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The purpose of this article is to review recent epidemiologic and pathophysiologic findings that advance the understanding of preeclampsia for the nurse in perinatal practice. Preeclampsia is different from other hypertensive disorders of pregnancy. Risk factors for preeclampsia and recent findings regarding normal and aberrant implantation are presented. Abnormal implantation and resulting poor placental perfusion may be the impetus for endothelial changes evidenced in preeclampsia; pathophysiology is described in relation to this event. The interaction of maternal factors, reduced placental perfusion, and endothelial cell dysfunction provides an explanation for the occurrence of preeclampsia and provides a basis for nursing practice and research. Implications for nursing care for women of childbearing age before, during, or after pregnancy may include (a) preconception or post-delivery counseling to reduce modifiable risk factors such as obesity, sedentary lifestyle, or high fat intake, (b) assessment of risk factors and increased surveillance when risk factors are present, and (c) surveillance of blood pressure changes of > 30 mmHg systolic or > 15 mmHg diastolic in advance of the third trimester of pregnancy.
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PMID:Current concepts in preeclampsia. 1040 59

Essential hypertension is a complex disease influenced by different genetic and environmental factors. The renin-angiotensin system (RAS) is implicated in blood pressure regulation. Angiotensinogen (AGT) is the precursor of the biologically active angiotensin II (Ang II). Initial studies on hypertensive siblings and case-control studies indicated the important role of the angiotensinogen gene (AGT) for the predisposition to essential hypertension, preeclampsia and obesity-related hypertension. Recently, different AGT polymorphisms had been identified and analyzed in case-control studies. The aim of present studies is the analysis of potentially functional AGT variants (C-532T, G-6A), which might be responsible for the regulation of gene expression and therefore AGT generation. The A-6 allele is in complete linkage disequilibrium with the T235 allele and is associated with higher AGT expression in vitro. Segregation linkage analysis demonstrated that the C-532T polymorphism influences plasma AGT variability more significantly than the G-6A variant. Since the C-532T polymorphism is located within a AP-2 consensus element, functional promoter analyses are required. The understanding of the molecular basis of RAS in essential hypertension may provide us with new and more specific pharmacological agents and perhaps the ability to individualize antihypertensive treatment.
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PMID:[Role of the angiotensinogen gene for essential hypertension]. 1071 6

Obesity-related metabolic and functional disorders may disturb adaptation process taking place in pregnant women body. Insufficient adaptation may lead to development of several medical complications during pregnancy, labor, delivery, and puerperium. Maternal obesity is associated with increased frequencies of hypertension, preeclampsia, gestational diabetes mellitus, fetal macrosomia, congenital malformations, labor abnormalities (including prolonged second stage of labor, meconium-stained amniotic fluid, FHR abnormalities and shoulder dystocia), postdatism, and cesarean delivery. Operative complications among obese women undergoing cesarean delivery include increased blood loss, prolonged operative time, and increased rates of postoperative infection, thrombophlebitis. Treatment of these complications increases hospital stays and costs. Obese women should be carefully examined by dietetician before conception and cared for dietetically and medically during gestation.
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PMID:[Obesity as an obstetric risk factor]. 1089 90

The number of patients with hypertension, obesity, diabetes, and hyperlipidemia is increasing. This tendency is observed in pregnant women, in whom many obstetrical and perinatal complications occur. The prevention of these abnormalities is important in reducing perinatal mortality and the risk of coronary disease. We established a pregnant rat model with diabetes and signs and symptoms mimicking preeclampsia. On day 6 of pregnancy, streptozotocin (STZ) or citrate buffer was injected into the tail vein. After STZ administration, plasma glucose was increased within 48 hours and sustained at a high level until day 20 of pregnancy, and plasma insulin was decreased. Fetuses from STZ-treated mothers were growth-restricted, and plasma glucose was 6-fold higher in fetuses of STZ-treated versus control rats. The systolic blood pressure, urinary protein, and hematocrit were increased significantly in STZ-treated rats. Total cholesterol and triglycerides were also elevated in STZ-treated rats, but plasma leptin levels were decreased. The STZ-induced diabetic pregnant rat model exhibited preeclampsia, hemoconcentration, hyperlipidemia, hypoleptinemia, and intrauterine growth restriction. This model closely mimics the features of human pregnancy complicated by diabetes and is useful for the basic study of the pathophysiology of pregnancy with diabetes.
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PMID:Streptozotocin-induced diabetic pregnant rats exhibit signs and symptoms mimicking preeclampsia. 1090 94

PURPOSE: Recent studies suggest prepregnancy obesity is a risk factor for preeclampsia, although only a handful of studies have examined the effect of gestational weight gain. The authors analyzed the effect of prepregnancy body mass index (BMI) and weight gain during pregnancy on risk of preeclampsia and transient hypertension.METHODS: Subjects were participants in a prospective cohort study of women who received prenatal care from thirteen obstetric practices in southern Connecticut (4/88-12/91). The women were interviewed in-person before 16 weeks gestation and in the immediate postpartum period. All subjects' hospital delivery charts were abstracted. BMI was categorized as: <19.8 (underweight), 19.8-26 (normal: referent), 26-29 (overweight), >29 (obese). A gestational weight gain index, created using multiple linear regression, compared observed weight gain to the weight gain expected after adjustment for significant covariables (e.g. gestational aged at delivery). Logistic regression was used to estimate risk of preeclampsia (N = 44) and transient hypertension (N = 172) associated with prepregnancy BMI and gestational weight gain.RESULTS: Obese women had a mild increased risk of preeclampsia (OR = 1.81; 0.73-4.52); women in the other BMI categories had risks similar to that of normal BMI subjects. In contrast, risk of transient hypertension was substantially decreased among underweight women (OR = 0.35; 0.14-0.87) and substantially increased among obese women (OR = 3.43; 2.27-5.21). Higher than expected gestational weight gain did not increase the risk of preeclampsia. In contrast, risk of transient hypertension was increased over twofold among women in the highest quartile of the weight gain index (OR = 2.55; 1.66-3.92).CONCLUSIONS: Obesity appears to be a strong risk factor for transient hypertension and a milder risk factor for preeclampsia. High gestational weight gain was associated with increased risk of transient hypertension but not preeclampsia.
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PMID:Prepregnancy body mass index and gestational weight gain as risk factors for preeclampsia and transient hypertension. 1101 13

Hypertension arising during pregnancy remains one of the two most frequently-cited causes of maternal death in the UK. In some cases, pregnancy is unmasking underlying hypertension, which manifests itself in later life. Pregnant women who develop de novo proteinuric hypertension (pre-eclampsia, PE) can share many risk factors with patients with the metabolic syndrome, such as obesity, dyslipidaemia and insulin resistance. However, more than half the women who develop PE remain normotensive thereafter. There is a genetic component(s) to the disease, but it is most improbable that there is a 'PE gene'. Rather, there are factors such as genetically-determined thrombophilias which are predisposers but not prerequisites. Impaired placentation is a feature, with inadequate invasion of the spiral arteries by syncytiotrophoblast and poor remodelling. However, similar features are found in association with non-hypertensive fetal growth restriction. Prospective studies have suggested a hyperdynamic circulation in early pregnancy, with cardiac output only falling in established disease. Baroreflex sensitivity is decreased in normal pregnancy, and still further decreased in established PE. Activation of endothelial cell function antedates the clinical diagnosis, and has features in common with atherosclerosis. Dyslipidaemia is common in PE and, via oxidation of susceptible lipids, may contribute to endothelial activation. Oxidative 'stress' is increased in PE, perhaps through a variant of the hypoxia-reperfusion phenomenon in the developing intervillous spaces. Such early changes might then lead to the clinically-evident syndrome in susceptible women. PE is a protean, multisystem, multifactorial disease, the causes of which are only slightly less enigmatic than a decade ago.
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PMID:Hypertension in pregnancy. 1109 61

The objective of this paper is to identify maternal risk factors for abnormal vascular coiling of the umbilical cord. The umbilical cords of 657 neonates were examined and the coiling index determined by dividing the total number of complete vascular coils by the length of the cord in cm. Obstetrical history, delivery data, and neonatal outcome were also evaluated. The frequency distribution of umbilical coiling index was normal (10 th and 90th percentile and mean +/- SD = 0.17, 0.37, and 0.26 +/- 0.09 coils/cm, respectively). Maternal risk factors for abnormal vascular coiling were extremes of age for hyper-coiling, obesity, gestational diabetes mellitus, and preeclampsia for non-coiling. Hyper-coiled and non-coiled cords were significantly associated with adverse perinatal outcome (p < 0.001) and cesarean delivery (p < 0.0001). Neonates whose mothers are old or young, obese, diabetic, or have preeclampsia are likely to have hyper-coiled or non-coiled umbilical blood vessels.
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PMID:Maternal risk factors for abnormal vascular coiling of the umbilical cord. 1114 96

Pregnancy-induced hypertension (PIH), which includes both gestational hypertension and preeclampsia, is a common and morbid pregnancy complication for which the pathogenesis remains unclear. Emerging evidence suggests that insulin resistance, which has been linked to essential hypertension, may play a role in PIH. Conditions associated with increased insulin resistance, including gestational diabetes, polycystic ovary syndrome, and obesity, may predispose to hypertensive pregnancy. Furthermore, metabolic abnormalities linked to the insulin resistance syndrome are also observed in women with PIH to a greater degree than in normotensive pregnant women: These include glucose intolerance, hyperinsulinemia, hyperlipidemia, and high levels of plasminogen activator inhibitor-1, leptin, and tumor necrosis factor-alpha. These observations suggest the possibility that insulin resistance may be involved in the pathogenesis of PIH and that approaches that improve insulin sensitivity might have benefit in the prevention or treatment of this syndrome, although this requires further study.
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PMID:Brief review: hypertension in pregnancy : a manifestation of the insulin resistance syndrome? 1123 Feb 77

In the insulin resistance (IR) syndrome, sex-specific differences have been reported. First, hypertension more often correlates with hyperinsulinemia in women than in men with the IR syndrome. In addition, salt sensitivity of blood pressure appears to be independent of the activity of the renin-angiotensin system in women, whereas in men there is a strong correlation between the two variables. Secondly, the dyslipidemia found in women with the IR syndrome is characterized by less postprandial plasma insulin, triglycerides, and fatty acid response to a standardized meal. However, this sex difference in lipids disappears after correction for visceral fat mass. Fat physiology and biochemistry differ between the two sexes. In women, adipose cells express less glucocorticoid receptors and less 11beta-hydroxysteroid dehydrogenase. In women visceral fat accumulation appears to be a constant feature of the IR syndrome but in men the syndrome can be present without central obesity. Lastly, during the reproductive years of women, the IR syndrome, such as in pre-eclampsia, may cause fetal growth retardation that has been proposed together with maternal malnutrition to be at the origin of the increased risk for impaired glucose tolerance, hyperinsulinemia, and hypertension in adult life. This gives yet another dimension to this disease in women since in essence they may ultimately transmit this syndrome to both sexes.
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PMID:Sex-related differences in the insulin resistance syndrome. 1127 93

Venous thromboembolism (VTE) remains the most common cause of maternal death during pregnancy and the puerperium. The risk is increased in women older than 35 years and those with obesity, previous VTE, operative delivery, and underlying thrombophilia. Anticoagulant therapy is indicated for short-term treatment of VTE and as thromboprophylaxis in high-risk patients. Warfarin is contraindicated during the first trimester because of fetotoxicity; unfractionated heparin (UFH) is associated with practical disadvantages and a risk of heparin-induced thrombocytopoenia (HIT) and osteoporosis with long-term use. Low-molecular-weight heparins (LMWHs) are convenient to use, do not cross the placenta, carry a lower risk of HIT and osteoporosis, and have been shown to be safe and effective during treatment of approximately 500 pregnant women. LMHWs are increasingly replacing UFH as the anticoagulant of choice during pregnancy; further studies are required to determine optimal therapeutic and thromboprophylactic doses. Women with inherited or acquired thrombophilia are at increased risk of severe pregnancy complications, including recurrent miscarriage, pre-eclampsia, fetal growth restriction, abruptio placentae, and stillbirth; uteroplacental microvascular thrombosis caused by thrombophilia appears to be the pathophysiologic link. LMWHs have been shown to improve pregnancy outcome in women with a history of obstetric complications and confirmed thrombophilia.
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PMID:Unexplored territories in the nonsurgical patient: a look at pregnancy. 1144 42


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