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This study was conducted to assess the relationship between blood lead levels and pregnancy-induced hypertension. Participants were 110 pregnant women, of whom 55 were hypertensive, 27 +/- 5.6 yr of age (mean +/- standard deviation) (range = 17-40 yr); the other 55 women were age- and gravidity-matched normotensive controls. Participants were selected on the basis of their medical history and the results of a questionnaire-based interview. Subjects were at gestational ages 37 +/- 2.5 wk (range = 30-41 wk) and were not occupationally exposed to lead. Blood samples were collected within 24 hr after delivery, and blood lead levels were measured. For the hypertensive cases, blood lead levels were 5.7 +/- 2 microg/dl (range = 2.2-12.6 microg/dl [0.27 +/- 0.10 micromol/l; range = 0.11-0.60 micromol/l]), which were significantly higher than those of the control group (i.e., 4.8 +/- 1.9 microg/dl; range = 1.9-10.6 microg/dl [0.23 +/- 0.09 micromol/l; range = 0.09-0.51 micromol/l]). There were no significant differences in blood lead concentrations among hypertensive subjects with proteinuria (n = 30) and those without proteinuria (n = 25). Results of this study indicated that low-level lead exposure may be a risk factor for pregnancy hypertension.
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PMID:Relationship between increased blood lead and pregnancy hypertension in women without occupational lead exposure in Tehran, Iran. 1607

Gestational hypertension is differentiated into higher and lower risk by the presence or absence of proteinuria. We asked if hyperuricemia, a common finding in pregnancy hypertension, might also be an indicator of increased risk. We examined fetal outcome data from 972 pregnancies collected from 1997 to 2002 in a nested case-control study. Participants were nulliparous with no known medical complications. The frequency of preterm birth, the duration of pregnancy, frequency of small-for-gestational-age infants, and birth weight centile were determined for pregnancies assigned to 8 categories by the presence or absence of combinations of hypertension, hyperuricemia, and proteinuria. In women with gestational hypertension, hyperuricemia was associated with shorter gestations and smaller birth weight centiles and increased risk of preterm birth and small-for-gestational-age infants. Hyperuricemia increased the risk of these outcomes in the presence or absence of proteinuria. Risk was also increased in a small group of women with hyperuricemia and proteinuria without hypertension. Women with only hypertension and hyperuricemia have similar or greater risk as women with only hypertension and proteinuria. Those with hypertension, proteinuria, and hyperuricemia have greater risk than those with hypertension and proteinuria alone. The risk of these outcomes increased with increasing uric acid. Hyperuricemia is at least as effective as proteinuria at identifying gestational hypertensive pregnancies at increased risk. Uric acid should be reexamined for clinical and research utility.
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PMID:Uric acid is as important as proteinuria in identifying fetal risk in women with gestational hypertension. 1624 74

Normal pregnancy is associated with significant changes in the neuronal and vascular control mechanisms of blood pressure (BP). Preeclampsia (PE) is a major complication of pregnancy characterized by proteinuria, and increased vascular resistance and BP. If untreated, PE leads to eclampsia with serious seizures and severe hypertension. However, the neurovascular mechanisms of hypertension in pregnancy and PE are unclear. Studies in animal models of hypertension in pregnancy suggest that inadequate cytotrophoblast invasion of uterine spiral arteries causes reduction in uteroplacental perfusion pressure leading to placental ischemia/hypoxia. Placental ischemia may promote the release of biologically active factors such as cytokines and reactive oxygen species. These circulating factors may increase the vascular permeability, cross the blood-brain barrier, and affect the sympathetic tone and the neuronal control mechanisms of BP. Placental factors could also cause endothelial cell dysfunction and inhibit nitric oxide (NO)-cyclic guanosine monophosphate (cGMP), prostacyclin (PGI(2))-cyclic adenosine monophosphate (cAMP), and hyperpolarizing factor vascular relaxation pathways. Additionally, placental factors may induce endothelium-derived contracting factors such as endothelin, thromboxane and angiotensin II, which stimulate Ca(2+)-dependent vascular smooth muscle (VSM) contraction or increase protein kinase C activity and enhance myofilament sensitivity to intracellular free calcium concentration ([Ca(2+)](i)). The increased sympathetic tone combined with systemic decrease in endothelium-dependent vascular relaxation and enhanced VSM contraction may contribute to the increased vascular resistance and BP associated with PE. The hypertensive state in severe PE may weaken the blood-brain barrier and precipitate convulsions and cerebral hemorrhage. Careful monitoring of maternal neuronal, endothelial, and VSM function during pregnancy should circumvent the life-threatening neurovascular complications of PE-eclampsia.
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PMID:Neurovascular mechanisms of hypertension in pregnancy. 1671 96

Hypertension in pregnancy is one of the main causes of maternal, fetal and newborn morbidity and mortality in civilised countries. Current recommendations of the European Society for Hypertension prefer definition of hypertension in pregnancy based on absolute values of blood pressure, i.e. systolic blood pressure > or = 140 mm Hg or diastolic blood pressure > or = 90 mm Hg. The most important task of classification of hypertension in pregnancy is to distinguish whether hypertension comes before pregnancy (the so called pre-existing hypertension) or whether it is a pregnancy-induced condition (the so called gestational hypertension). Pre-existing hypertension is diagnosed either before pregnancy or within the first 20 weeks of pregnancy. Gestational hypertension is characterised with poor blood circulation in many body organs, higher value of blood pressure usually being just one of the characteristic features. Non-pharmacological treatment of hypertension must be considered in pregnant women with systolic blood pressure 140-150 mm Hg or diastolic blood pressure 90-99 mm Hg. Salt restriction is not recommended, as well as weight reduction in obese women. Systolic blood pressure > or = 170 mm Hg or diastolic blood pressure > or = 110 mm Hg in pregnant women must be considered serious condition necessitating hospitalisation. Pharmacological therapy should include labetalol i.v. or metyldopa or nifedipin administered orally. Intravenous administration of dihydralazine is no longer a therapy of choice, for its use is connected with increased occurrence of adverse effects. The threshold values for commencement of anti-hypertension therapy are systolic blood pressure 140 mm Hg or diastolic blood pressure 90 mm Hg in females with gestational hypertension without proteinuria or with pre-existing hypertension before commencement of 28th week of pregnancy. Drug administration to reduce hypertension is instituted after reaching the same threshold values in females with gestational hypertension and proteinuria or after occurrence of the symptoms any time during pregnancy, with the same threshold values of blood pressure in the case of pre-existing hypertension at the presence of accompanying diseases or organ malfunction and further in the case of pre-existing hypertension and gestational hypertension. In other cases drug treatment of hypertension is recommended at systolic blood pressure values of 150 mm Hg or diastolic blood pressure values of 95 mm Hg. Unless serious hypertension is involved, the drugs of choice include metyldope, labetalol, calcium channel blockers and beta-blockers. Calcium channel blockers are considered safe, unless administered concurrently with magnesium sulphate (risk of hypotension in the case of potential synergism). ACE inhibitors and angiotensine blockers II (AT1-blockers) are contraindicated in pregnancy. Treatment with diuretics is not substantiated, unless oliguria is present. I.v. magnesium sulphate is recommended for prevention of eclampsia and spasm treatment.
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PMID:[Hypertension in pregnancy]. 1672 58

Hypertensive pregnancy disorders complicate 10% of all pregnancies and cover a spectrum of conditions, namely preeclampsia, eclampsia, and chronic and gestational hypertension. Preeclampsia is a pregnancy-specific disorder clinically characterized by hypertension and proteinuria that occurs after 20 weeks of gestation. It remains a leading cause of both fetal and maternal morbidity and mortality worldwide. Traditionally, hypertensive pregnancy disorders were considered not to have any long-term impact on mothers' cardiovascular health; however, recent studies consistently have supported the role of hypertension in pregnancy as a risk factor for cardiovascular disease later in life. Therefore, improved screening, and preventive and treatment strategies may not only optimize management of hypertensive pregnancy disorders, but may have a long-term impact on women's cardiovascular events and outcomes years after the affected pregnancies. This article will provide a brief review of hypertensive pregnancy disorders and important recent discoveries regarding their pathogeneses, while focusing on current diagnostic and treatment strategies.
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PMID:Hypertensive pregnancy disorders: current concepts. 1761 69

The National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy has defined four categories of hypertension in pregnancy: chronic hypertension, gestational hypertension, preeclampsia, and preeclampsia superimposed on chronic hypertension. A maternal blood pressure measurement of 140/90 mm Hg or greater on two occasions before 20 weeks of gestation indicates chronic hypertension. Pharmacologic treatment is needed to prevent maternal end-organ damage from severely elevated blood pressure (150 to 180/100 to 110 mm Hg); treatment of mild to moderate chronic hypertension does not improve neonatal outcomes or prevent superimposed preeclampsia. Gestational hypertension is a provisional diagnosis for women with new-onset, nonproteinuric hypertension after 20 weeks of gestation; many of these women are eventually diagnosed with preeclampsia or chronic hypertension. Preeclampsia is the development of new-onset hypertension with proteinuria after 20 weeks of gestation. Adverse pregnancy outcomes related to severe preeclampsia are caused primarily by the need for preterm delivery. HELLP (i.e., hemolysis, elevated liver enzymes, and low platelet count) syndrome is a form of severe preeclampsia with high rates of neonatal and maternal morbidity. Magnesium sulfate is the drug of choice to prevent and treat eclampsia. The use of magnesium sulfate for seizure prophylaxis in women with mild preeclampsia is controversial because of the low incidence of seizures in this population.
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PMID:Hypertensive disorders of pregnancy. 1864 16

Altered levels of pregnancy hormones have been suggested to initiate testicular cancer prenatally in the male fetus. The placenta is the main source of pregnancy hormones, and pregnancy hypertension and preeclampsia are associated with placental malfunction, including altered levels of hormones such as estrogen and human chorionic gonadotropin. We therefore evaluated fetal exposure to pregnancy hypertension and preeclampsia in relation to risk of testicular cancer in adolescent and adult life. We identified 293 cases of germ cell testicular cancer in the Swedish Cancer Register, and 861 controls in the Swedish Medical Birth Register. The standardized antenatal and delivery charts of the cases and controls were traced in the archives of the delivery units, and information about maternal and pregnancy characteristics such as gestational hypertension, proteinuria, anemia, and glucosuria were extracted. Odds ratios (OR) with 95% confidence intervals (CI) were calculated using conditional logistic regression. We found a strongly decreased risk of testicular cancer among subjects exposed to severe gestational hypertension (OR, 0.29; 95% CI, 0.12-0.74, compared with no hypertension), whereas the risk was increased among those exposed to mild gestational hypertension (OR, 1.62; 95% CI, 0.98-2.69) during the fetal period. The mechanism behind the association between pregnancy hypertension and testicular cancer is unclear, but our findings may reflect a potentially protective effect of the altered pregnancy hormones such as human chorionic gonadotropin that occur in severe gestational hypertension and preeclampsia.
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PMID:Gestational hypertension, preeclampsia, and risk of testicular cancer. 1897 26

Pre-eclampsia is a pregnancy-associated disease of the second part of the pregnancy, occurring mainly after 20th weeks gestation. The prevalence of hypertension in pregnancy is between 5 to 11% and affects mainly women under 20 years of age. An inadequate invasion of trophoblasts with consequential placental ischemia as a result of insufficiently dilated uterine spiral arteries is thought to be an initial cause in the pathogenesis of pre-eclampsia. The clinical symptoms of pre-eclampsia, such as loss of intravascular volume and edema, are caused by generalized endothelial dysfunction. These symptoms are potentiated by hypertension and reduced colloid osmotic pressure in the plama. The organs being affected by pre-eclampsia are those of the vascular-, hepatic-, renal-, cerebral- and coagulatory systems. The prognosis is much more severe when pre-eclampsia develops very early in the pregnancy. The symptoms include elevated blood pressure (over 140 mmHg systolic, 90 mmHg diastolic) combined with proteinuria. Frequent symptoms are hyperreflexia and edema. The etiology of pre-eclampsia has not been clearly defined. Risk factors/triggers for the development of pre-eclampsia can include chronic hypertension, advanced maternal age at first pregnancy (over 35 y), nephropathy, thrombophilia (heterozygous factor V Leiden mutation, antiphospholipid syndrome, heterozygous prothrombin mutation and homozygous MTHFR), multiple gestation and prior pregnancy with preeclampsia. The incidence of preeclampsia is higher in nulliparous than multiparous women. In many countries pre-eclampsia is still most frequent cause of maternal perinatal mortality. HELLP-Syndrome (haemolysis-elevated liver enzyme- low platelets) is a severe progressive course of this disease. Eclampsia, characterized by generalized tonic-clonic convulsion, is the most dangerous complication of pre-eclampsia, and may develop before or after delivery. This form of pre-eclampsia is associated with higher maternal and fetal mortality. Constant maternal hypertension potentially alter vascular integrity of the placenta with further consequences in fetal blood supply leading to growth restriction or zero growth and subsequently resulting in low birth weight or fetal death. The sooner the disease is detected and confirmed, the better the maternal and fetal prognoses are. This is the reason why it is major importance, together with the employment of preventive measures, to identify patients with risk factors with pre-eclampsia though an adequate screening method, thereby detecting the disease earlier and ensuring better pregnancy outcomes for both mother and child.
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PMID:[Pre-eclampsia screening in first and second trimester]. 1897 29

A 25-year-old female at 10 weeks of her first pregnancy abruptly developed severe hypertension as high as 230/160 mmHg and thus was referred to our hospital. Her past history was unremarkable and no medication or supplement was prescribed. The laboratory findings revealed that plasma renin activity was 59.0 ng mL hr and plasma aldosterone concentration was 1700 pg mL together with serum creatinine of 0.42 mg dL and serum potassium of 2.8 mEq L. Urinalysis revealed insignificant findings. Her hypertension was extremely resistant to antihypertensive agents, including hydralazine, alpha-methyldopa, and alpha beta blocker, leading to suspicion of secondary hypertension as a cause. Adrenal tumor was not detected but Doppler ultrasonography suggested the constriction of the right renal artery consistent with renovascular hypertension. Considering the following imaging test and medications, the patient and her family decided to abort the pregnancy. 3D-CT and MR angiography showed stenosis of the right renal artery, therefore, percutaneous transcatheter renal angioplasty was performed, resulting in normalization of the blood pressure without antihypertensives. Two years later she successfully gave birth uneventfully. Her hypertension was presumably irrelevant to preeclampsia because it occurred at 10 weeks of pregnancy and proteinuria was not associated. The stenosis of the right renal artery was probably due to fibromuscular dysplasia, which is one of the major causes of renal artery stenosis in young women. This patient was such a case and presented a difficult decision on how to treat and whether or not to abort. We will discuss the mechanism of hypertension in pregnancy and the advantages and disadvantages of available treatments for such cases.
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PMID:[Case of fibromuscular dysplasia revealed by the emergence of severe hypertension in the early phase of pregnancy]. 1960 60

The American Society of Hypertension is publishing a series of Position Papers in their official journals throughout the 2008-2009 years. The following Position Paper originally appeared: JASH. 2008;2(6):484-494. Hypertension complicates 5% to 7% of all pregnancies. A subset of preeclampsia, characterized by new-onset hypertension, proteinuria, and multisystem involvement, is responsible for substantial maternal and fetal morbidity and is a marker for future cardiac and metabolic disease. This American Society of Hypertension, Inc (ASH) position paper summarizes the clinical spectrum of hypertension in pregnancy, focusing on preeclampsia. Recent research breakthroughs relating to etiology are briefly reviewed. Topics include classification of the different forms of hypertension during pregnancy, status of the tests available to predict preeclampsia, and strategies to prevent preeclampsia and to manage this serious disease. The use of antihypertensive drugs in pregnancy, and the prevention and treatment of the convulsive phase of preeclampsia, eclampsia, with intravenous magnesium sulfate is also highlighted. Of special note, this guideline article, specifically requested, reviewed, and accepted by ASH, includes solicited review advice from the American College of Obstetricians and Gynecologists.
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PMID:ASH position paper: hypertension in pregnancy. 1961 6

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