When we receive a diagnosis, we don’t always understand what it means and what impacts this new condition will have on our lives. When this happens during pregnancy—a time already full of doubts and uncertainties—these feelings tend to intensify.
To help you understand what having high blood pressure during pregnancy means and what precautions should be taken, we have prepared this article. Here you’ll find everything you and your family need to know about the topic and how to proceed.
- Hypertensive Disorders in Pregnancy
- Risk Factors and Prevention
- Symptoms
- Diagnosis
- Medical Management and Approaches
- Precautions You Should Take
- Risks and Consequences
- Access to Healthcare and Maternal Mortality in Brazil
- Pregnancy Interruption
Hypertensive Disorders in Pregnancy
As the name suggests, hypertensive disorders in pregnancy are health changes caused by an increase in blood pressure (BP) in pregnant women. Not every blood pressure problem starts before pregnancy; therefore, it is possible for a woman who never had hypertension to develop it during pregnancy.
There are different types of hypertensive disorders, each with its own characteristics and different levels of severity.
- Arterial Hypertension: diagnosis is made when systolic blood pressure is greater than or equal to 140 mmHg and/or diastolic blood pressure is greater than or equal to 90 mmHg.
When the heart pumps blood through our body, it performs two types of movements: one to contract and one to relax. These movements are called systole and diastole. When we measure blood pressure, the first value is for systole (contraction of the heart muscle), and the second value is for diastole (when the vessels relax to allow blood passage).
- Gestational Hypertension: arterial hypertension that appears for the first time after the 20th week of pregnancy, not accompanied by any symptoms or laboratory changes characteristic of pre-eclampsia.
- Mild Pre-eclampsia: defined by arterial hypertension first identified after the 20th week of pregnancy, associated with proteinuria (presence of proteins in the urine, above normal levels), and may be superimposed on another hypertensive state.
- Severe Pre-eclampsia (SPE): defined by a diagnosis of pre-eclampsia associated with maternal-fetal complications that are severe enough to pose imminent risks of maternal-fetal impairment.
- Eclampsia: the occurrence of generalized seizures in a pregnant woman with pre-eclampsia. These seizures are not caused by a neurological disease unrelated to pregnancy. The seizures can occur before birth, during labor, or in the postpartum period.
- HELLP Syndrome: a syndrome that causes several changes which, if left uncontrolled, can lead to serious complications for both mother and baby. It usually occurs in the third trimester but can also appear in the early trimesters or even postpartum. The changes caused by HELLP syndrome are: hemolysis (fragmentation of blood cells), elevated liver enzymes, and low platelets.
Where They Come From
Over the years, many theories have been suggested to explain the causes of gestational hypertension; but unfortunately, despite scientific efforts and advances, there is still no definitive answer. Recent studies point to a theory attributing these problems to a mix of genetic and immunological factors. The main hypothesis is that they are caused by placental abnormalities that occur early in pregnancy, but whose effects only become noticeable around the 20th week.
To better understand what happens, we need to talk about the moment when the cells that will become the placenta join with the uterus. It is believed that events leading to hypertensive syndromes occur at this stage.
Placentation begins very early in fetal development, when the placenta is not yet fully formed and is just a cluster of cells called trophoblasts. Between the 6th and 10th week of pregnancy, an event called trophoblastic invasion occurs, which is when the cells that will form the placenta attach to the uterus, causing the mother’s spiral arteries to adapt.
When this connection occurs and the trophoblasts reach the spiral arteries, they undergo remodeling. In this process, the wall structure changes and the vessels expand to allow more blood (from both mother and baby) to flow through.
Hypertension problems happen when, for some reason, these arteries do not dilate enough, remaining with a smaller diameter than necessary. This causes the vessel to carry less blood than it should, which ends up overloading the mother’s circulatory system and increasing blood pressure.
This poor formation of the arteries brings a series of consequences, as it impairs the transport of nutrients, oxygen, and hormone production. This malfunction leads to a series of physiological consequences that will later be identified and considered symptoms, such as increased blood pressure and proteinuria.
Risk Factors and Prevention
Although we cannot talk about preventing hypertensive syndromes, some risk factors have been identified over the years. That way, we can be more attentive to the signs and symptoms in order to identify, diagnose, and start control measures as quickly as possible.
Risk factors can be intrinsic or extrinsic, meaning “internal” or “external.”
External (extrinsic)
- Mother and sisters with a history of hypertensive syndromes
- Hypertension
- Diabetes Mellitus
- Socio-economic-cultural status
- Obesity
- Psychological state
Internal (intrinsic)
- First pregnancy
- Twin pregnancy
- Fetal macrosomia
- Polyhydramnios
- Advanced ectopic pregnancy
- Rh isoimmunization
Knowing these factors will not prevent or solve a hypertensive syndrome, but it certainly helps us stay alert from the beginning so we can act at the right time.
Reducing salt in the diet of pregnant women with the sole purpose of preventing pre-eclampsia is NOT RECOMMENDED by the World Health Organization. However, prudent salt consumption in the diet remains recommended for general health reasons.
Symptoms
Many people say that hypertension is silent, but that’s not entirely true. There are a number of symptoms that can indicate blood pressure issues. If you experience any of these symptoms, seek medical evaluation immediately. The sooner the cause is identified and treatment starts, the lower the risk for you and your baby.
Watch out for these symptoms:
- Headache
- Nausea and vomiting
- Pain in the upper abdomen
- Visual changes (blurred vision, dark spots, visual loss, or seeing bright spots)
- Neck pressure
- Difficulty breathing and/or shortness of breath
Diagnosis
Due to the “silent” nature of the disease in the first months, the diagnosis of hypertensive syndromes can only be effectively confirmed after 20 weeks of pregnancy. In other words, before this period, only suspicion is possible.
The diagnosis for each hypertensive syndrome is made according to certain clinical criteria, such as blood pressure, level of proteinuria, red blood cells, leukocytes, etc.
To establish a definitive diagnosis, the doctor responsible for your prenatal care must request the necessary tests to identify which type of hypertensive syndrome you have.
One of the most important resources for diagnosis is blood pressure measurement. It should be done at every prenatal consultation, preferably by a member of the nursing team. If the values are above 140 mmHg for systolic and/or 90 mmHg for diastolic, additional tests should be ordered.
Tests commonly requested to establish diagnosis
- Proteinuria/creatininuria ratio or dipstick proteinuria
- Pulse oximetry
- Complete blood count
- Creatinine
- Platelet count
- Aspartate transaminase (AST) or LDH
Medical Management and Approaches
What will be done to control a case of hypertensive syndrome will depend on many details regarding care, medical history, allergies, gestational age, among many other specific factors for each pregnant woman.
Usually, pre-eclampsia is managed with low daily doses of aspirin and calcium supplementation, both at low doses. In addition, additional tests should be ordered regularly to evaluate the progress of the pregnant woman’s condition.
If your obstetrician has not requested or prescribed these control medications after your diagnosis, ask about it. It’s important to understand why you haven’t started treatment.
IMPORTANT: Never, under any circumstances, decide to start any kind of medication without the supervision or indication of a qualified professional.
Precautions You Should Take
After receiving the diagnosis and starting your treatment, it is very important to take certain precautions to ensure the whole process is safe and smooth. Even being considered a high-risk pregnancy, it is more than possible for everything to go well, and for you and your baby to remain healthy.
One of the most important things is to perform blood pressure monitoring, that is, a daily check of your blood pressure. For this, you will need to get an electronic blood pressure monitor and measure at least three times per day.
TIP – Record the readings, date, and time of each measurement to help your prenatal team with valuable information to understand and determine the best care strategies.
Avoid buying a wrist-type monitor. These usually provide inaccurate readings. It is better to choose a model with a cuff for the upper arm. If you measure and the readings are above the recommended levels, wait 15 minutes and measure again. If it remains high, seek medical care.
Risks and Consequences
So far, we’ve discussed the clinical aspects and precautions if you’ve been diagnosed with a hypertensive syndrome; however, we often have no idea of the real meaning of having a certain condition.
Hypertensive syndromes are among the top three causes of maternal death worldwide and are the leading cause in Brazil. For this reason, it’s important to discuss the risks and consequences, not just of having, but also of not properly treating any of these.
Risks for the mother
- Hemorrhage
- Seizures
- Organ damage to the liver, kidneys, and brain
- Placental abruption
- Death
Risks for the baby
- Prematurity
- Growth restriction
- Bronchopulmonary dysplasia
- Neurological damage
- Death
Access to Healthcare and Maternal Mortality in Brazil
As previously mentioned, hypertensive syndromes are the leading cause of maternal mortality in Brazil. Most of these deaths occur among women living where access to healthcare is more difficult and precarious, such as rural areas, villages, poorer states, and municipalities. According to the Pan American Health Organization, most of these deaths arising from pregnancy and postpartum complications could be avoided with proper healthcare. High-quality prenatal care is essential to identify, monitor, and seek to control the physiological factors that can turn this special experience into a risk.
Even though this problem is more common in vulnerable areas, any pregnant woman can be the victim of poor-quality prenatal care. This is why it’s essential that you take an active role in your prenatal care—seeking information, asking questions, and if possible, consulting different professionals. The more people involved in your care, the less chance important details will be missed.
Pregnancy Interruption
As with everything in life, pregnancy involves different trade-offs, risks, and benefits. In a normal pregnancy, the best thing to do is to wait for the spontaneous onset of labor, since this is the only real sign that the baby is ready to be born.
In high-risk pregnancies things do not work the same way, since, for physiological reasons, there comes a time when the risks of continuing the pregnancy outweigh the benefits. When this moment arrives, the best thing to do is to induce labor, because (in the case of hypertensive syndromes) delivery is the only way to resolve the issue.
Labor Induction
There are two ways to end a pregnancy: one is by inducing labor, and the other is through surgery.
In what we call labor induction, the medical team will help the mother’s body begin labor. The induction protocols will vary according to each patient, as there are restrictions for certain methods and patient conditions.
In cases of Pre-eclampsia, Severe Pre-eclampsia, Eclampsia, and HELLP Syndrome, the main goal is always to reach 37 weeks, meaning the baby is no longer considered premature. So, when all goes well, the mother will have her labor induced at this gestational age.
Unfortunately, not all pregnancies go smoothly, and sometimes interrupting the pregnancy before 37 weeks is necessary, as the risks of continuing outweigh the benefits.
In cases where the pregnancy is between 33 and 36 weeks with uncontrolled hypertension, the woman should be admitted to a hospital unit with a Neonatal ICU, and the conduct will be decided with the healthcare team. In these circumstances, the main goal is to prolong the pregnancy as much as possible to reach term (37 weeks). If the woman develops Severe Pre-eclampsia or another more serious condition, pregnancy must be interrupted, as continuing it poses a high risk of death for both mother and baby.
Route of Delivery
The Brazilian Federation of Gynecology and Obstetrics (FEBRASGO) and the World Health Organization (WHO) recommend that in cases of Pre-eclampsia, preference should be given to vaginal delivery, as it is the alternative that offers fewer risks and presents numerous benefits for both mother and baby.
Many people believe that a normal delivery is dangerous and risky, when in fact it is the safest option, since in most cases, it doesn’t require invasive procedures such as cuts, anesthesia, or other interventions. Furthermore, recovery is much quicker and smoother.
Cesarean Section
Cesarean section is a surgery that saves thousands of lives every day. However, it should never be the first option.
According to WHO, Brazil is the second highest country in the world in terms of cesarean deliveries, with rates of approximately 55%. The recommendation is that rates should not exceed 10%. Even though it’s a very common procedure, always keep in mind that a cesarean is major surgery, and thus brings risks for both mother and baby.
When a woman has gestational hypertension—often severe and uncontrolled—performing major surgery is highly risky and not recommended. In some situations, a cesarean will be the best option, but you should not consider it your only alternative simply because of a hypertensive disorder.
Research, read, and get informed. A choice is only truly a choice when you know all your options and the pros and cons of each. Don’t let others decide what’s best for you and your baby!
