Preeclampsia, under this term, probably the least pregnant women can spontaneously imagine something. The colloquial term "pregnancy poisoning" suggests: It is a serious complication - in the worst case, it can end fatally. The causes of the disease, which was formerly also called EPH-gestosis and affects about two to three percent of all pregnant women , are still unclear. The symptoms are often nonspecific, making the diagnosis difficult.
Depending on the degree of severity, the medicine distinguishes four forms of the so-called hypertensive pregnancy disorder, whose leading symptom is the high blood pressure:
- Gestational hypertension
- Preeclampsia (pregnancy poisoning)
- eclampsia
- HELLP syndrome
If left untreated, hypertensive pregnancy can be very dangerous for both mother and child. Failure to implant the fertilized ice into the uterus causes changes in the blood vessels in the developing placenta . This leads to the release of signaling substances from the altered placenta into the circulation, which then trigger the symptoms. If left untreated, it can lead to life-threatening blood pressure crises in the mother, to miscarriages or damage to the child.
Causes of high blood pressure during pregnancy
What causes a hypertensive pregnancy is not yet fully understood. However, everything indicates that heredity plays a role: if the mother was suffering from high blood pressure during pregnancy, the risk of her daughter also being affected is increased by about 25 percent. Even if the mother of the child's father had it, the risk can be increased. Apparently, among other things, the genes of the unborn child are responsible, if the mother develops a gestational pressure.
Substances of the misfolded placenta enter the mother's bloodstream and cause high blood pressure and also a blood coagulation disordercan develop. The clinical picture that emerges can vary in severity - from pregnancy hypertension to preeclampsia and eclampsia to HELLP syndrome.
Of these hypertensive diseases, which develop only during pregnancy, a distinction is made between "high blood pressure during pregnancy". These are patients who already had high blood pressure before pregnancy. In most cases, sufficient therapy with uncomplicated pregnancies is expected here. However, the hypertension remains after pregnancy and must continue to be treated.
Symptoms of pregnancy hypertension
The ideal blood pressure is 120/80 mmHg. Values starting at 140/90 mmHg are considered elevated blood pressure. Severe hypertension is present when the lower (diastolic) value is 120 mmHg or above. In women who had low blood pressure before they were pregnant , the values shift slightly downwards - what is considered normal in other women can be considered as elevated blood pressure.
Symptoms of pregnancy
hypertension The affected women usually do not notice the onset of pregnancy high pressure. At the preventive appointments , however, the doctor determines the increased blood pressure.
Increased scores are not always worrying because, for example, blood pressure also increases when you're excited. Higher values - especially after the 20th week of pregnancy - are always a reason for regular blood pressure checks. Pregnancy-related hypertension returns to normal about three months after birth .
Symptoms of preeclampsia (EPH-gestosis, pregnancy poisoning)
A pre-eclampsia can also go unnoticed at first. At the latest at the check-up then it is noticeable that in addition to the increased blood pressure, protein in the urine can be detected. The patient may also notice water retention in the feet and lower legs, hands, and facial area.
Other symptoms that should alert you are :
- Headache , dizziness , flicker in front of the eyes
- photosensitivity
- drowsiness
- confusion
- Pain in the upper abdomen
If you experience one or more of these symptoms, contact your doctor quickly.
Symptoms of Eclampsia
Eclampsia is a serious complication of pre-eclampsia. In addition to pre-eclampsia symptoms, seizures occur before, during and after birth. Before the seizure, sufferers often complain of headaches, blurred vision and upper abdominal pain.
Symptoms of HELLP syndrome
HELLP syndrome is also a serious complication of pre-eclampsia. HELLP is the main symptoms of this disease: Hypertonie (high blood pressure), e levated li ver enzymes (elevated liver enzymes) and low p latelet count (reduced number of platelets , i.e. platelets).
Symptoms of HELLP syndrome usually do not occur until the 25th to 30th week of pregnancy: In addition to the signs of preeclampsia, there are strong, usually radiating upper abdominal pain due to liver damage: For many patients, it feels as though they are a ring compressed below the costal arch.
Treatment of high blood pressure in pregnancy
The easiest way to treat pregnancy high pressure and possible complications such as pre-eclampsia is to recognize and treat the blood pressure increase at an early stage. Almost always, you need medication that lowers your blood pressure. Your doctor knows which ones are suitable for pregnant women.
In severe forms of hypertensive pregnancy, premature birth may be required - for example, when the mother has seizures (eclampsia), threatens kidney failure, or indicates that the unborn child is no longer receiving adequate care.
Symptoms usually from the 20th week of pregnancy
One thing is certain: "The placenta does not nest in the eighth to thirteenth week, as a result of which harmful substances enter the maternal circulation", explains Dr. med. Dietmar Schlembach, Chief Physician of the Clinic for Obstetrics at Vivantes Klinikum Neukölln in Berlin. "They have a delayed, negative effect on the mother's vascular system, probably as soon as a certain threshold is exceeded." From about the 20th week of pregnancy , the first signs can show. Depending on their severity, they range from mild headaches to fluid retention in the tissue to severe upper abdominal pain and vomiting.
Close monitoring
According to the definition, only two criteria have to be fulfilled for pre-eclampsia: hypertension and increased protein levels in the urine. "The actual clinical spectrum is very broad," Dr. Stefan Verlohren, Senior Physician of the Clinic for Obstetrics at the Berlin Charité. If the clinical picture is limited to increased protein levels in the urine and increased blood pressure (from 140/90 mmHg), the gynecologist usually monitors the pregnant women more closely. Partly he prescribes antihypertensive agents.
Eclampsia: complication with seizures
Heavier gradients always require a hospital stay. "In eclampsia, for example, seizures occur during pregnancy, during or after birth , which can be life-threatening for both the pregnant woman and the child," says Verlohren. For example, placental detachment or kidney failure is possible. "In rare cases, the blood pressure very quickly rises very high, so that it can lead to circulatory disturbances in the brain to stroke in pregnant women," said Schlembach.
HELLP syndrome: impaired liver function
HELLP syndrome is another serious complication. Here are disorders of liver function and blood clotting, sometimes without the blood pressure increases. Upper abdominal pain is a warning sign. "Therefore, any pregnant woman should visit the gynecologist for pain in the upper abdomen or behind the sternum, in case of sudden swelling especially in the face, with very rapid weight gain or nausea and vomiting immediately and not go to the family doctor."
Clear prognosis now possible
Up to now, it has been virtually impossible to predict the presence of pre-eclampsia in the first suspected symptoms. An international study has now shown that the ratio of certain protein messenger substances in the blood reliably excludes or predicts possible gestosis. It's about a certain separation value. Stefan Verlohren, senior author of the study: "Women who are below the age of 38 do not contract pre-eclampsia within one week with 99.3 percent confidence." This does not sound spectacular to laymen, but offers those affected a great relief. You do not have to worry about a sudden deterioration of your condition in the short term. Instead of being admitted in a hospital, they are allowed to look after themselves at home.
Early preeclampsia particularly problematic
The earlier signs of preeclampsia appear, the more problematic for both mother and child. The actual therapy consists in the timely delivery and the removal of the nut cake. Only then does the mother's vascular system recover completely under normal circumstances. "That puts us at an early eclampsia in the 24th week a dilemma: How can we extend the pregnancy as far as possible to give the child more time to develop without harming mother and child? "Schlembach, the chief physician, says that if the blood pressure can be stopped by medication and the child is not in need of care, they become pregnant Mostly monitored intensively to gain a few more weeks, here the new blood test, which is still not a cash benefit, helps doctors and affected women to better prepare for impending complications.
New treatment method is being researched
A new therapeutic approach, which is currently used in only a few centers and under a strict study protocol, is the so-called blood wash. "The problematic messenger, the protein sFlt-1, is purposefully removed from the blood," says Verlohren. "The method is still in the experimental stage and is currently only in individual cases in question." A quick cure is not yet available. Until then, women should stay alert for early warning signs and know if they belong to a high risk group.
Know risk factors
"Especially young first-time mothers are more likely to develop pre-eclampsia, but even with multiple pregnancies or after fertility treatments there is a higher risk," says Schlembach. Existing autoimmune diseases, diabetes, high blood pressure or other previous cardiovascular problems are also a reason for pregnant women to ask the doctor at the slightest suspicion for advice. Although women who have already suffered from pre-eclampsia have a slightly higher risk of developing another pregnancy, the symptoms can also be completely absent.
What you can do yourself
If you have been diagnosed with pregnancy hypertension, you are likely to be on medication to lower your blood pressure. If you suffer from water retention, it is better not to take medicines or teas that have a flushing effect - unless your doctor has prescribed it. The advice to consume low salt to promote the elimination of fluid is outdated. Eat well-balanced and healthy , and save yourself otherwise - a lot of rest, no stress and no excitement.
NON-MEDICAMENTAL MEASURES
Pregnant women with high blood pressure should take care. Strict bed rest is rarely required. It has no favorable influence on the course of preeclampsia. Low-salt food is not recommended. Salt deprivation lowers the plasma volume, which is in any case lowered in hypertensive pregnant women. Also from low-calorie diets for weight loss is not recommended during pregnancy. Women with preeclampsia should be cared for inpatient care.
INDICATION AND GOAL MEDICINE THERAPY
Whether pregnant women with mild hypertension benefit from a drug therapy, remains open. An American consensus report in 1990 recommended treating diastolic pressures of 100 mm Hg and above. Other authors consider antihypertensives to be indicated only at 105 to 110 mm Hg diastolic. In order not to endanger the blood supply of the fetal sera unit, the pressure must not be lowered too much. For pre-eclampsia, diastolic values of 100 mm Hg would be desirable. In women with renal disease or left ventricular hypertrophy, values above 90 to 95 mm Hg should be avoided.
The treatment is intended to prevent organ complications such as brain haemorrhage in the mother. The therapeutic goal is derived from high-pressure treatment in the general population and from retrospective studies with pregnant women. There is insufficient evidence that the available antihypertensives may favorably affect the blood supply of the fruit and fetal growth, prevent pre-eclampsia, prevent the worsening of pre-eclampsia or premature birth.
SELECTION OF HIGH-PRESSURE MEDICINAL PRODUCTS
Most experiences and randomized studies on chronic hypertension in pregnant women are available with the central alpha- blocker methyldopa (PRESINOL et al.), Which is only rarely used in general high-pressure treatment. Fruit damaging effects are not described. Methyldopa is the only extreme pressure agent whose potential long-term effects on children have been studied in studies. There are no undesirable effects until the age of seven.
However, users of methyldopa often suffer from fatigue, dizziness and dry mouth. The agent should be avoided in the case of a history of depression. Threats such as hemolytic anemia, hepatitis, vasculitis and lupus erythematosus-like disorders are to be expected. The direct COOMBS test is positive for 20% of users. Nevertheless, methyldopa is still considered the drug of choice for chronic hypertension in pregnant women or for long-term treatment of pre-eclampsia, especially in English-speaking countries.
Proliferation in high-pressure therapy Pregnant women have beta-blockers . Teratogenic effects in humans are not described. In the newborn, treatment of the mother may cause bradycardia, hypotension, hypoglycemia and respiratory depression. Obstetricians and pediatricians should be informed about the medication. The child should be closely monitored.
Internationally, different beta-blockers are preferred. However, it has not yet been proven whether certain active substances or groups of active substances actually have advantages. German textbooks recommend beta1-selective receptor blockers. Studies do not justify this preference. The relatively cardioselective atenolol (TENORMIN et al.) Reduces uteroplacental perfusion compared to nonselective pindolol (VISKEN et al.). From the second trimester onwards, the weight of the newborn decreases compared to placebo. Metoprolol (BELOC et al.) And Atenolol attenuate the fetal heart rate. Compared with the calcium antagonist nicardipine (ANTAGONIL), metoprolol decreases the perfusion of the fetal serine unit. The number of cesarean deliveries increases due to fetal distress. However, one of our consultants notes that metoprolol is widely prescribed in practice without any indication of serious adverse effects from individual reports or reports to the European network of teratology consultation centers (ENTIS). However, caution seems appropriate when fete retardation is to be feared, as in pre-eclampsia, as well as during long-term use in pregnancy.
Atenolol is not recommended. This also applies to propranolol (DOCITON and others). The non-selective beta-blocker is associated, among other things, with low birth weight and increased perinatal mortality.
A Scandinavian workshop recommends the non-selective beta-blocker pindolol , which is said to reduce heart rate and stroke volume because of intrinsic stimulating activity (ISA). The blocker, which is little used here in Germany, does not appear to influence the fetus unfavorably according to previous findings. However, larger studies with pindolol and data on long-term use during pregnancy are lacking.
In English-speaking and Nordic countries also obsolete in Germany alpha and beta adrenergic receptor blocker is labetalol (Switzerland: Trandate) is recommended. After taking in chronic hypertension from the end of the first trimester there is no difference to methyldopa. However, after use in pre-eclampsia, one study found a reduced neonatal weight over the control group, which is ingested only.
Dihydralazine (NEPRESOL et al.), In other countries hydralazine (in TREPRESS), is mainly used for the acute parenteral treatment of severe hypertension during pregnancy, especially in preeclampsia. Based on their extensive experience, these vasodilators are still considered the drug of choice. In order to avoid a sharp drop in blood pressure with worsening of the uteroplacental blood flow, it is necessary to dose very slowly or perfusor-controlled. Because of mutagenic effects, (di-) hydralazine should not be used in the first trimester. There is no evidence of teratogenic effects in humans when dihydralazine is taken during organogenesis. The long-term use per os is less common for pregnant women today because of frequent parasitic effects. Headache and vomiting can mimic threatening eclampsia. Increase in uterine and placental blood flow in dihydralazine seen in previous studies was later confirmed.
calcium antagonists are not suitable for the first trimester of pregnancy due to teratogenic effects in animal experiments and inadequate documentation in humans. Nifedipine (ADALAT et al.) Is among the best studied . The uteroplacental blood flow does not appear to attenuate the calcium antagonist. In the acute treatment of severe hypertension, non-sustained nifedipine performs similarly in several studies as (di-) hydralazine parenterally. However, nifedipine capsules are no longer recommended during high-pressure crises because of poor control of the drop in blood pressure with potentially life-threatening cardiovascular consequences. For prolonged use of dihydropyridines retardation forms should be used. Caution is advised in women with pre-eclampsia, who get magnesium for the prevention of convulsions: Simultaneous intake of calcium antagonists can provoke a sharp fall in blood pressure1 (including constipation to the ileus). Long-term data for the treatment of chronic hypertension with retarded nifedipine are missing. Not least on suspicion of carcinogenicity, we consider calcium antagonists as a reserve during pregnancy.
CONTESTED AND CONTRAINDICATED MEDICINES
Diuretics are non-teratogenic. Theoretical concerns - the reduction in plasma volume - argue against their application. A meta-analysis of randomized trials involving more than 7,000 women showed no adverse effects on the fetus 10 years ago. Current data is missing. If the blood pressure in chronic hypertension is well adjusted prior to pregnancy with diuretics, the medication may be maintained. There are rarely any reasons for recruiting during pregnancy (eg pulmonary edema). For pre-eclampsia and intrauterine growth delay, diuretics are considered contraindicated.
Because of oligohydramnios, kidney failure in neonates and congenital malformations ACE inhibitors prohibit pregnancy. Women who become pregnant on receipt should be promptly switched to other high-pressure products. Based on experience with ACE inhibitors, angiotensin II antagonists are considered contraindicated. The data on alpha-receptor blockers is far from sufficient for recommendations.
Following minor studies and meta-analyzes, calcium (CALCIUM SANDOZ et al.) Was orally suggested for the prevention of pre-eclampsia. However, in a randomized clinical trial of more than 4,500 healthy first-time mothers, 2 g of calcium daily are not protective against either pregnancy hypertension or pre-eclampsia or obstetric complications. Also the prophylaxis with Acetylsalicylic acid (ASPIRIN et al.) Fails in two large randomized trials. Magnesium per os (MAGNESIUM VERLA and others) is also not recommended for protection against preeclampsia. In manifest eclampsia but magnesium sulfate (serving (MG 5 SULPHATE etc.) parenterally peripheral attenuation of seizures
CONCLUSIONS
In the high-pressure treatment of pregnant women, two otherwise rarely used veterinary medicinal products are preferred: methyldopa (PRESINOL et al.) Per os for long-term treatment and dihydralazine (NEPRESOL et al.) Iv for acute therapy. The proven methyldopa for fetal development has the disadvantage of frequent and - although rarely - possibly threatening disturbances for the mother. Conflicting recommendations are available on the more tolerable beta-blockers for pregnant women. Data on the influence on uteroplacental blood flow and fetal development are inconsistent or absent. Short-term use of metoprolol (BELOC, etc.) seems safe. A Scandinavian working group recommends pindolol (VISKEN et al.). Atenolol (TENORMIN etc.) is not recommended. For the long-term use in chronic hypertension, the reserve for methyldopa is also the relatively well studied alpha and beta-blocker Labetalol (Switzerland: TRANDATE). A teratogenic effect has not yet been demonstrated in any of the antihypertensives commonly used today, so that accidental ingestion is not an indication for termination of pregnancy.