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Among the most severe forms of cardiovascular diseases include hypertonic diseases, essential
hypertension. Arterial hypertension is seen in 5-15% of pregnant women. Among these women, 70% of
cases is detected in late gestosis, 15-25% in hypertension, 2-5% in secondary hypertension associated
with kidney disease, endocrine pathology, heart and major blood vessels, etc.

 

 

So far, there is no single classification of hypertension. In Russia, classification for which 3 stages of the
disease is distinguished (Table 1).

Table 1: Classification of hypertension, used in Russia


  

   
I There is a rise in blood pressure, but no change, but the cardiac-vascular system, caused by
arterial hypertension (no left ventricular hypertrophy on ECG data. Changes retinopathy).
II There is a rise in blood pressure, combined with changes in the cardiovascular system, caused
by both arterial hypertension (left ventricular hypertrophy on ECG. Angiopathy of retina), and
coronary heart disease (angina) or brain (hemodynamic disturbance of brain) but function of
internal organs is not impaired.
III Previously, high blood pressure may drop because of a heart attack or stroke. There is
significant dysfunction of the heart (heart failure), and / or brain (stroke). and / or kidney
(chronic renal insufficiency).

According to the WHO classification, introduced in recent years, the following degrees of hypertension is
distinguished (Table 2).

Table 2: Classification of the degree of arterial hypertension (WHO, 1999)


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I 140-159 and/or 90-99
II 160-179 and/or 100-109
III > 180 and/or > 110


    




Clinical manifestations of hypertensive disease in pregnancy have the same character as of non-
pregnant women. It depends on the stage of disease. However, a slight decrease blood pressure in the
first half of pregnancy is characteristic hemodynamic of healthy pregnant women. This feature also
applies to pregnant women with hypertension.

The main diagnostic difficulty is to determine the following circumstances. Many pregnant women
(especially young one) are unaware of BP changes. Specialist examining pregnant women may have
difficulties to assess the depression effect of pregnancy in early form of hypertension. In III trimester of
pregnancy, gestosis often makes it difficult to diagnose hypertension.

Diagnosis may be helped by medical history, including family history. It should establish the presence of
BP increase in the next child. It is necessary to establish whether there had been increase blood
pressure, such as prophylactic examinations at school and at work, prior to pregnancy. Information
during previous pregnancies and births is important too. In patient͛s complaints, pay attention to
complaints of headaches, nose bleed, pain in the heart region, etc.
Objective examination is necessary by measuring blood pressure on both hand and by repeating the
measurements 5 minutes after decreasing emotional stress in women. ECG and examination of eye
fundus are also required.

In stage I hypertension, most patients do not feel significant physical limitations. In history, we can find
complaints of recurrent headaches, tinnitus, sleep disturbances, episodic nosebleeds. In ECG, signs of
hyperfunction of left ventricular can detect. Eye fundus changes are absent. Functions of kidney id not
disturbed.

In stage II hypertensive disease, constant headache, shortness of breath on physical activity is seen. this
stage of disease is characterized by hypertensive crisis. Signs of hypertrophy left ventricle are clearly
showed. In eye fundus, narrowing of arteries and arterioles lumen is detected. Moderate thickening of
their walls, compression of veins compacted arterioles. No changes in urine analysis.
Clinical observations suggest that pregnancies in stage III hypertensive disease are rarely observed due
to the decrease ability of this group of women to conceive.

Differential diagnosis of early stages of hypertension and gestosis, as a rule, does not cause serious
difficulties, since I and II stages of the disease there are no changes in the urine, swelling do not occur,
no hypoproteinemia, no reduction of daily urine output.


   
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Most women taking monotherapy and whose hypertension is well controlled prior to pregnancy do well.
Even these women, however, are at increased risk for superimposed preeclampsia and placental
abruption. Pregnancy-aggravated hypertension manifests as a sudden increase in blood pressure.
Systolic pressures greater than 200 mm Hg or diastolic pressures of 130 mm Hg or more may rapidly
result in renal or cardiopulmonary dysfunction. When there is superimposed severe preeclampsia or
eclampsia, the outlook for the mother is serious unless the pregnancy is terminated. Placental abruption
is another common and serious complication. There have also been reported aortic dissection at term

 
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There is no precise definition of superimposed preeclampsia in women with chronic hypertension. The
risk of superimposed preeclampsia is directly related to the severity of baseline hypertension, as well as
the need for treatment to achieve control.

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From a number of reports, the incidence of placental abruption of about 1 in 150 pregnancies is
increased in women with chronic hypertension. Reports had concluded that abruption doubled in
women with chronic hypertension.
When hypertension is severe, the likelihood of abruption is concomitantly increased. Vigil-De Gracia and
colleagues (2003) reported its incidence to be 8.4 percent in 154 women with severe chronic
hypertension in the second half of pregnancy. Smoking further increases these risks.

    
   

There are few quantitative data to assess economic and lifestyle factors in pregnant women with
chronic hypertension. These women require more time with their physicians, including office visits,
fetalʹmaternal assessment in the third trimester, and increased hospitalization. Rest at home affects
economic stability and family dynamics. Women must take more time off from work, and this is
especially burdensome if women are self-employed or must care for children or other family members.



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Almost all adverse perinatal outcomes are increased in pregnancies complicated by chronic
hypertension.

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The incidence and severity of restricted fetal growth are directly related to the severity of hypertension.
Both are also dependent on other maternal factors, on the growth chart used to arrive at this diagnosis,
and on the accuracy of gestational dating. Maternal factors include age; hypertension control, including
the need for additional antihypertensive medications; and the presence of end-organ damage such as
renal or cardiac dysfunction. Growth restriction is further increased in women who develop
superimposed preeclampsia.

Reports shown that women with chronic hypertension had small-for-gestational age (SGA) perinates. If
these women had proteinuria early in pregnancy, 23 percent had infants with birthweights less than the
10th percentile. Although fetal growth restriction did not develop, Gainer other reports found that
women with chronic hypertension requiring medication who developed superimposed preeclampsia
displayed sustained, slower fetal growth velocity by sonography as early as 23 weeks.

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In a study, it is reported that 33 percent of 763 women with chronic hypertension delivered before 37
weeks and 18 percent before 35 weeks. The perinatal death rate is increased threefold to fourfold in
women with chronic hypertension.

'    Therapy of hypertensive disease should begin with a calm mental and emotional state of
patient and their confidence in the efficacy of therapy and the prosperous outcome of pregnancy. Ask
patient to pay attention and comply with strict regime of the day (work, rest, sleep) and food. Food
should be easily digestible, rich in proteins and vitamins.

Drug treatment is carried out using a complex drugs acting on the various links in the pathogenesis of
disease. Use the following antihypertensive drugs: diuretics (dichlothiazide. spironolactone. furosemide.
brinaldix) drugs acting at different levels of sympathetic system including ɲ-and ɴ-adrenergic receptors
(anaprilin/propanolol, clonidine, methyldopa), vasodilators and calcium antagonists (apressin, verapamil,
phenytidin), antispasmodic (dibasol, papaverine, no-spa, aminophylline). Physiotherapy shall be selected
together with drug therapy: conversations electrons, inductothermy of feet and lower legs, diathermia
of perirenal area. Hyperbaric oxygenation has positive effect too.

    

Hypertensive heart disease may cause an adverse effect on the course and outcome of pregnancy. More
frequent complication is the development of gestosis. Gestosis manifests early, in 28-32th week,
progresses severely, do not respond well to therapy, and is often reoccur in subsequent pregnancies.

Hypertenssion mother can cause fetus to suffer. Increased peripheral vascular resistance due to
vasoconstriction and sodium retention, causes liquid to go into interstitial spaces, increased
permeability of cellular membranes leads to dysfunction of placenta. Thus, hypertension significantly
reduces utero-placental blood flow. These changes lead to hypoxia, malnutrition, and even fetal death.
Antenatal fetal death may occur as a result of placental abruption which is a frequent complication of
hypertension. Birth in hypertension mother often become fast, rapid period or delayed that have the
same adverse affects to fetus.
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Women with arterial hypotension often are asthenic with pale skin, in almost half of them varicose veins
are detected. Hands and feet are cold when touched; pulse is labile, weak in content and tension, often
marked bradycardia, increase in left ventricular systolic murmur on top. However, most patients with
percussion and auscultation, heart disease are not detected. Specific ECG changes are absent. Minute
volume of blood is increased, and reduced peripheral resistances cause inadequate blood flow, resulting
in decreases blood pressure.

Hypotonic crises occur as collaptoid state, for a few minutes. During the crisi,s of blood pressure
decreases to 80/50 mmHg and below. Increased headache and head spins, severe weakness, feeling of
filled in ears, note the skin and mucous membranes is pale, and cold sweat. arterial hypotension in
pregnancy is complicated by gestosis. Patients with arterial hypotension blood pressure may not exceed
the normal digits (120/80 mm Hg), but if it is 30 mm Hg higher than the original, it is considered to be
pathological. Toxicosis in the early stages occurs more often in pregnant women with arterial
hypotension than in healthy women. Risk of miscarriage and premature delivery is 3-5 times more often
in pregnancy with arterial hypotension than in healthy pregnant.

Only 25% of patients with arterial hypotension, physiological process of delivery is observed.
Complications of labor are due to disturbance of uterine contractions. When combined with arterial
hypotension with the weakness of labor often develops fetal hypoxia. Dangerous complication of this
pathology is bleeding in the third and early postpartum periods. It may be due disturbance of uterine
contractions, and reduced clotting ability of blood (decrease in plasma fibrinogen, platelet counts and
their adhesive ability, increased fibrinolytic activity of blood). When bleeding occurs in patients with
arterial hypotension, hemorrhagic shock develops earlier and occurs more severe than normotension.
Hypotension, even the decompensated one (this happens rarely, usually in late pregnancy) is not an
indication for abortion.

'   . To treat of arterial hypotension, it is importance to comply with the regime of work and rest
with exemptions of working at night, as well as associated physical and emotional overstrain.
Therapeutic exercise is desirable. Nutrition should be a full, varied in content in the diet of vitamins and
protein products to 1,5 g per 1 kg of body weight. The basic treatment of arterial hypotension is the use
of bracing and-or modify the medicine to be useful to use with hemodynamic version of the disease.
With the decreased tone of peripheral vessels and cardiac small changes (eukinetic version) Pregnant
appoint sedatives (valerian), 20-40 ml of 40% solution of glucose, vitamin complex, and also other
means with stimulating effect on CNS: tincture of ginseng, Chinese Lemon, Eleutherococcus 20 drops 2-3
times 20 minutes before meal, Apilak 1 tablet (0,001 grams) 3 times a day under the tongue referred to
treatment is carried out, usually as an outpatient with three courses of 10-15 days.

By reducing blood pressure due to reduced cardiac output (hypokinetic version of circulation)
pathogenetic justified the appointment of contributing to an increase volume of blood. These include
Izadrin, selective stimulator of ɴ-adrenoreceptor of myocardum. Izadrin is used in tablets containing
0.005 g of the drug, under the tongue 3 times/day within 10-14 days, the means and products that
improve the metabolic processes of myocardium (riboxin, panangin, ascorbic acid, vitamin B1, B2, B6)
Given the positive effect of oxygen therapy, pregnant women are assigned sessions of hyperbaric
oxygenation. In hypotensive crises, causing a significant decrease in BP, sometimes it is enough to enter
subcutaneously 0.5 ml of 5% solution of ephedrine hydrochloride, and then 1 ml of 10% solution of
caffeine or 1ml of 10% kordiamin.

In pregnant women with arterial hypotension during the preparation for childbirth with delayed
character, calcium chloride, glucose, estrogen, vitamins, is given and indication of medical sleep ʹ rest,
and not to seek the immediate appointment of excited by giving the labor activities. in slow-
development of labor, patients with arterial hypotension may be mistaken for primary weakness of
labor, Labor stimulation in such cases involve discoordination of labor forces. Women with arterial
hypotension poorly tolerate blood loss; they may have hemorrhagic shock even for relatively minor
bleeding, and therefore recommended to prevent bleeding in early postpartum period