Keterangan
Preeclampsia-eclampsia, prenatal hypertension, chronic hypertension with superimposed preeclampsia, and chronic hypertension are the four types of hypertensive diseases that can occur during pregnancy. These conditions are among the primary causes of maternal and fetal morbidity and death. Proper diagnosis in the emergency room is critical for initiating appropriate treatment and minimizing potential damage to the mother and fetus.
Ringkasan
- Hypertensive disorders in pregnancy affect 5-10% of pregnant women and are a significant contributor to maternal mortality, accounting for approximately 25.5% of such deaths in some countries. Beyond mortality, they lead to increased morbidity, with many near-miss cases, and a threefold increase in perinatal mortality. Recognizing and managing these disorders is crucial to reduce adverse outcomes.
- Hypertension in pregnancy is defined as a systolic blood pressure of 140 mmHg or higher, or a diastolic blood pressure of 90 mmHg or higher, confirmed by repeat measurement. Severe hypertension is diagnosed when blood pressure exceeds 160/110 mmHg. Careful blood pressure measurement is essential, using appropriate equipment and patient positioning.
- Hypertensive disorders of pregnancy are classified into chronic hypertension, pre-eclampsia, gestational hypertension, and pre-eclampsia superimposed on chronic hypertension. These classifications are based on the timing of hypertension onset, presence of proteinuria, and evidence of end-organ damage. Diagnosing these disorders requires careful differentiation.
- Gestational hypertension is diagnosed when hypertension occurs after 20 weeks of gestation without proteinuria or end-organ damage, while pre-eclampsia is characterized by hypertension after 20 weeks with proteinuria or end-organ damage. If gestational hypertension resolves within 12 weeks postpartum, it is termed transient hypertension; otherwise, it is considered chronic hypertension.
- Proteinuria, a key diagnostic criterion for pre-eclampsia, can be assessed via urine dipstick (≥2+), 24-hour urine collection, or spot urine protein-creatinine ratio. Severe pre-eclampsia is indicated by blood pressure >160/110 mmHg and signs of end-organ damage. Patients with pre-eclampsia require careful monitoring for complications, including neurological, renal, hepatic, and hematological issues.
- Antihypertensive medications such as labetalol and nifedipine are used to manage hypertension in pregnancy, aiming to keep blood pressure between 130/85 mmHg and 140/90 mmHg. Methyl dopa is no longer the first line because of its side effects. ACE inhibitors and angiotensin receptor blockers are contraindicated due to fetal risks. Delivery is the definitive treatment for pre-eclampsia and is typically recommended at 37 weeks gestation, or earlier in severe cases.
- Early-onset pre-eclampsia (before 34 weeks) is often associated with placental insufficiency and carries a higher risk of maternal and fetal complications. Late-onset pre-eclampsia (after 34 weeks) is generally milder. Early identification of high-risk patients is crucial for prevention and management, involving lifestyle modifications, low-dose aspirin, and calcium supplementation. The Jistice scoring system can be used to assess the risk of pre-eclampsia.
- Eclampsia, characterized by seizures in the context of pre-eclampsia, requires immediate management of airway, breathing, and circulation, and seizure control with magnesium sulfate. Magnesium sulfate is the treatment of choice and requires monitoring for toxicity. Prompt delivery is essential to prevent complications.
- Chronic hypertension in pregnancy can lead to superimposed pre-eclampsia, abruption placentae, and adverse fetal outcomes. Pre-conception counseling and medication adjustments are crucial for women with chronic hypertension who are planning pregnancy. Labetalol is the preferred antihypertensive agent in such cases.
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