
|
Catheterization: |
|
Treatment |
|
Special Scenarios:
|
|
Cardiac disease in pregnancy and hypertension On the Web |
|
American Roentgen Ray Society Images of Cardiac disease in pregnancy and hypertension |
|
Directions to Hospitals Treating Cardiac disease in pregnancy |
|
Risk calculators and risk factors for Cardiac disease in pregnancy and hypertension |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Anjan K. Chakrabarti, M.D. [2] Stacie Zelman, M.D. [3]
Overview
Hypertension in pregnancy can be broadly classified as chronic hypertension, pregnancy-induced hypertension (or gestational hypertension), and pre-eclampsia/eclampsia. All of these conditions are the source of significant maternal morbidity and mortality.
Chronic Hypertension in Pregnancy
This condition is defined as hypertension (blood pressure ≥140 mm Hg systolic or ≥90 mm Hg diastolic) present before pregnancy or that is diagnosed before the 20th week of gestation. In general, antihypertensive medications are effective in treating this condition, in contrast to pre-eclampsia.[1]
Safe anti-hypertensive drugs that can be used during pregnancy include;
- Calcium channel blockers
- Lasix
- Beta-blockers
- Hydralazine
- Methyldopa
For a more broad discussion of chronic hypertension, click here.
Pregnancy-Induced Hypertension
Pregnancy-induced hypertension (PIH) (or gestational hypertension) is defined as the development of new arterial hypertension in a pregnant woman after 20 weeks gestation. There is no specific treatment, but is monitored closely to rapidly identify pre-eclampsia and its life-threatening complications (HELLP syndrome and eclampsia). Treatment options are limited, as many antihypertensives may negatively affect the fetus; methyldopa and labetalol are most commonly used for severe pregnancy hypertension.
Pre-Eclampsia
Pre-eclampsia (US: preeclampsia) is a medical condition where hypertension arises in pregnancy (pregnancy-induced hypertension) in association with significant protein in the urine. Its cause remains unclear, although the principal cause appears to be a substance or substances from the placenta causing endothelial dysfunction in the maternal blood vessels.[2] While blood pressure elevation is the most visible sign of the disease, it involves generalized damage to the maternal endothelium and kidneys and liver, with the release of vasopressive factors only secondary to the original damage.
Pre-eclampsia may develop at varying times within pregnancy and its progress differs among patients; most cases are diagnosed pre-term. It has no known cure apart from ending the pregnancy (induction of labor or abortion). It may also occur up to six weeks post-partum. Of dangerous pregnancy complications, it is the most common; it may affect both the mother and the fetus.[2]
For a more detailed discussion of pre-eclampsia, click here.
Eclampsia
Eclampsia, an acute and life-threatening complication of pregnancy, is characterized by the appearance of tonic-clonic seizures in a patient who had developed preeclampsia; rarely does eclampsia occur without preceding preeclamptic symptoms. Hypertensive disorder of pregnancy and toxemia of pregnancy are terms used to encompass both preeclampsia and eclampsia. Seizures and coma that happen during pregnancy but are due to preexisting or organic brain disorders are not eclampsia.
The term is derived from the Greek and refers to a flash, a term used by Hippocrates to designate a fever of sudden onset. [3]
Prevalence
Eclampsia is a leading cause of maternal and perinatal mortality. The prevalence of eclampsia is reported to be 0.56 per 1,000 births (US data from 1979-86) versus 26 per 1,000 births for pre-eclampsia.[4] While mortality can be kept low when antenatal care and maternal-fetal services are provided, mortality rates are substantial in challenging settings. Thus in a setting in India , maternal mortality and perinatal mortality were reported to be 32% and 39%, respectively, in 1993.[5]
Eclamptic convulsions may appear in the last trimester (rarely before), during labour, and in the first two days postpartum; it would be highly unusual to see eclampsia later than 48 hours after delivery. [6]
Typically patients show signs of pregnancy-induced hypertension and proteinuria prior to the onset of the hallmark of eclampsia, the eclamptic convulsion. Other cerebral signs may precede the convulsion such as nausea, vomiting, headaches, and cortical blindness. In addition, with the advancement of the pathophysiological process, other organ symptoms may be present including abdominal pain, liver failure, signs of the HELLP syndrome, pulmonary edema, and oliguria. The fetus may have been already compromised by intrauterine growth retardation, and with the toxemic changes during eclampsia may suffer fetal distress. Placental bleeding and placental abruption may occur.
The eclamptic seizure
Chesley distinguishes these four stages of an eclamptic event: In the stage of invasion facial twitching can be observed around the mouth. In the stage of contraction tonic contractions render the body rigid; this stage may last about 15 to 20 seconds. The next stage is the stage of convulsion when involuntary and forceful muscular movements occur, the tongue may be bitten, foam appears at the mouth. The patient stops breathing and becomes cyanotic; this stage lasts about one minute. The final stage is a more or less prolonged coma. When the patient awakens, she is unlikely to remember the event.[7] In some rare cases there are no convulsions and the patient falls directly into a coma. Some patients when they awake from the coma may have temporary blindness.
The treatment of eclampsia requires prompt intervention and aims to prevent further convulsions, control the elevated blood pressure and deliver the fetus.
For a more detailed discussion of eclampsia, click here.
References
- ↑ "Report of the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy". Am J Obstet Gynecol. 183 (1): S1–S22. 2000. PMID 10920346.
- ↑ 2.0 2.1 Drife JO, Magowan (eds). Clinical Obstetrics and Gynaecology, chapter 39, pp 367-370. ISBN 0-7020-1775-2.
- ↑ Chesley LC. Hypertensive Disorders in Pregnancy, in Williams Obstetrics, 14th Edition. Appleton Century Crofts, New York (1971), page 700.
- ↑ Saftlas AF, Olson DR, Franks AL, Atrash HK, Pokras R. "Epidemiology of preeclampsia and eclampsia in the United States, 1979-1986". Am J Obstet Gynecol. 1990 Aug;163(2): 460-5. PMID 2396132.
- ↑ Swain S, Ojha KN, Prakash A, Bhatia BD. "Maternal and perinatal mortality due to eclampsia". Indian Pediatr. 1993 Jun;30(6):771-3.
- ↑ Chesley, ibid p.701
- ↑ Chesley, ibid. page 702