Diagnosis of hypertension in pregnant women. Classification of arterial hypertension in pregnancy. Causes of hypertension during pregnancy

In the structure of diseases of pregnant women, arterial hypertension is 15-20%. Among these 20%, primary hypertension makes up a third, hypertension with preeclampsia - about 70% and secondary hypertension due to other diseases - 25%. Arterial hypertension - serious illness, which imperceptibly undermines the strength of the body from the inside. The essence of the disease: vasoconstriction occurs under the influence of nerve impulses and certain hormones. At first, arterial hypertension does not manifest itself. The woman does not feel the increase in pressure and performs the same load. However, the internal organs suffer, because little blood flows through the narrowed vessels, there is not enough oxygen (hypoxia), connective tissue begins to grow in the organs (its cells can grow with a lack of oxygen). Specialized cells of organs do not live without oxygen, and the organ loses its function. That's when women complain. They can be different: dizziness, headaches, flies before the eyes.

In severe forms of hypertension, there may be a sharp rise in blood pressure - a hypertensive crisis (a complication of hypertension). There is the following classification of hypertensive crises: neurovegetative form, edematous form, convulsive form. During a crisis, the woman's health deteriorates sharply: a sudden onset, arousal, fear, sweating, pallor of the skin appear (neurovegetative form). Another form of crisis is edematous: the development is gradual, the woman has drowsiness, lethargy, there is a decrease in activity and poor orientation in space, swelling and puffiness of the face and whole body increase. With a sudden loss of consciousness, the appearance of convulsions, a convulsive form develops, threatening sudden death as a result of cerebral edema. First aid for hypertensive crisis in pregnant women should be carried out only by doctors of the "Ambulance". When a pregnant woman complains of feeling unwell, an ambulance is immediately called. Arterial hypertension has its own classification, which is based on the levels of pressure increase: the optimal pressure is 120 to 80 mm Hg. Art., in pregnant women it is desirable 100-110 and 60-70 mm Hg. Art.

I degree - 140-159 and 90-99 mm Hg. Art.
II degree - 160-179 and 100-109 mm Hg. Art.
III degree - 160-179 and more 110 mm Hg. Art.

Causes of hypertension during pregnancy

Arterial hypertension during pregnancy often occurs if:

• the woman had hypertension before pregnancy;
• a woman suffers from kidney diseases (pyelonephritis, glomerulonephritis, kidney infarction, diabetic nephropathy, etc.) and (or) diseases of the endocrine system (hypothyroidism, hypercortisolism, etc.), which can contribute to the development of hypertension during pregnancy;
• there are mental and (or) neurogenic disorders, which can also serve as triggers for increasing blood pressure.

Symptoms and signs of hypertension during pregnancy

The main symptom of hypertension is an increase in blood pressure. An increase in blood pressure may be asymptomatic, but often a woman may experience the following unpleasant symptoms.

• headache;
• heartbeat;
• sleep disorders;
• fatigue;
• visual impairment;
• noise in ears;
• nosebleeds, etc.

The main difficulty in diagnosing arterial hypertension in pregnant women is as follows: young women do not measure their pressure, and if there is hypertension, they do not feel it. Due to the peculiarities of pregnancy at its beginning, blood pressure decreases in all expectant mothers. In addition, the presence of preeclampsia, which is also manifested by an increase in pressure, masks hypertension. It is possible to make a diagnosis of "arterial hypertension" only under certain criteria: the presence of a disease in the next of kin and an increase in pressure in a woman at least once in her life, in comparison with blood pressure levels during previous pregnancies, if any, complaints of a pregnant woman about frequent headaches, nasal bleeding or pain in the heart, etc. Naturally, the main criterion for hypertension is the fact of increased blood pressure. At the first stage of hypertension, a pregnant woman does not experience any inconvenience. May complain of recurrent headaches (often after a stressful situation), tinnitus, or nosebleeds. At the same time, there are no changes in other organs; the kidneys, the brain and the fundus of the eye are the first to suffer in hypertension. In the second stage of arterial hypertension, there are constant headaches, limitation of physical activity and stress due to shortness of breath. Here hypertensive crises can appear. There are changes in the fundus when examined by an ophthalmologist, the wall of the left ventricle of the heart thickens (hypertrophy). With hypertension of the third degree, pregnancy and the ability to conceive a child are unlikely due to adverse conditions. When diagnosing hypertension in a pregnant woman, it is necessary to begin immediate treatment to create conditions normal growth and maturation of the fetus. First you need to create a calm environment for a pregnant woman, protect her from stress and worries, provide her with sufficient good sleep and rest, and a balanced diet. With excessive excitability, sessions of auto-training and hypnosis, acupuncture can help well. The expectant mother should be under the constant supervision of a general practitioner, who must prescribe certain drugs to reduce pressure. Women should remember: many drugs that they took before pregnancy to reduce pressure are not suitable during pregnancy, as they negatively affect the child. Arterial hypertension has an adverse effect on the course of pregnancy, woman and child. The child suffers the most. Against the background of hypertension, preeclampsia develops, accompanied by insufficiency of all organs. The placenta, which nourishes and protects the fetus, uteroplacental blood flow suffers. These manifestations lead to a lack of oxygen, nutrients, and the fetus dies. Labor activity in arterial hypertension is also perverted: childbirth either lasts slowly or very quickly, which threatens the child with injury or hypoxia. It is important for pregnant women with hypertension to be hospitalized for less than 12 weeks. The clinic specifies the severity of the disease, its complications, the possibility of bearing a child. At the first stage of hypertension, the prognosis for expectant mothers is favorable: with all the recommendations and supervision of a doctor, pregnancy is possible and the child will be born healthy. In the second stage, the possibility of maintaining pregnancy is decided on an individual basis and depends on the severity of complications from other organs. The third stage is a contraindication for pregnancy. The second time, the expectant mother is hospitalized at 28-32 weeks to prevent excessive stress on the heart and blood vessels. The third hospitalization - two to three weeks before childbirth to prepare for childbirth, determine the tactics of childbirth and the necessary methods of anesthesia. Often women give birth to a child themselves, a caesarean section is needed only for certain indications. The basis for the course of pregnancy in a woman with arterial hypertension is the correct daily routine, lack of stress, proper nutrition, regular medication and observation by specialists.

Arterial hypertension is dangerous for its complications during pregnancy, as it can cause:

• placental insufficiency;
• massive bleeding;
• premature birth,
• intrauterine fetal death;
• premature detachment of the placenta, etc.

During pregnancy, the internal organs and vital systems of the child are laid. A lot depends on the woman's health. What if the expectant mother has hypertension?

Of course, the situation should not be dramatized, although it would be unwise to completely ignore the risk.

Arterial hypertension in our time is very common in people of the most different ages. Therefore, it is difficult to surprise anyone with increased pressure. Most people know from their own experience what it is, so they do not believe that a pregnant woman with hypertension needs special care. This is an erroneous opinion. After all, it is relatives and friends who, first of all, should be interested in her well-being and the successful course of pregnancy.

The vast majority of women with hypertension tolerate pregnancy well and give birth healthy babies. But problems, of course, can arise and often do. The modern level of development of medicine allows us to cope with them. However, there is severe stage III hypertension. At this stage of the disease, pregnancy is deadly to a woman's life. Fortunately, stage III is extremely rare, and stages I and II arterial hypertension are not a contraindication to pregnancy.

Usually a woman suffering from hypertension knows about it before pregnancy. Most likely, she already has a certain understanding of the disease, regularly or periodically takes some medications and is observed by a cardiologist.

At the very beginning of pregnancy, a woman who has been diagnosed with hypertension should definitely consult a cardiologist, and later, throughout the entire pregnancy, regularly undergo examinations, including blood pressure measurement, urine tests (to determine protein), and an electrocardiogram (ECG). It is very important that the specialist regularly monitors the development of the fetus. Not all medicines can be taken during pregnancy. That is why the independent choice of medications is unacceptable. Only a doctor prescribes drugs that do not have a teratogenic effect, that is, they will not harm the unborn child. When choosing drugs, it is very important individual characteristics body of a woman, as well as the presence of concomitant diseases.

Beyond the destination drug treatment, the doctor should give the necessary recommendations that relate to the lifestyle of a woman suffering from hypertension. During pregnancy, such patients will have to reconsider their lifestyle, pay special attention to their diet, and refuse some foods. Moderate physical activity is very important.

It often happens that in the early stages of pregnancy, the pressure decreases even in those women who had high blood pressure before pregnancy. In some cases, on the contrary, there is a sharp increase in blood pressure. Sometimes it is during pregnancy that a woman learns about a new diagnosis for herself - arterial hypertension.

The consequence of hypertension in pregnant women can be late toxicosis, which occurs in severe form.

At the same time, a woman has severe headaches, sometimes even vision is impaired.

Very dangerous complications of hypertension during pregnancy can be cerebral hemorrhage and retinal detachment. That is why, throughout the entire period of pregnancy, a woman should regularly undergo medical examinations, follow all the doctor's instructions, be sure to measure blood pressure, do an ECG, and take a urine test to determine the protein content. Consultations of the oculist are not less necessary.

During pregnancy, patients with arterial hypertension should visit once every 14 days women's consultation and do a urine test. After 30 weeks of pregnancy, a urine test should be taken every week.

If the level of diastolic pressure rises above 90 mm Hg. Art. in a sitting position, a pregnant woman needs antihypertensive therapy.

If, despite following all the recommendations, a hypertensive crisis occurs during pregnancy, signs of late toxicosis appear, or a woman feels a noticeable deterioration in her condition, it is better for her not to refuse hospitalization.

At least 2 weeks before the expected birth, even with a favorable course of pregnancy, experts still recommend that the woman go to the hospital. This is associated with the risk of unexpected complications in the expectant mother or child. When complications occur, a woman is prescribed a special therapy aimed at lowering blood pressure. At the same time, doctors carefully monitor the condition of the fetus. Sometimes a woman is given C-section. In some cases, they cause premature birth.

High blood pressure during pregnancy can cause fetal death and prematurity, placental abruption, and several other problems. Therefore, timely assistance of a specialist is necessary.

Diagnostics and treatment of arterial hypertension in pregnant women

During each examination, the doctor necessarily measures the blood pressure of a pregnant woman and writes down its indicators in the card. This is necessary to monitor the dynamics of blood pressure on different terms pregnancy.

Often you can meet with a situation where blood pressure rises as a reaction to the "white coat".

For example, in a healthy woman, during an appointment with a doctor, pressure can noticeably “jump”, while this does not happen at home and her well-being future mother good. If you know this feature behind you, if you are afraid of doctors and react to them in this way, warn your doctor in advance about the possibility of receiving incorrect blood pressure numbers at the appointment.

Most often, in this case, the doctor prescribes home monitoring of blood pressure. It is good if you begin to measure and record blood pressure data three times a day for a long time, so that the doctor is convinced of your "sensitivity to the medical staff." In this case, you will have to independently control blood pressure at home throughout the pregnancy.

Treatment of the expectant mother is aimed at stabilizing pressure and eliminating complications for the baby (if any have begun). Quite often, a pregnant woman is required to be hospitalized for examination and normalization of her condition.

With hypertension, the expectant mother is shown:

• consultation with a psychologist in order to eliminate psycho-emotional negative manifestations (stress, fears, anxiety, etc.);
• dieting;
• daily leisurely walks fresh air, preferably in nature (park or forest area);
• day rest;
• limiting weight gain (avoid being overweight);
• daily measurement of blood pressure at home;
• physiotherapy.

Antihypertensive drugs prescribed and controlled by a doctor should be taken constantly, since missed medications can cause sudden pressure surges, which is dangerous for blood vessels.

In the second semester of pregnancy, but sometimes even in the first, blood pressure often decreases. In the third semester, blood pressure becomes the same as usual. In some cases, it exceeds the normal rate. If, when examining a pregnant woman, the doctor notes high blood pressure, he will definitely recommend a thorough examination in order to clarify the nature of hypertension, find out the presence of concomitant diseases, and also determine the need for antihypertensive treatment.
Treatment is carried out depending on the degree of risk. If the patient has normal ECG and echocardiography, no protein in the urine, and blood pressure levels are 140-149/90-199 mmHg. Art., then it belongs to the low-risk group. If the patient has severe arterial hypertension, a poor obstetric history, there are concomitant diseases (collagenosis, diabetes mellitus, kidney disease are especially dangerous) and changes internal organs she is in the high-risk group.

Regardless of the degree of risk for each individual patient, there are general recommendations. They relate to the correct mode, the absence of overload, the obligatory 8-9-hour sleep. During pregnancy, a woman in the diet should limit the amount of fats and carbohydrates. The diet should contain as little salt as possible, no more than 5 g. This rule is common for people suffering from arterial hypertension, but during pregnancy it is especially important.

If the patient is in a low-risk group, she is often not prescribed special drugs. It is enough to use non-drug therapy, which consists in eliminating excessive loads, dieting, exercise, taking care of your emotional state. Every day she must necessarily walk as long as possible. It is advisable to take walks not along gassed city streets, but in a forest or park. Good results are given by autogenic training, relaxation. In this difficult, but very important period for the health of the baby, the expectant mother must learn not to take all worries and troubles to heart. It is very important that relatives provide a woman with psychological support and do not cause trouble.

However, despite various non-drug remedies, blood pressure may increase. If blood pressure rises to 160/100 mm Hg. Art. and above, the patient must be prescribed antihypertensive drugs. Medicines make it possible to control the level of blood pressure. But, I must say, even taking medications is not always reliable protection from the onset of preeclampsia. That is why, even if a pregnant woman belongs to a low-risk group, she should undergo an examination in a timely manner.

In some cases, in patients with I degree of arterial hypertension, the pressure decreases to a normal level. Then there is no need to take medication. But you still need to control your blood pressure. If a pregnant woman is at high risk, she is usually advised to start antihypertensive therapy immediately. Timely treatment will make it possible to avoid a number of complications. If the blood pressure level is 140/90 mm Hg. Art., then the uteroplacental circulation is disturbed, which entails various pathologies of fetal development. The child does not have enough oxygen, since it is the blood that carries it. Due to high pressure, premature detachment of the placenta can begin. There is also a risk of slowing down the development of the fetus.

Treatment of arterial hypertension in pregnant women is complicated by the fact that not all drugs are harmless to the child. But modern medicine is at a very high level.

Despite the clear need for treatment, some pregnant women themselves try not to take medication, as they are worried about the harmful effects on the fetus. With severe arterial hypertension, this is unacceptable. Lack of treatment will do much more harm.

There are some general rules for pregnant women regarding taking medications.

1. Most experts believe that angiotensin receptor antagonists (for example, valsartan, ibesartan, etc.) should not be used during pregnancy, because they have a teratogenic effect.
2. In the first trimester of pregnancy, it is better not to take angiotensin-converting enzyme inhibitors that have a teratogenic effect (for example, quinapril, enalopril).
3. After the eighth week of pregnancy, some drugs can have an embryotoxic effect (in particular, a number of antibiotics, antidiabetic, anti-inflammatory drugs). Therefore, it is undesirable to use a drug that worsens the hemodynamics of the mother, because it also worsens the blood supply to the fetus. A drug that reduces blood clotting in the mother, therefore, reduces blood clotting in the fetus.

A number of drugs do not have a harmful effect on either the expectant mother or the unborn child. The first-line drug for the treatment of arterial hypertension during pregnancy is methyldopa (dopegyt, aldomet). Many years of research and observation of children born have allowed scientists to assert that methyldopa is absolutely safe. Usually it is prescribed in 3-4 doses of 0.75-4 g per day. Taking the drug can lead to the fact that some people experience fluid retention in the body. Therefore, if long-term use of the drug is required, it is combined in small doses with diuretics. If the patient has impaired renal or hepatic function, the drug should be taken with caution, the patient should be constantly under the supervision of the attending physician.

Calcium channel blockers are also used to treat hypertension during pregnancy. Nifedipine, a dihydropyridine group drug, is often used. Doses are set by the doctor. The drug is able to quickly stop the impending hypertensive crisis.

The undoubted advantages of beta-blockers include a gradual effect on blood pressure. Also, drugs stabilize the function of platelets. It is very important that beta-blockers do not adversely affect plasma volume. Examples of beta-blockers include pindolol, atenolol, metoprolol, oxprenolol, and some others.

It is important to remember that the choice of the necessary medicines remains with the doctor, because it is the specialist who must take into account the individual health status of the patient and other factors that affect the course of pregnancy.

The most severe complications of pregnancy with arterial hypertension are preeclampsia and eclampsia. Such complications are very dangerous for the life of a woman and a child.

Preeclampsia during pregnancy

Preeclampsia is a condition that occurs in late term pregnancy. In this condition, a woman has high blood pressure. Protein is found in the urine. The woman's legs and arms are swollen. The woman feels a headache, vomiting, visual disturbances are observed. There are also signs of nephropathy.

There is a risk of preeclampsia progressing to the last and most severe phase. In this case, there is a threat of coma or death of both the mother and the child during or after childbirth, if the necessary treatment is not carried out. Severe forms of preeclampsia and eclampsia lead to dysfunction of vital organs, that is, the brain, lungs, kidneys, liver, and heart. The consequences of preeclampsia and eclampsia can affect the rest of your life if you do not carry out appropriate treatment in time. This applies to both mother and child. According to the World Health Organization, preeclampsia is responsible for 15-40% of maternal and 38% of perinatal deaths worldwide.

Preeclampsia is most common during the first pregnancy. At risk are the youngest girls and women who are over 35 years old.

Risk factors are:

• arterial hypertension, which was diagnosed before pregnancy;
• obesity;
• multiple pregnancy;
• diabetes;
• rheumatoid arthritis;
• systemic lupus erythematosus;
• cases of preeclampsia that have already been observed in the past in the patient herself;
• cases of preeclampsia in the sister or mother of the patient.

Preeclampsia leads to the fact that the blood flow through the placenta is disturbed, that is, the child may be born underdeveloped. In some cases, preeclampsia also causes preterm labor. A newborn may have pathologies such as impaired vision and hearing, cerebral palsy, epilepsy.

Some doctors tend to underestimate the dangers of preeclampsia. A simplified view of it is based on the fact that the main problem is high blood pressure, edema and proteinuria (protein excretion in the urine). But such symptoms are only superficial manifestations of the syndrome of multiple organ and polysystemic failure. These signs make it possible to make the diagnosis of preeclampsia itself, but are not the cause of the disease.

If we talk about swelling of the hands, feet and face, then such symptoms often accompany normal pregnancy. Also, a clear correlation has not been established between the fact that one or another degree of arterial hypertension is observed and edema is present at the same time.

Often, edema can occur in those women whose blood pressure is normal. The presence of protein in the urine is a later sign of preeclampsia. Approximately 5-10% of pregnant women with preeclampsia first have seizures, and then proteinuria, that is, protein in the urine, appears. Based on this, it was concluded that if the patient developed preeclampsia, then there are morphological damage to the kidneys, such as pyelonephritis, glumerulonephritis, nephrosclerosis. Before protein appears in the urine, other symptoms occur: the concentration of urea and creatinine in the blood plasma increases.

Preeclampsia also manifests itself in early pregnancy, up to 20 weeks. In this case, the cause may be a disease of the fetal egg in a pregnant woman, which is characterized by the growth of the surface layer of the villous membrane (chorion) and swelling of the substance of the villi (vesical skid).

There are several types of preeclampsia.

• Type I - there is low pressure in the pulmonary artery system, low cardiac output. The total peripheral vascular resistance is high.
• Type II - there is high pressure in the pulmonary artery system, high cardiac output. The overall vascular resistance is high.
• Type III - there is normal pressure in the pulmonary artery system, high cardiac output. The total peripheral resistance is low.
• Type IV - high pressure appears in the pulmonary artery system, a high cardiac output occurs. Plasma volume is normal or increased.

Specialists often use the term "mild preeclampsia". In this case, the outcome is favorable, because the pregnant woman has only a single increase in blood pressure. There are no other symptoms associated with preeclampsia. With a mild degree of preeclampsia, special measures are usually not taken. A woman should only limit activity, take care of her health.

If there is a risk of preterm birth, then with preeclampsia, special treatment is carried out, which must be prescribed by the attending physician. Sometimes it is better for a woman to be in a hospital in order to be constantly monitored. At a long gestational age, childbirth can be forced.

If a pregnant woman manifests gestosis (late toxicosis of pregnant women, nephropathy is a complication accompanied by impaired function of the placenta and the condition of the fetus), this means that there are signs of a critical condition, expressed to varying degrees.

These signs include:

• hypovolemia - a decrease in the volume of blood circulating in the body (it may be associated with restriction of fluid intake or its loss);
• hypoxemia - reduction of gas exchange in goblin, hemoglobin content in the blood;
• circulatory disorders in the kidneys, brain, liver.

Similar signs are associated with the fact that the properties of the blood are deteriorating, microthrombosis is present. Probable insufficiency of the function of the kidneys, lungs, myocardium. The severity of the patient's condition exacerbates vascular spasm, violation of all types of metabolism, and especially water-salt.

Severe forms of preeclampsia are very dangerous for a woman during pregnancy. Lack of special treatment can lead to her death. In some cases, other methods of treatment are prescribed, for example, magnesium sulfate (magnesia) is used. It helps prevent seizures and lower blood pressure. It is also possible to use various drugs that lower blood pressure. Fluid control is important. An extreme measure is the immediate induction of childbirth, regardless of the gestational age.

If a pregnant woman with manifestations of preeclampsia is observed in a hospital, eclampsia develops very rarely in her. This is due to the fact that the patient is under the constant supervision of specialists, to improve her condition, the most various methods intensive care. Due to this, the development of the convulsive stage is prevented.

Eclampsia in pregnancy

The term "eclampsia" comes from the Greek. the words "eklampsis", which means "flash". The main symptom of eclampsia is muscle spasms of the whole body and loss of consciousness.

For specialists, a very important, but at the same time complex problem is the ability to predict eclampsia, despite the suddenness of its onset. There are certain criteria that allow one or another patient to be considered at risk.

In eclampsia, great importance is given to the study of hereditary factors. This is very important because eclampsia most often develops during the first pregnancy. If the patient's mother had eclampsia, her daughter has a 49% chance of developing it. If the patient's sister had eclampsia, then the patient's risk of developing eclampsia increases to 58%. At multiple pregnancy the likelihood of developing eclampsia increases. The risk of this condition is also high in pregnant women under the age of 25 and in women after 35 years.

Eclampsia leads to a spasm of the respiratory muscles, while breathing is disturbed, the tongue sinks, hypoxia (oxygen starvation) and hypercapnia occur.

As a result of hypercapnia, the secretion of the glands increases, an increased separation of saliva, bronchial secretions, gastric and intestinal juice begins. There is no cough reflex during loss of consciousness. There is an accumulation of bronchial secretions and saliva, the airways narrow. Their lumen can completely close, which leads to disruption of gas exchange.
With hypercapnia, the excitability of the respiratory center decreases, and the violation of gas exchange is aggravated. The vasomotor center and sinoaortic receptors are irritated, as a result of which blood pressure rises.

Vasospasm progresses, excess blood enters the circulatory bed from spasmodic muscles. As a result, the load on the heart increases significantly. This load is exacerbated by hypoxia and hypercapnia. Therefore, with eclampsia, there is a violation of the heart rhythm. (These changes are clearly diagnosed on the ECG.)

The increased load on the heart leads to tachycardia and expansion of the cardiac cavity. Circulatory insufficiency occurs, it only exacerbates hypoxia and hypercapnia.
Violation of cardiac function in eclampsia is often accompanied by pulmonary edema. As a result, hypoxia and hypercapnia are aggravated.

There are severe bouts of eclampsia. With them, a very strong hypercapnia develops, which affects the peripheral vessels and the vasomotor center. In this case, in addition to the central circulatory insufficiency, there is also a peripheral one.

More than 70% of patients with eclampsia have liver failure, and impaired renal function is also manifested. Various changes in kidney function lead to the fact that the filtration of the body is disturbed. Due to impaired renal function, compensation occurs only as a result of increased ventilation if there is free patency of the respiratory center and there is no brain damage. Otherwise, a mixed form of acidosis may develop and hypoxia and hypercapnia may worsen. At the same time, intracranial pressure increases and seizures become more frequent.

It happens that it is not possible to stop what is happening. Then there is a risk of cerebral hemorrhage, paralysis of the respiratory center, cardiac arrest. The lungs swell, or respiratory and metabolic acidosis occurs. Death may not occur immediately, but after a few days. Thus, main reason death in eclampsia is (in 70%) cerebral hemorrhage, followed by respiratory failure with pulmonary edema, acute renal failure, postpartum hemorrhage, placental abruption, liver rupture, septic shock. If the patient has had eclampsia and survived, in the future she may experience a number of complications. In particular, disorders of the central nervous system, such as paralysis, autonomic disorders, headache, memory disorders, psychosis. Pathologies of other vital organs and systems of the body may also appear.
The development of eclampsia is considered a syndrome of multiple organ failure, because in this condition there is a failure of a number of systems and organs: respiratory, cardiac, renal, hepatic. There are also pronounced disorders in the distribution of blood flow, rheological properties of blood, various kinds metabolism.

Complications of severe eclampsia may include:

• disseminated intravascular coagulation with uncontrolled bleeding;
• capillary leak syndrome;
• intrahepatic bleeding;
• heart attacks;
• acute renal failure.

Arterial hypertension associated with the presence of late taxicosis can cause premature placental abruption, miscarriage, hypoxia, developmental delays and even death.

Against the background of multiple organ failure, convulsive seizures develop. These seizures are not associated with a violation cerebral circulation. Convulsive seizures are rare. But a whole series of seizures can occur, which follow one after another. This phenomenon is called "eclamptic status". After a seizure, a woman sometimes loses consciousness, that is, an eclamptic coma develops. (Sudden loss of consciousness may occur without an attack of convulsions.)

Before convulsions appear, the head begins to hurt sharply, insomnia occurs, and pressure rises. The woman feels intense anxiety. The seizure lasts 1 to 2 minutes.

A convulsive seizure consists of several stages.

1. Preconvulsive period. It lasts approximately 30 s. The muscles of the face twitch, the corners of the mouth drop, the eyelids close.
2. Period of tonic convulsions. It also lasts about 30 seconds. The muscles of the whole body are reduced, the torso is tensed. The face turns blue, breathing stops.
3. period of clonic convulsions. Continues 30 s. There is twitching of the facial muscles, muscles of the whole body and limbs. Convulsions become weaker. Breathing becomes hoarse, there is foam from the mouth with blood.
4. Consciousness gradually returns. The woman does not remember anything that happened to her just a few minutes ago.

The excitability of the central nervous system during eclampsia increases markedly. A new attack can occur from a variety of stimuli, such as light and noise.

Magnesium sulfate is often used in the treatment of eclampsia. This drug is also used for preeclampsia. Magnesium sulfate is administered slowly intravenously or intramuscularly. At the same time, tendon reflexes and respiratory rate are necessarily controlled. But if the patient is taking calcium channel blockers, magnesium sulfate is not prescribed, because there is a danger of a sharp drop in blood pressure.

With eclampsia, chlorpromazine or diazoxide is sometimes administered intravenously. It is also possible intravenous, then drip administration of diazepam (seduxen).

Long-term rehabilitation therapy is of great importance. It is necessary for women who have suffered preeclampsia and eclampsia. Rehabilitation therapy can lower blood pressure, improve microcirculation and hemodynamics of the brain.

During the period of rehabilitation therapy, patients are advised to take mildronate 1 tablet (125 mg) three times a day in the period after childbirth. Mildronate affects the redistribution of blood flow in the brain, helps to eliminate functional disorders of the nervous system, improves blood supply to the brain.

If the patient has had eclampsia or preeclampsia, then even after discharge she should be under the supervision of a cardiologist, urologist, internist and neuropathologist. Timely treatment and further monitoring can avoid serious consequences that can lead to disability.

Arterial hypertension in pregnant women

The concept of "arterial hypertension in pregnancy" is used to refer to various painful conditions.

First of all, we mean the following diseases:

• Hypertension in pregnancy. Pregnant hypertension is said to be when a pregnant woman's blood pressure is greater than 140/90 mm PC and rises for the first time after the 20th week.
• Severe hypertension in pregnancy. If blood pressure readings exceed 160/110 mm PC.
• Preeclampsia. The diagnosis is made when, along with high blood pressure, protein in the urine is observed in an amount of more than 300 mg per day. Clinical manifestations such as headaches, double vision and ripples in the eyes, pain in the upper part of the eye can also indicate preeclampsia.
• Eclampsia. The most severe form of preeclampsia, accompanied by convulsive seizures.

Measurement of blood pressure. Important conditions are a wide cuff and rest, otherwise the indicators may be unreliable.

At 20 weeks' gestation, a woman's blood pressure rises. This happens due to the occurrence of another circle of blood circulation. But normally, the pressure should not rise much, and the well-being of the expectant mother from higher blood pressure, as a rule, does not worsen. Otherwise, the doctor assumes arterial hypertension and prescribes examinations.

High blood pressure in a pregnant woman can be the result of various diseases. Before making a diagnosis of hypertension during pregnancy, the doctor must exclude other pathologies leading to increased pressure in the arteries:

• Atherosclerosis;
• Aortic valve insufficiency;
• Thyrotoxicosis (intoxication of the body with thyroid hormones of the thyroid gland);
• Hypothyroidism (lack of thyroid hormones);
• Body temperature above 37 degrees Celsius;
• Arteriovenous fistulas;
• Congenital heart defect;
• Pyelonephritis in a chronic form;
• Glomerular nephritis;

Causes of high blood pressure

Arterial hypertension — the cause of high blood pressure in 90 percent of patients awaiting the birth of a baby. They had such a diagnosis before conception.

Scientists believe that hypertension is neurogenic in nature. Stress, negative thoughts, mental overstrain provoke its appearance. All these factors lead to malfunctions in the central nervous system, one of the important tasks of which is to control the level of blood pressure. More often the disease occurs in people who are prone to excessive consumption of table salt, in those who smoke, abuse alcohol. At first, there is a periodic increase in blood pressure, with the development of the disease it becomes persistent.

During pregnancy, expectant mothers at 20 weeks are often diagnosed with gestational hypertension. The reason for this condition is pregnancy. It is not accompanied by protein loss and disappears 6 weeks after birth.

One of the most terrible diagnoses for a pregnant woman is pulmonary hypertension. Its causes are still not exactly established. If a pulmonary pathology is detected, as a rule, a woman is recommended to terminate the pregnancy, since such hypertension in pregnant women in 50 percent of cases leads to maternal death in the last months of waiting for the baby to be born or within a few years after childbirth.

Causes of arterial hypertension in pregnant women

• hereditary predisposition;
• Hypertension or other disease (see list above), which results in high blood pressure before conception;
• Excessive weight;
• preeclampsia;
• Stress;
• Hypodynamia;
• Smoking;
• Alcohol consumption.
• A large amount of salt in the diet, smoked meats.

Why is high blood pressure dangerous during pregnancy?

• If at the beginning of pregnancy the vessels are narrowed due to hypertension, at a later date there is placental insufficiency, oxygen starvation of the fetus, fetal developmental delay (hypotrophy).
• Hypertension during pregnancy can cause placental abruption, which leads to bleeding, stroke.
• Accession to AG preeclampsia and its development, which leads to edema, convulsions. Severe toxicosis in the later stages is a mortal danger for both mother and baby.
• A high risk of acute renal failure, circulatory disorders in the brain.

Symptoms

• High blood pressure at first from time to time, then constantly.
• Fast fatiguability.
• Severe headaches, dizziness.
• Feel the heartbeat (tachycardia).
• Rapid and labored breathing.
• Insomnia.
• Thoracalgia (chest pain).
• Noisy in the ears.
• Vision is impaired.
• The limbs become cold, goosebumps “crawl” over them.
• Thirst.
• At night, the urge to urinate more often than during the day.
• Hidden blood in urine.
• No justified anxiety.
• Bleeding from the nose.
• Nauseous, vomiting.
• The face turns red, the feeling that it is "burning".

Diagnostics

The federal clinical recommendations of the Ministry of Health of the Russian Federation, the national recommendations of the All-Russian National Health Committee on the topic of hypertension in pregnant women help the doctor to make the correct diagnosis and prescribe an effective treatment for arterial hypertension.

Anamnesis

Taking a history, the doctor should find out if the patient had high blood pressure before pregnancy - if so, it is likely that the pregnancy will proceed against the background of hypertension. This probability is increased by:

• smoking;
• diabetes;
• elevated blood cholesterol levels;
• premature death of a close relative due to cardiovascular disease;
• arterial hypertension in the patient during the previous expectation of the birth of the baby;
• past kidney disease, urination disorders;
• damage to the abdomen, abdominal organs before pregnancy;

The doctor examines the data of previous examinations, listens to the patient's complaints. If among them - a constant desire to drink, copious urine output, especially at night, lumbar pain - all these are symptoms of hypertension. A pregnant woman should definitely tell the doctor what medications she is taking in order to get rid of pain and relieve unpleasant symptoms.

Physical diagnostics

1. After weighing, the body mass index is calculated. If it is more than 27 kilograms per square meter - there is excess weight which increases the risk of developing hypertension.
2. The shape of the face is examined (the diagnosis of hypercortisolism is excluded), whether the limbs are proportionally developed (the diagnosis of coarctation of the aorta is excluded).
3. Having measured the patient's blood pressure, pulse in a sitting position, the doctor compares the indicators on both hands.
4. By palpation and listening, a study of the carotid arteries is carried out (the diagnosis of stenosis is excluded).
5. Examining the heart and lungs, the doctor can identify symptoms of cardiomyopathy, heart failure (the apex beat is localized, there are III, IV heart sounds, and moist rales in the lungs).
6. Palpation of the abdomen is performed, which makes it possible to detect polycystic kidney disease, thyroid gland.
7. Examination of the limbs reveals the presence of edema, how strong they are.
8. The doctor conducts a study of the urinary system.
9. If the patient complains of pain in the head, dizziness, her ability to keep balance with her eyes closed (Romberg's position), whether there are repetitive involuntary eye movements (nystagmus) is checked.

Research in the laboratory

• Determination of the presence of protein, occult blood, sugar in the urine.
• Blood test for biochemistry.
• Detailed blood test (clinical).

If there is a suspicion of symptomatic arterial hypertension, as well as in case of ineffectiveness of the treatment of hypertension prescribed by the doctor, additional tests are carried out: urine is examined by the Nechiporenko method, a microbiological analysis of urine is done, the amount of glucose in the blood plasma is determined (the analysis must be taken on an empty stomach), the hormonal composition of the blood is determined. analysis is prescribed depending on the suspicion of a particular disease, a symptom of which may be high blood pressure.

Non-invasive diagnostics

• Measurement of blood pressure according to N.S. Korotkov. The pressure is measured in silence, calm, 2 hours after eating, after a minimum of 5 minutes of rest. The first tone is systolic pressure, the last one is diastolic. There is such a phenomenon in many pregnant women (about 30 percent) - white coat hypertension. View medical worker causes a state of stress in the patient, in connection with which her blood pressure rises. In such cases, daily monitoring of blood pressure is prescribed.
• Echocardiography. This study is necessary if there is a suspicion of heart disease.
• Ultrasound examination of the kidneys, adrenal glands.
• Ophthalmoscopy (the condition of the vessels of the microvasculature is assessed).
• Dopplerography of the vessels of the fetoplacental system.

Treatment

If the blood pressure of a pregnant woman has increased by 30 millimeters of mercury or more, urgent hospitalization is necessary. Hospitalization is also needed to clarify the causes of arterial hypertension, in cases where preeclampsia is associated with hypertension or outpatient therapy is ineffective.

Treatment with non-drug means

To cope with hypertension during pregnancy, if the systolic pressure is not higher than 150, and the diastolic pressure is not higher than 100 mm Hg, there is no kidney disease, the fundus and the fetoplacental system are normal, you can use the following measures:

• gaining emotional peace;
• switching to proper, regular nutrition (less fats, especially saturated ones, more vegetable fiber, dairy products, cereals);
• sufficient physical activity;
• daytime sleep;
• reducing the amount of salt in food to 5 grams (daily rate);
• daily walks in the fresh air;
• physiotherapy (neuroson, inductothermy);
• HBO (pressure chambers).

Medical treatment

If systolic ("upper") pressure during pregnancy becomes 30 mm Hg higher than normal, and diastolic ("lower") pressure is 15 mm Hg higher than normal, treatment of hypertension in pregnant women with medications to reduce pressure, especially if there are symptoms of preeclampsia.

A pregnant woman with a diagnosis of hypertension is indicated for monotherapy (a combination of drugs is used in extreme cases), the doses of the drug should be minimal, the approach to treatment is chronotherapeutic.

For hypertension of 1-2 degrees, the doctor usually prescribes one of the following medications:

• "Methyldopa";
• "Labetalol";
• "Pindolol";
• "Oxprenolol";
• "Nifedipine".

To correct placental insufficiency, drugs are prescribed that affect the metabolism in the placenta, its bioenergetics, microcirculation processes, and protein synthesis.

Women diagnosed with arterial hypertension during pregnancy must be registered with a therapist. Every year this disease in women of childbearing age is more common. According to data provided by WHO, as the cause of death, hypertensive syndrome occurs in 30 percent of maternal deaths. Every year, due to complications caused by arterial hypertension, 50 thousand women die on our planet during pregnancy and childbirth.

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 WHO, hypertensive syndrome is the second cause of maternal death after embolism, accounting for 20-30% of cases in the structure of maternal mortality. Rates of perinatal mortality (30-100 0/00) and preterm birth (10-12%) in pregnant women with chronic hypertension are significantly higher than those in pregnant women without hypertension. Hypertension increases the risk of abruption 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 last years in surveys of the population, elevated blood pressure (BP) numbers were found in 23.1% of people aged 17-29 years. At the same time, the early appearance of AH is one of the factors that determine the unfavorable prognosis of the disease in the future. It is important that the frequency of detection of patients with hypertension in terms of negotiability is significantly lower than in mass surveys of the population. This is due to the fact that a significant proportion of people, mostly with early stages of the disease, feel well and do not visit a doctor. This, apparently, also explains to a certain extent the fact that many women find out that they have high blood pressure only during pregnancy, which greatly complicates the diagnosis and treatment of such patients.

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

Hemodynamic changes during physiological pregnancy are an adaptation to the coexistence of mother and fetus, they are reversible and 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;
• gradual increase in body weight of a pregnant woman;
• an increase in the size of the uterus and limitation of the mobility of the diaphragm;
• increased intra-abdominal pressure;
• change in the position of the heart in the chest;
• increase in blood levels of estrogen, progesterone, prostaglandins E.

Physiological hypervolemia is one of the main mechanisms that ensure the maintenance of optimal microcirculation (oxygen transport) in the placenta and 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 blood volume during childbirth without developing severe hypotension. The volume of blood plasma 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, so-called physiological anemia of pregnancy occurs, on the one hand, and hypervolemic dilution, leading to a decrease in blood viscosity, on the other.

By the time of birth, blood viscosity reaches a normal level.

Systemic BP healthy women changes slightly. In a normal pregnancy, systolic blood pressure (SBP) and diastolic blood pressure (DBP), as a rule, decrease in the II 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, causing a drop in total peripheral vascular resistance (OPSS).

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

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

With a physiologically proceeding pregnancy, there is a significant decrease in OPSS, which is associated with the formation of a uterine circulation with low resistance, as well as with the vasodilating effect of estrogens and progesterone. A decrease in peripheral vascular resistance, as well as a decrease in blood viscosity, facilitates hemocirculation and reduces 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 peripheral vascular resistance and blood viscosity, aimed at reducing blood pressure;
• an increase in 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 the subject of discussion, since there are no uniform criteria and classification signs of hypertension during pregnancy, there is no single terminology base (for example, the term preeclampsia is used to refer to the same process in Russia and in many European countries, in the USA and UK - preeclampsia, Japan - toxemia).

More than 100 classifications of hypertensive conditions during pregnancy have been proposed. In particular, the International Classification of Diseases of the 10th revision (ICD-10) combines all such manifestations associated with pregnancy in the 2nd obstetric block. In Russia, all diseases are encrypted 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 in pregnancy (no preeclampsia by the time of delivery and the pressure returns to normal by the 12th week after birth (retrospective diagnosis)); b) chronic hypertension (the rise in pressure after childbirth persists (retrospective diagnosis)).

Chronic hypertension refers to hypertension 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 diagnosed for the first time during pregnancy but not resolved after delivery is also classified as chronic.

The pregnancy-specific gestosis 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 determine SBP above 140 mm Hg. Art. and DBP above 90 mm Hg. Art. in women who had normal blood pressure before the 20th week. At the same time, proteinuria is considered to be a 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. In the case of its use, it is necessary to obtain two urine samples with a difference of 4 hours or more. For analysis, an average portion of urine or urine obtained through a catheter is used. The sample is considered positive if the amount of albumin in both samples reaches 1 g/L.

Previously, the rise in SBP by 30 and DBP by 15 mm Hg. Art. it was recommended to consider it as a diagnostic criterion, even if the absolute values ​​of blood pressure are below 140/90 mm Hg. Art. Some authors do not consider this a sufficient criterion, since the available data show that there is no increase in the number of adverse outcomes in women in this group. Nevertheless, most experts call for special attention to women in this group who have a rise in SBP by 30 and DBP by 15 mm Hg. Art., especially in the presence of concomitant proteinuria and hyperuricemia.

Diagnostics

The most common errors in measuring blood pressure include: a single blood pressure measurement without prior rest, using the wrong cuff size ("cuff" hyper- or hypotension) and rounding numbers. The measurement must be taken on both hands. The SBP value is determined by the first of two consecutive auscultatory tones. In the presence of an auscultatory failure, there may be an underestimation of blood pressure numbers. The value of DBP is determined by the fifth phase of the Korotkoff sounds. Measurement of blood pressure should be made with an accuracy of 2 mm Hg. Art., which is achieved by slowly releasing air from the cuff of the tonometer. At different values, the greater is considered true blood pressure. Measurements in pregnant women are preferably performed in a sitting position. In the supine position, due to compression of the inferior vena cava, blood pressure values ​​\u200b\u200bcan be distorted.

Single increase in blood pressure ≥ 140/90 mm Hg. Art. registered in approximately 40-50% of women. It is obvious that a random single measurement of blood pressure for the diagnosis of hypertension in pregnant women is clearly not enough. In addition, the phenomenon of so-called “white-coat hypertension”, i.e., high blood pressure when measured in a medical environment (office blood pressure) compared to ambulatory (home) measurement, is widely known. Approximately 30% of pregnant women with hypertension registered at the doctor's office during the daily monitoring of blood pressure (ABPM) had a normal average daily blood pressure. Until now, the question of the prognostic value 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 fully defined. In addition to diagnosing "white coat hypertension", evaluating the effectiveness of therapy in 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 in severe preeclampsia, the circadian rhythm of blood pressure can be perverse, with a peak in blood pressure at 2 am.

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

Antihypertensive therapy for hypertension in pregnant women

The long-term use of antihypertensive drugs in pregnant women with chronic hypertension is a matter of controversy. A decrease in blood pressure can impair uteroplacental blood flow and compromise fetal development. Over the past 30 years, there have been seven international studies comparing groups of women with mild chronic gestational hypertension when using various schemes management (with the appointment of antihypertensive therapy and without pharmacological correction of hypertension). Treatment did not reduce the incidence of superimposed preeclampsia, preterm birth, placental abruption, or perinatal mortality compared to no treatment groups.

Some centers in the United States currently keep women with chronic hypertension who have stopped taking antihypertensive drugs under close observation. 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 monitoring 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 of the Working Group on High Blood Pressure in Pregnancy, 2000, consider the following criteria for prescribing treatment: 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 starting antihypertensive therapy: with blood pressure over 170/110 mm Hg. Art. (with 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 elevated blood pressure. At the same time, normal numbers of arterial hypertension give a picture of false well-being. European guidelines for the diagnosis and treatment of pregnant women with hypertension suggest the following tactics for managing pregnant women with various options AG.

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

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

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

FDA Fetal Safety Classification Criteria (2002):

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

B - a risk to the fetus is found in animals, but not in humans, or there is no risk in the experiment, but there are not enough studies in humans;

C - Side effects have been reported in animals, but insufficient studies have been reported 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 exceed 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 to 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 very responsible and difficult. a case that requires strict consideration of all the pros and cons of this treatment.

Methyldopa

This drug belongs to class B according to the FDA classification. It is preferred as a first line treatment by many clinicians based on reports of stability in uteroplacental blood flow and fetal hemodynamics, as well as 7.5 years of follow-up with a limited number of children without any delayed developmental adverse effects following methyldopa administration during pregnancy. their mothers.

Benefits of methyldopa:

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

Disadvantages of methyldopa:

• it is not recommended to use at the 16-20th week (possible effect on the content of dopamine in nervous system 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 combined into 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 pregnancy comes from studies on the effects of adrenoblockers, including β-blockers and the α-β-blocker labetalol. There is an opinion that β-blockers given in early pregnancy, in particular atenolol, can cause fetal growth retardation. However, none of these drugs gave serious side effects; although long-term follow-up is not enough to state this with complete certainty.

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

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

In accordance with the FDA classification, atenolol, metoprolol, timolol, oxprenolol, propranolol, labetolol belong to class C, pindolol, acebutolol belong to class B.

Dadelszen in 2000 conducted a "fresh" meta-analysis of clinical trials on β-blockers and made some very interesting findings. The intrauterine growth retardation 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 has not been carried out in humans. With limited uncontrolled use of prazosin and a β-blocker, 44 pregnant women showed no adverse effects. The use of prazosin in the III trimester in 8 women with hypertension did not reveal any clinical complications after 6-30 months, the children developed normally.

The advantages of this group of drugs are as follows:

• effective reduction 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).

Flaws:

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

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

calcium antagonists. Experience with the use of calcium antagonists is limited to their appointment mainly in the third trimester of pregnancy. However, a multicentre 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 the control group that did not receive treatment.

Benefits of calcium antagonists:

• fetal weight 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 II trimester, neither positive nor negative effects of the drug were found when compared with the control group that received no treatment);
• the 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 found 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 for the relief of a hypertensive crisis in pregnant women is better taken orally than sublingually);
• 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 are class C.

Diuretics(hypothiazid 25-100 mg/day). Opinions about the use of diuretics during pregnancy are controversial. Medical concerns are largely understandable. It is known that preeclampsia is associated with a decrease in plasma volume and the prognosis for the fetus is worse in women with chronic hypertension who have not experienced an increase in BCC. Dehydration can impair uteroplacental circulation.

Against the background of treatment, electrolyte disturbances, an increase in the level of uric acid may develop (which means that this indicator cannot be used to determine the severity of preeclampsia). 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 not usually given in the first place. A meta-analysis of nine randomized trials involving more than 7000 subjects treated with diuretics showed a trend towards a decrease in the development of edema and / or hypertension with a confirmed absence of an increase in adverse fetal outcomes. At the same time, 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 a decrease in uteroplacental blood flow (preeclampsia and intrauterine growth retardation). A number of experts believe that pregnancy is not a contraindication to the use of diuretics in women with essential hypertension that preceded conception or manifested before mid-pregnancy. However, data on the use of diuretics to lower blood pressure in pregnant women with hypertension is insufficient.

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, and is prescribed in the II and III trimesters according to strict indications.

Clonidine- the central α 2 -agonist has limitations for use during pregnancy, and when taken in the postpartum period, one 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 was detected.

Myotropic antispasmodics currently not used for planned 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 dysplasia with impaired ossification of the cranial vault, shortening of the limbs, oligohydramnios (oligohydramnios), neonatal renal failure (kidney dysgenesis, acute renal failure in the fetus or newborn), death 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 these drugs should also 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 starting 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 begin already when it rises to 100 mm Hg. Art. .

The spectrum of drugs used in the treatment of acute severe hypertension in pregnancy includes hydralazine (start with 5 mg IV or 10 mg IM). If not effective, repeat after 20 minutes (5 to 10 mg depending on response; if desired blood pressure is achieved, repeat as needed (usually after 3 hours); if no effect from a total dose of 20 mg intravenously or 30 mg intramuscularly, use another agent ); labetalol (start with a dose of 20 mg IV; if the effect is insufficient, give 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 per os and repeat after 30 minutes if necessary); sodium nitroprusside (rarely used when no effect of the above agents and/or signs of hypertensive encephalopathy; start at 0.25 mg/kg/min up to a maximum of 5 mg/kg/min; cyanide poisoning of the fetus may occur with therapy lasting more than 4 hours).

Sudden and severe hypotension may occur with any of these drugs, especially the 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 is safer than the oral or intramuscular route, as it is easier to prevent accidental hypotension by stopping intravenous infusion than to stop 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, pregnancy is indicated in the instructions for this drug 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 falls. This is necessary for the normal growth of placental vessels and 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 the background of high blood pressure or hypertension occurs already during pregnancy. This condition is dangerous for the mother and the fetus.

In what cases 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 death. Therefore, the disease must be detected and treated in a timely manner.

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

1. Increased blood pressure up 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 passed.
4. Single increased diastolic pressure above 110 mm Hg. Art.

Pregnancy hypertension proceeds through stages similar to conventional 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 - blood pressure from 180/110 and more.

According to the classification, pathology can be of several types. Depending on the date of occurrence:

• Hypertension that existed before pregnancy - the woman was diagnosed with hypertension or the first signs appeared before the 20th week of gestation, symptoms of this form persist for more than 42 days after childbirth.
• Gestational hypertension - initially normal pressure after 20 weeks rises to significant levels exceeding 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.
• Unclassifiable hypertension due to lack of information.

The course of the disease is gradual. 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. Signs of ischemia increase in the heart, angina pectoris, 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 causes. This is a deep neurosis, which leads to a breakdown in the regulation of the work of blood vessels. The development of pathology is aggravated by past diseases of the vessels, brain, and kidneys. The situation is aggravated by excess weight, excessive consumption of table salt, smoking and alcohol.

The mechanism of development 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 go into a state of spasm, which entails an increase in pressure.

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

What does it threaten?

Hypertension and pregnancy are a dangerous combination. At high pressure, narrowing of the lumen of the vessels occurs. At the same time, already in the early stages of pregnancy, the blood flow in the placenta is disturbed. The fetus does not receive enough nutrition and oxygen, its development slows down and, according to the results of ultrasound, does not correspond to the deadline. In some cases, the violation of blood flow ends with a 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.

Increased pressure can turn into full-fledged preeclampsia. At the same time, 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 in 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 pathology?

Chronic hypertension during pregnancy can be both a primary disease and 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, polycystosis, kidney infarction, diabetic lesion, nephrosclerosis;
• diseases of the endocrine system: acromegaly, hypothyroidism, pheochromocytoma, hypercortisolism, Itsenko-Cushing's disease, thyrotoxicosis;
• vascular pathology: aortic coarctation, 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 the internal organs.

How does hypertension manifest itself?

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

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

• sleep disorders;
• palpitations that are felt on their own;
• dizziness;
• cold hands and feet;
• chest pain;
• dyspnea;
• blurred vision in the form of flies before the eyes, blurred vision;
• noise or ringing in the ears;
• paresthesia in the form of a feeling of "crawling";
• unmotivated feeling of anxiety;
• nosebleeds;
• rarely - thirst, frequent nighttime urination.

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

Additional examination

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

Data are needed on the expectant mother's addiction to smoking, existing diabetes mellitus, overweight or diagnosed obesity, and a violation of the ratio of lipids in the blood. The presence of diseases of the cardiovascular system in young relatives and death from them at a young age is important.

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

Be sure to specify the time of the appearance of complaints, they increased gradually or appeared suddenly, correlate this with the gestational age. Particular attention is paid to the weight of the expectant mother. A body mass index greater than 27 significantly increases the risk of developing hypertension. Therefore, even before the onset of pregnancy, it is recommended to lose at least 10% of the weight for those who have an excess of this indicator.

During the examination, the following studies 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;
• examine the pulse on the femoral arteries and once the pressure on the lower extremities.

If, when moving from a horizontal to a vertical position, diastolic pressure increases, then this speaks in favor of hypertension. A decrease in this indicator is symptomatic hypertension.

Diagnosis includes mandatory examination methods and additional ones, which are used in case of disease progression or treatment failure. The following methods 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 checked at every visit to the doctor. 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 alleged 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;
• consultation with an ophthalmologist and examination of the fundus vessels;
• daily monitoring of blood pressure;
• urine test for bacteria.

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

Principles of therapy

During pregnancy, the 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 by 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 allow you to determine how high the risk of progression of the condition, its transition to preeclampsia or the occurrence of pregnancy complications. Hospitalized pregnant women who are undergoing outpatient treatment, but without positive dynamics.

1. Non-drug treatment.
2. Medical therapy.
3. Dealing with complications.

Non-drug treatment

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

What about those who are at home? It is necessary to evenly distribute the regime of the day, leaving time for daytime rest, and preferably a short sleep. In the evening, going to bed should also be no later than 22 hours. 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, which can provoke nervous tension, or try to change your attitude towards them from a sharp emotional to a neutral one.

Additionally, reasonable physical activity is needed. It can be hiking in the fresh air, swimming or special gymnastics for pregnant women.

Both in the hospital and at home, a change in the nature of nutrition is provided. Frequent fractional nutrition 5 times a day, with the last meal no later than 3 hours before bedtime. Limit salt intake to 4 g per day. It is optimal to cook food without it, and add a little salt directly to your plate. Overweight women are limited in the amount of fats and simple carbohydrates. All pregnant women are advised to increase the proportion of vegetables and fruits, grains, dairy products in their diet.

For those who are undergoing treatment on an outpatient basis or in a hospital, it is possible to prescribe physiotherapy treatment:

• 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.

Medical treatment

Tablets under certain conditions:

• pressure rises higher than 130/90-100 mm Hg. Art.;
• systolic pressure increased by more than 30 units from normal for a woman or diastolic 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 minimal dosages that can be used as monotherapy. Taking pills should be regular, regardless of the indicators of the tonometer. Sometimes, deciding that the results of the measurement and general well-being are satisfactory, women will arbitrarily decide to stop taking the 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.

Preference is given to long-acting drugs. In case of ineffectiveness, combination therapy with several drugs may be used.

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

Atenolol is included in the list of permitted 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 hypertension:

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

In some situations, the above 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 feto-placental insufficiency. They use agents 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 its interruption. Therefore, sedative therapy, antispasmodics and progesterone treatment (Dufaston, 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.

Choice of due date

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

Early delivery is necessary in the following situations:

• treatment-resistant severe hypertension;
• fetal aggravation;
• serious complications of hypertension: heart attack, stroke, retinal detachment;
• severe forms of preeclampsia:,;
• premature detachment of a normally located placenta.

Natural childbirth is preferred, and an amniotomy is performed at an early stage. Necessary anesthesia and careful control of blood pressure. In the postpartum period, there is a high risk of bleeding, so the introduction of uterotonics (Oxytocin) is necessary.

Prevention options

It is not always possible to avoid hypertension during pregnancy, but it is possible to reduce the risk of developing it. To do this, you need to plan a pregnancy. Overweight women are advised to switch to proper nutrition in order to gradually reduce weight. But you can not use strict diets, starvation. After them, in most cases, extra pounds come back.

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

Women diagnosed with hypertension during childbearing are recommended to be hospitalized three times during pregnancy to clarify the condition and correct the therapy.

It is important to remember about 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 recommendations of the doctor.

Arterial hypertension during pregnancy - an increase in the absolute value of blood pressure to 140/90 mm Hg. and higher or rise in blood pressure compared to its values ​​before pregnancy or in the first trimester: systolic blood pressure - by 25 mm Hg. and more, diastolic blood pressure - by 15 mm Hg. and more from normal with 2 consecutive measurements with an interval of at least 4 hours or a single recorded diastolic blood pressure > 110 mm Hg.

Synonyms

arterial hypertension.
Hypertension (essential hypertension), neurocirculatory asthenia, symptomatic hypertension.

ICD-10 CODE
O10 Pre-existing hypertension complicating pregnancy, childbirth and the puerperium.
O16 Maternal hypertension, unspecified.

EPIDEMIOLOGY

AH occurs in 4–8% of pregnant women. This is the second (after embolism) cause of MS. According to WHO, MS in hypertension reaches 40%. PS indicators and the frequency of preterm birth (10-12%) in pregnant women with hypertension significantly exceed those in healthy pregnant women. Hypertension increases the risk of PONRP, can cause cerebrovascular accident, retinal detachment, eclampsia, massive coagulopathic bleeding, FPI, antenatal fetal death.

In various regions of Russia, the frequency of hypertensive conditions in pregnant women is 7–29%.

CLASSIFICATION OF ARTERIAL HYPERTENSION

The European Society for the Study of Hypertension in 2003 proposed to use to refer to hypertension in pregnant women
the following concepts:

• pre-existing hypertension - an increase in blood pressure diagnosed before pregnancy or during the first 20 weeks of gestation and persisting for at least 42 days after birth;
• gestational hypertension - hypertension registered after 20 weeks of pregnancy in women with initially normal blood pressure (with blood pressure normalizing within 42 days after birth);
• preeclampsia - a combination of gestational hypertension and proteinuria (proteinuria - the presence of protein in the urine in an amount of> 300 mg / l or > 500 mg / day, or more than "++" when it is qualitatively determined in a single portion of urine);
• pre-existing hypertension with gestational hypertension and proteinuria - a condition in which hypertension was diagnosed before pregnancy, but after 20 weeks of pregnancy, the severity of hypertension increases, proteinuria appears;
• unclassifiable hypertension - an increase in blood pressure, unclassified due to lack of information.

According to the WHO classification, it is customary to distinguish the following stages of arterial hypertension:
Stage I - increase in blood pressure from 140/90 to 159/99 mm Hg;
Stage II - increase in blood pressure from 160/100 to 179/109 mm Hg;
Stage III - increase in blood pressure from 180/110 mm Hg. and higher.

Allocate:
primary hypertension;
symptomatic hypertension.

Stages of hypertension.

● Stage I - no target organ damage.
● Stage II:

• left ventricular hypertrophy;
• local or generalized vasoconstriction of the retina;
• microalbuminuria, proteinuria, increased plasma creatinine concentration;
• signs of atherosclerotic lesions of the aorta, coronary, carotid or femoral arteries.

● Stage III:

• from the side of the heart: angina pectoris, myocardial infarction, heart failure;
• on the part of the brain: transient cerebrovascular accident, stroke, hypertensive encephalopathy;
• on the part of the kidneys: renal failure;
• on the part of the vessels: exfoliating aneurysm, symptoms of occlusive lesions of peripheral arteries.

US Department of Health and Human Services classification (1990)

● Hypertension that is not specific to pregnancy.
● Transient (gestational, transient) hypertension.
● Pregnancy-specific hypertension: preeclampsia/eclampsia.

ETIOLOGY OF ARTERIAL HYPERTENSION DURING PREGNANCY

In more than 80% of cases, hypertension that preceded pregnancy or manifested during the first 20 weeks of gestation is due to hypertension. In 20% of cases, hypertension before pregnancy increases due to other causes - symptomatic hypertension.

Causes of hypertension in pregnant women

● Conditions leading to systolic hypertension with high pulse pressure (arteriosclerosis, aortic valve insufficiency, thyrotoxicosis, fever, arteriovenous fistulas, patent ductus arteriosus).

● Conditions leading to the formation of systolic and diastolic hypertension:
- due to an increase in peripheral vascular resistance: chronic pyelonephritis, acute and chronic glomerulonephritis, polycystic kidney disease, stenosis of the kidney vessels, kidney infarction, nephrosclerosis, diabetic nephropathy, renin-producing tumors, endocrinopathies (hypercorticism, Itsenko-Cushing's disease, primary hyperaldosteronism, congenital adrenogenital syndromes, pheochromocytoma, hypothyroidism, acromegaly);
- Mental and neurogenic disorders: psychogenic hypertension, hypothalamic syndrome, familial autonomic dysfunction (Riley-Day syndrome);
- coarctation of the aorta;
- true polycythemia;
- nodular polyarteritis;
- hypercalcemia;
- hypertension (more than 90% of all cases of hypertension);
- preeclampsia;
- acute intermittent porphyria, etc.

In domestic cardiology, the leading mechanism for the formation of hypertension is still considered neurogenic, while emphasizing the uncertainty of its etiology.

At the initial stages of development, hypertension is a kind of neurosis that has arisen under the influence of stress factors, negative emotions, neuropsychic overstrain, leading to a breakdown in higher nervous activity. The combination of psycho-emotional overstrain with other predisposing factors matters. These include features of higher nervous activity, hereditary burden, past brain and kidney damage. Excess consumption of table salt, smoking, alcohol can have a certain value. It is believed that the formation and development of hypertension occurs due to dysfunction of the central nervous links that regulate the level of blood pressure, as well as as a result of shifts in the function of humoral regulation systems. Implementation of violations of corticovisceral regulation occurs through pressor (sympathicoadrenal, renin-angiotensin-aldosterone) and depressor (kallikrein-kinin, vasodilator series of prostaglandins) systems, which are normally in a state of dynamic equilibrium. In the process of developing hypertension, both excessive activation of pressor factors and inhibition of vasodilator systems are possible, leading to the predominance of the vasopressor system.

The initial stages of the disease, as a rule, proceed against the background of activation of the pressor systems and an increase in the level of prostaglandins. In the early stages, depressor systems are able to compensate for vasoconstrictor effects and AH wears labile character. Subsequently, the weakening of both pressor and depressor systems leads to a persistent increase in blood pressure.

PATHOGENESIS OF ARTERIAL HYPERTENSION DURING PREGNANCY

During pregnancy, a hereditary predisposition to hypertension may be realized, hypertension may be associated with insufficient production of 17-hydroxyprogesterone in the placenta, vascular sensitivity to angiotensin II, excessive activation of the renin-angiotensin-aldosterone system (at the same time, renal ischemia contributes to an increase in the production of renin and angiotensin II and secretion of vasopressin), a corticovisceral model of manifestation of hypertension in pregnant women is also possible. Consider the immunological theory of hypertension in pregnant women. Much attention is paid to endothelial dysfunction as a trigger for the development of hypertension.

Pathogenetic mechanisms of increased blood pressure, along with disorders in the central nervous system and the sympathetic division of the autonomic nervous system, are an increase in cardiac output and bcc, an increase in peripheral vascular resistance, mainly at the level of arterioles. Further, electrolyte ratios are disturbed, sodium accumulates in the vascular wall, and the sensitivity of its smooth muscles to humoral pressor substances (angiotensin, catecholamines, etc.) increases. Due to the swelling and thickening of the vascular wall, the blood supply to the internal organs worsens (despite the increase in blood pressure), and over time, due to the development of arteriolosclerosis, the heart, kidneys, brain and other organs are affected. The heart, forced to overcome increased peripheral resistance, hypertrophies, and with a long course of the disease, it dilates, which ultimately can contribute to the onset of heart failure.

Damage to the kidney vessels contributes to ischemia, growth of the juxtaglomerular apparatus, further activation of the renin-angiotensin system and stabilization of blood pressure at a higher level. Over time, kidney damage is manifested by a decrease in their filtration function and, in some cases, chronic renal failure may develop. As a result of damage to the cerebral vessels in patients with hypertension, there are hemorrhagic strokes, sometimes fatal. A prolonged increase in blood pressure contributes to the development of atherosclerosis. AH causes functional and morphological changes in blood vessels associated with narrowing of their lumen.

Atherosclerotic lesions of the coronary vessels leads to the occurrence of coronary heart disease, which occurs unfavorably in patients with hypertension. With cardiac hypertrophy, the number of capillaries does not increase, and the “capillary-myocyte” distance becomes larger. Atherosclerotic lesions of cerebral vessels can increase the risk of stroke, and atherosclerotic changes in other vessels cause more and more new clinical manifestations of damage to the corresponding organs.

Thus, primary disorders in the central nervous system are realized through the second link, i.e. neuroendocrine system (increase in pressor substances, such as catecholamines, renin-angiotensin, aldosterone, as well as a decrease in depressor prostaglandins of group E, etc.), and are manifested by vasomotor disorders - tonic contraction of arteries with increased blood pressure and subsequent ischemia and dysfunction of various organs .

The pathogenesis of complications of gestation

AH causes functional and morphological changes in blood vessels associated with narrowing of their lumen. At the same time, in the early stages of pregnancy, disturbances occur in the placental bed, which subsequently can lead to placental insufficiency, hypoxia and fetal hypotrophy. Hypertension increases the risk of PONRP, the development of preeclampsia with characteristic complications for the fetus and mother.

Preeclampsia of varying severity develops in 28–89.2% of pregnant women with hypertension and often appears early, at 24–26 weeks of gestation. Clinical manifestations of gestosis are very diverse and are caused by microcirculation disorders in vital organs, changes in the mineralocorticoid function of the adrenal glands, intravascular coagulation, etc. The hyperactivity of smooth muscle fibers observed in preeclampsia leads to an increase in peripheral, including renal, vascular resistance, which is ultimately accompanied by an increase in blood pressure. Preeclampsia, which developed against the background of hypertension, usually recurs in subsequent pregnancies, but is more severe.

Accession to hypertension gestosis is dangerous for both the mother and the fetus; increases the risk of stillbirth, premature birth, PONRP, eclampsia, acute renal failure, cerebrovascular accident. Stroke, eclampsia, and bleeding due to DIC caused by PONRP are the main causes of death in hypertensive pregnant women and women in childbirth.

WITH early dates Pregnancy with hypertension develops morphological and functional changes in the placenta, which leads to dysfunction of the placenta. FP is developing. As a result, the exchange of gases, nutrients and excretion products in the placenta worsens, which contributes to malnutrition and even death of the fetus.

Microscopic examination of the placenta reveals: thrombosis of blood vessels and intervillous spaces; signs of sclerosis and obliteration, narrowing of the lumen, atheromatosis of the arteries; edema of the stroma of the villi; necrotic changes in the placenta; the predominance of chaotic sclerosed villi. The spiral vessels of the placental bed retain the muscular and elastic layers either throughout the vessel or in its individual sections.

CLINICAL PICTURE (SYMPTOMS) OF INCREASED BLOOD PRESSURE DURING PREGNANCY

The clinical picture of hypertension is determined by the degree of increase in blood pressure, the functional state of the neuroendocrine system, various organs (primarily parenchymal), the state of hemodynamics (macro- and microcirculation) and blood rheology.

It is necessary to remember the depressive effect of pregnancy on the value of blood pressure in the first trimester. It is known that at various stages of a physiological pregnancy, blood pressure indicators undergo regular changes. During the first trimester of pregnancy, blood pressure (especially systolic) tends to decrease, and in the third trimester it gradually increases. In addition, during pregnancy and especially during childbirth, moderate tachycardia is observed, and immediately after childbirth, i.e. in the early postpartum period - bradycardia. It was found that the level of blood pressure reaches a maximum during attempts due to occlusion of the distal aorta.

Blood pressure in patients with hypertension during pregnancy is subject to fluctuations. Many researchers noted its regular decrease and increase at various stages of pregnancy. These observations do not always coincide. In some patients, the high level of blood pressure does not change significantly, in others it rises even more, and in the third, blood pressure normalizes or even turns out to be below normal. An increase in the level of previously elevated blood pressure is often due to the combination of preeclampsia in pregnant women and then swelling and albuminuria appear. A temporary decrease in blood pressure in patients with hypertension is usually observed in the first or second trimester; in the III trimester and after childbirth, after the elimination of depressant effects, blood pressure rises again and may exceed the values ​​​​set before the onset of pregnancy.

Typical complaints of patients - periodic fatigue, headaches, dizziness, palpitations, sleep disturbance, shortness of breath, chest pain, visual impairment, tinnitus, cold extremities, paresthesia, sometimes thirst, nocturia, hematuria, unmotivated anxiety, less often nasal bleeding. An increase in blood pressure, both systolic and diastolic, is considered the main symptom of the disease.

Initially, the increase in blood pressure is transient, non-permanent, then it becomes permanent and its degree corresponds to the severity of the disease. In most cases, pregnant women with hypertension have anamnestic evidence of an increase in blood pressure even before pregnancy. With an insufficiently defined history, the presence of hypertension can be assumed with heredity aggravated by this disease, an early increase (up to 20 weeks of pregnancy) in blood pressure, not accompanied by edema and albuminuria, as well as by the relatively middle age of the patient, retinal angiosclerosis, left ventricular hypertrophy, data on an increase BP during previous pregnancies.

DIAGNOSTICS OF HYPERTENSION IN PREGNANCY

Anamnesis

Periodic increase in blood pressure in the past can lead to suspicion of hypertension. Attention is drawn to the presence of such risk factors for hypertension as smoking, diabetes, dyslipidemia, as well as cases of early death of relatives due to cardiovascular disorders. An indication of hypertension that occurred during a previous pregnancy is important. Secondary hypertension often develops before the age of 35 years.

It should also pay attention to previous kidney diseases, dysuric diseases in the past, abdominal trauma, heredity, data from past examinations, details of complaints with an emphasis on thirst, polyuria, nycturia, discoloration of urine, back pain and their outcomes, use of drugs (taking analgesics , contraceptives, corticosteroids, sympathomimetics), the relationship of blood pressure with pregnancy, the presence of diabetes and tuberculosis in close relatives, etc.

Physical examination

It should be clarified for how long the complaints are disturbing, whether they arose gradually or suddenly, compare the time of their appearance with the gestational age.

A woman's body mass index >27 kg/m2 is a risk factor for the development of hypertension. Pay attention to the shape of the face, the presence, type and degree of obesity (suspicion of Cushing's syndrome), the proportionality of the development of the muscles of the upper and lower extremities (the violation may indicate coarctation of the aorta). Compare the value of blood pressure and pulse on both upper limbs, and measurements made in a horizontal position, with measurements in a standing position.

An increase in diastolic blood pressure during the transition from a horizontal to a vertical position is characteristic of hypertension, a decrease in blood pressure - for symptomatic hypertension. Palpation and auscultation of the carotid arteries reveal signs of their stenosis. When examining the heart and lungs, attention is paid to signs of left ventricular hypertrophy and decompensation of the heart (localization of the apex beat, the presence of III and IV heart sounds, moist rales in the lungs). Palpation of the abdomen reveals an enlarged polycystic kidney. The pulse on the femoral arteries is examined, blood pressure should be measured at least once in the lower extremities. Examine the limbs in order to detect edema and assess their degree. Examine the anterior surface of the neck, palpate the thyroid gland. Examine the urinary system. If neurological complaints (headaches, dizziness) are detected, nystagmus is determined, stability in the Romberg position.

Laboratory research

All studies in hypertension are divided into mandatory (basic studies) and additional. The latter are carried out in the event that symptomatic hypertension is suspected and / or therapy for hypertension is not effective.

Basic Research

● study of daily urine for the presence of protein (amount of protein or microalbuminuria), blood and glucose;
● biochemical blood test (total protein and its fractions, liver enzymes, electrolytes, glucose
blood);
● clinical blood test (concentration of Hb, Ht and platelet count);
● ECG.

Additional Research

If kidney disease is suspected, a urine test according to Nechiporenko is performed, a microbiological examination of urine is performed, the filtration (endogenous creatinine clearance) and concentration (urine analysis according to Zimnitsky) function is evaluated, and ultrasound of the kidneys is performed. The choice of other methods depends on the cause of the development of symptomatic hypertension.

● Complete blood count.
● Urinalysis (general and Nechiporenko).
● Determination of the level of glucose in the blood plasma (on an empty stomach).
● Serum levels of potassium, uric acid, creatinine, total cholesterol, high-density lipoproteins, triglycerides.
● Determination of potassium, phosphorus, uric acid in blood serum.
● Determination of serum creatinine or urea nitrogen.
● Determination of aldosterone, renin, determination of the ratio of potassium and sodium in plasma.
● Determination of urine 17-ketosteroids.
● Determination of 17-hydroxycorticosteroids and adrenocorticotropic hormone in the blood.

Instrumental Research

The main non-invasive method for diagnosing hypertension is auscultation of blood pressure according to N.S. Korotkov. For the correct measurement of blood pressure, see

For the correct measurement of blood pressure in order to classify hypertension, it is necessary to observe the conditions and methodology for measuring blood pressure: a quiet, calm environment, not earlier than 1-2 hours after eating, after rest (at least 10 minutes), before measuring blood pressure, tea, coffee and adrenomimetics are excluded . Blood pressure is measured in the "sitting" position, the cuff of the tonometer is placed at the level of the heart. Additional measurements of blood pressure while standing to detect orthostatic hypotension are carried out 2 minutes after the transition to a vertical position. It is advisable to measure blood pressure in orthostasis in the presence of diabetes mellitus, circulatory failure, vegetative-vascular dystonia, as well as in women receiving drugs with a vasodilating effect or with a history of episodes of orthostatic hypotension.

The pressure gauge must be checked and calibrated. The cuff is selected individually, taking into account the circumference of the arm (the latter is measured in its middle third): with OP<33 см используют манжету размером 12x23 см, при ОП=33– 41 см - 15x33 см, а при ОП >41 cm - 18x36 cm. Before measurement, it is necessary to evaluate systolic blood pressure by palpation (on the radial or brachial artery). When inflating the cuff, avoid the appearance of pain at the patient. The rate of decrease in air pressure in the cuff should be 2–3 mmHg. per second. The appearance of the first tone corresponds to systolic blood pressure (the first phase of the Korotkoff sounds). Diastolic blood pressure is determined by the 4th phase (the moment of a sharp weakening of tones). If “white coat hypertension” is suspected (occurs in 20–30% of pregnant women), 24-hour blood pressure monitoring is indicated. This method allows confirmation of hypertension, assessment of circadian rhythms of blood pressure and provides an individualized approach to the chronotherapy of hypertension. If congenital or acquired heart diseases are suspected, echocardiography is performed to assess the characteristics of the central hemodynamics of a pregnant woman and to resolve the issue of inversion of her types (against the background of pregnancy or with the ineffectiveness of drug therapy). Clarify the state of the vessels of the microvasculature during ophthalmoscopy. To assess the fetoplacental system, ultrasound and dopplerography of the vessels of the fetoplacental complex are performed.

● ECG.
● Echocardiography.
● Examination of the fundus.
● Ambulatory daily monitoring of blood pressure.
● Ultrasound of the kidneys and adrenal glands.
● Chest x-ray.
● Urine bacteriuria.

Complications of pregnancy in hypertension

Characteristic complications are preeclampsia, FPI, premature birth.

MM. Shechtman distinguishes three degrees of risk of pregnancy and childbirth:
● I degree (minimum) - complications of pregnancy occur in no more than 20% of women, pregnancy worsens the course of the disease in less than 20% of patients.
● II degree (severe) - extragenital diseases often (in 20-50% of cases) cause pregnancy complications such as preeclampsia, spontaneous abortion, premature birth; fetal hypotrophy is often observed, PS is increased; the course of the disease may worsen during pregnancy or after childbirth in more than 20% of patients.
● III degree (maximum) - most women suffering from extragenital diseases have pregnancy complications (more than 50%), term babies are rarely born and PS is high; pregnancy is a danger to the health and life of a woman.

As the severity of the underlying disease increases, the frequency of pregnancy complications such as spontaneous abortions and premature births increases. In the structure of pregnancy complications in hypertension, the highest specific gravity preeclampsia. As a rule, preeclampsia is extremely difficult, poorly amenable to therapy and repeated in subsequent pregnancies. The high frequency of gestosis in hypertension is due to the common pathogenetic mechanisms of dysregulation of vascular tone and kidney activity. One of the severe complications of pregnancy is PONRP.

Differential Diagnosis

Differential diagnosis of hypertension in pregnant women is carried out on the basis of an analysis of clinical and anamnestic data and the results of laboratory and instrumental examinations.

Differential diagnosis of hypertension is carried out with polycystic kidney disease, chronic pyelonephritis, diffuse diabetic glomerulosclerosis with renal failure and hypertension, renovascular hypertension, anomalies in the development of the kidneys, nodular periarthritis, coarctation of the aorta, pheochromocytoma, thyrotoxicosis, Itsenko-Cushing and Conn syndrome, acromegaly, en cephalitis and brain tumors .

Screening

To screen for hypertension during pregnancy, blood pressure is measured at each appointment. Prevention of complications is to normalize blood pressure.

A pregnant woman suffering from arterial hypertension is hospitalized three times during pregnancy.

The first hospitalization is up to 12 weeks of pregnancy. If stage I of the disease is detected, pregnancy can be saved, stages II and III serve as an indication for termination of pregnancy.

The second hospitalization at 28–32 weeks is the period of greatest stress on the cardiovascular system. During these terms, a thorough examination of the patient, correction of the therapy and treatment of FPI are carried out.

The third hospitalization should be carried out 2-3 weeks before the expected birth to prepare women for delivery.

Indications for consulting other specialists

To clarify the type of hypertension in a pregnant woman, the correction of drug therapy, a consultation is held with a general practitioner, cardiologist, ophthalmologist, urologist, nephrologist, endocrinologist.

Diagnosis example

Pregnancy 30 weeks. AG.

TREATMENT OF HYPERTENSION IN PREGNANCY

Treatment Goals

Reduce the risk of pregnancy complications and PS.

Indications for hospitalization

An absolute indication for hospitalization and the beginning of parenteral antihypertensive therapy is an increase in blood pressure by more than 30 mm Hg. from the initial and / or the appearance of pathological symptoms from the side of the central nervous system. Relative indications: the need to clarify the cause of hypertension in a pregnant woman, the addition of signs of preeclampsia or disorders of the fetoplacental system to the previous hypertension, the lack of effect from outpatient therapy for hypertension.

Non-drug treatment

Non-drug measures are indicated for all pregnant women with hypertension. With stable hypertension, when blood pressure does not exceed 140–
150/90–100 mmHg and there are no signs of damage to the kidneys, fundus and fetoplacental system in patients
with pre-existing hypertension, only non-drug effects are possible:

• elimination of emotional stress;
• change in diet;
• reasonable physical activity;
• day rest mode (“bed rest”);
• control of risk factors for the progression of hypertension;
• limiting salt intake to 5 g per day;
• limiting the intake of cholesterol and saturated fats in case of excess body weight.

An integral part of medical measures in pregnant women with hypertension should be an increase in the educational level
patients to ensure the conscious participation of the patient in the treatment and prevention process and increase its
efficiency.

• rational psychotherapy;
• reduction in salt intake to 5 g / day;
• change in diet with a decrease in the consumption of vegetable and animal fats, an increase in the diet of vegetables, fruits, grains and dairy products;
• being outdoors for several hours a day;
• physiotherapy procedures (electrosleep, inductothermy of the feet and legs, diathermy of the perirenal region);
• Hyperbaric oxygen therapy works well.

Medical treatment of hypertension during pregnancy

The main goal of hypertension therapy is to effectively lower blood pressure.

Medical treatment is indicated for:
● BP value more than 130/90–100 mm Hg;
● systolic blood pressure greater than 30 mmHg. and / or diastolic blood pressure - more than 15 mm Hg. exceeding the characteristic for this woman;
● with signs of preeclampsia or lesions of the fetoplacental system - regardless of the absolute numbers of blood pressure.

Principles of drug treatment of hypertension in pregnant women:
● carry out monotherapy with minimal doses;
● use chronotherapeutic approaches to treatment;
● preference is given to long-acting drugs;
● in some cases, combination therapy is used to achieve the maximum hypotensive effect and minimize undesirable manifestations.

According to the recommendations of the European Society for the Study of Hypertension, pregnant women with hypertension try not to prescribe angiotensin-converting enzyme blockers, angiotensin receptor antagonists and diuretics. To quickly reduce blood pressure, use: nifedipine, labetalol, hydralazine. For long-term therapy of hypertension, β-blockers are used: oxprenolol, pindolol, atenolol (taking the drug is associated with IGR), labetalol, nebivolol, methyldopa, slow calcium channel blockers - nifedipine (prolonged release forms), isradipine.

The recommendations of the All-Russian Scientific Society of Cardiology (2006) declare a list of drugs for the treatment of hypertension of varying severity in pregnant women. For the treatment of hypertension of 1-2 degrees, the drug of the 1st line - methyldopa (500 mg 2-4 r / day), 2 lines - labetalol (200 mg 2 r / day), pindolol (5-15 mg 2 r / day), oxprenolol ( 20-80 mg 2 r / day) and nifedipine (20-40 mg 2 r / day). For the treatment of grade 3 hypertension, the first-line drugs of choice are hydralazine (5–10 mg IV bolus, if necessary, repeated administration after 20 minutes until a dose of 30 mg is reached or IV administration at a rate of 3–10 mg/h), labetalol ( 10-20 mg IV bolus, repeated if necessary after 30 minutes or IV administration at a rate of 1-2 mg/h), nifedipine (10 mg every 1-3 hours).

1st line drugs.
● α2-Adrenergic agonists (methyldopa 500 mg 2-4 times a day).

2nd line drugs.
● Selective β-blockers (atenolol 25-100 mg 1 time per day; metoprolol 25-100 mg 1 time per day).
● Blockers of slow calcium channels (dangerous, but the benefits may outweigh the risks!): dihydropyridine derivatives - nifedipine 10-20 mg 2 times a day; amlodipine inside 2.5-10 mg 1-2 times a day; derivatives of phenylalkylamine - verapamil inside 120-240 mg 1-2 times a day (up to 12 weeks during the feeding period); felodipine 2.5–20 mg orally twice a day.

3rd line drugs.
● Methyldopa + 2nd line drug.

To correct FPI, therapeutic and preventive measures have been developed, including, in addition to agents that normalize vascular tone, drugs that affect placental metabolism, microcirculation (pentoxifylline, aminophylline), protein biosynthesis (orciprenaline) and placental bioenergetics.

To reduce the severity of the adverse effects of prescribed drugs and achieve a pronounced hypotensive effect, it is preferable to use combination therapy with low doses of two antihypertensive drugs (preferred combinations):
β-blockers + thiazide diuretics;
β-blockers + blockers of slow calcium channels of the dihydropyridine series;
slow calcium channel blockers + thiazide diuretics.

Prevention and prediction of complications of gestation

Pregnant women with hypertension should be identified as a high-risk group for both the fetus and the mother. Pregnant women are registered with a general practitioner and should be examined by a general practitioner 2-3 times during pregnancy. During pregnancy, there is a tendency to reduce blood pressure, in some cases, you can do without antihypertensive drugs. With the normal development of the fetus, pregnancy can continue until natural childbirth. There are three planned hospitalizations during pregnancy (see above).

Features of the treatment of complications of gestation

Treatment of complications of gestation by trimester

The goals of treatment are to reduce blood pressure to target levels with the minimum effective amount of prescribed therapy in order to minimize the risk of developing cardiovascular and obstetric complications in a pregnant woman and create optimal conditions for fetal development.

Treatment is carried out by a therapist.

In the first trimester, the minute volume of blood increases, and pregnancy is rarely complicated by fetal death and spontaneous miscarriage. An increased blood volume is a reflection of a compensatory reaction aimed at eliminating hypoxic shifts. With the threat of abortion, sedative, anti-stress, antispasmodic and hormonal therapy is used. When an abortion has begun, hemostatic agents are used to stop bleeding.

From the second trimester of pregnancy, AH develops morphological and functional changes in the placenta, which leads to dysfunction of the placenta and develops FPI. From the second half of pregnancy, when peripheral vascular resistance increases and minute blood volume decreases, the course of pregnancy worsens, malnutrition and intrauterine asphyxia of the fetus develop, and its death is possible. Combined forms of late preeclampsia develop from early pregnancy, sometimes up to 20 weeks.

Pharmacotherapy for preeclampsia should be comprehensive and include the following drugs: regulatory functions of the central nervous system; hypotensive; diuretics; for normalization of rheological and coagulation parameters of blood; for infusion-transfusion and detoxification therapy; drugs that improve uteroplacental blood flow; antioxidants, membrane stabilizers, hepatoprotectors; immunomodulators.

With the development of FPI in the II and III trimester, therapy is prescribed aimed at normalizing the function of the central nervous system, improving uteroplacental blood flow, affecting the rheological properties of blood, improving the trophic function of the placenta and normalizing metabolic processes.

If chronic fetal hypoxia occurs in the II and III trimester, therapy is aimed at improving uteroplacental blood flow, correcting metabolic acidosis, activating metabolic processes in the placenta, improving oxygen utilization and reducing the effect of hypoxia on the fetal central nervous system.

Treatment of complications in childbirth and the postpartum period A frequent obstetric pathology in this contingent of pregnant women is preterm birth. Arterial hypertension is one of the main causes of premature detachment of a normally located placenta. Preeclampsia against the background of hypertension, no matter what cause it is caused, with inadequate treatment, it can end in eclampsia.

Stroke, eclampsia, and bleeding due to DIC caused by placental abruption are the main causes of death in pregnant women and women in labor with arterial hypertension.

In the first and, especially, in the second stage of labor, a significant increase in blood pressure is noted, which is associated with psycho-emotional stress, a pain component during childbirth. Compensatory mechanisms are not able to provide an optimal level of blood pressure, there is a persistent increase in it, and cerebrovascular accidents are possible.

Childbirth is often accompanied by disorders labor activity, often acquire a fast and impetuous current.

In the third stage of labor, against the background of a sharp drop in intra-abdominal pressure and a decrease in aortic compression, blood is redistributed, which contributes to a decrease in blood pressure compared to the first two periods.

Often in childbirth, hypotonic bleeding occurs, often accompanied by vascular insufficiency.

Treatment of severe preeclampsia, including preeclampsia: hospitalization of patients has one goal -
delivery on the background of intensive care. Tactics for severe gestosis includes such points as:

• intensive therapy;
• abortion;
• delivery mainly by CS;
• anesthesia protection from the moment of admission to the maternity hospital;
• full readiness for possible massive coagulopathic bleeding during delivery;
• continued treatment of preeclampsia in the first 2–3 days after delivery;
• prevention of inflammatory and thrombotic complications in the postoperative (postpartum) period.

The main components of the treatment of pregnant women with severe preeclampsia:

• elimination of hypovolemia;
• administration of fresh frozen plasma;
• antihypertensive therapy;
• administration of magnesium sulfate.

Terms and methods of delivery

Determined individually. If the blood pressure of the pregnant woman is well controlled, the obstetric history is not burdened, the fetal condition is satisfactory - the pregnancy is prolonged to full term, programmed delivery is advisable through the natural birth canal with antihypertensive therapy, adequate analgesia of the birth act and monitoring control over the woman's blood pressure and the condition of the fetus.

Indications for early delivery:
● refractory to hypertension therapy;
● complications from target organs - myocardial infarction, stroke, retinal detachment;
● severe forms of preeclampsia and their complications - preeclampsia, eclampsia, posteclamptic coma, PON, pulmonary edema, PONRP, HELLP syndrome;
● deterioration of the fetus.

Most often, childbirth is carried out through the natural birth canal. In the first period, it is necessary to carefully monitor the dynamics of blood pressure in the first stage of labor, adequate pain relief, antihypertensive therapy, and early amniotomy. During the period of exile, antihypertensive therapy is enhanced with the help of ganglionic blockers. Depending on the condition of the woman in labor and the fetus, the second period is reduced by perineotomy or obstetric forceps. In the third stage of labor, bleeding is prevented. Throughout the birth act, fetal hypoxia is prevented.

Evaluation of the effectiveness of treatment

Achievement of target blood pressure in a pregnant woman with optimal perfusion of the placenta (decrease in diastolic blood pressure to 90 mm Hg).

PREVENTION OF HYPERTENSION DURING PREGNANCY

Patients with hypertension before pregnancy are classified as a high risk group for the formation of preeclampsia and FPI. For their prevention, it is recommended to take acetylsalicylic acid in a daily dose of 80–100 mg.

The feasibility of using low molecular weight heparins and magnesium preparations has not been confirmed.

INFORMATION FOR THE PATIENT

● AH worsens the prognosis of pregnancy and its outcomes.
● BP control should be achieved at the stage of pregnancy planning.
● Drug correction of hypertension prevents the progression of hypertension, but does not prevent the addition of preeclampsia.
● Hypertension requires regular medical supervision during pregnancy.
● All patients with hypertension are shown:
- elimination of emotional stress;
- change in diet;
- regular dosed physical activity;
- day rest mode ("bed rest").
● Antihypertensive therapy, individually prescribed and corrected by a doctor, should be permanent.
● With hypertension during pregnancy, it is necessary to regularly examine and carry out prevention and treatment of disorders of the fetoplacental system.

Medical rehabilitation allows women to restore their health and reproductive function; 90% of women after rehabilitation successfully completed a second pregnancy.

FORECAST

It is determined by the genesis and severity of hypertension, the development of lesions of target organs and the fetoplacental system, the effectiveness of antihypertensive therapy.

With compensated stages, the prognosis is favorable.