Pregnancy induced hypertension

Overview of Pregnancy induced hypertension

Hypertension is one of the common medical complications of pregnancy and contributes significantly to maternal and perinatal morbidity and mortality. Hypertension is a sign of an underlying pathology, which may be pre-existing or appears for the first-time during pregnancy.

The identification of this clinical entity and effective management plays a significant role in the outcome of pregnancy, both for the mother and the baby. Some amount of edema is common in a normal pregnancy. Edema has been excluded from the diagnostic criteria unless it is pathological.

The preeclamptic features may appear even before the 20th week as in cases of hydatidiform mole and acute polyhydramnios. The term, “Pregnancy-induced hypertension (PIH)” is defined as the hypertension that develops as a direct result of the gravid state.

Pregnancy induced hypertension includes

(i) Gestational hypertension,

(ii) Preeclampsia and

(iii) Eclampsia.[1]

Causes of Pregnancy induced hypertension

Generally, the exact cause of preeclampsia likely involves several factors. In detail, Experts believe it begins in the placenta — the organ that nourishes the fetus throughout pregnancy. Besides this, Early in a pregnancy, new blood vessels develop and evolve to supply oxygen and nutrients to the placenta.

In women with preeclampsia, these blood vessels don’t seem to develop or work properly. All in all, Problems with how well blood circulates in the placenta may lead to the irregular regulation of blood pressure in the mother.

Other high blood pressure disorders during pregnancy

Preeclampsia is one high blood pressure (in other words; hypertension) disorder that can occur during pregnancy. Other disorders can happen, too:

Gestational hypertension

It is high blood pressure that begins after 20 weeks without problems in the kidneys or other organs. Some women with gestational hypertension may develop preeclampsia.

Chronic hypertension

It is high blood pressure that was present before pregnancy or that occurs before 20 weeks of pregnancy. High blood pressure that continues more than three months after a pregnancy also is called chronic hypertension.

Chronic hypertension with superimposed preeclampsia

It occurs in women diagnosed with chronic high blood pressure before pregnancy, who then develop worsening high blood pressure and protein in the urine or other health complications during pregnancy.[4]

Risk factor of Pregnancy induced hypertension

Conditions that are linked to a higher risk of preeclampsia include:

• Preeclampsia in a previous pregnancy
• Being pregnant with more than one baby
• Chronic high blood pressure (hypertension)
• Type 1 or type 2 diabetes before pregnancy
• Kidney disease
• Autoimmune disorders
• Use of in vitro fertilization
• First pregnancy with current partner
• Obesity
• Family history of preeclampsia
• Maternal age of 35 or older
• Complications in a previous pregnancy
• More than 10 years since previous pregnancy [4]

Pathophysiology 

• While the question as to why the syndrome occurs still remains unsolved, the pathological changes are well documented, especially in severe preeclampsia or in eclampsia.
• Central to today’s explanations are impaired placental development, with defective trophoblast invasion into the spiral arteries and gradual reduction in placental perfusion.
• This leads to the release of substances in the maternal circulation which cause a generalized dysfunction of endothelial cells.
• This produced generalized vasospasm with increased vascular permeability and can be associated with an intravascular activation of the coagulation cascade.

Uteroplacental bed:

• There are increased evidences of premature aging of the placenta. Areas of occasional acute red infarcts and white infarcts are visible on the maternal surface of the placenta.
• Villi: Syncytial degeneration, increased syncytial knots, marked proliferation of cytotrophoblast, thickening of the basement layer, and proliferative endarteritis are evident in varying degrees. In preeclampsia, the normal endovascular invasion of cytotrophoblast into the spiral arteries fails to occur beyond decidua-myometrial junction.
• As a result, the musculoelastic media in the myometrial segment remains responsive to vasoconstrictor stimuli resulting in decreased blood flow. There is acute atherosis of spiral arteries with obliteration of lumen.
• Intervillous circulation: The blood flow is impaired to the extent of about one-third, secondary to the changes in the maternal blood vessels.
• This results in placental changes, anatomical and functional, which are responsible for fetal jeopardy.[1]

Kidney:

• The changes are conspicuous in the glomerulus which becomes enlarged. Endothelial cells swell up and fibrin-like deposits occur in the basement membrane.
• The lumen may be occluded. Interstitial cells in between the capillaries proliferate. There is associated spasm of the afferent glomerular arterioles.
• Patchy areas of damage of the tubular epithelium due to anoxia are evident. The net effects are reduced renal blood flow and glomerular filtration rate (25%), and impaired tubular reabsorption or secretory function.
• Recovery is likely to be complete following delivery. In severe cases, intense anoxia may produce extensive arterial thrombosis leading to bilateral renal cortical necrosis.

Blood vessels:

• There is intense vasospasm. Circulation in the vasa vasorum is impaired leading to damage of the vascular walls, including the endothelial integrity.

Liver:

• Periportal hemorrhagic necrosis of the liver occurs due to thrombosis of the arterioles.
• The necrosis starts at the periphery of the lobule. There may be subcapsular hematoma.
• Hepatic insufficiency seldom occurs because of the reserve capacity and regenerative ability of liver cells.
• Liver function tests are especially abnormal in women with HELLP syndrome.

HELLP Syndrome:

• This is an acronym for Hemolysis (H), Elevated Liver enzymes (EL) and Low Platelet count (LP) (70 IU/L, LDH >600 IU/L) and bilirubin (>1.2 mg/dL).
• There may be subcapsular hematoma formation (which is diagnosed by CT scan) and abnormal peripheral blood smear.
• Eventually liver may rupture to cause sudden hypotension, due to hemoperitoneum.[1]

Sign & Symptoms 

The defining feature of preeclampsia is high blood pressure, proteinuria, or other signs of damage to the kidneys or other organs. You may have no noticeable symptoms. The first signs of preeclampsia are often detected during routine prenatal visits with a health care provider.

Along with high blood pressure, preeclampsia signs and symptoms may include:

• Excess protein in urine (proteinuria) or other signs of kidney problems
• Decreased levels of platelets in blood (thrombocytopenia)
• Increased liver enzymes that indicate liver problems
• Severe headaches
• Changes in vision, including temporary loss of vision, blurred vision or light sensitivity
• Shortness of breath, caused by fluid in the lungs
• Pain in the upper belly, usually under the ribs on the right side
• Nausea or vomiting
• Weight gain and swelling (edema) are typical during healthy pregnancies.
• However, sudden weight gain or a sudden appearance of edema — particularly in your face and hands — may be a sign of preeclampsia. [4]

Diagnosis

A diagnosis of preeclampsia happens if you have high blood pressure after 20 weeks of pregnancy and at least one of the following findings:

• Protein in your urine (proteinuria), indicating an impaired kidney
• Other signs of kidney problems
• A low blood platelet count
• Elevated liver enzymes showing an impaired liver
• Fluid in the lungs (pulmonary edema)
• New headaches that don’t go away after taking pain medication
• New vision disturbances

High blood pressure

• A blood pressure reading has two numbers. The first number is the systolic pressure, a measure of blood pressure when the heart is contracting.
• The second number is the diastolic pressure, a measure of blood pressure when the heart is relaxed.
• In pregnancy, high blood pressure is diagnosed if the systolic pressure is 140 millimeters of mercury (mm Hg) or higher or if the diastolic pressure is 90 mm Hg or higher.
• A number of factors can affect your blood pressure. If you have a high blood pressure reading during an appointment, your health care provider will likely take a second reading four hours later to confirm a diagnosis of high blood pressure.

Additional tests

• If you have high blood pressure, your health care provider will order additional tests to check for other signs of preeclampsia:
• Blood tests- A blood sample analyzed in a lab can show how well the liver and kidneys are working. Blood tests can also measure the amount of blood platelets, the cells that help blood clot.
• Urine analysis- Your health care provider will ask you for a 24-hour urine sample or a single urine sample to determine how well the kidneys are working.
• Foetal ultrasound- Your primary care provider will likely recommend close monitoring of your baby’s growth, typically through ultrasound. The images of your baby created during the ultrasound exam allow for estimates of the baby’s weight and the amount of fluid in the uterus (amniotic fluid).
• Nonstress test or biophysical profile- A nonstress test is a simple procedure that checks how your baby’s heart rate reacts when your baby moves. A biophysical profile uses an ultrasound to measure your baby’s breathing, muscle tone, movement and the volume of amniotic fluid in your uterus.[4]

Differential Diagnosis

• Lupus nephritis
• Superimposed preeclampsia
• Hemolysis
• Elevated liver enzymes, low platelets syndrome
• Catastrophic APS
• Hepatorenal syndrome

Complications

The Complications of preeclampsia may include:

• Fetal growth restriction
• Abruptio placenta
• DIC
• Acute renal failure
• Severe ascites
• Pulmonary edema
• Pleural effusions
• Cerebral edema
• Laryngeal edema
• Retinal detachment
• Subcapsular liver hematoma
• ARDS
• Sepsis, and death
• Preterm birth
• Placental abruption
• Eclampsia

Other Complications

• HELLP syndrome- HELLP stands for hemolysis (the destruction of red blood cells), elevated liver enzymes and low platelet count. This severe form of preeclampsia affects several organ systems. HELLP syndrome is life-threatening to the mother and baby, and it may cause lifelong health problems for the mother.
• Other organ damage- Preeclampsia may result in damage to the kidneys, liver, lung, heart, or eyes, and may cause a stroke or other brain injury. The amount of injury to other organs depends on how severe the preeclampsia is.
• Cardiovascular disease-Having preeclampsia may increase your risk of future heart and blood vessel (cardiovascular) disease. The risk is even greater if you’ve had preeclampsia more than once or you’ve had a preterm delivery.[1][4]

Prevention 

Medication

• The best clinical evidence for prevention of preeclampsia is the use of low-dose aspirin.
• Your primary care provider may recommend taking an 81-milligram aspirin tablet daily after 12 weeks of pregnancy if you have one high-risk factor for preeclampsia or more than one moderate-risk factor.
• It’s important that you talk with your provider before taking any medications, vitamins or supplements to make sure it’s safe for you.

Lifestyle and healthy choices

• Before you become pregnant, especially if you’ve had preeclampsia before, it’s a good idea to be as healthy as you can be.
• Talk to your provider about managing any conditions that increase the risk of preeclampsia.[4]

Homeopathic Treatment

Homeopathy treats the person as a whole. It means that homeopathic treatment focuses on the patient as a person, as well as his pathological condition. The homeopathic medicines selected after a full individualizing examination and case-analysis.

which includes

• The medical history of the patient,
• Physical and mental constitution,
• Family history,
• Presenting symptoms,
• Underlying pathology,
• Possible causative factors etc.

A miasmatic tendency (predisposition/susceptibility) also often taken into account for the treatment of chronic conditions.

What Homoeopathic doctors do?

A homeopathy doctor tries to treat more than just the presenting symptoms. The focus is usually on what caused the disease condition? Why ‘this patient’ is sick ‘this way’?.

The disease diagnosis is important but in homeopathy, the cause of disease not just probed to the level of bacteria and viruses. Other factors like mental, emotional and physical stress that could predispose a person to illness also looked for. No a days, even modern medicine also considers a large number of diseases as psychosomatic. The correct homeopathy remedy tries to correct this disease predisposition.

The focus is not on curing the disease but to cure the person who is sick, to restore the health. If a disease pathology not very advanced, homeopathy remedies do give a hope for cure but even in incurable cases, the quality of life can greatly improved with homeopathic medicines.

The Homeopathic Medicines for Pregnancy induced hypertension (Preeclampsia)

The homeopathic remedies (medicines) given below indicate the therapeutic affinity but this is not a complete and definite guide to the homeopathy treatment of this condition. The symptoms listed against each homeopathic remedy may not be directly related to this disease because in homeopathy general symptoms and constitutional indications also taken into account for selecting a remedy.

Aconite

• Intense anxiety, fear, restlessness and tossing about.
• Sudden, violent acute conditions, due to fright, shock, cold dry winds; getting chilled whilst sweating.
• Hyperpyrexia with burning thirst, hot dry skin and rapid pounding pulse. Profuse arterial hemorrhages.
• Numbness and tingling of affected parts.
• Congestions and inflammations with sweating, redness and burning.
• Better – warmth and after sweating. 

Glonoine

• Confusion with dizziness.
• Head heavy but cannot lie it on a pillow, can’t bear anything about the head.
• Surging of blood to heart and head. Severe congestions to the head.
• Tendency to sudden and violent irregularities of the circulation.
• Any exertion brings rush of blood to heart and fainting spells. Pulsating sensation through’ body.
• Face flushed hot, livid; sweaty.
• Worse – in the sun, exposure to sun rays, gas open fire: jar, stooping, having hair out; peaches, stimulants, from 6am to noon, L side.[2]

Strophanthus Hispidus:

• Acts on the heart; diminishes the rapidity. Arteriosclerosis, rigid arteries of the old age person.
• Restores tone to a brittle tissue, esp. heart muscle and valves.

Sepia:

• Irritable, easily offended. Sad, indifferent to those loved best. Averse to occupation, to family.
• Weakness, yellow complexion.
• Pulsating headache in cerebellum.
• Violent intermittent palpitation, Beating in all arteries.
• Tremulous feeling with flushes. Feet hot and hands cold and vice versa.
• Worse – standing. cold air, Forenoon, evenings, washing, dampness, L side, before thunderstorm.
• Better – exercise, press., warmth of bed, hot applications, after sleep.

Veratrum viride:

• Quarrelsome and delirious. Especially adapted to full blooded, plethoric persons. Additionally, Controls action of heart and pulse.
• Paroxysms of auricular fibrillation.
• Valvular diseases, Beating of pulse throughout especially in R thigh. Bloated livid face.
• Bloodshot eyes. Great prostration. Lastly, Narrow well developed streak right through the middle of the tongue. 

Crataegus:

• Apprehensiveness and despondency.
• Heart tonic, Acts on heart muscle, Irregularity of heart.
• Insomnia of aortic sufferers; Oedema. High arterial tension.
• Sedative to cross, irritable patients.
• Arteriosclerosis; said to have a solvent power upon crustaceous deposits in arteries.
• Extreme Dyspnoea on least exertion, without much increase in pulse.
• Worse – warm room. Better – fresh air, quiet and rest.[2]

Diet & Regimen 

Recommendations for PIH

Dietary

• Reduce Sodium Intake: Limit processed foods, salty snacks, and added salt to reduce fluid retention and lower blood pressure.
• Increase Potassium Intake: Foods rich in potassium like bananas, sweet potatoes, and leafy greens can help counter the effects of sodium.
• Focus on Calcium: Adequate calcium intake is essential for blood pressure regulation. Include dairy products, fortified plant milk, or calcium supplements as advised by your doctor.
• Healthy Protein Sources: Choose lean protein like fish, poultry, beans, and lentils.
• Complex Carbohydrates: Opt for whole grains, fruits, and vegetables for sustained energy and fiber.
• Hydration: Drink plenty of water throughout the day to help your body flush out toxins.

Regimen for PIH

• Regular Prenatal Care: Frequent checkups are crucial to monitor blood pressure and overall health.
• Blood Pressure Monitoring: Home blood pressure monitoring may be recommended to track your levels between appointments.
• Medications: In some cases, your doctor may prescribe medication to manage blood pressure.
• Rest and Relaxation: Adequate rest and stress management techniques are important.
• Weight Management: Maintaining a healthy weight gain during pregnancy can help reduce the risk of complications.
• Regular Exercise: Light to moderate exercise, as approved by your doctor, can improve circulation and overall health.

References 

1. DC Dutta’s Text Book of OBSTETRICS
2. Homoeopathic Body-System Prescribing – A Practical Workbook of Sector Remedies
3. https://www.fernandezhospital.com/ Uploads/Document/189/dietary_guidelines _for_pregnancy_induced_hypertension.pdf
4. https://www.mayoclinic.org/diseases-conditions/preeclampsia/diagnosis-treatment/drc-20355751.
5. Prevalence and Risk Factors of Pregnancy Induced Hypertension Including Preeclampsia/Eclampsia in Women of Odisha, an Eastern I – Acta Scientific (2019).
6. Prevalence of pregnancy induced hypertension and associated factors in Kashmiri women attending a tertiary care hospital at Srinagar: a cross-sectional study | International Journal of Reproduction, Contraception, Obstetrics and Gynecology (2023). 
7. Williams Obstetrics, 26th Edition, F. Gary Cunningham, Kenneth J. Leveno, Steven L. Bloom, Jodi S. Dashe, Barbara L. Hoffman, Brian M. Casey, Catherine Y. Spong, 2020,  McGraw-Hill Education.