High Blood Pressure during Pregnancy…A SILENT KILLER!

The whole family was standing and praying, with teary eyes, in front of an operation theatre, lost in time and space, hearing the tick tock of the clock. It seemed that the time had stopped, their daughter was having a Caesarian section. Her husband was holding his 2 years daughter in arms, with the eldest son standing beside him. They were expecting a baby in a weeks’ time, she had her last checkup two and a half months ago, everything was fine except high blood pressure. A medication was prescribed, tests were advised and the couple was told to come back with reports. They were busy in house-shifting and she felt no problem, the couple decided to go after few weeks. And now she was 9 months pregnant, having headaches, swelling of feet and high blood pressure off and on, but they assumed it would settle. One crisp morning, all of a sudden, she fell down, started having fits and was taken to the emergency. Now she was having a C-section to save her and her baby’s life!! 

The family was thinking about what went wrong? could it been avoided? what will happen now? what if something happens? No! God please save them.

What do you think; isn’t this scary? does this happens in real or just a scenario? The distressing truth is that it’s a real case which I encounter very frequently. High Blood Pressure in pregnancy is one of the leading cause of maternal deaths, taking lives of women all over the world due to three very important factors:

1. delay in deciding to get a medical help
2. delay in reaching the medical facility 
3. delay in receiving the appropriate treatment 

But all of this is preventable, if we are aware of the causes of disease, danger signs, diagnostic and prognostic tests and treatment options. The doctor can not only save life of a mother and her baby but also prevent complications.

So let’s talk about high blood pressure; as it’s the most studied but least understood problem of pregnancy. It can exist before pregnancy or start due to pregnancy and then can exist throughout the life.

The fact is that it is a global problem but is very common amongst Asian and African population.

What is High Blood Pressure?
If your blood pressure is more than 140 /90 mmHg then it is high. Re-check after 6 hours, if same reading then you need to see your doctor immediately. Similarly if your diastolic blood pressure is more than 80 mmHg then you must not try home remedies or herbal medicines during pregnancy. If you had it before five months (20 week) of pregnancy then you were a high BP patient, but if you are having it after 20 week of pregnancy, then its pregnancy induced high blood pressure. This pregnancy induced high blood pressure has various types like pre-eclampsia ,pre-eclamptic toxaemia (severe pre-eclamsia) and eclampsia.

Types of Pregnancy Induced High Blood Pressure
You need to know certain medical terms about this condition: 

• Pregnancy induced hypertension (PIH) is… Pregnancy + high BP > (140/90)
• Pre-eclampsia (PE) is… Pregnancy + high BP > (140/90) + protein in urine + fluid retention
• Pre-eclampsia toxemia (PET) is… Pregnancy +high BP > (160/110) + proteins in urine + fluid retention + blood changes
• Eclampsia is… Pregnancy + high BP > (160/110) + proteins in urine + swelling + blood changes and fits.

The blood changes are due to low Hemoglobin, Elevated Liver enzymes and low Platelets; collectively called HELP syndrome.

Causes of High Blood Pressure During Pregnancy 
Remember, PLACENTA is the main culprit causing all the troubles of pregnancy induced hypertension whereas the growing fetus is only the target. The placental tissues form constriction rings in blood vessels of placenta and uterus causing reduced blood supply in placenta. It could be genetic, autoimmune, placental growth factors, hormones and abnormal ratio of chemicals acting on blood vessels, all this leads to high blood pressure. Similarly, situation worsens with pre-existing diabetes mellitus, renal disease, autoimmune disorders, twin pregnancy, placental tumors, family history of high blood pressure.

Effects of High Blood Pressure on Mother
Here are some of the major effects of high blood pressure:

1. The blood gets thick with a tendency for clots formation, but later when all the clotting factors and platelets are depleted then blood fails to clot causing life threatening bleeding from anywhere.
2. High blood pressure damages kidneys causing protein loss in urine, water retention and swelling of body tissues and if not treated, then eventually kidney failure occurs.
3. There is fluid accumulation around brain and irritation of brain cells cause fits. Sometimes there is bleeding or clot formation in brain which can cause brain damage, stroke, blindness or death.
4. The liver functions are disturbed as it becomes congested and inflamed, and it may rupture.
5. The electrolyte imbalance occurs causing more fluid retention, high uric acid damages heart and inside of blood vessels.

Effects of High Blood Pressure on Baby

1. Placenta insufficiency occurs due to thick contraction rings formation around the placental blood vessels, placenta can bleed or get detached due to high BP.
2. The reduced blood supply to baby makes it smaller in size, growth retarded and low birth weight.
3. The baby is more prone for premature delivery, breathing problems, jaundice and intestine damage.
4. The still birth or death of baby can occur in uterus in worst cases.

Danger Signs of High Blood Pressure
There are some life threatening signs for mother and baby, if you have any one of them Immediately go to nearest tertiary care hospital, as it cannot be handled in a basic health unit or a small clinic.

Blood pressure more than 159/110, headache, dizziness, irritability, blurred vision, pain in upper right part of tummy, vomiting, swelling of body, it is possible that some patients start having fits or suddenly become unconscious and at this stage mother and baby’s life are at risk.

Identification of High Risk Patients of Pet or Eclampsia
YES, we can predict, identify and treat high risk patients of high BP who are going to be affected during pregnancy with problems of PET. Please note all pregnant high BP patients do not have toxemia and fits, so only high risk patients need hospital admission. The detailed history, examination and laboratory tests are really helpful.

PLEASE SEE YOUR DOCTOR IF:
History of:

• Age > 40 years
• BMI > 35 or Marked Obesity
• First pregnancy or twins, last born > 10 years
• Patients of renal disease, diabetes, high BP, auto-immune disorders 
• Family history of high BP, PET 
• Feeling of lessened movements of baby

Physical Examination showing:
Mother

• BP more than 159 / 109
• Swelling feet (edema)
• Brisk reflexes 

Baby (fetal examination)

• Small in size as compared for pregnancy duration
• Intra-uterine growth retardation 

Laboratory Tests having the following vitals

• Proteins in urine
• High uric acid 
• Low hemoglobin
• Low platelets 
• High liver enzyme (ALT)
• High kidney creatinine
• Disturbed coagulation of blood 
• Increase in Flt/ PlGF

Latest Test for Predicting PET Complications
There is a new test which is really helpful in pregnant patients with BP more than 150/109, protein in urine and signs of pre-eclampsia. It predicts the problematic patients who are going to suffer in a weeks’ time. Therefore early referral and treatment is required.

Increase in s Flt 1/PlGF ratio 
Flt 1 is blood vessel growth factor where PlGF is placental growth factor. In high risk patients placental growth factors are really low. Therefore this ratio keeps on rising in patients with PET as compared to non-problematic patients. This test helps unnecessary hospital admissions, reduces total cost of treatment. It guides us for early referral to a tertiary care setup with senior consultants involvement, start of treatment and in long term improves maternal and feral outcome.

Medical Evaluation
It includes history, examination and certain blood tests:

• Blood complete counts 
• Coagulation profile 
• Liver and kidney function tests 
• Electrolytes and uric acid 
• Urine for proteins 

Prevention & Treatment
Salt restriction and taking rest are not really effective for controlling blood pressure and preventing complications. Low doses of Asprin has been proven a beneficial preventive medicine, as it lowers maternal blood pressure, improves blood flow to placenta and prevents intrauterine growth retardation of baby.

Please note High Risk patients are admitted in the hospital for multi-disciplinary approach in a tertiary care hospital where there are senior doctors, intensive care units and a good nursery for baby. The patients are monitored, treated and delivered.

For baby monitoring, there are different tests available that includes Cardiotocography, Serial ultrasounds and doppler studies, these help to monitor growth of baby, anticipate problems and decide time and mode of delivery.

Various blood pressure medicine is given to control BP, but they should be started by a doctor as all medicines are not safe during pregnancy. Once these medicines are started, proper BP monitoring is needed to adjust dose and avoid side effects.

In case of fits, patient should be managed in intensive care and baby is delivered to save maternal and fetal lives. These fits can also occur within 48 hours of delivery for a high BP patient; hence, first 48 hours after delivery are really crucial for observation and monitoring. 

The final treatment of these problems is the delivery of baby. 

In conclusion pregnancy induced high blood pressure is a predictable, preventable and manageable disease, if dealt timely and appropriately.

Oh I forgot to tell you about the above mentioned case…

A week later… they were going home with a beautiful baby and healthy mother; as they were timely and  appropriately managed by a competent team in a tertiary care unit.

Dr. Ayesha Azam Khan