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Hypertensive diseases of pregnancy

Hypertensive disorders complicate about 5-10% of all pregnancies, but they do account for 15-20% of maternal mortality and a high amount of maternal morbidity.There are four types of hypertensive disease that include pregnancy- induced hypertension, chronic hypertension, preeclampsia and superimposed preeclampsia. Preeclampsia is a disease with heterogenous etiology.The main pathophysiological mechanism is a disturbed placental implantation and an impaired forming of the spiral arterioles during second trimester.These processes lead to an increased reactivity of the vascular system against vasoactive agents with a generalized vasoconstriction and a dysfunction of the endothelial cell system resulting in activation of coagulation and production of microthrombi.Vascular changes can affect all organs,predominantly the placenta and consequently the fetus, the kidneys and the brain. The likelihood of recurrence during a subsequent pregnancy depends on the etiology, the severity and how early the disease occurred during pregnancy and is between 10% and 40%.

The pregnant women and their fetuses have to be under thorough surveillance, if necessary at the hospital because 31 all types of hypertensive disorders can result in a HELLP syndrome or an eclampsia. Severe diseases demand delivery as soon as possible, if possible via vaginal delivery and after treatment for fetal lung maturation, but always taking into consideration further pregnancy complications on the one hand and preterm delivery with a premature infant on the other hand. Intravenous magnesium is the treatment of choice in severe preeclampsia and in eclampsia. Oral antihypertensive therapy for outpatients is only useful in chronic hypertension,α-Methyldopa und β-blocking agents are preferred, for second line therapy dihydralazine or calcium channel blockers such as nifedipine can be used. At blood pressure levels >160/110 mmHg the patients have to be admitted to the hospital and treated with intravenous urapidil, for second line dihydralazine or calcium channel blockers. If a cesarean section is indicated, regional anaesthetic methods should be chosen. As no parameter has been proven to be of prognostic value and there is no effective prophylactic treatment of preeclampsia, management of hypertensive disorders should focus on early diagnosis and adaequate treatment.

Frank Chen
Charité - Universitätsmedizin Berlin, Klinik für Geburtsmedizin,
Charité Campus Virchow-Klinikum,Berlin

Reviewer: Ulrike Friebe-Hoffmann, Düsseldorf
und Britta Reichstein, Bremerhaven

CME Prakt Fortbild Gynakol Geburtsmed Gynakol
Endokrinol 2008; 4(1): 24-34