The reasons for the development of hypertension in pregnant women. Complications from the fetus. Treatment of pregnant women with hypertension

Russian Society of Obstetricians, Gynecologists, Perinatology

named after academician V.I. Kulakov "of the Ministry of Health of the Russian Federation Federal State Budgetary Institution" State Research Center for Preventive Medicine "of the Ministry of Health of Russia

DIAGNOSTICS AND TREATMENT OF ARTERIAL HYPERTENSION IN PREGNANT WOMEN

Tkacheva Olga Nikolaevna	First Deputy Director for Scientific and Medical
	work of the Federal State Budgetary Institution "State Research
	center for preventive			medicine "Ministry of Health			Russia,
	professor, d.m.s.
Shifman Efim Munevich	Professor of the Department of Anesthesiology and Reanimatology
	RUDN, professor, doctor of medical sciences
Mishina Irina Evgenievna	professor, doctor of medical sciences, head of the department of hospital
		Ivanovsky		state		medical
	Institute named after A.S. Bubnova
Runikhina Nadezhda Konstantinovna	Head of the therapeutic department of the Federal State Budgetary Institution "Scientific
	center for obstetrics, gynecology and perinatology named after
	Academician V.I. Kulakov "of the Ministry of Health of Russia, MD.
Ushkalova Elena Andreevna	Leading Researcher, Therapeutic Department
	FSBI "Scientific Center for Obstetrics, Gynecology and
	Russia, professor, d.m.s.
Khodzhaeva Zulfiya Sagdulaevna	Chief Researcher of the 1st obstetric department
	pathology of pregnancy FSBI "Scientific Center
	obstetrics, gynecology and perinatology named after academician
	IN AND. Kulakov "of the Ministry of Health of Russia, MD.
Kirsanova Tatiana Valerievna	Senior Researcher, Therapeutic Department
	FSBI "Scientific Center for Obstetrics, Gynecology and
	perinatology named after academician V.I. Kulakov "Ministry of Health
	Russia, Ph.D.
Chukhareva Natalia Alexandrovna	Junior Researcher, Therapeutic Department
	FSBI "Scientific Center for Obstetrics, Gynecology and
	perinatology named after academician V.I. Kulakov "Ministry of Health
Sharashkina Natalia Viktorovna	Physician-therapist		therapeutic		branches
	"Scientific Center for Obstetrics, Gynecology and Perinatology
	named after academician V.I. Kulakov "of the Ministry of Health of Russia, Ph.D.
Bart Boris Yakovlevich	prof., head of the department of polyclinic therapy
	curative	faculty		Russian		national
	research			medical		university
	named after N.I. Pirogov
Bartosh Leonid Fedorovich	GBOU DPO "Penza Institute for Improvement
	doctors "Ministry of Health of Russia, Department of Therapy, General
	medical practice, endocrinology, MD, professor

1. Introduction

2. Definition and classification of hypertension during pregnancy

3. Diagnosis of hypertension during pregnancy

4. Management of pregnant women with hypertension

5. Drug therapy during pregnancy

6. Follow-up after childbirth.

7. Antihypertensive therapy during lactation

8. Remote forecast

Credibility level
	evidence
I: evidence obtained from					A. strong evidence that this recommendation will improve
randomized			controlled
good quality research					exceed the possible risk
II-1: a systematic review of cohort					B. good evidence that this recommendation will improve
research					important indicators and outcomes from the side of the patient's health, when
II-2:	separate			cohort
study			systematic		possible risk
review of case-control studies					WITH . good evidence that this recommendation can
II-3: a separate study					improve important health indicators and outcomes
control"
III: expert opinion based on					to introduce them to the rank of routine and ubiquitous.
clinical			descriptive		D. good evidence that this recommendation is not
research		or reports		committees	effective or that the benefits outweigh the risks
experts					I. not enough arguments to make a recommendation
					For or against because the performance data
					absent, poor quality or inconsistent, balance
					between benefit and risk cannot be determined, however,
					other factors can influence decision making.

LIST OF ABBREVIATIONS

AH - arterial hypertension; BP - blood pressure

AKC - associated clinical conditions AK - calcium antagonists ALT - alanine aminotransferase

AsAT - aspartate aminotransferase

β-AB - β-blockers

ARBs - angiotensin II receptor blockers

WHO - World Health Organization HD - essential hypertension DBP - diastolic blood pressure

DIC - disseminated intravascular coagulation ACE inhibitors - angiotensin-converting enzyme inhibitors LDH - lactate dehydrogenase drugs - MAU drug - microalbuminuria OAC - complete blood count OAM - general urine analysis

POM - damage to organs - targets PE - preeclampsia

SBP - systolic blood pressure ABP - 24-hour blood pressure monitoring CVD - cardiovascular diseases ultrasound - ultrasound ultrasound ultrasound - Doppler ultrasound heart rate - heart rate ECG - electrocardiography Echocardiography - echocardiography

HELLP syndrome - hemolysis elevated liver enzymes and low platelets syndrom

(hemolysis, increased liver enzyme activity and thrombocytopenia)

FDA - Food and Drug Administration

MgSO4 - Magnesium sulfate

1. Introduction

Arterial hypertension (AH) in pregnant women is one of the most common and, at the same time, dangerous conditions. In Russia, hypertension occurs in 5

30% of pregnant women. According to the WHO, in the structure of maternal mortality, the share of hypertensive syndrome is 12%; every year around the world more than 50 thousand women die during pregnancy due to complications associated with hypertension. Arterial hypertension increases the risk of detachment of a normally located placenta and massive bleeding, can cause the development of cerebrovascular accident in a woman, retinal detachment, eclampsia. Complications of hypertension are progressive placental insufficiency and fetal growth retardation syndrome, and in severe cases -

asphyxia and fetal death. The long-term prognosis of women with hypertension during pregnancy is characterized by an increased incidence of obesity, diabetes mellitus, coronary heart disease, and strokes. The children of these mothers also suffer from various metabolic, hormonal, cardiovascular diseases.

2. Definition and classification of arterial hypertension during pregnancy

Arterial hypertension is a condition characterized by increased

the level of blood pressure (BP).

The criterion for hypertension in pregnant women is systolic blood pressure levels> 140 mm

Hg and / or diastolic blood pressure> 90 mm Hg.

An increase in blood pressure must be confirmed by at least two measurements at an interval of at least four hours.

Previously, hypertension in pregnant women was also diagnosed with an increase in the SBP level by 30 mm Hg. Art. and / or DBP at 15 mm Hg. Art. compared to the original data. V

at present, this diagnostic criterion has been excluded from all international recommendations.

Classification of the degree of increase in blood pressure

There are two degrees of severity of hypertension, moderate and severe, which has

of fundamental importance for assessing the prognosis and choosing tactics for managing patients.

Hg and is associated with a high risk of stroke. To confirm

repeated measurement is made within 15 minutes.

Classification of hypertension during pregnancy

1. Chronic hypertension

2. Gestational hypertension

3. Preeclampsia / eclampsia

4. Preeclampsia / eclampsia associated with chronic hypertension

Chronic hypertension is hypertension diagnosed before pregnancy or before 20 weeks of gestation.

Chronic hypertension accounts for approximately 30% of all hypertensive conditions in pregnant women. The prevalence of chronic hypertension among young women is not high,

however, it increases significantly with increasing age of patients. Among pregnant women aged 18-29 years, chronic hypertension is observed in 0.6-2% of women, and at the age of 30-39 years - in 6-22.3%.

Chronic hypertension is hypertension (HD) or secondary

(symptomatic) hypertension. During pregnancy, in patients with chronic hypertension, it is not possible to adequately assess the degree of increase in blood pressure, because in the first and second trimesters, a physiological decrease in blood pressure is usually noted.

Gestational hypertension - increase in blood pressure, first recorded after 20

weeks of pregnancy and not accompanied by proteinuria. Gestational hypertension is transformed into PE in 50% of cases.

Preeclampsia is a pregnancy-specific syndrome that occurs after the 20th week of gestation, determined by the presence of hypertension and proteinuria (more than 300 mg of protein in daily urine). Severe PE is accompanied by multiple organ failure. Occurs in 3-14% of pregnant women. The presence of edema is not a diagnostic criterion for PE. With a physiologically ongoing pregnancy, the frequency of edema

reaches 60%.

Eclampsia is diagnosed when women with PE have seizures,

which cannot be explained by other reasons.

International coding of hypertensive conditions in pregnant women

classification of diseases of the 10th revision (ICD-10)

Chronic hypertension
	pregnancy, childbirth and the puerperium
Chronic hypertension (GB)	Preexisting essential hypertension
	Preexisting cardiovascular hypertension
	complicating pregnancy, childbirth and the postpartum period
	The existing		renal	hypertension
	complicating pregnancy, childbirth and the postpartum period
	Preexisting cardiovascular and renal
	hypertension complicating pregnancy, childbirth and
	postpartum period
Chronic hypertension	The existing		secondary	hypertension
(secondary hypertension)	complicating pregnancy, childbirth and the postpartum period
Chronic hypertension	Preexisting hypertension complicating
(unspecified)	pregnancy, childbirth and the puerperium, unspecified

PE on the background of chronic			The existing			hypertension
			associated proteinuria
			Pregnancy-induced edema and proteinuria
			hypertension
			Pregnancy-induced edema
			Pregnancy-induced proteinuria
			Pregnancy-induced edema with proteinuria
Gestational hypertension			Summoned	pregnancy		hypertension
			significant proteinuria
Preeclampsia (PE)			Summoned	pregnancy		hypertension
			significant proteinuria
PE is moderately pronounced			Moderate preeclampsia (nephropathy)
PE heavy			Severe preeclampsia
			Preeclampsia (nephropathy), unspecified
Eclampsia			Eclampsia
Eclampsia			Eclampsia during pregnancy
pregnancy
Eclampsia in labor			Eclampsia in labor
Eclampsia in the postpartum			Eclampsia in the postpartum period
Eclampsia	unspecified		Eclampsia, unspecified by timing
by timing
			Maternal hypertension, unspecified
The criterion for hypertension in pregnant women is systolic blood pressure levels> 140 mm Hg.
and / or diastolic blood pressure> 90 mm Hg.
Severe hypertension is diagnosed when SBP is ≥ 160 mm Hg. and / or DBP ≥ 110 mm

3. Diagnostics of the arterial hypertension during pregnancy

Blood pressure measurement should be carried out with a pregnant woman at rest after a 5-minute rest; during the previous hour, the woman should not perform heavy physical activity. Measurement of blood pressure is carried out in the position of a pregnant woman

"Sitting", in a comfortable position. The cuff is applied to the arm in such a way that the lower

its edge was 2 cm above the elbow bend, and the rubber part of the cuff covered

at least 80% of the shoulder circumference. Usually the cuff is 12-13 cm wide,

30-35 cm long, i.e. medium size. For patients with very large or very small shoulder circumferences, it is necessary to have a large and small cuff.

The column of mercury or the arrow of the tonometer before starting the measurement must be at the zero mark. Measurement of blood pressure is carried out twice, with an interval of at least a minute, on both hands.

The SBP level is determined by the I phase of Korotkov tones, DBP - by the V phase (complete disappearance of sound signals). Phase V cannot be determined in 15% of pregnant women. V

In these cases, the level of DBP is established according to the IV phase, i.e. at the moment of significant weakening of tones. The "gold standard" for measuring blood pressure in pregnant women is the auscultatory method; validated oscillometric tonometers can also be used.

After detecting hypertension in a pregnant woman, the patient should be examined with a view to

clarification of the origin of hypertensive syndrome, exclusion of symptomatic hypertension;

determining the severity of hypertension;

identifying concomitant organ disorders, including the state of organs

targets, placenta and fetus.

Examination plan for chronic hypertension:

Consultations: therapist (cardiologist), neurologist, ophthalmologist, endocrinologist.

Instrumental examinations: ECG, Echo-KG, ABPM, ultrasound of the kidneys + USDG of the vessels of the kidneys.

Laboratory tests: OAK, OAM, biochemical blood test (+ lipid spectrum), microalbuminuria (MAU).

If the diagnosis was not clarified at the stage of pregnancy planning, additional examinations are necessary to exclude the secondary nature of hypertension. The plan of special examinations to identify the secondary nature of hypertension in each patient is drawn up individually, depending on the alleged pathology

(kidney disease, coarctation of the aorta, thyrotoxicosis, acromegaly, Itsenko-Cushing's syndrome and disease, primary hyperaldosteronism, pheochromocytoma). Secondary hypertension occurs in about 5% of cases, of which renal hypertension is the most common, it is less than 3% (renoparenchymal hypertension accounts for 2/3, renovascular hypertension occupies 1/3). In this regard, the appointment of ultrasound of the kidneys and USDG is justified.

renal vessels to all pregnant women with hypertension. Primary hyperaldosteronism occurs in 0.3-

1% of cases, Itsenko-Cushing's syndrome - less than 1%, pheochromocytoma - less than 1%. Other forms of secondary hypertension are diagnosed even less frequently.

Examination plan for suspected PE:

Consultations: therapist (cardiologist), neurologist, ophthalmologist.

Instrumental studies: ECG, ABPM, ultrasound of renal vessels, transcranial Doppler ultrasonography of the vessels of the base of the brain and periorbital Doppler ultrasonography.

Laboratory tests: KLA + schizocytes, OAM, biochemical blood test

(+ albumin, AST, ALAT, LDH, uric acid), hemostasiogram + D-dimer, Reberg's test + daily proteinuria + MAU.

Typical changes in a number of laboratory parameters during the development of PE

Laboratory		Changes with the development of PE
indicators
Hemoglobin and	Enhancement	values	indicators		due to
hematocrit	hemoconcentration. It is characteristic of PE and is
	indicator of the severity of the process. With an unfavorable course
	values ​​can be reduced in the event that develops
Leukocytes	Neutrophilic leukocytosis
Platelets	Decrease, level less than 100 x 109 / l indicates
	development of severe PE
Peripheral smear	The presence of erythrocyte fragments (schizocytosis, spherocytosis)
	indicates the development of hemolysis in severe PE
Hemostasiogram	Signs of disseminated intravascular coagulation
Serum Creatinine /	Increase / decrease in the glomerular filtration rate, in
Rehberg test	combined with oliguria, indicates the presence of severe PE
Uric acid	Enhancement	associated		unfavorable
	perinatal outcomes, and is also a predictor of PE
	with gestational hypertension
AsAT, AlAT	An increase is indicative of severe PE.
	Increase (indicates the development of hemolysis)
Serum albumin	Decrease
Serum bilirubin	Increased due to hemolysis or liver damage
Microalbuminuria	Is a predictor of the development of proteinuria
Proteinuria	Hypertension during pregnancy, accompanied by proteinuria,
	should be considered PE until proven
	the opposite

Isolation of two degrees of severity of PE, moderate and severe, in principle for determining the tactics of managing pregnant women:

1. With moderate PE, hospitalization and careful monitoring of the condition of the pregnant woman is necessary, but at the same time, prolongation of pregnancy is possible.

2. In severe PE, it is necessary to address the issue of delivery immediately after stabilization of the mother's condition.

Criteria for the severity of PE

Index	Moderate
	≥ 140/90 mm Hg		> 160/110 mm Hg
Proteinuria	> 0.3 g, but< 5 г/сут		> 5 g / day
Creatinine			> 100 μmol / L
Albumen	norm / reduced		< 20 г/л
Oliguria	absent		<500 мл/сут
Liver dysfunction	absent		increasing ALAT, ASAT
Platelets	norm / reduced		<100х109 /л
	absent
Neurological symptoms	absent
Fetal growth retardation

PE on the background of chronic hypertension diagnosed in pregnant women with chronic hypertension in the following cases:

1) the appearance after 20 weeks of proteinuria for the first time (0.3 g of protein or more in daily urine) or a noticeable increase in previously existing proteinuria;

2) the progression of hypertension in those women whose blood pressure was easily controlled before the 20th week of pregnancy;

3) the appearance after 20 weeks of signs of multiple organ failure.

Diagnosis of hypertension during pregnancy is based on the office measurement of blood pressure in the
institution
The position of the patient when measuring blood pressure in the "sitting" position, the cuff should
be at heart level
The cuff of the blood pressure monitor must match the circumference of the upper arm
patients
The SBP level is determined by the I phase of Korotkov tones, DBP - by the V phase
ABPM can be used for suspected white coat hypertension
Laboratory tests should be done for women with suspected PE
to clarify the diagnosis
Proteinuria should be assessed for all pregnant women
The highest limit of the norm of daily protein loss during pregnancy is 0.3 g / l

4. Management of pregnant women with various forms of hypertension

The goal of treating pregnant women with hypertension of various origins is to prevent the development of complications in the mother and the fetus caused by high blood pressure levels during pregnancy and during childbirth. Pharmacotherapy, if possible, should be pathogenetic and provide organoprotection. Adequate antihypertensive therapy during pregnancy will also help to maximize the overall risk of CVD in the long term.

Blood pressure (BP) in the body forces blood to move through the vessels and supply organs and tissues with nutrients. The force of pressure on the vessels is measured in millimeters of mercury (mm Hg). Upper, or systolic, pressure is a condition in which the heart muscle is absolutely compressed for further pumping of blood through the vessels. The lower pressure, diastolic, is an indicator when the heart muscle is completely relaxed. Indicators of upper pressure from 90 to 120 mm Hg are recognized as normal. Art. AD is allowed up to 130 / 80-60. But during pregnancy, these norms sometimes deviate. Arterial hypertension in pregnant women, as well as diagnosed hypertension in pregnant women, occurs for several reasons at once.

During pregnancy, hormonal changes occur, with the growth of the fetus, one or more additional circles of blood circulation in the placenta are formed with multiple pregnancies. This is necessary to provide food for the unborn child. The load on the heart muscle increases sharply, as the heart works hard. During this period, the likelihood of arterial hypertension is high. If the difference between the normal working blood pressure does not exceed 10%, the health of the woman and the unborn child is not in danger. But indicators exceeding the norm above 15-20% indicate the occurrence of gestational hypertension, and in the case of persistent excess pressure, hypertension in a pregnant woman is suspected.

Hypertension during pregnancy occurs for the same reasons as everyone else, although there are specific factors that can attract the attention of the attending physician, namely:

1. Heredity. The doctor finds out if any of the relatives suffer from hypertension, the level of pressure before pregnancy.
2. The age of the woman. After 30-35 years, there is a greater chance that hypertension may develop during pregnancy.
3. The sequence of pregnancy. The doctor analyzes the features of the course of previous pregnancies in order to form an overall picture.
4. The interval between births. The optimal interval is considered to be from two years. If the body did not have time to rest from a previous pregnancy, the likelihood that a woman will develop gestational hypertension or hypertension increases many times over.
5. Multiple pregnancies. Hypertension in pregnant women with multiple pregnancy occurs almost always, but usually disappears immediately after childbirth. Exception: if a woman previously suffered from hypertension.

1. The presence of mental, neurogenic disorders, depression.
2. Physical activity, lifestyle, bad habits.
3. Toxicosis.

Hypertension in pregnant women is often provoked by concomitant diseases:

• diabetes mellitus;
• anemia;
• hypothyroidism;
• obesity;
• cardiovascular disease;
• renal failure.

Classifications of hypertension in pregnancy

Arterial hypertension during pregnancy is classified into the following types:

• Light: BP up to 150/90 mm Hg. Art. Swelling of the legs is observed, protein appears in the urine (up to 1 g).
• Average: BP up to 170/110 mm Hg. Art.
• Severe: BP is above 180/120 mm Hg. Art.

In moderate-severe forms of a pregnant patient, hospitalization or bed rest, drug treatment in order to preserve the fetus is indicated.

This form is also called late toxicosis. The most dangerous is the combination of preeclampsia with chronic hypertension. The exact cause of preeclampsia has not been identified. It is believed that this is a genetically determined pathology.

If the diagnosis is diagnosed before 34 weeks, the patient is prescribed corticosteroids to accelerate the laying of the lungs in the fetus, followed by premature delivery.

1. Gestosis is an excess of blood pressure in the second or third trimesters of pregnancy. It is a complication as a result of the persistence of high blood pressure during pregnancy, characterized by the appearance of edema, protein in the urine. In the future, renal failure, brain damage, seizures like epilepsy appear. Doctors call the main cause of preeclampsia a large weight gain in pregnant women. This is why doctors regularly weigh expectant mothers during appointments. The danger is that the vessels of the placenta during gestosis are damaged due to the accumulation of excess fluid and edema, and the fetus does not receive enough oxygen and nutrition, the condition develops into the following form.
2. Eclampsia. This form is extremely dangerous and is the leading cause of death among pregnant women. A woman "in position" has convulsions as in epilepsy, she loses consciousness.

Symptoms of hypertension in pregnant women

The symptoms of high blood pressure in pregnant women are in many ways similar to the general manifestations of arterial hypertension, these are:

• severe pain in the head, upper peritoneum, dizziness;
• visual impairment, fear of light, tinnitus;
• sudden nausea that turns into vomiting;
• increased heart rate - tachycardia;
• weight gain due to fluid retention;
• shortness of breath, weakness;
• nosebleeds;
• liver dysfunction, resulting in dark feces, yellowness of the skin;
• redness of the face due to flushing;
• a decrease in the level of platelets in the blood due to its poor coagulability. Seen from a blood test;
• mental disorders: the appearance of fear of death, anxiety.

Impaired vision or hearing with simultaneous headaches indicate the onset of cerebral edema and a preconvulsive state. Shortness of breath sometimes occurs not only due to increased pressure, but also due to the growth of the abdomen.

With a deep breath, the chest rises slightly, and with a strong exhalation, it narrows. In a pregnant woman, a growing belly does not allow the chest to contract normally, this causes an increase in blood pressure. The heart muscle has to work harder to deliver oxygen to all organs, including the placenta.

If at least one of the listed signs appears, you should immediately consult a doctor, such late complications in pregnant women as preeclampsia and eclampsia are difficult to correct. The risk of developing complications due to an increase in blood pressure is that the fetus, due to a violation of the blood supply in the placenta, experiences oxygen starvation, or hypoxia. As a result, intrauterine development is delayed or premature exfoliation of the placenta occurs, leading to the death of the fetus.

Diagnosis of pregnant women with high blood pressure

For a complete examination, pregnant women with arterial hypertension are prescribed:

• general examination with measurement of pulse, heart rate;
• Ultrasound of the heart, or echocardioscopy;
• identification of concomitant diseases;

• examination by an ophthalmologist of the fundus;
• examination by an endocrinologist;
• biochemical and general blood test;
• examination of urine for protein, the presence of blood in it, the level of glomerular filtration.

Treatment and contraindications

Drug treatment in pregnant women is reduced to the correction of antihypertensive therapy. Pregnant women should not take the usual drugs that lower blood pressure, so they are not prescribed ATP inhibitors: "Captopril", "Enalapril".

Also, during pregnancy, one should not take blockers of receptors for angiotensin II: "Valsartan", "Losartan", since their teratogenic property causes pathology, fetal deformities. For the same reason, due to the teratogenic effect, the drug "Diltiazem" is contraindicated.

"Reserpine" inhibits the nervous system, circulates in the blood for a long time and is also not used in treatment during pregnancy.

"Spironolactone" due to its antiandrogenic effect - a decrease in the level of male hormones - and the associated risk of developing anomalies of the genitourinary system in the fetus, is also not used in the treatment of pregnant and lactating patients.

Medical treatment of pregnant women in the event of an ambulance with blood pressure values ​​of 140/90 mm Hg. Art .:

1. "Nifedipine" (10 mg): under the tongue, one tablet at a time. It is recommended to take up to three pieces during the day. During the intake, it is required to be in a supine position due to possible dizziness after taking the medication.
2. "Magnesia", or magnesium sulfate, - intravenously, sometimes after a rapid infusion, a drip is placed in a vein. Anticonvulsant with hypotensive action. The dosage is prescribed only by the doctor.
3. "Nitroglycerin" - intravenously, with a dropper, slow infusion. It is rarely used if other medicines do not help. Strong vasodilator with antihypertensive effect.

Non-drug treatment of pregnant women is reduced to early registration: up to 12 weeks. By this time, the issue of maintaining or terminating pregnancy is usually resolved. With late calls, the interruption issue becomes problematic. Subsequently, the patient is measured the pressure on both hands at each visit to the antenatal clinic. With arterial hypertension of a pregnant woman, it is recommended to keep a daily diary, where you need to record blood pressure, pulse in the morning and in the evening. When taking the medicine, it is necessary to count the number of daily urinations.

If there is a need for planned hospitalization of the patient, it is carried out in three stages.

Stage I hospitalization: for up to 12 weeks. The patient is placed in the cardiology department and it is decided whether the pregnancy can be left without a threat to the mother. In the presence of grade I hypertension (blood pressure up to 140/90 mm Hg), there are no contraindications to pregnancy.

With hypertension II degree (up to 160/95 mm Hg. Art.), Pregnancy is left under the close supervision of a specialist. But this is possible if there are no concomitant diseases: diabetes, heart rhythm disturbances, kidney diseases.

If II degree of hypertension cannot be corrected or III degree develops, this is the reason for termination of pregnancy.

The second stage of hospitalization is carried out for a period of 28-32 weeks. The pregnant woman is admitted to the cardiology department to assess compensatory cardiac activity. At this time, the vascular bed is maximally loaded with fluid, with an unstable state of the cardiovascular system, the issue of premature birth is resolved.

The third stage of hospitalization takes place approximately two weeks before delivery. At this time, the question of the method of obstetrics is being decided, the risks for the mother and the baby are assessed.

Unscheduled hospitalizations are carried out at any time according to indications.

Preventive actions

Pregnancy and concomitant hypertension is a serious test for a woman's body. It is irresponsible to ignore the symptoms and hope that "everything will go away".

As with any disease, with arterial hypertension or hypertension, preventive measures must be followed:

1. Eat right, excluding fatty, salty, canned foods. Keep track of your own weight: the increase is no more than 15 kg for the entire pregnancy. It is useful to take at least one glass of cranberry juice, birch juice, ¼ glass of beet juice before meals to lower blood pressure every day.
2. Give up smoking and alcohol.
3. Anti-infective and anti-inflammatory therapies are especially important before pregnancy.
4. Moderate physical activity, walking outside.
5. Avoid stressful situations, overload, observe the regime of work and rest, get enough sleep. Psychological support from loved ones helps the pregnant woman.
6. Measure blood pressure regularly.

It is important to remember that self-medication of pregnant women with arterial hypertension, hypertension is categorically contraindicated. Improper use of drugs leads to the development of complications: eclampsia, preeclampsia, which is the leading cause of death in pregnant women.

Arterial hypertension(Hypertension) is the most common complication pregnancy and the cause of maternal and perinatal morbidity and mortality worldwide. During normal pregnancy systolic pressure changes slightly; however, diastolic in the early stages (13-20 weeks) decreases by an average of 10 mm Hg. Art. and in the third trimester it returns to the values ​​that were before pregnancy. The term "hypertension pregnancy & quot; covers a wide range of conditions in which arterial pressure varies widely . A study of the literature reveals that the classification hypertension at pregnant is associated with a number of problems, including, for example, the question of which Korotkoff tone (phase IV or V) should be used to measure diastolic pressure. All modern definitions and classifications, when applied for diagnosis and treatment, reveal certain disadvantages. However, the latest report of the High arterial pressure in pregnant women (Working Group on High Blood Pressure in Pregnancy), the classification system proposed by the American College of Obstetrics and Gynecology in 1972 is recommended. hypertensive disorders in pregnant women into three categories: chronic hypertension... gestational hypertension and preeclampsia(Table 1).

Chronic hypertension

Prevalence chronic hypertension in pregnant women it is 1-5%. This indicator rises with age, it is also higher in obese women. The diagnosis is based on anamnestic data (pressure level before pregnancy) or an increase in pressure up to 140/90 mm Hg. and more until the 20th week of pregnancy.

It is very difficult to diagnose chronic hypertension in pregnant women if the pressure before pregnancy is not known. In such cases, the diagnosis is usually based on the presence of hypertension before the 20th week of pregnancy. However, in some women, hypertension during these periods may be the first manifestation of preeclampsia. Moreover, due to the physiological decrease arterial pressure during the second trimester, many women with chronic hypertension have normal levels before the 20th week of pregnancy arterial pressure.

Hypertension is often classified as mild, moderate, severe, and very severe based on the level of systolic or diastolic pressure. Chronic hypertension during pregnancy can be considered mild or severe . Although there is no unambiguous definition of mild hypertension, it is generally accepted that a diastolic pressure level of 110 mm Hg and above (according to Korotkoff's V tone) indicates severe hypertension.

Newborns from women with chronic hypertension have a serious prognosis, mainly due to preeclampsia.

Neither exacerbation of hypertension nor edema are reliable indicators of developing preeclampsia. The best indicator of preeclampsia is the occurrence of proteinuria (at least 300 mg in 24 hours) in the absence of kidney disease.

Risk to mother and fetus

Pregnant women with chronic hypertension are at increased risk of developing preeclampsia and placental abruption, and their babies have increased perinatal morbidity and mortality. The likelihood of these complications is especially high in women who have been suffering from severe hypertension for a long time or who have cardiovascular and renal pathology. Besides, maternal and child morbidity and mortality increase if a pregnant woman has a diastolic pressure of 110 mm Hg or more during the first trimester. In contrast, outcomes in women with mild, uncomplicated chronic hypertension during pregnancy and in their children are similar to those in healthy pregnant women.

Treatment

Results from retrospective studies involving pregnant women indicate that antihypertensive therapy reduces the incidence of strokes and cardiovascular complications in pregnant women with diastolic blood pressure above 110 mmHg. There is general agreement that pregnant women with severe hypertension should receive drug therapy, but it is unclear whether such therapy is warranted for mild essential hypertension.

The benefits of long-term therapy aimed at reducing arterial pressure in non-pregnant, middle-aged and elderly people with diastolic pressure less than 110 mm Hg (mild hypertension). These benefits are most pronounced after 4-6 years of treatment in men over 50 years of age and with risk factors for cardiovascular disease or stroke. However, the majority of pregnant women with mild chronic hypertension are younger than 40 years of age and have an uncomplicated course of hypertension. That's why treatment of mild chronic hypertension in pregnant women is not justified .

It is necessary that antihypertensive therapy in pregnant women with mild hypertension reduced the risk of preeclampsia, placental abruption, premature birth and perinatal mortality. There is currently uncertainty about the advisability of treating pregnant women with mild chronic hypertension.

Antihypertensive drugs can have harmful effects on the mother, fetus, or newborn moreover, some effects appear after the neonatal period. Antihypertensive drugs can have both an indirect effect on the fetus, reducing uteroplacental blood flow, and direct, by affecting the umbilical or cardiovascular circulation of the fetus.

Most commonly used for the treatment of chronic hypertension in pregnant women methyldopa . Short-term (average 24 days) methyldopa therapy during the third trimester does not affect uteroplacental blood flow and fetal hemodynamics. In addition, after prolonged use of methyldopa in pregnant women, there was no immediate or delayed effect on the fetus and newborn. Atenolol ... against, has a pronounced effect on uteroplacental blood flow and fetal hemodynamics ... as well as the growth of the fetus. There are conflicting data on the side effects of other b-blockers when used during pregnancy. Moreover, there have been no studies on the delayed effects of these drugs in children.

A meta-analysis of 9 randomized trials comparing diuretic therapy versus no treatment in 7,000 normal blood pressure pregnant women found no difference in the prevalence of side effects between the two groups. The effect of diuretics on fetal growth has not been analyzed. Therapy diuretics of pregnant women with mild chronic hypertension leads to a decrease in plasma volume, which can be extremely unfavorable for fetal growth.

The use of angiotensin-converting enzyme inhibitors during pregnancy is contraindicated as these drugs cause fetal growth retardation, oligohydramnios, congenital malformations, neonatal renal failure, and neonatal death.

Women with chronic hypertension should be evaluated prior to conception. ... so that drugs that may be harmful to the fetus (angiotensin-converting enzyme inhibitors and atenolol) are replaced by other drugs such as methyldopa and labetalol. Many women with chronic hypertension receive diuretics; Opinions differ on whether such therapy should be continued during pregnancy.

When deciding whether to initiate drug therapy in women with chronic hypertension, it is necessary to take into account the severity of hypertension, the potential risk of target organ damage, and the presence or absence of preexisting pathology of the cardiovascular system. The first line is methyldopa ... If there are contraindications to its use (such as drug damage to the liver) and if it is ineffective or intolerant, it can be prescribed labetalol .

Gestational hypertension

Gestational hypertension is defined as the occurrence of high blood pressure without other symptoms of preeclampsia after the 20th week of pregnancy in women. , who previously had normal blood pressure. In some women, gestational hypertension may be an early manifestation of preeclampsia, while in others it may be a sign of unrecognized chronic hypertension. Generally, pregnancy outcome with gestational hypertension is good without drug therapy.

Preeclampsia

Traditionally under preeclampsia is understood as the appearance of hypertension, edema and proteinuria after the 20th week of pregnancy with previously normal blood pressure . The differences between preeclampsia and gestational hypertension are summarized in Table 1. In general, preeclampsia is defined as hypertension plus hyperuricemia or proteinuria ; it is classified as mild or severe depending on the degree of increase in blood pressure, the severity of proteinuria, or both. There is currently no agreement on the definition of mild hypertension, severe hypertension, or severe proteinuria. However, an emphasis on hypertension or proteinuria may minimize the clinical significance of other organ disorders. For example, some women with hemolysis syndrome, increased liver enzyme activity and low platelet count (HELLP syndrome) have life-threatening complications (pulmonary edema, acute renal failure, or liver rupture), but there is little or no hypertension with minimal proteinuria. Moreover, among women with preeclampsia who develop seizures (eclampsia), diastolic blood pressure is below 90 mmHg in 20% of cases. and proteinuria is absent. Some women with preeclampsia have signs and symptoms that are mistaken for other disorders (Table 2).

Etiology and pathogenesis

One of the earliest abnormalities found in women who later develop preeclampsia is lack of penetration of trophoblast cilia into the spiral arteries of the uterus ... This defect in placentation leads to impaired cardiovascular adaptation (increased plasma volume and decreased systemic vascular resistance) characteristic of normal pregnancy. In preeclampsia, both cardiac output and plasma volume are reduced, while systemic vascular resistance increases. These changes lead to a decrease in perfusion of the placenta, kidneys, liver and brain. Endothelial dysfunction, manifested by vasospasm, changes in vascular permeability and activation of the coagulation system, can explain many clinical manifestations in women with preeclampsia. Indeed, many of the pathological manifestations described in these women are associated with a decrease in perfusion rather than a damaging effect of hypertension.

Complications

The main dangers to women associated with preeclampsia are - convulsions, cerebral hemorrhage, placental abruption with disseminated intravascular coagulation, pulmonary edema, renal failure . For the fetus, the greatest danger is expressed by growth retardation, hypoxemia, acidosis. The frequency of these complications depends on the timing of pregnancy at the time of onset of preeclampsia, the presence or absence of associated complications, the severity of preeclampsia, and the quality of care. In women with mild preeclampsia, under close supervision, the risk of developing seizures is 0.2%, placental abruption is 1%, fetal death or neonatal death is less than 1%. The incidence of fetal growth retardation ranges from 5 to 13%, premature births - from 13 to 54%, depending on the timing of pregnancy at the time of onset and the presence or absence of proteinuria. In contrast, maternal and child morbidity and mortality are significant among women with eclampsia and those with preeclampsia before 34 weeks of gestation.

Treatment

Early diagnosis, close medical supervision and timely delivery are cardinal requirements in the treatment of preeclampsia; To the final cure is childbirth ... When establishing a diagnosis, further tactics are determined by the results of a study of the state of the mother and fetus. Based on these results, a decision is made on the need for hospitalization, expectant tactics or delivery. In this case, factors such as the severity of the pathological process, the condition of the mother and fetus, and the duration of pregnancy are taken into account. Regardless of the chosen treatment strategy, the main goal should be, firstly, mother's safety and secondly birth of a viable child ... which will not need long-term intensive care.

Light degree. Women with preeclampsia need close observation ... since a sudden deterioration of the condition is possible. Symptoms (such as headache, epigastric pain, and blurred vision) and proteinuria increase the risk of eclampsia and placental abruption ; for women with these symptoms, hospital observation is indicated. Outpatient observation is possible with strict adherence to recommendations, mild hypertension and normal fetal health. Observation calls for monitoring maternal blood pressure, weight, urinary protein excretion, platelet count, and fetal health . In addition, the woman should be informed about the symptoms of an increase in preeclampsia. With the progression of the disease, hospitalization is indicated.

It is generally accepted that women with mild preeclampsia who have reached the term of labor need to induce delivery to avoid complications for the mother and fetus. On the contrary, there is no consensus on the tactics for mild preeclampsia at an earlier stage of pregnancy. Most of the disagreement concerns the need for bed rest, prolonged hospitalization, antihypertensive therapy and prevention of seizures.

Women with mild preeclampsia are generally advised to adherence to bed rest at home, or in a hospital. It is believed to help reduce edema, improve fetal growth, prevent severe preeclampsia, and improve pregnancy outcomes.

Severe degree. Severe preeclampsia can progress rapidly, resulting in a sudden deterioration in both the mother and the fetus; at the same time, immediate delivery is shown, regardless of the gestational age. Urgent delivery is clearly indicated in case of threat of eclampsia, multiple organ dysfunction, abnormal fetal condition, or the development of severe preeclampsia after 34 weeks. However, early pregnancy can be continued under close supervision to improve neonatal survival and reduce neonatal morbidity. Three recent studies show that conservative treatment of women with more severe preeclampsia who have not reached the term of delivery leads to a decrease in neonatal morbidity and mortality . However, due to the fact that in these studies only 116 women received conservative therapy, and such therapy may pose a certain danger to the mother and fetus, conservative treatment should be carried out in perinatal centers and involve very careful monitoring of the mother and fetus.

The main goal of treating women with severe hypertension and preeclampsia is to prevent cerebral complications such as encephalopathy and stroke. The indication for drug treatment is the level of diastolic pressure 110 mm Hg. and higher. Some experts recommend starting treatment with a diastolic pressure of 105 mmHg. and even less, while others consider the mean arterial pressure value exceeding 125 mm Hg as an indication for starting treatment.

The goal of treatment is to keep the mean arterial pressure below 126 mm Hg. (but at the same time it should not be lower than 105 mm Hg) and diastolic pressure - not higher than 105 mm Hg. (but not lower than 90 mm Hg) . The first-line drug for women with severe perinatal hypertension is hydralazine ... administered intravenously at a dose of 5 mg. If necessary, the administration can be repeated every 20 minutes until a total dose of 20 mg is reached. If the indicated dose of hydralazine does not achieve the desired result, or if the mother develops adverse reactions such as tachycardia, headache, nausea, you can use labetalol (With 20 mg intravenously) if labetalol is ineffective, then administration is indicated nifedipine at a dose of 10 mg / day. Because hydralazine can worsen the fetus, some researchers recommend other drugs for the treatment of severe preeclampsia (dihydralazine, diazoxide) .

Women with preeclampsia have an increased risk of developing seizures... The degree of risk depends on the severity of preeclampsia and on the characteristics of the woman's body. For many years, experts in the United States have recommended the prophylactic use of magnesium sulfate during labor and the postpartum period for all women with preeclampsia. In contrast, experts in other countries considered lowering maternal blood pressure to be an adequate preventive measure. This controversy is not surprising because the prevalence of eclampsia in women with preeclampsia is very low and differs to a large extent in different groups of women.

Two randomized trials have investigated the effectiveness of magnesium sulfate prophylaxis in women with preeclampsia. In one of them, 112 women with severe preeclampsia were treated with an antihypertensive drug in combination with magnesium sulfate, and an antihypertensive drug as monotherapy was used in 116 patients. There was one case of eclampsia in the group of women receiving magnesium sulfate, and no case in the other group. Another study compared magnesium sulfate and phenytoin for the prevention of eclampsia in 2,137 women with mild preeclampsia. There were 10 cases of eclampsia (1%) in the phenytoin group and no cases in the group of women receiving magnesium sulfate.

In a recent large study, magnesium sulfate was more effective than phenytoin and diazepam in treating and preventing seizures in women with eclampsia. Therefore, all women with eclampsia should receive magnesium sulfate during labor and for at least 24 hours after birth.

Prophylaxis

For many years, salt restriction and diuretic drugs have been used to prevent preeclampsia. It is currently known that dietary sodium restriction during pregnancy reduces blood volume without reducing the incidence of hypertension ... The results of epidemiological studies indicate that normal calcium intake during pregnancy effectively reduces the risk of hypertension ... however, the effect of this factor on preeclampsia (defined as hypertension + proteinuria) was negligible.

Conclusion

When monitoring pregnant women with hypertension, it is very important to distinguish between chronic hypertension, gestational hypertension and preeclampsia. Antihypertensive therapy allows these women to fully carry the pregnancy. Careful medical supervision and timely delivery are key to the management of hypertension in pregnant women.

Arterial hypertension of pregnant women. Classification of hypertension in pregnant women.

Violations... associated with arterial hypertension, often develop during pregnancy and remain a serious problem for obstetricians. Despite improved prenatal management, these abnormalities can lead to both fetal and maternal death. The etiology of hypertension during pregnancy remains unknown.

Arterial hypertension... pregnancy-related, usually defined as a rise in diastolic blood pressure (BP) to 90 mmHg. Art. and more, systolic blood pressure up to 140 mm. rt. Art. and more, or as an increase in diastolic blood pressure by at least 15 mmHg. Art. and systolic by 30 mm Hg. Art. compared with the value of blood pressure before pregnancy. It is also required that elevated blood pressure be determined with at least two measurements taken after 6 hours or more. Despite the sufficient clarity and unambiguity of this definition, its use in clinical practice is accompanied by certain difficulties, primarily associated with the reliability of the method for measuring blood pressure.

By the amount of blood pressure the position of the patient is affected: the minimum values ​​are determined in the supine position, the maximum - in the standing position, intermediate - in the sitting position. The size of the measured blood pressure is also influenced by the width of the cuff of the apparatus: overestimated values ​​are determined when using a cuff of the usual width in obese patients. It should also be borne in mind that in the normal course of pregnancy, blood pressure usually decreases slightly in the second trimester, rising to the initial (pre-pregnancy) level shortly before the onset of labor. In the absence of information on the value of blood pressure before pregnancy, it is impossible to judge the dynamics of blood pressure during pregnancy, therefore, it is difficult to establish a diagnosis of hypertension associated with pregnancy.

Arterial hypertension... associated with pregnancy, observed after the first trimester in 5-10% of pregnancies, with multiple pregnancies - in 30% of cases. Maternal morbidity is directly related to the severity and duration of hypertension; maternal mortality is very low, even with complications such as placental abruption, liver rupture, or preeclampsia / eclampsia. Perinatal mortality progressively increases with each increase in mean blood pressure by 5 mm Hg. Art. and is usually associated with uteroplacental insufficiency and placental abruption.

Classification of hypertension in pregnant women.

Various classification of hypertensive conditions during pregnancy. Since hypertensive conditions during pregnancy are represented by a whole spectrum of diseases, this classification system should not be considered as a rigid scheme on the basis of which decisions on patient management are made.

Preeclampsia is defined as the development of arterial hypertension, accompanied by proteinuria and (or) edema associated with pregnancy and usually occurs in the second half. Preeclampsia develops more often in women who have had their previous pregnancy terminated before 20 weeks, and also when the end of the childbearing period is approaching. Preeclampsia is assessed as severe with systolic blood pressure equal to or greater than 160 mm Hg. Art. or diastolic, equal to or more than PO mm Hg. Art. severe proteinuria (usually> 1 g in 24 hours, or 2+ or more with a single urinalysis), oliguria, cerebral disorders (headache), visual disturbances (scotoma), pulmonary edema or cyanosis, pain in the epigastrium or the right upper quadrant of the abdomen (usually due to subcapsular hemorrhage in the liver or distension of the Glisson capsule), signs of liver dysfunction or thrombocytopenia.

This wide spectrum of violations illustrates the multisystemicity of lesions associated with preeclampsia.

Eclampsia characterized by the presence of seizures that are not associated with neurological disease, in the presence of the above criteria for preeclampsia. This most serious hypertensive condition occurs in 0.5-4.0% of pregnant women, in about 25% of cases - in the first 72 hours after childbirth.

Chronic arterial hypertension defined as hypertension that persists before the 20th week of pregnancy or persists 6 weeks after delivery. Chronic hypertension can be secondary (symptomatic hypertension) to a variety of diseases, although in most cases it is essential hypertension (hypertension). The greatest danger during pregnancy in women with chronic hypertension is the development of preeclampsia and eclampsia, which occurs in about 25% of cases. The distinction between preeclampsia and chronic hypertension is difficult, especially when an elevated blood pressure is detected with late treatment of the patient. In such cases, the condition should always be regarded as preeclampsia and treated accordingly. In general, preeclampsia or eclampsia associated with chronic hypertension is defined as the development of preeclampsia or eclampsia in a patient with previous chronic hypertension.

In the ACAG classification no mention is made of hypertension found late in pregnancy in the absence of other signs suggestive of preeclampsia. This condition is terminologically referred to as transient pregnancy hypertension, or gestational hypertension. Although isolated hypertension is determined exclusively in late pregnancy and within 1–2 days after delivery, vigilance is required to rule out other signs of preeclampsia.

- Return to the table of contents of the section “Obstetrics. "

Arterial hypertension in pregnant women

Ishmaeva Dilyara Adelevna, obstetrician-gynecologist of the highest category

Arterial hypertension (AH) is currently one of the most common forms of pathology in pregnant women. It occurs in 5-30% of pregnant women, and over the past decades, there has been a tendency to an increase in its prevalence. During pregnancy, arterial hypertension significantly affects its course and outcome, is the main cause of perinatal losses and maternal mortality. According to the World Health Organization (WHO), hypertensive complications rank 3-4 after thromboembolism, bleeding, extragenital diseases among the causes of death in pregnant women. During pregnancy, arterial hypertension can lead to the development of premature detachment of the normally located placenta, retinal detachment, eclampsia with impaired cerebral circulation, multiple organ failure, severe forms of DIC syndrome with the development of massive coagulopathic bleeding, thromboembolism, and premature birth. Complications of hypertension are also progressive placental insufficiency and intrauterine growth retardation (IUGR), low birth weight, and in severe cases - asphyxia and antenatal death of the fetus and newborn. Long-term prognosis in women with hypertension during pregnancy is characterized by an increased incidence of obesity, diabetes mellitus, and cardiovascular diseases. The children of these mothers are susceptible to the development of various metabolic and hormonal disorders, cardiovascular pathology.

Classification of arterial hypertension in pregnant women:

1. Chronic hypertension.

- hypertonic disease,

- symptomatic hypertension.

2. Gestational hypertension (diagnosis during pregnancy).

- rolling AG,

- chronic hypertension.

3. Preeclampsia.

- moderately severe, severe

- critical forms (eclampsia; edema, hemorrhage and retinal detachment; pulmonary edema; acute renal failure; premature detachment of the normally located placenta; acute fatty hepatosis; HELP syndrome).

4. Preeclampsia against the background of chronic hypertension.

Chronic arterial hypertension (CAH).

This is hypertension diagnosed before pregnancy or before the 20th week of gestation. The diagnostic criterion is SBP> 140 mm Hg. Art. and / or DBP> 90 mm Hg. Art. arising hypertension after 20 weeks of gestation, but not disappearing after childbirth. This is hypertension.

AH can be symptomatic (secondary hypertension) against the background of:

Lesions of the renal arteries.

Pheochromocytoma, primary aldosteronism.

Itsenko-Cushing's syndrome and disease.

Coartation of the aorta.

Taking medications.

Gestational arterial hypertension (GAG).

It is a pregnancy-specific syndrome that arose after the 20th week of pregnancy and is determined by the presence of arterial hypertension, proteinuria. Risk factors for preeclampsia are:

First pregnancy.

Pregnant age> 30 years.

Family history of preeclampsia, in previous pregnancies.

Extragenital diseases (hypertension, kidney disease, respiratory system, diabetes mellitus, obesity).

Multiple pregnancies.

Polyhydramnios.

Bubble drift.

In Russia, the term is adopted "Gestosis"- a number of pathological conditions characterized by multiple organ failure with impaired renal and liver function, vascular and nervous system, fetoplacental complex.

Clinical forms of gestosis:

Dropsy (edema).

Nephropathy (hypertension, proteinuria, edema, decreased urine output).

Preeclampsia (attachment to hypertension and proteinuria of neurological, visual disturbances, pain in the epigastric region, vomiting).

Eclampsia (the occurrence of seizures in women with preeclampsia).

The danger of a seizure of eclampsia is that during it hemorrhage may occur in the retina, or in the brain, or other vital organs. In this connection, loss of consciousness and death are possible.

For the purpose of effective prevention and early diagnosis of preeclampsia, the risk group for the development of preeclampsia should be determined by a doctor.

At each visit, the following studies are required:

Weighing.

Measurement of blood pressure on both hands.

General urine analysis.

Revealing hidden edema.

Monitoring the condition of the fetus.

Consultation of a therapist, ophthalmologist, neurologist.

Blood test.

Hemostasis, biochemical blood test.

Preeclampsia in the presence of CAH.

This is the most unfavorable clinical form of arterial hypertension in pregnant women for the prognosis of the mother and the fetus. It is diagnosed if, against the background of arterial hypertension, existing before pregnancy, or diagnosed before the 20th week, proteinuria appears, a sharp increase in blood pressure.

How does arterial hypertension affect the body of a pregnant woman and the fetus?

The effect of arterial hypertension on the course of pregnancy and the reverse effect (of pregnancy on the course of arterial hypertension) depends on its stage:

Stage I arterial hypertension has little effect on the course of pregnancy and childbirth, complications are almost not observed.

Stage II arterial hypertension. Pregnancy worsens the course of arterial hypertension. Typical is a temporary decrease in blood pressure for a period of 15-16 weeks, however, after 22-24 weeks, blood pressure rises continuously, and 50% of pregnant women develop preeclampsia.

Stage III arterial hypertension. Pregnancy significantly aggravates the course of arterial hypertension. This condition is an indication for termination of pregnancy. If a woman refuses to terminate the pregnancy, hospitalization is indicated in a specialized department.

In the presence of arterial hypertension, as a result of associated pathological changes, placental blood flow is disrupted, which increases the risk of perinatal morbidity and mortality.

Treatment of hypertensive conditions in pregnant women.

The goal of treatment is to prevent complications due to high blood pressure levels, to ensure the preservation of pregnancy, the normal development of the fetus and a successful birth.

1. Change in lifestyle. Compliance with the work and rest regimen, psychoemotional rest, prolonged stay in the fresh air, increased sleep up to 9-10 hours a day due to the daytime.

2. Rational nutrition. Protein diet, enriched with polyunsaturated fatty acids, vegetarian, lightly salted (with increased tissue hydrophilicity - limit table salt to 6-7 g per day, limit liquid), fasting days (1.5 kg of low-fat cottage cheese or apples, fractionally during the day , once every 7-10 days).

3. Vitamin therapy (vitamin E, P-carotene, folic acid).

4. Psychotherapy.

5. Acupuncture.

6. Physiotherapy exercises.

7. Balneotherapy (rubdowns, mineral baths, circular shower, whirlpool and foot baths).

8. UFO, warm air baths (t – 22 ° С), general sunbathing.

9. Physiotherapy. These are electrosleep, inductometry on the feet and lower legs, diathermy of the perineal region.

10. Adaptogens (tincture of eleutherococcus, valerian, motherwort).

11. Herbal medicine. Use medicinal herbs that have hypotensive properties and regulate the activity of the nephron: blood-red hawthorn, lingonberry, medicinal valerian, medicinal lemon balm, peppermint, field mint, beetroot, willow-herb, marsh beetroot.

12. Drug therapy. The threshold blood pressure for prescribing drugs during pregnancy is BP-140/90 mm Hg. Art. Used: magnesium sulfate, methyldopa, a-p-blockers, prolonged calcium channel blockers, vasodilators of direct action. Contraindicated: ACE inhibitors, rauwolfia drugs, diuretics. The ultimate goal of treating pregnant women with hypertension should be to lower blood pressure to 120-130 / 80 mm Hg. Art. at which the risk of complications is minimal.

In conclusion, I would like to say that the earlier the pregnant woman registers at the antenatal clinic, the earlier the risk factors for the development of arterial hypertension, preeclampsia are identified, or the treatment of existing hypertensive conditions is adjusted, the lower the risk of fetal disorders and obstetric pathology will be. Prevention and timely diagnosis of hypertension in pregnant women is the most important task of a doctor.

Arterial hypertension (AH) occurs in 4-8% of pregnant women. Hypertension includes a whole range of different clinical and pathogenetic conditions: hypertension, symptomatic hypertension (renal, endocrine), preeclampsia. According to the WHO, hypertensive syndrome is the second cause of maternal mortality after embolism, accounting for 20-30% of cases in the structure of maternal mortality. The indicators of perinatal mortality (30-100 0/00) and premature birth (10-12%) in pregnant women with chronic hypertension significantly exceed the corresponding indicators in pregnant women without hypertension. Hypertension increases the risk of detachment of a normally located placenta, may be the cause of cerebrovascular accident, retinal detachment, eclampsia, massive coagulopathic bleeding as a result of placental abruption.

Until recently, hypertension was thought to be relatively rare in people younger than 30 years of age. However, in recent years, during population surveys, increased blood pressure (BP) figures were found in 23.1% of persons aged 17-29 years. At the same time, the early appearance of hypertension is one of the factors that determine the unfavorable prognosis of the disease in the future. An important fact is that the frequency of detection of patients with hypertension by referral is significantly lower than in mass surveys of the population. This is due to the fact that a significant part of people, mainly with the early stages of the disease, feel well and do not visit a doctor. This, apparently, to a certain extent explains the fact that many women find out that they have high blood pressure only during pregnancy, which significantly complicates the diagnosis and treatment of such patients.

The physiological features of the cardiovascular system, depending on the developing pregnancy, sometimes create a situation where it is difficult to distinguish physiological from pathological changes.

Hemodynamic changes during physiological pregnancy represent an adaptation to the coexistence of mother and fetus, they are reversible and are due to the following reasons:

• strengthening of metabolic processes aimed at ensuring the normal functioning of the fetus;
• an increase in the volume of circulating blood (BCC);
• the appearance of an additional placental circulatory system;
• a gradual increase in the body weight of a pregnant woman;
• an increase in the size of the uterus and a limitation of the mobility of the diaphragm;
• increased intra-abdominal pressure;
• a change in the position of the heart in the chest;
• an increase in blood levels of estrogens, progesterone, prostaglandins E.

Physiological hypervolemia is one of the main mechanisms that maintain optimal microcirculation (oxygen transport) in the placenta and in such vital organs of the mother as the heart, brain and kidneys. In addition, hypervolemia allows some pregnant women to lose up to 30-35% of their blood volume during childbirth without the development of severe hypotension. The blood plasma volume in pregnant women increases from about the 10th week, then increases rapidly (until about the 34th week), after which the increase continues, but more slowly. The volume of erythrocytes increases at the same time, but to a lesser extent than the volume of plasma. Since the percentage increase in plasma volume exceeds the increase in erythrocyte volume, the so-called physiological anemia of pregnant women occurs, on the one hand, and hypervolemic dilution, leading to a decrease in blood viscosity, on the other.

By the time of delivery, blood viscosity reaches normal levels.

Systemic blood pressure in healthy women changes insignificantly. With a normal pregnancy, systolic blood pressure (SBP) and diastolic blood pressure (DBP), as a rule, decrease in the second trimester by 5-15 mm Hg. Art. The reasons for these changes are the formation of placental circulation during these periods of pregnancy and the vasodilating effect of a number of hormones, including progesterone and prostaglandins E, which cause a drop in total peripheral vascular resistance (OPSR).

Physiological tachycardia is observed during pregnancy. The heart rate (HR) reaches its maximum in the third trimester of pregnancy, when it is 15-20 beats / min higher than the HR in a non-pregnant woman. Thus, the normal heart rate in late pregnancy is 80-95 beats / min, and it is the same in both sleeping and waking women.

It is currently known that the cardiac output (MOC) increases by about 1-1.5 liters per minute, mainly during the first 10 weeks of pregnancy, and by the end of the 20th week reaches an average of 6-7 liters per minute. By the end of pregnancy, MOS begins to decline.

With a physiologically ongoing pregnancy, there is a significant decrease in OPSS, which is associated with the formation of the uterine circulation with low resistance, as well as with the vasodilating effect of estrogens and progesterone. A decrease in OPSS, as well as a decrease in blood viscosity, facilitates blood circulation and reduces the afterload on the heart.

Thus, the individual level of blood pressure in pregnant women is determined by the interaction of the main factors:

• a decrease in OPSS and blood viscosity, aimed at reducing blood pressure;
• an increase in the BCC and MOS, aimed at increasing blood pressure.

In the event of an imbalance between these groups of factors, blood pressure in pregnant women ceases to be stably normal.

Classification of hypertension

AH in pregnant women is a heterogeneous concept that combines various clinical and pathogenetic forms of hypertensive conditions in pregnant women.

Currently, the classification is a subject of discussion, since there are no uniform criteria and classification signs of hypertension during pregnancy, there is no single terminological base (for example, the term gestosis is used to denote the same process in Russia and in many European countries, in the USA and Great Britain - preeclampsia, in Japan - toxemia).

More than 100 classifications of hypertensive conditions in pregnancy have been proposed. In particular, by the International Classification of Diseases of the 10th revision (ICD-10), all such manifestations related to pregnancy are combined in the 2nd obstetric unit. In Russia, all diseases are encrypted exactly in accordance with this classification, although due to different terminology, encryption in accordance with ICD-10 causes controversy among specialists.

Working Group on High Blood Pressure in Pregnancy in 2000 developed a more concise classification of hypertensive conditions during pregnancy, which includes the following forms:

• chronic hypertension;
• preeclampsia - eclampsia;
• preeclampsia superimposed on chronic hypertension;
• gestational hypertension: a) transient hypertension of pregnant women (there is no gestosis at the time of childbirth and the pressure returns to normal by the 12th week after childbirth (retrospective diagnosis)); b) chronic hypertension (pressure rise after childbirth persists (retrospective diagnosis)).

Chronic hypertension refers to hypertension that was present before pregnancy or diagnosed before the 20th week of gestation. Hypertension is defined as a condition with SBP equal to or greater than 140 mm Hg. Art. and DBP - 90 mm Hg. Art. Hypertension that is diagnosed for the first time during pregnancy but does not disappear after childbirth is also classified as chronic.

Pregnancy-specific preeclampsia syndrome usually occurs after the 20th week of gestation. It is determined by the increased level of blood pressure (gestational rise in blood pressure), accompanied by proteinuria. Gestational increase in blood pressure is determined by SBP above 140 mm Hg. Art. and DBP above 90 mm Hg. Art. in women who had normal blood pressure before the 20th week. In this case, proteinuria is considered the concentration of protein in the urine of 0.3 g per day and higher when analyzing a daily urine sample. The test strip method can be used to diagnose proteinuria. If used, it is necessary to obtain two urine samples with a difference of 4 hours or more. For analysis, the average portion of urine or urine obtained through the catheter is used. A sample is considered positive if the amount of albumin in both samples reaches 1 g / L.

Earlier SBP rise by 30 and DBP by 15 mm Hg. Art. it was recommended to be considered a diagnostic criterion, even if the absolute values ​​of blood pressure are below 140/90 mm Hg. Art. Some authors do not consider this to be a sufficient criterion, since the available data show that the number of adverse outcomes does not increase in women in this group. Nevertheless, most experts urge to pay special attention to women in this group, who have an increase in SBP by 30 and DBP by 15 mm Hg. Art., especially in the presence of concomitant proteinuria and hyperuricemia.

Diagnostics

The most common mistakes in measuring blood pressure include: a single measurement of blood pressure without prior rest, using a cuff of the wrong size ("cuff" hyper- or hypotension) and rounding of numbers. Measurement should be done on both hands. The SBP value is determined by the first of two consecutive auscultatory tones. In the presence of an auscultatory dip, an underestimation of the BP figures may occur. The DBP value is determined by the V phase of Korotkoff tones. Measurement of blood pressure should be carried out with an accuracy of 2 mm Hg. Art., which is achieved by slowly releasing air from the tonometer cuff. At different values, the true blood pressure is considered greater. Measurements in pregnant women are preferable to take in a sitting position. In the supine position, blood pressure values ​​may be distorted due to compression of the inferior vena cava.

Single increase in blood pressure ≥ 140/90 mm Hg. Art. registered in about 40-50% of women. Obviously, a random single measurement of blood pressure for the diagnosis of hypertension in pregnant women is clearly not enough. In addition, the phenomenon of the so-called "white coat hypertension" is widely known, that is, high blood pressure when measured in a medical environment (office blood pressure) in comparison with an outpatient (home) measurement. Approximately 30% of pregnant women with hypertension registered at a doctor's appointment during 24-hour blood pressure monitoring (ABPM) had a normal mean daily blood pressure. Until now, the issue of the prognostic significance of the phenomenon of "white coat hypertension" has not been finally resolved. Currently, most researchers believe that it reflects an increased reactivity of the vascular wall, which, in turn, potentially increases the risk of cardiovascular disease. The role of ABPM in pregnant women is also not completely defined. In addition to diagnosing "white coat hypertension", assessing the effectiveness of therapy with established hypertension, this method can be used to predict the development of preeclampsia. Blood pressure usually decreases at night in patients with mild preeclampsia and chronic hypertension, but with severe preeclampsia, the circadian rhythm of blood pressure can be perverted, with a peak in blood pressure at 2 am.

However, given the complexity of the technique, the high cost of equipment, as well as the existence of other alternative methods for predicting preeclampsia, it can be assumed that ABPM is not included in the group of mandatory (screening) methods for examining pregnant women with high blood pressure. At the same time, it can be successfully applied according to individual indications.

Antihypertensive therapy for hypertension of pregnant women

Long-term administration of antihypertensive drugs to pregnant women with chronic hypertension is a matter of controversy. A decrease in blood pressure can impair uteroplacental blood flow and jeopardize fetal development. Over the past more than 30 years, seven international studies have been carried out, in which groups of women with mild chronic hypertension of pregnant women were compared using different management regimens (with the appointment of antihypertensive therapy and without pharmacological correction of hypertension). Treatment did not reduce the incidence of accumulated preeclampsia, preterm birth, placental abruption, or perinatal mortality compared to the non-treated groups.

Several centers in the United States are currently keeping women with chronic hypertension who have stopped taking antihypertensive drugs under close supervision. In women with hypertension that has developed over several years, with damage to target organs, taking large doses of antihypertensive drugs, therapy should be continued. Reports on the experience of observing patients with severe chronic hypertension without adequate antihypertensive therapy in the first trimester describe fetal loss in 50% of cases and significant maternal mortality.

Experts Working Group on High Blood Pressure in Pregnancy, 2000, the criteria for prescribing treatment are: SBP - from 150 to 160 mm Hg. Art., DBP - from 100 to 110 mm Hg. Art. or the presence of target organ damage such as left ventricular hypertrophy or renal failure. There are other provisions on the criteria for the initiation of antihypertensive therapy: when blood pressure is more than 170/110 mm Hg. Art. (with a higher blood pressure, the risk of placental abruption increases, regardless of the genesis of hypertension). There is an opinion that the treatment of hypertension at lower values ​​of the initial blood pressure "removes" such a significant marker of preeclampsia as increased blood pressure. At the same time, normal hypertension figures give a picture of false well-being. The European guidelines for the diagnosis and treatment of pregnant women with hypertension suggest the following management tactics for pregnant women with various types of hypertension.

• Pre-pregnancy hypertension without target organ damage - non-drug therapy with blood pressure 140-149 / 90-95 mm Hg. Art.
• Gestational hypertension, developed after 28 weeks of gestation - drug therapy with blood pressure 150/95 mm Hg. Art.
• Pre-pregnancy hypertension with target organ damage, pre-pregnancy hypertension with superimposed preeclampsia, preeclampsia, gestational hypertension that developed before the 28th week of pregnancy - drug therapy with blood pressure 140/90 mm Hg. Art.

Basic principles of drug therapy for pregnant women: proven efficacy and proven safety.

In Russia, there is no classification of drugs according to the safety criteria for the fetus. It is possible to use the criteria of the American Food and Drug Administration classification of drugs and food products (FDA-2002).

FDA (2002) Fetal Safety Classification Criteria for Medicinal Products:

A - studies in pregnant women did not reveal a risk to the fetus;

B - in animals, a risk to the fetus was found, but in humans it was not identified, or there was no risk in the experiment, but there was not enough research in humans;

C - There are side effects in animals, but there is not enough research in humans. The expected therapeutic effect of the drug may justify its appointment, despite the potential risk to the fetus;

D - in humans, the risk to the fetus has been proven, but the expected benefit from its use for the expectant mother may outweigh the potential risk to the fetus;

X is a drug that is dangerous to the fetus, and the negative effects of this drug on the fetus outweigh the potential benefits for the expectant mother.

Despite the fact that the range of drugs used in the treatment of hypertension in pregnant women is quite wide (methyldopa, beta-blockers, alpha-blockers, calcium antagonists, myotropic antispasmodics, diuretics, clonidine), the choice of drug therapy for a pregnant woman is a very responsible and difficult a case that requires strict consideration of all the pros and cons of this treatment.

Methyldopa

This drug is classified as Class B by the FDA. It is preferred as a first line by many clinicians, based on reports on the stability of uteroplacental blood flow and fetal hemodynamics, as well as on the basis of 7.5 years of follow-up with a limited number of children who do not have any delayed adverse developmental effects after prescribing methyldopa during pregnancy their mothers.

Benefits of methyldopa:

• does not impair uteroplacental blood flow and fetal hemodynamics;
• does not give delayed adverse developmental effects in children after administration during pregnancy to their mothers;
• reduces perinatal mortality;
• safe for mother and fetus.

Disadvantages of methyldopa:

• not recommended for use at 16-20 weeks (possibly affecting the dopamine content in the nervous system of the fetus);
• intolerance: 22% have depression, sedation, orthostatic hypotension.

Adequate and strictly controlled studies on other groups of antihypertensive drugs during pregnancy have not been conducted. Even when the results of studies are pooled in a meta-analysis, there is no clear evidence of the efficacy and safety of antihypertensive drugs in pregnancy.

β-blockers

Most of the published material on antihypertensive therapy in pregnant women comes from studies of the effects of adrenergic blockers, including β-blockers and the α-β-blocker labetalol. It is believed that beta-blockers given early in pregnancy, in particular atenolol, may cause fetal growth retardation. However, none of these drugs produced serious side effects; although in order to assert this with complete certainty, there is not enough long-term follow-up observation.

The advantage of β-blockers is the gradual onset of hypotensive action, characterized by a decrease in the incidence of proteinuria, no effect on the BCC, absence of postural hypotension, and a decrease in the incidence of respiratory distress syndrome in a newborn.

The disadvantages of β-blockers are a decrease in the weight of the newborn and the placenta due to increased vascular resistance when administered in early pregnancy.

According to the FDA classification, atenolol, metoprolol, timolol oxprenolol, propranolol, labetolol are class C, pindolol, acebutolol are class B.

Dadelszen in 2000 conducted a "fresh" meta-analysis of clinical trials on β-blockers and made very interesting conclusions. The delay in fetal development is not due to the effect of β-blockers, but to a decrease in blood pressure as a result of antihypertensive therapy with any drug. All antihypertensive drugs equally reduced the risk of developing severe hypertension by 2 times compared with placebo. When comparing various antihypertensive drugs with each other, no advantages were found regarding the effect on endpoints (development of severe hypertension, maternal and perinatal mortality).

α-blockers are used in the treatment of hypertension in pregnant women, but adequate and strictly controlled studies in humans have not been conducted. With the limited uncontrolled use of prazosin and a β-blocker in 44 pregnant women, no adverse effects were identified. The use of prazosin in the third trimester in 8 women with hypertension did not reveal clinical complications after 6-30 months, the children developed normally.

The advantages of this group of drugs are as follows:

• effective lowering of blood pressure (used in combination with β-blockers);
• do not affect the BCC;
• no adverse effects (according to the results of clinical studies in a small number of women).

Disadvantages:

• a sharp decrease in blood pressure;
• possible orthostatic reactions;
• lack of adequate and strictly controlled studies in humans.

In accordance with the FDA classification, prazosin, terazosin belong to class C, doxazosin - to class B. In our country, according to the instructions of the Pharmaceutical Committee of the Russian Federation, α-blockers are not used in hypertension in pregnant women.

Calcium antagonists. The experience of using calcium antagonists is limited by their appointment mainly in the third trimester of pregnancy. However, a multicenter prospective cohort study on the use of these drugs in the first trimester of pregnancy did not reveal teratogenicity. A recent multicenter randomized trial with slow-release nifedipine in the second trimester showed neither positive nor negative effects of the drug when compared with an untreated control group.

Benefits of calcium antagonists:

• the weight of the fetus in women taking nifedipine is higher than in women taking hydralazine;
• early use reduces the incidence of severe preeclampsia and other complications in the mother and fetus (however, in a number of studies using nifedipine in the second trimester, neither positive nor negative effects of the drug were found when compared with the control group that did not receive treatment);
• absence (according to the results of clinical studies) of embryotoxicity in humans;
• antiplatelet effect;
• when used in the first trimester of pregnancy, the absence of teratogenic effects (not identified in studies).

Disadvantages of calcium antagonists:

• embryotoxicity of calcium antagonists in animals;
• a rapid decrease in blood pressure can lead to a deterioration in uteroplacental blood flow (therefore, nifedipine is better taken orally than sublingually to relieve hypertensive crisis in pregnant women);
• side effects: swelling of the legs, nausea, heaviness in the epigastrium, allergic reactions.

According to the FDA classification, nifedipine, amlodipine, felodipine, nifedipine SR, isradipine, diltiazem belong to class C.

Diuretics(hypothiazide 25-100 mg / day). Opinions about the use of diuretics in pregnancy are controversial. The medical concern is mostly understandable. It is known that gestosis is associated with a decrease in plasma volume and the prognosis for the fetus is worse in women with chronic hypertension, who did not have an increase in BCC. Dehydration can impair uteroplacental circulation.

Against the background of treatment, electrolyte disturbances may develop, an increase in the level of uric acid (which means that this indicator cannot be used to determine the severity of gestosis). In women taking diuretics, from the beginning of pregnancy, there is no increase in BCC to normal values. For this reason, due to theoretical concerns, diuretics are usually not prescribed in the first place. A meta-analysis of nine randomized trials involving more than 7,000 diuretic-treated subjects found a trend towards a decrease in edema and / or hypertension with a confirmed no increase in adverse fetal outcomes. Moreover, if their use is justified, they manifest themselves as safe and effective agents that can significantly potentiate the action of other antihypertensive drugs, and are not contraindicated in pregnancy, except in cases of decreased uteroplacental blood flow (gestosis and intrauterine growth retardation). A number of experts believe that pregnancy is not a contraindication for taking diuretics in women with essential hypertension prior to conception or manifest before mid-pregnancy. However, there are insufficient data on the use of diuretics for lowering blood pressure in pregnant women with hypertension.

In accordance with the FDA classification, hypothiazide belongs to class B. However, the instructions of the pharmaceutical committee of the Russian Federation state that hypothiazide is contraindicated in the first trimester of pregnancy, in the second and third trimesters it is prescribed for strict indications.

Clonidine- the central α 2 -adrenomimetic has limitations for use during pregnancy, and when taken in the postpartum period, you should refrain from breastfeeding. The drug has no advantages over β-blockers. Sleep disorders have been identified in children whose mothers received clonidine during pregnancy. When used in early pregnancy, embryotoxicity has been identified.

Myotropic antispasmodics not currently used for routine therapy. They are prescribed only in emergency situations - with a hypertensive crisis. Hydralazine (apressin) with prolonged use can cause: headache, tachycardia, fluid retention, lupus-like syndrome. Diazoxide (hyperstat) with long-term treatment can cause sodium and water retention in the mother, hypoxia, hyperglycemia, hyperbilirubinemia, thrombocytopenia in the fetus. Sodium nitroprusside can cause cyanide intoxication with many hours of use.

Angiotensin-converting enzyme inhibitors(ACE) are contraindicated in pregnancy due to the high risk of intrauterine growth retardation, the development of bone dysplasias with impaired ossification of the cranial vault, shortening of the limbs, oligohydramnios (oligohydramnios), neonatal renal failure (renal dysgenesis, acute renal failure in the fetus or newborn) fetus.

Although no data have been accumulated regarding the use of angiotensin II receptor antagonists, their adverse effects are likely to be similar to those of ACE inhibitors, so prescription of these drugs should be avoided.

Treatment of acute severe hypertension in pregnant women

Some experts raise DBP to 105 mm Hg. Art. or higher is considered as an indication for the initiation of antihypertensive therapy, others consider it possible to refrain from antihypertensive therapy up to 110 mm Hg. Art. ... There is evidence that if the initial diastolic blood pressure did not exceed 75 mm Hg. Art., treatment should be started already when it rises to 100 mm Hg. Art. ...

The range of drugs used in the treatment of acute severe hypertension in pregnant women includes hydralazine (starting with 5 mg IV or 10 mg IM). If the effectiveness is insufficient, repeat after 20 minutes (from 5 to 10 mg, depending on the reaction; when the desired blood pressure is reached, repeat as needed (usually after 3 hours); if there is no effect from the total dose of 20 mg intravenously or 30 mg intramuscularly, use another agent ); labetalol (start with a dose of 20 mg intravenously; if the effect is insufficient, prescribe 40 mg 10 minutes later and 80 mg every 10 minutes 2 more times, the maximum dose is 220 mg; if the desired result is not achieved, prescribe another drug; do not use in women with asthma and heart failure); nifedipine (start with 10 mg orally and repeat after 30 minutes if necessary); sodium nitroprusside (rarely used when there is no effect from the above drugs and / or there are signs of hypertensive encephalopathy; start at 0.25 mg / kg / min to a maximum of 5 mg / kg / min; the effect of fetal cyanide poisoning can occur with therapy lasting more 4 hours).

Sudden and severe hypotension can develop with any of these drugs, especially short-acting nifedipine. The ultimate goal of lowering blood pressure in emergency situations should be its gradual normalization.

In the treatment of acute hypertension, the intravenous route of administration is safer than the oral or intramuscular route, since it is easier to prevent accidental hypotension by stopping the intravenous infusion than to stop the intestinal or intramuscular absorption of drugs.

Of the above drugs for the relief of hypertensive crisis in pregnant women, only nifedipine is currently registered with the Pharmaceutical Committee of the Russian Federation. However, in the instructions for this drug, pregnancy is indicated as a contraindication to its use.

Thus, the problem of arterial hypertension in pregnant women is still far from being resolved and requires the combined efforts of obstetricians, clinical pharmacologists and cardiologists.

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A. L. Vertkin,
O. N. Tkacheva, Doctor of Medical Sciences, Professor
L. E. Murashko, Doctor of Medical Sciences, Professor
I. V. Tumbaev
I. E. Mishina
MGMSU, TsAGiP, IvGMA, Moscow, Ivanovo

Changes in the body of a pregnant woman normally lead to a decrease in blood pressure. Under the influence of placental estrogens and progesterones, the vessels lose their sensitivity to the hormone angiotensin-II. They are in an expanded state, their resistance to blood flow decreases. This is necessary for the normal growth of blood vessels in the placenta and to ensure the nutrition of the fetus.

Therefore, in the first trimester, the pressure decreases from the initial one by 5-15 mm Hg. Art., falls a little more in the second. And in the third, there is a return to the physiological norm. But in some women, conception occurs against a background of high blood pressure or hypertension occurs already during pregnancy. This condition is dangerous for the mother and the fetus.

When can we talk about hypertension?

In pregnant women, arterial hypertension is diagnosed in 4-8% of all pregnancies. Despite such a small percentage of the disease, it ranks second among the causes of maternal mortality. Therefore, the disease must be detected and treated in a timely manner.

If the pressure above the norm was determined with a single measurement, then this still does not mean anything. For the diagnosis, several conditions must be met:

1. Increase in blood pressure to 140/90 mm Hg. Art. and higher.
2. The rise in indicators in comparison with the period before pregnancy: systolic by 25 mm Hg. Art., diastolic - 15 mm Hg. Art.
3. Changes are determined by two consecutive measurements, between which at least 4 hours have elapsed.
4. A one-time increase in diastolic pressure above 110 mm Hg. Art.

Hypertension of pregnant women proceeds in stages similar to the usual hypertension:

• Stage 1 - pressure from 140/90 to 159/99 mm Hg. Art .;
• Stage 2 - BP from 160/100 to 179/109 mm Hg. Art .;
• Stage 3 - BP from 180/110 and more.

According to the classification, pathology can be of several types. Depending on the time of appearance:

• Hypertension that existed before pregnancy - the woman had a diagnosis of hypertension or the first signs appeared before 20 weeks of gestation, symptoms of this form persist for more than 42 days after childbirth.
• Gestational hypertension - initially normal blood pressure after 20 weeks rises to significant levels that exceed the norm.
• Preeclampsia is a combination of high blood pressure and protein in the urine.
• Existing hypertension in combination with proteinuria and gestational hypertension - the pregnant woman was diagnosed, but after 20 weeks the symptoms begin to increase, protein appears in the urine.
• Unclassified hypertension due to lack of information.

The course of the disease is phased. At the initial stage, there is no damage to target organs. With the progression of the condition, pathological changes in the kidneys are observed, up to renal failure. In the heart, signs of ischemia are growing, angina pectoris and heart failure are formed. It is also possible to damage the vessels of the brain, retina, the development of atherosclerosis of the carotid arteries.

Why is the pressure rising?

It is generally accepted that initially any hypertension has neurotic reasons. This is a deep neurosis that leads to disruption of the regulation of the work of blood vessels. The development of pathology is aggravated by the past diseases of the vessels, brain, kidneys. The situation is aggravated by excess weight, excessive consumption of table salt, smoking and alcohol.

The development mechanism is associated with a physiological increase in the volume of circulating blood. If at the same time there is a lack of placental 17-hydroxyprogesterone, then the high sensitivity of the vessels to the hormone vasopressin remains, they easily pass into a state of spasm, which entails an increase in pressure.

Changes in the heart (hypertrophy) are aimed at compensating for the condition of hypertension, but this leads to an even greater deterioration. The vessels of the kidneys are gradually affected, which further reinforces the pathology.

What is the threat?

Hypertension and pregnancy are a dangerous combination. At high pressure, the vascular lumen narrows. In this case, already in the early stages of pregnancy, blood flow in the placenta is disrupted. The fetus does not receive enough nutrition and oxygen, its development slows down and, according to the results of ultrasound, does not meet the deadline. In some cases, impaired blood flow ends in spontaneous interruption of gestation at an early stage.

At a later date, generalized vasospasm can lead to a normally located placenta. In most cases, with such a development of events, the child cannot be saved.

High blood pressure can turn into full-fledged gestosis. In this case, edema of varying severity joins, and protein appears in the urine. The disease can progress and lead to preeclampsia or eclampsia - the appearance of seizures and loss of consciousness, up to coma.

Changes in the placenta with this pathology form placental insufficiency, which is manifested by a violation of the supply of nutrients, a delay in its development and, in severe cases, death.

What causes the pathology?

Chronic hypertension during pregnancy can be either a primary disease or secondary to the pathology of other organs. Then it is called symptomatic.

The following reasons lead to an increase in blood pressure during the period of bearing a child:

• existing hypertension (90% of cases);
• kidney pathology: glomerulonephritis, pyelonephritis, polycystic, kidney infarction, diabetic damage, nephrosclerosis;
• endocrine system diseases: acromegaly, hypothyroidism, pheochromocytoma, hypercortisolism, Itsenko-Cushing's disease, thyrotoxicosis;
• vascular pathology: coarctation of the aorta, aortic valve insufficiency, arteriosclerosis, periarteritis nodosa;
• neurogenic and psychogenic causes: stress and nervous strain, hypothalamic syndrome;

Hypertension carries risks of damage to the kidneys, heart and brain, impaired fetal development. But she herself can be a consequence of the pathology of internal organs.

How does hypertension manifest?

Physiologically, the pressure during pregnancy naturally decreases during the first two trimesters, and only by the time of childbirth does it return to its normal state. But with the existing hypertension, pressure can behave in different ways. In some cases, it decreases and stabilizes. But there may be a worsening of the condition - an increase in blood pressure, the addition of edema and proteinuria.

At a doctor's appointment, women may complain of increased fatigue, headaches. Sometimes the following symptoms are disturbing:

• sleep disturbances;
• palpitations that are felt on their own;
• dizziness;
• cold hands and feet;
• chest pain;
• dyspnea;
• visual impairment in the form of flashes of flies before the eyes, clouding;
• noise or ringing in your ears;
• paresthesia in the form of a feeling of "creeping";
• unmotivated feeling of anxiety;
• nosebleeds;
• rarely - thirst, increased urination at night.

Initially, the pressure rises periodically, but gradually, with increasing severity, hypertension becomes permanent.

Additional examination

It will be correct even when planning pregnancy to find out whether there are prerequisites for raising blood pressure. Those who come to the doctor after receiving a positive pregnancy test need to remember whether there were episodes of increased pressure before gestation or during the previous gestation. These data are necessary for the doctor to assign a risk group in order to plan the further management of pregnancy and to carry out the necessary diagnostics, to determine the methods of prevention.

There is a need for data on the expectant mother's addiction to smoking, diabetes mellitus, overweight or diagnosed obesity, a violation of the ratio of lipids in the blood. It is important that young relatives have diseases of the cardiovascular system and death from them at a young age.

Arterial hypertension is a therapeutic pathology, therefore, the gynecologist conducts examination and treatment of such women in conjunction with a therapist.

The time of the onset of complaints must be specified, whether they grew gradually or appeared suddenly, correlating this with the duration of pregnancy. Particular attention is paid to the weight of the expectant mother. A body mass index of more than 27 significantly increases the risk of developing hypertension. Therefore, even before pregnancy, it is recommended to lose at least 10% of weight for those who have an excess of this indicator.

During the examination, the following examinations can be used:

• auscultation and palpation of the carotid arteries - allows you to identify their narrowing;
• examination, auscultation of the heart and lungs may reveal signs of left ventricular hypertrophy or cardiac decompensation;
• palpation of the kidneys allows in some cases to identify cystic changes;
• be sure to examine the thyroid gland for enlargement.

If there are neurological symptoms, then check for stability in the Romberg position.

• on two hands, and compare the result;
• in a prone position, and then - standing;
• to examine the pulse on the femoral arteries and once the pressure on the lower extremities.

If during the transition from the horizontal to the vertical position the diastolic pressure increases, then this speaks in favor of hypertension. A decrease in this indicator is symptomatic hypertension.

Diagnostics includes mandatory examination methods and additional ones, which are used in case of progression of the disease or ineffectiveness of treatment. The following techniques are mandatory:

• clinical blood test (general indicators, hemoglobin);
• biochemical blood test: glucose, protein and its fractions, liver enzymes, basic electrolytes (potassium, calcium, chlorine, sodium);
• general urine analysis, the presence of glucose, erythrocytes, as well as the daily protein content;

All women have their blood pressure measured at every doctor's appointment. On the eve of the visit, the pregnant woman must pass a general urine test.

Additional methods are prescribed selectively depending on the clinical picture, as well as the presumptive cause of the increase in pressure:

• urine tests according to Nechiporenko and Zimnitsky;
• Ultrasound of the kidneys;
• blood lipid profile;
• determination of aldosterone, renin, the ratio of sodium and potassium in the blood;
• urinalysis for 17-ketosteroids;
• blood for adrenocorticotropic hormone and 17-hydroxycorticosteroids;
• Ultrasound of the heart;
• ophthalmologist consultation and fundus vessels examination;
• daily monitoring of blood pressure;
• urine analysis for bacteria.

The condition of the fetus is monitored using ultrasound and Doppler ultrasonography of the vessels of the placenta and the fetoplacental complex.

Principles of therapy

During pregnancy, treatment of hypertension is aimed at reducing the risk of complications for the mother and.

With a slight increase in pressure, treatment can take place on an outpatient basis, but always with periodic visits to the doctor. An absolute indication for hospitalization is a jump in blood pressure of more than 30 mm Hg. Art. or the appearance of symptoms of involvement in the pathology of the central nervous system.

If the disease is detected for the first time, then hospitalization is recommended to clarify the diagnosis and in-depth examination. It will also determine how high the risk of progression of the condition, its transition to gestosis or the appearance of complications of pregnancy. Pregnant women are hospitalized who are undergoing outpatient treatment, but without positive dynamics.

1. Drug-free treatment.
2. Drug therapy.
3. Fighting complications.

Drug-free treatment

The technique is used for all pregnant women diagnosed with hypertension. Arterial hypertension is primarily a psychosomatic illness, long-term neurosis. Therefore, it is necessary to create conditions in which there will be the least amount of stressful situations.

What should those who are at home do? It is necessary to evenly distribute the daily regimen, leaving time for daytime rest, and preferably a short sleep. In the evening, going to bed should also be no later than 10 pm. They reduce the time spent at the computer and watching TV, exclude programs that make you nervous. It is also necessary to distance yourself as much as possible from all life situations that can provoke nervous tension, or try to change your attitude towards them from a sharp emotional to a neutral one.

Additionally, you need reasonable physical activity. This can be walking in the fresh air, swimming or special exercises for pregnant women.

Both in the hospital and at home, a change in the nature of the diet is provided. We recommend frequent fractional meals 5 times a day, with the last meal no later than 3 hours before bedtime. Limit the intake of table salt to 4 g per day. It is optimal to cook food without it, and add a little salt directly on your plate. Overweight women are limited to fat and simple carbohydrates. All pregnant women are advised to increase the proportion of vegetables and fruits, cereals, and fermented milk products in their diet.

For those who are undergoing treatment on an outpatient basis or in a hospital, physiotherapy may be prescribed:

• electrosleep;
• hyperbaric oxygenation;
• inductothermy on the feet and legs;
• diathermy of the kidney area.

Additionally, psychotherapeutic treatment is needed, improvement of the general emotional state.

Medication treatment

Tablets under certain conditions:

• the pressure rises higher than 130 / 90-100 mm Hg. Art .;
• systolic pressure is increased by more than 30 units from the normal for a woman or diastolic pressure by more than 15 mm Hg. Art .;
• regardless of blood pressure indicators in the presence of signs of preeclampsia or pathology of the fetoplacental system.

Treatment of pregnant women is associated with the danger of the effect of drugs on the fetus, therefore, drugs are selected in minimum dosages that can be used as monotherapy. Taking pills should be regular, regardless of the tonometer's readings. Sometimes, after deciding that the measurement results and overall well-being are satisfactory, women will arbitrarily decide to stop taking medication. This threatens with sharp jumps in blood pressure, which can lead to premature birth and fetal death.

Do not use or use as a last resort for health reasons:

• ACE blockers: Captopril, Lisinopril, Enalapril;
• angiotensin receptor antagonists: Valsartan, Losartan, Eprosartan;
• diuretics: Lasix, Hydrochlorothiazide, Indapamide, Mannitol, Spironolactone.

Long-acting drugs are preferred. In case of ineffectiveness, it is possible to use a combination therapy with several drugs.

Drugs for the treatment of hypertension in pregnant women belong to several groups of antihypertensive drugs:

Atenolol is included in the list of approved drugs, but it is used very rarely, because there is evidence that it causes fetal growth retardation. The choice of a specific drug depends on the severity of the hypertension:

• 1-2 degree - Methyldopa is considered the first line drug, 2 lines - Labetolol, Pindolol, Oxprenolol, Nifedipine;
• Grade 3 - 1 line drug - Hydralazine or Labetolol are used intravenously, or Nifedipine is prescribed every 3 hours.

In some situations, the listed methods are ineffective, and it becomes necessary to prescribe slow calcium channel blockers. This is possible if the benefits outweigh the risks of using them.

Additionally, treatment is aimed at correcting fetal-placental insufficiency. Use means that normalize vascular tone, improve metabolism and microcirculation in the placenta.

Treatment of complications

With the development of complications of gestation, the methods of therapy depend on the duration of pregnancy. In the first trimester, it is necessary to prevent the threat of interruption. Therefore, sedative therapy, antispasmodics and progesterone treatment (Duphaston, Utrozhestan) are prescribed.

In the second and third trimester, it is necessary to correct placental insufficiency. Therefore, drugs are prescribed that improve microcirculation, metabolism in the placenta (Pentoxifylline, Phlebodia), hepatoprotectors (Essentiale), antioxidants (vitamins A, E, C). Treatment is carried out against the background of antihypertensive therapy. If necessary, infusion therapy, detoxification is carried out.

Choosing a due date

The preservation of pregnancy directly depends on the effectiveness of the treatment. If blood pressure is well controlled, it is possible to prolong gestation until the term of full-term fetus. Childbirth is carried out under strict control over the condition of the mother and fetus and against the background of antihypertensive therapy.

Premature birth is necessary in the following situations:

• treatment-resistant severe hypertension;
• worsening from the fetus;
• serious complications of hypertension: heart attack, stroke, retinal detachment;
• severe forms of gestosis:,;
• premature detachment of a normally located placenta.

Vaginal delivery is preferred and an amniotomy is performed at an early stage. Anesthesia and careful control of blood pressure are required. In the postpartum period, there is a high risk of bleeding, therefore, the introduction of uterotonics (Oxytocin) is necessary.

Prevention options

It is not always possible to avoid hypertension during pregnancy, but the risk of developing it can be reduced. This requires planning a pregnancy. Overweight women are advised to switch to proper nutrition in order to gradually lose weight. But you can not use strict diets, fasting. After them, in most cases, extra pounds are returned.

In the presence of diseases of the kidneys, thyroid gland, heart, diabetes mellitus, it is necessary to stabilize the condition, the selection of adequate therapy, which will minimize the possibility of deterioration during pregnancy.

Women who have been diagnosed with hypertension while carrying a child are recommended to be hospitalized three times during pregnancy to clarify the condition and correct the therapy.

It is important to remember about the non-drug methods that are used for any form of hypertension. With a slight increase in pressure and the absence of complications, they are enough to stabilize the condition. In other cases, you must strictly follow the doctor's recommendations.