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BAB 7

CHRONIC HYPERTENSION IN PREGNANCY AND SUPERIMPOSED PREECLAMPSIA

Chronic hypertension in pregnancy is defined as hypertension present before pregnancy


or before 20 weeks of gestation. Chronic hypertension complicating pregnancy is diagnosed
when high blood pressure is known to predate pregnancy. When prepregnancy blood pressure is
not known, elevated blood pressure detected before 20 weeks of gestation is often due to chronic
hypertension. Howefer, if blood pressure was normal in first trimester and then increases before
20 weeks of gestational, gestational hypertension or early preeclampsia also should be
considered. In pregnancy, blood pressure is categorized as mild to moderate (systolic, 1400-159
mmHg or diastolic 90-109 mmHg) or severe (systolic 160mmHg or higher diatolic 110mmHg or
higher), although a distinction is not made between chronic, gestational or preeclampsia
hypertension. The diagnosis of chronic hypertension is easily established when prepregnancy
hypertension is well documented and in women already receiving antihypertensive medications.
Chronic hypertension also is the most likely diagnosis when hypertension is present in the first
trimester. Difficulties may arise when pregnant women with prepregnancy, undiagnosed
hypertension initially present in the second trimester with normal blood pressure after having
experienced the pregnancy associated physiologyc decrease in blood pressure. These women will
have been presumed to be normotensive and if blood pressure increases in the third trimester,
they may be erroneously diagnosed with either gestational hypertension or if proteinuria is
present with preeclampsia rather than superimposed preeclampsia. Thus, chronic hypertension
may not be diagnosed until well after delivery.
Preexisting hypertension is a recognized risk factor for preeclampsia. Superimposed
preeclampsia develops in 13-40% of women with chronic hypertension depending on diagnostic
criteria, etiology (essential versus secondary), duration and the severity of hypertension. Women
with higher prepregnancy blood pressure or those with secondary hypertension are at greater risk
of developing severe hypertension during pregnancy. The risk of abruption placenta is increased
threefold in women with chronic hypertension, although most of the increased risk is associated
with superimposed with preeclampsia.
Antepartum Management
All women with preexisting hypertension should be assessed either before pregnancy or
early in npregnancy is outline. Baseline concentrantions of serum creatinine, elektrolite, uric
acid, liver enzyme, platelet count and urine protein (either dipstick) should be documented to use
are comparators in superimposed preeclampsia is suspectetd later in pregnancy. Good clinical
practice suggest performing assessment of left ventricular function with either
electrocardiography or echocardiography in women with severe hypertension of long duration

(eg.more than 4 years). Screening for secondary hypertension with routine blood chemistries and
urinalisis. Suggestive clinical features of secondary hypertension (resistant hypertension,
hypokalemia.Monitoring blood pressure with checked monthly in all pregnant women as a part
of standard obstetric practice. Although most superimposed preeclmpsia occurs nears near term,
it can accurs before 24 weeks of gestational and there are even anecdotal reports of its accurence
before 20 weeks of gestational.
Treatment
The goals of therapy also include minimizing risks to the fetus that are attributable to
hypertension, vascular disease and the possible effect of antyhipertensive medications that may
alter maternal hemodynamics and reduce uteroplacental perfucion or that may cross the placenta
and be harmful to the fetus. Nonpharmacological with two basic strategies lowering blood
pressure and minimazing cardiovascular risk factor. Adopting specific diet DASH (Dietary
Approaches to Stop Hypertension) with abundant fruit and vegetables, low fat diary product and
hight fiber and sodium intake. Antyhipertension medication of during the second trimester or
third trimester of the pregnancy was significantly associated with and increased risk of SGA.
Another important issue regarding treatment of maternal hypertension during pregnancy is the
risk of teratogenicity attributable to drugs. Therefore in the absence of strong evidence
supporting use of antyhipertensive therapy for mild to moderate chronic hypertension during
pregnancy, initiation of therapy isnot suggested unless blood pressure approaches 160mmHg
systolic or higher or 105 mmHg diastolic or higher or both. Given the unlikelihood of future
trials focusing specifically on acute treatment of pregnant women with chronic hypertension, it is
reasonable to extrapolate management recommendations based on these data. IV labetalol, IV
hydratalazine or oral nifedipine are reasonable fist line agents for acute lowering of blood
pressure on the hospital setting. There is theoretical concern that the combined use of nifedipine
and IV magnesium sulfate can results in hypotension and neuromuscular blockade. For drug
continuous management with methyldopa, a centrally acting alpha 2 agonist adrenergic remains a
commonly use drug mainly because of the long history of use in pregnancy and childhood safety
data. Blood pressure control is gradual, over 6-8 hours as a results of the indirect mechanism of
action.

Labelatolol, a nonselective -blocker with vascular alpha receptor-blocking ability is commonly


used in pregnancy. Based on comparisons with placebo or other antihypertensive agents for mild
to moderate hypertension in pregnancy.