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Chronic Hypertension versus Pregnancy Induced Hypertension PIH

In the first trimester of pregnancy the marked vasodilatation and drop in vascular resistance sees blood pressure fall in both normotensive and hypertensive women, (the drop being greater in the CHT group)1. As such hypertension may not be seen until the third or late in the second trimester. CHT can therefore only be diagnosed with reference to non-pregnant BP readings and this requires either prenatal BPs or more commonly detailed postnatal follow-up. Pharmacological management of CHT and PIH is identical and as a general rule if hypertension is present before 20 weeks CHT is more likely.

44 Pregnancy Induced Hypertension

Pregnancy-induced hypertension (PIH) is considered a serious complication during pregnancy (9), and pre-eclampsia, a form of PIH, has been associated with depression during pregnancy (58). Some of the symptoms associated with severe pre-eclampsia are hypertension, pro-teinuria, with associated edema in the last half of pregnancy, headaches, visual disturbances, and upper abdominal pain (9,59,60). Although the etiology of this condition is as yet uncharacterized, investigators have hypothesized that altered elimination of vasoactive hormones as a result of depression may increase the risk for PIH (58,61). A recent Finnish study found a 2.5-fold increase in the risk of pre-eclampsia in pregnant women suffering from depression (61).

Pulmonary Arterial Hypertension

Pulmonary arterial hypertension is due mainly to changes in the pulmonary arterioles. It may be idiopathic (IPAH) or familial (FPAH), often with autosomal dominant inheritance, and there may be worsening of the disease in subsequent generations5. PAH is often associated (APAH) with one or more triggering factors (+ - a genetic pre-disposition), resulting in endothelial injury, vasoconstriction and vascular remodelling. The main triggers are Portal hypertension6,7 Persistent pulmonary hypertension of the newborn

Persistent Pulmonary Hypertension

Meconium Aspiration Syndrome

Persistent pulmonary hypertension of the newborn (persistent fetal circulation) is a condition in which there is persistence of the fetal high pulmonary vascular resistance. The condition can be primary, but is generally secondary to odier causes such as meconium aspiration or diaphragmatic hernia. This chest radiograph shows no significant pulmonary pathology. There is decreased vascularity with mild cardiomegaly. There is severe respiratory distress and cyanosis, and the response to oxygen is initially poor. Figure 1.112. Medical therapy of persistent pulmonary hypertension of the newborn can cause severe complications as depicted in this radiograph. Vigorous positive pressure ventilation resulted in the development of interstitial emphysema and bilateral pneumo thoraces. Persistent shunt pathways (shunting at the foramen ovale and ductus arteriosus) and high pulmonary vascular resistance make the condition poorly responsive to medical therapy with a mortality of 30 to...

281 Arterial hypertension and pregnancy

Different kinds of arterial hypertension should be distinguished from one another as follows (for pulmonary hypertension, see section 2.8.14) m Chronic hypertension (with or without proteinuria) which was diagnosed before, during or after pregnancy Pre eclampsia, eclampsia that is proteinuria (> 300mg d), and newly diagnosed hypertension (edemas are no longer necessary symptoms) Pre-eclampsia in a pregnant woman with pre-existing chronic hypertension, which occurs in 20-25 percent of all pregnancies with chronic hypertension Pregnancy-induced hypertension (P1H) that occurs beyond 20 weeks without proteinuria and returns to normal 12 weeks after delivery approximately half of these pregnant women develop pre-eclampsia. Blood pressure of 140 90 mmHg is the threshold for hypertension in pregnancy. Treatment should only be initiated at levels higher than 160 110 mmHg, because below that there are no advantages in treatment for the outcome of mother and child. If a patient has no...

Hypertension in pregnancy

Normal gestation is associated with a fall in blood pressure toward the end of the first trimester, reaching a nadir between 22 and 24 weeks. Hypertension during pregnancy, defined by an absolute systolic or diastolic blood pressure exceeding 140 or 90 mmHg, respectively, complicates approximately 15 of pregnancies 61 . Increased vascular distensibility and reduced peripheral vascular resistance occurring in pregnancy are accompanied by physiologic changes, including sodium retention, increased extracellular fluid, and up-regulation of the RAS 62 .

Hypertensive disorders of pregnancy Pregnancyinduced hypertension PIH

Hypertension, or high blood pressure, is defined as a level of 140 90 or more. It is considered potentially serious when measured at this level after the 20th week of pregnancy and on at least two separate occasions after that. It is usually accompanied by protein in the urine and by oedema.

Metabolic syndrome When hypertension and diabetes meet

The striking increase in the prevalence of obesity, diabetes mellitus (DM), hypertension, and cardiovascular disease in the last two decades1 has led to the concept of the metabolic syndrome.2 Also termed syndrome X,3 insulin resistance syndrome,4 and the deadly quartet,5 metabolic syndrome is characterized by a constellation of well-documented risk factors for cardiovascular disease, namely, glucose intolerance, insulin resistance, central obesity, dyslipidemia, and hypertension, that co-occur in individuals at a higher rate than expected by chance. Extensive research has still not completely elucidated the precise cause of the syndrome, although some strong positions have been taken. Nevertheless, it is widely recognized that a combination of genetic predisposition and environmental factors, particularly those associated with socioeconomic status is involved. The environmental factors include both postnatal life habits and nutrition, and - no less important - intrauterine...

Insulin resistance and hypertension in pregnancy

In normal pregnancy, insulin resistance results in a metabolic advantage for the fetus. The mother enters a state of accelerated starvation in which she increases her reliance on lipolysis and protein catabolism as a source of energy. Thus, glucose is reserved for the fetus, which uses it as its primary fuel.89 A steady supply of glucose is essential for the growing fetomater-nal unit normally, pregnant women are able to increase their insulin secretion to three times that of nonpregnant women.90 In GDM, however, there is no increase in maternal insulin secretion in reaction to the increasing insulin resistance.91 Some investigators believe this effect is due to a metabolically limited beta-cell reserve.92,93 In most women with GDM, insulin sensitivity is restored after pregnancy. However, some may later develop Type 2 DM. The reported cumulative incidence rate of Type 2 DM after GDM is approximately 50 after 5 years.94,95 It is even higher in women with excessive weight gain or with...

Microalbuminuria diabetes and hypertension in pregnancy

The role of microalbuminuria in DM has been established over the last 20 years. At the early stage of DM, when glucose metabolism is not controlled, the increase in glomerular plasma flow and intraglomerular pressure is probably responsible for the increased protein excretion.144 Some authors believe these hemodynamic alterations are major determinants of both the initiation and progression of diabetic nephropathy.145 Several studies have reported that patients with Type 1146 or Type 2 DM147 who have above-normal urinary albumin excretion rates are more likely to acquire diabetic nephropathy, eventually progressing to renal failure.148 Microalbuminuria is also associated with an excess of known and potential cardiovascular risk factors, and it is a marker of established cardiovascular disease in both hypertensive149 and nonhypertensive150 individuals. Its role in diabetic and hypertensive pregnancy is less clear,151 but becoming increasingly recognized. One study found that the...

2If you have high blood pressure during pregnancy

In those suffering from long standing essential hypertension (even before pregnancy), antihypertensive medications and a low-salt diet is advocated to help treat this condition. In hypertension that arises only during the course of the pregnancy (gesta-tional hypertension or preeclampsia), the only definative cure for this condition is through the delivery of the baby and the placenta (see Chapter 21). However, while not a cure for pre-eclampsia, limiting salt intake is advised.

Chronic hypertension

Chronic hypertension refers to high blood pressure that occurs independently of pregnancy. Although many women who have this condition are aware that they have it before they conceive, doctors occasionally diagnose it during pregnancy. If you have mild or moderate chronic hypertension, chances are good that you'll have an uneventful pregnancy. However, your doctor will be on the lookout for certain conditions that can affect you or the baby. Women with chronic hypertension stand an increased risk of developing preeclampsia, so your doctor looks for any signs that you're developing this condition. The main risk for the baby is intrauterine growth restriction (IUGR) or placental abruption (see Chapter 16). Your doctor may use repeated sono-grams to check on the baby's growth and to make sure that you have adequate amniotic fluid. She may also suggest that you undergo some tests later during your pregnancy for fetal well-being, such as non-stress tests (see Chapter 8). The overall...

121 Macronutrients 1211 Energy

The goal is to avoid both ends of the spectrum, both excessive energy intake as well as inadequate energy intake. Overnutrition and excess weight gain in pregnancy impart risk of gestational diabetes, macrosomia, delivery complications such as shoulder dys-tocia, cesarean delivery and post operative problems, difficulty initiating breastfeeding, and risk of subsequent maternal and child obesity 8-10 . Conversely, undernutrition and inadequate weight gain during pregnancy can lead to impaired intrauterine growth and consequent low birth weight of the newborn. In addition to complications at birth, intrauterine growth retardation has been associated with metabolic abnormalities in adulthood, such as hyperlipidemia, hypertension, cardiovascular disease, glucose intolerance, and type 2 diabetes 10, 11 .

Pre Pregnancy Preparation

The prime of your fertility is when you are 20-24 years old, with a sharp decline from 35 years old onwards. On average, there is a drop of 3 in fertility with each increasing year of the woman's age (Figure 1.1). The chance of genetic abnormalities like Down syndrome as well as complications in pregnancy like miscarriages, high blood pressure and diabetes, increase as you grow older, particularly beyond 35 years of age. So, start young when you are in your prime

Evaluating your current health

Some women, however, do have medical disorders that can affect the pregnancy. Expect your practitioner to ask whether you have any one of a list of conditions. For example, if you have diabetes, optimizing your blood sugar levels before you get pregnant and watching those levels during your pregnancy are important. If you're prone to high blood pressure (hypertension), your doctor will want to control it before you get pregnant, because controlling hypertension can be time-consuming and can involve changing medications more than once. If you have other problems epilepsy, for example checking your medications and controlling your condition are important. For a condition like systemic lupus erythematosus (SLE), your practitioner may encourage you to try to become pregnant at a time when you're having very few symptoms.

Getting to your ideal body weight

The last thing most women need is another reason to be concerned about weight control. But this point is important Pregnancy goes most smoothly for women who aren't too heavy or too thin. Overweight women stand a higher-than-normal risk of developing diabetes or high blood pressure during pregnancy, and they're more likely to end up delivering their babies via cesarean section. Underweight women risk having too-small (low birth-weight) babies.

Optimize Your Medical Conditions

Controlling your medical conditions such as diabetes mellitus and hypertension improves the prognosis for you and your baby. Consult your obstetrician early as pregnancy could be complicated with such medical conditions. If the medical conditions are well-controlled before you conceive, you are more likely to have a smooth pregnancy and a healthy baby.

Cardiorespiratory System

Differential Cyanosis

The proper circulatory pathways must also be established following birth in order to ensure adequate pulmonary blood flow. The normal increase in pulmonary blood flow after birth may be prevented by a failure of pulmonary vascular resistance to fall, as in persistent pulmonary hypertension of the newborn, or in congenital heart disease, where there is an obstruction of systemic venous blood flow into the lungs as occurs in pulmonary atresia. Furthermore, oxygen transport to the tissues may be inadequate because systemic arterial supply is reduced by myocardial failure, or by congenital heart lesions in which left ventricular output is impaired, as with severe aortic stenosis or aortic atresia. Figure 1.6. Differential cyanosis in an infant with congenital heart disease. Note the demarcation line in the mid-abdomen, and that the proximal part of the body is cyanotic, but the distal portion is pink (this infant had blue hands and pink feet). In this infant, this was due to...

Physical Activity and Exercise in Pregnancy

Because habits adopted during pregnancy can result in persistent lifestyle improvements, exercise during pregnancy could significantly reduce the lifetime risks of obesity, chronic hypertension and diabetes not only for pregnant women, but also for their families as well. Overall, a woman whose exercise habits have become firmly entrenched during pregnancy stands a much better chance of maintaining them after her child is born.

36exercise guidelines for healthy pregnancies

The exercise recommendations from the American College of Obstetricians and Gynecologists (ACOG) mirror those of the Center of Disease Control (CDC), and the American College of Sports Medicine (ACSM). The ACSM recommends moderate intensity exercise for 30 min or more on most days of the week as part of a healthy lifestyle in the nonpregnant population 4 . A moderate level of exertion for 30 min duration has been associated with significant health benefits decreasing risk of chronic diseases including coronary heart disease, hypertension, type 2 diabetes mellitus, and osteoporosis 33 . Women who are sedentary prior to pregnancy should gradually increase their duration of activity to 30 min. Those who are already fit should be advised that pregnancy is not the time to greatly enhance physical performance and that overall activity and fitness tend to decline during pregnancy. Pregnant women should exercise caution in increasing intensity, especially when an exercise session extends...

Nonpregnancy Treatment And Care

Excellent guidelines have been produced for management of hypertension4. Because the aetiology of the hypertension can be varied, different care pathways will exist and they are beyond the scope of this section. The majority of women with proven essential hypertension will be on one or more antihy-pertensive drugs as well as possibly other medications, and those with additional medical problems such as diabetes will have lower blood pressure targets. Initial therapy will be with either an angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker or a beta-blocker and either a calcium channel blocker or a diuretic. For those with an interest the authors recommend the British Hypertension Society (BHS) guidelines for further reading. Statins are recommended for women either who already have evidence of cardiovascular disease and hypertension or who have a ten-year risk of cardiovascular disease of > 20 .

Explanation Of Condition

Pre-eclampsia, or pre-eclamptic toxaemia (PET), is a major cause of maternal and fetal mortality and morbidity. It is a syndrome characterised by the development of new hypertension and proteinuria in the second half of pregnancy which will always resolve postnatally1. Pregnancy Induced Hypertension (PIH) or Gestational Hypertension (GH) are terms used to describe new onset hypertension occurring in the second half of pregnancy which resolves postnatally (similarly for gestational proteinuria). Pre-eclampsia can begin antenatally, intrapartum or post-natally. Approximately 10 of all women will have PIH during their pregnancy. Within this group 3-4 will have preeclampsia, 5 PIH and 1-2 will have chronic hypertension.

Microscopic evaluation

Microscopic Diabetes

Placental pathology in pregnancies complicated by maternal diabetes relates to the different aspects of the maternal disease. Although some findings are thought to be related to the direct effect of insulin on the placenta, most are due to associated maternal pathologies, especially hypertension. This makes the study of placental effects of hyperinsulinemia (in insulin resistance) and hyperglycemia difficult as most diabetic pregnancies have other confounding variables, especially hypertension. What is known is often anecdotal or based on series of maternal diabetic pregnancies in which these confounding variables are either ignored or an attempt has been to ferret them out. resulting in a greater distance for oxygen and nutrients to pass from maternal to fetal circulation).32 Neither of these histopathologic findings are specific nor are they easily defined. In general, the non-hypertensive diabetic placenta has fewer syncytial knots, fewer vasculosyncytial membranes, larger villi,...

Adverse effects of acupuncture

Another lady I treated had high blood pressure and was suffering from sickness in early pregnancy. I used PC-6 but the minute I put the needles in, she started to vomit. On questioning her, I learnt that she had had no breakfast and had taken her blood pressure tablets on an empty stomach (she was my first appointment of the day). She never returned for another treatment.

Considering occupational hazards

Occupations that are physically demanding can be problematic. Most jobs fall somewhere in between sedentary and demanding, but even then the amount of stress varies according to the individual. If your pregnancy proceeds without complications, you probably can continue to work right up until delivery. However, some complications that may arise during pregnancy may make reducing your workload or stopping work altogether advisable. For example, if you develop preterm labor, your practitioner will most likely advise you to stop working. Other conditions that may warrant a reduction in physical activity are hypertension or problems with the baby's growth. Some studies suggest that women who have jobs associated with physically demanding responsibilities, such as heavy lifting, manual labor, or significant physical exertion, may be at a slightly higher risk of preterm birth, high blood pressure, preeclampsia, or small-for-gestational-age babies. On the other hand, long working hours...

Understanding pregnancy and the law

Take the time to understand your rights as they pertain to pregnancy. In the United States, an amendment to Title VII of the Civil Rights Act of 1964, called The Pregnancy Discrimination Act, requires pregnant women to be treated in a manner equal to all employees or applicants. According to this act, employers can't refuse to hire a woman because of her pregnancy-related condition, as long as she's capable of performing the job's major functions. If an employee is temporarily unable to carry out her job due to the pregnancy, the employer must treat her the same as any other temporarily disabled employee, taking such actions as providing alternative tasks, disability leave, or leave without pay. A disability may arise due to the pregnancy itself, such as significant nausea and vomiting. A disability may also occur due to complications of pregnancy, such as bleeding, preterm labor, or high blood pressure, or may occur due to hazardous job exposures. If your healthcare provider decides...

533 Preeclampsia and Gestational Diabetes

While the normal pregnancy is characterized by maternal hemodynamic changes and an insulin resistant state, obesity in pregnancy appears to complicate these expected physiological adaptations to pregnancy. Accordingly, the risk for hypertensive disorders and gestational diabetes (GDM) is reportedly higher in obese and morbidly obese women compared to women who are not obese. In a prospective, multicenter study of more than 16,000 women, Weiss et al. 31 observed a 2.5-fold greater risk of gestational hypertension, and a 2.6-fold greater risk of GDM among obese versus nonobese women. Risk for these conditions was even greater in a morbidly obese subset, e.g., 3.2- and 4-fold respectively. Similarly, these researchers found the risk for developing preeclampsia was 1.6 and 3.3 times more likely to develop in obese and morbidly obese women, respectively. Results from this study have been confirmed by others 32, 33 and found to be independent of other related factors including age, parity,...

535Preterm Delivery Cesarean Section and Operative Complications

Cesarean section rates are higher among obese women compared to nonobese women. In Washington State, Baeten et al. 40 examined delivery data from over 96,000 mother-infant pairs. These researchers found that obese women had nearly a threefold greater risk of having a cesarean section than women who were not obese. After adjusting for gestational hypertension, GDM, and preeclampsia, the risk decreased nominally, to 2.7-fold. In another study, Brost et al. 41 found that for each 1-kg m2 increase in prepregnancy BMI, the odds of having a cesarean section increased by 7 . Obesity is associated with a reduced likelihood of vaginal birth after cesarean section (VBAC) 42 , and a lower success rate for VBAC compared with normal weight women (68 versus 79.9 , respectively 42, 43 ). Operative and postoperative complications associated with cesarean surgery in obese women, especially the morbidly obese, are many including greater risk of excessive blood loss, prolonged operative time, higher...

552Considerations for Bariatric Surgery

Absorption of calcium, iron, folic acid, and vitamin B12 69 . While these surgeries have had a positive impact on reducing maternal risk for GDM and hypertensive disorders, case reports of intrauterine growth restriction, premature birth, and NTDs have been described 70 . Because of these limitations, the laparoscopic adjustable gastric banding procedure is being used more frequently as a means of restricting stomach volume, decreasing intake, and promoting weight loss 71 . The adjustability of banding also allows for adaptations to altered requirements of pregnancy. Early reports on follow-up of pregnant women who have had this type of procedure are encouraging and indicate reduced risk of malabsorption, GDM, gestational hypertension, and preterm deliveries 71 . To ensure optimal pregnancy outcome and minimize maternal and fetal risks, the American College of Obstetricians and Gynecologists recommends that women delay pregnancy for 12-18 months after surgery to avoid pregnancy during...

53 Reported Adverse Outcomes 531 Poor Neonatal Adaptability

Persistent Pulmonary Hypertension in the Newborn At press time, a newly released case-control study reported a significantly elevated risk of persistent pulmonary hypertension in the newborn (PPHN) in infants exposed to SSRIs following the 20th week of gestation. Although the absolute risk of PPHN in SSRI-exposed infants was relatively low ( 1 in 100), it was six times higher than that of control group infants. The study findings raise an important concern and should be reviewed carefully during risk-benefit discussions regarding treatment of depression during pregnancy. Children exposed to SSRIs prior to the 20th week of gestation, or to non-SSRIs at any time of pregnancy, were not found to be at an increased risk for PPHN (138).

Nutritioninduced diabetes

When animals are fed a high carbohydrate diet, consisting mainly of fructose, they display features of Type 2 diabetes within a short time. Fasting hyperglycemia, hyperinsulinemia and hyper-lipidemia as well as insulin resistance develop.101-103 Some of these features can be ameliorated by supplementing the diet with fish oil104 or by troglitazone as a food admixture.105 Although this has been known for a long time surprisingly little use has been made of this model in pregnancy. One additional effect of the diet is the development of hypertension. This was also found in pregnancy106 suggesting that the fructose-induced diabetes may result in the development of sustained hypertension during pregnancy via the

Fetal Risk Summary

Amiloride is a potassium-conserving diuretic. In general, diuretics are not recommended in the treatment of pregnancy-induced hypertension because of the maternal hypovolemia characteristic of this disease. Three reports of fetal exposure to amiloride have been located (3,4 and 5) . In one case, a malformed fetus was discovered after voluntary abortion in a patient with renovascular hypertension (3). The patient had been treated during the 1st trimester with amiloride, propranolol, and captopril. The left leg of the fetus ended at midthigh without distal development and no obvious skull formation was noted above the brain tissue. The authors attributed the defects to captopril. *Risk Factor D if used in pregnancy-induced hypertension. Breast Feeding Summary

62considerations for bariatric surgery

In pounds divided by the square of their height in inches and multiplied by 703. BMI is measured in units of kg per m2. A BMI between 18 and 25 kg m2 is considered normal. Individuals are considered candidates for bariatric surgery when their BMI is greater than 40 kg m2, or greater than 35 kg m2 with one or more comorbidities including severe hypertension, sleep apnea, or diabetes. For most patients, this BMI corresponds to being approximately 45 kg (100 lb) or more above ideal body weight 5 .

Sarah C Couch and Richard J Deckelbaum

Summary Obesity in pregnancy is associated with numerous maternal and neonatal complications including difficulty conceiving, increased risk of miscarriage, fetal anomalies and mortality, higher rates of gestational hypertension, gestational diabetes and preeclampsia, and an increased risk of cesarean section and delivery related complications. Nevertheless, more women are entering pregnancy with excessive weight and are gaining weight above the Institute of Medicine (IOM) recommendations during pregnancy. Weight loss is not recommended during pregnancy however, overweight and obese women should be advised to aim for a moderate weight loss prior to conception and during the postpartum period. Strategies for achieving moderate progestational and postpartum weight loss include a low-calorie, low-fat diet and at least 45 min of daily physical activity. Benefits to mother and child are achieved with even a moderate weight loss. Importantly, health care professionals should counsel women...

Can treatment of GDM improve adverse outcome

To perform four times daily, visualized but not verified, self-monitoring of blood glucose. The women in the intensified group were selected per memory reflectance meter availability and instructed to test their blood glucose seven times daily with a memory reflectance meter to ascertain accurate and reliable blood glucose information. The study revealed, firstly, a significant adverse outcome for LGA and macrosomia, metabolic complications, respiratory complications, and shoulder dystocia rates when the conventional group was compared to the intensified therapy group. Secondly, there was a higher rate of neonatal intensive care unit admission and length of stay for the conventional group. Thirdly, with regards to maternal complications, no significant difference was found in the rates of pre-eclampsia, chronic hypertension or chorioamnionitis between the three study groups the perinatal outcome variables also included Cesarean section rates. The above variables were all found to be...

Maternal and paternal factors associated with fetal growth

For example, in the Early Bird Study12 300 British children were followed longitudinally. Insulin resistance was the same in children who had high birthweight and remained at an elevated birthweight centile through age 5 years, compared with those who had a lower birthweight but attained a similar centile at age 5. In fact, the IUGR model for the fetal programming hypothesis is more robust relative to aspects of the metabolic syndrome such as hypertension rather than obesity.13 Unfortunately, the human studies addressing the issue of maternal under nutrition in pregnancy mostly relate to starvation conditions during wartime. The best documented of these are the Dutch famine studies of 1944-1945.14

Blood pressure urine and oedema

Pre-eclampsia or pregnancy-induced hypertension (PIH) is an increase in blood pressure during pregnancy that affects 5-29 of women (Sweet 1997), most commonly in the last 8 weeks of pregnancy. It is often accompanied by protein in the urine (which would show up in a urine test) and by swelling of the feet and ankles (or more general oedema, where a gentle fingertip pressure briefly applied leaves behind an indentation). Complete bedrest with medical supervision is usually recommended. If eclampsia develops, a caesarean section may be needed immediately. Symptoms usually disappear within 48-72 hours of delivery.

Impaired glucose tolerance as a risk factor of adverse outcome

In another recent study of 2904 pregnant women the following outcomes measures increased significantly with increasing glucose values on the OGTT shoulder dystocia, macrosomia, emergency Cesarean section, assisted delivery, hypertension, and induction of labor.58 However, when corrections were made for other risk factors, hypertension and induction of labor were only marginally associated with glucose levels.

Trudy Boyce Rgn Rm Mbe

Recently Specialist Midwife in Hypertension at the University Hospitals of Leicester NHS Trust Trudy worked as a midwife for 40 years in all areas of midwifery care including ten in the community. For the last 15 years of her career she dedicated herself to the care of women and their families who had experienced the hypertensive disorders of pregnancy. She was involved in setting up the Leicester Hypertension Clinic and founded the Leicester branch of the APEC support group. Trudy was awarded an MBE in 2005 for her outstanding services to the NHS and midwifery.

Hypertensive disorders

Pre-eclampsia and gestational hypertension are apparently more frequent in women with GDM. A large study by Xiong et al.13 detected pre-eclampsia in 2.7 of 2755 patients with GDM compared with only 1.1 of 108,664 patients with normal pregnancies (adjusted OR 1.3, 95 CI 1.20-1.41). Similar results were observed for gestational hypertension. Likewise, Dukler et al.72 studied 380 primiparous women with pre-eclampsia and 385 primiparous control women for a total of 1207 and 1293 deliveries, respectively. When adjusted for confounding variables, GDM was strongly associated with the recurrence of pre-eclampsia in the second pregnancy (OR 3.72, 95 CI 1.45-9.53). Go et al.,73 in an 11-year follow-up study of a cross-sectional sample of African-American women with a history of GDM (n 289), reported one of the highest rates of microalbuminuria (MA) of all ethnic groups. The presence of MA was not associated with insulin resistance, but it was significantly and independently associated with...

Cognitive development in children of diabetic mothers

In summary, the existing evidence clearly suggests that there is adverse neurological and cognitive outcomes in addition to the possibility of early development of metabolic syndrome (hypertension, obesity and diabetes) when gesta-tional diabetes is not treated or poorly managed. Of note, the adverse neonatal outcome is reported to be similar regardless of the type of diabetes. Finally, the maternal long-term implications for the future development of Type 2 diabetes should be included in the morbidity spectrum of this disease.

536 Macrosomia Shoulder Dystocia and Fetal Death

> 4,000 g or above the 90th percentile 40, 44-46 . Risk for having a macrosomic infant appears to increase in mothers with degree of excess weight. For example, in the multicenter study by Weiss et al. 31 , the incidence of macrosomia was 8.3 in nonobese women, 13.3 in obese women, and 14.6 in morbidly obese women. In the study by Baeten et al. 40 , the odds of having a macrosomic infant were 1.2 in women who were normal weight, 1.5 in women who were overweight, and 2.1 in women who were obese. The analysis excluded women with chronic hypertension, pregestational and gestational diabetes, and preeclampsia. National and international trends in North America 47 and Europe 48, 49 report an increase in incidence of large for gestational age infants, and implicate rising trends in maternal obesity and diabetes, and declining trends in maternal smoking as causal factors. Risk for late-gestation fetal demise is also greater among obese women compared with their normal weight counterparts....

Personal experience at the Juan A Fernandez Hospital

The most frequently associated maternal pathologies were urinary infection and hypertension. Hospitalization during gestation was required for 48.6 of the patients. Gestational age at delivery was > 37 weeks in 74 of the population. Cesarean sections were performed in 51.3 of the cases. There were four intrauterine death. Neonates were vigorous at 1 and 5 min after birth in 88 and 93 of the cases, respectively.

74 confounding variables

There are many confounding variables that can contribute to birth weight and early neonatal outcomes in multifetal pregnancies. All multifetal pregnancies can be considered high risk because of the increase of many obstetrical complications, compared with those of singleton pregnancies. Maternal complications include preeclampsia, hypertension, gestational diabetes, placenta previa, abruptio placenta, cesarean birth, and maternal mortality. For the fetuses, the risks include prematurity, low birth weight, birth asphyxia, cerebral palsy, and neonatal death. First, pregnancy complications such as preeclampsia, hypertension, diabetes, abruptio placenta, or placenta previa can be very problematic for the clinician and can result in medical or surgical interventions or even early delivery 34 . Some of these pathologic conditions are known to influence intrauterine growth. Would bed rest with reduced maternal activity and stress reduction alter interuterine fetal growth Can overdistension...

Is there an associated increased adverse outcome in GDM

Children is strongly correlated with childhood hypertension (both systolic and dystolic) and resembles the metabolic syndrome albeit at a younger age. Moreover, the presence of hypertension in LGA infants was suggested as a cause for this condition in children.50 In another study, Vohr et al. reported that LGA infants of GDM mothers had higher BMI waist circumference and abdominal skin folds at one year compared to infants of nondiabetic mothers. The mean postprandial glucose value for the second and third trimester correlated with waist circumference (r 0.28, P < 0.04) and subscapular skinfold (r 0.37, P < 0.007). They concluded that macrosomic infants of GDM mothers have unique patterns of adiposity that are present at birth and persist at age 1 year.51

82scope of teen pregnancy

Data from the Centers for Disease Control (CDC) underline a decline in 2004 in the teenage birth rate in the US, with 41.2 births per 1,000 females aged 15-19 years 11 . Rates increased slightly in 2004 for girls aged 10-14 years 11 . These data are worrisome, as these young women are nearer to menarche, and still growing themselves, with increased nutritional needs. These very young women also have increased risk for maternal death 12 . The younger-aged group received the lowest rate of timely prenatal care, highest rates of late or no prenatal care, and was at highest risk of pregnancy-associated hypertension. Among the youngest cohort, pregnancy outcome was poor, e.g., infants were more likely to be preterm, to be born with low birth weight, and to die in their first year at a rate that was three times the overall rate of 15.4 per 1,000 13 .

210 Assessing Fetal Maturity And Wellbeing

Fetal Maturity

(2) Non-stress test is used to screen the high-risk pregnancy where the placental compromise is anticipated to include post-term pregnancy, pregnancy induced hypertension, gestational diabetes, intrauterine growth retardation, and maternal complaints of decreased fetal movement.

284 Hydralazine and dihydralazine

Hydralazine and dihydralazine are structurally similar vasodilator drugs that have been used for the treatment of hypertension in Magee (2003) compared the maternal, fetal, and perinatal outcomes of pregnancies with severe hypertension, treated either by hydralazine or by other hypertensive drugs, mostly nifedipine or labetalol, in a meta-analysis. Therapy took place during the second and or third trimesters. There are conflicting results, but it is clear that hydralazine is not the first-line drug of choice for severe hypertension in pregnancy. Recommendation. (Di)hydralazine may be used for the treatment of hypertension in pregnancy. In acute hypertensive crisis, it is used intravenously.

2810 Magnesium sulfate

Magnesium sulfate, although not actually an antihypertensive, has proven valuable in the treatment of pre-eclampsia. Magnesium sulfate is the drug of choice for treatment of seizures in eclampsia (Oettinger 1993). In a group of 31 fetuses where the mothers were administered the drug i.v. as an initial loading dose of 4-6g, followed by an infusion of 2-3.5 g h. magnesium sulfate was found not to be harmful (Gray 1994). A significantly lower risk of repeated convulsions in eclampsia was seen in a study of 1700 women given parenteral magnesium sulfate compared with those given Phenytoin or diazepam (Duley 1995). In a comparative study of 400 pregnancies, neither magnesium sulfate nor phenytoin treatment for hypertension or prevention of eclampsia adversely affected the course of labor (Leveno 1998).

283 adrenergic receptor blockers

Nebivolol, oxprenolol, pindolol, propranolol, sotalol, and timolol) have a wide spectrum of activity, and are often used to treat hypertension. There are two types of (3-receptors i -receptors predominate in the heart, and -receptors mediate relaxation (dilatation) of vascular and other smooth muscle (e.g. in the airways and blood vessels). Metoprolol is ii-specific, whereas the classic i-blockers such as propranolol and oxprenolol have both rtj and 2 activity. Labetalol has both - and a-receptor blocking activity, and has been successfully used in a number of pregnancies (Pickles 1992, Plouin 1990, 1987). All 3-blockers cross the placenta. Bayliss (2002) analyzed 491 pregnant hypertensive women, of whom 302 took at least one antihypertensive drug the remaining 189 women, without medication, were the controls. Only those newborns who were exposed from conception or from the first trimester until birth (n 40) had a significant lower birth weight. Some studies have compared i.v....

Why do panic attacks happen

There is some evidence that for those who have a history of anxiety problems, their symptoms can improve in pregnancy. If you are experiencing regular panic symptoms, then this can actually have negative effects on your pregnancy. High levels of anxiety in pregnancy have been linked to higher levels of hypertension in mothers. Often when people are experiencing panic attacks it is because problems are not being addressed or

8Does pregnancy affect my eyesight

Visual changes in pregnancy are common, and many are specifically associated with the pregnancy itself. Serious retinal detachments and blindness occur more frequently during pre-eclampsia (high blood pressure). A decreased tolerance to contact lenses is also common during pregnancy therefore, it is advisable to wear contact lenses only after delivery.

294 Lowdose aspirin LDA

Many studies have looked at the use of 'low-dosage' treatment to prevent high blood pressure in pregnancy, and its consequences -such as, for instance, intrauterine growth delays (see Chapter 2.1.2 for further details). No adverse effects in the mother, fetus or newborn in association with the use of low-dose aspirin were observed.

Maternal and fetal morbidity and mortality

The present authors believe there have been no reports of maternal deaths from AI in pregnancy since the 1950s, with the introduction of cortisone, earlier diagnosis, and improved antenatal care. However, a reported case of maternal death at 8 months after delivery illustrates the importance of careful postpartum follow-up 26 . Some cases that were not diagnosed during pregnancy had normal maternal and fetal outcomes, suggesting that women with unrecognized AI benefit from transplacental passage of cortisol from the fetus. Therefore, AI may only become apparent in the immediate postpartum period 29 . In women known to have the disease, careful titration of glucocorticoid and mineralocorticoid replacement are required to avoid an adrenal crisis and potential side effects, including hypertension and exacerbation of preeclampsia 26,30 .

Preconception Issues And Care

Medication should be reviewed and where possible changed to agents that are safer in pregnancy. In particular ACEI should be stopped, and, where treatment for hypertension is required, methyldopa substituted. Insulin regimens may be intensified - twice daily injections with biphasic preparations are unlikely to allow sufficient flexibility of dose adjustment. Only insulin aspart (NovoRapid ) is licensed for use in pregnancy. Theoretical concerns about insulin glargine (Lantus ) and animal insulins mean that human isophane insulins or insulin detemir (Levemir ) are preferred as basal insulins1 (though increasing evidence now supports insulin glargine use in pregnancy).

Gestational diabetes mellitus

The timing of beginning and the frequency of fetal monitoring depend on the presence of complications of the pregnancy such as pre-eclampsia, hypertension, antepartum hemorrhage, and fetal growth retardation. The intensity and the type of monitoring should be dictated by the severity of the obstetric complication. Ultrasonography should be considered around the 24th week to detect abnormalities of fetal

Pregestational diabetes

A complete anamnesis is imperative before planning for pregnancy. This should include, but not be limited to, questioning for duration and type of diabetes (Type 1 or Type 2), acute complications, including history of infections, ketoaci-dosis, and hypoglycemia, chronic complications, including retinopathy, nephropathy, hypertension, atherosclerotic vascular disease, and autonomic and peripheral neuropathy, diabetes management, including insulin regimen, prior or current use of oral glucose-lowering agents, SMBG regimens and results, medical nutrition therapy, and physical activity, concomitant medical conditions and medications, thyroid disease in particular for patients with Type 1 diabetes, menstrual pregnancy history contraceptive use and support system, including family and work environment.70 To minimize the occurrence of malformations, standard care for all women with diabetes who have child-bearing potential should include (3) integration of the patient into the management of...

Maternal And Fetal Determinants Of Adult Disease

The notion that events occurring during the time of gestation might predispose an individual to chronic diseases later in life has recently been supported by epidemiologic data (7.1,7.2,7.3 and 74). Observations made in the United Kingdom have led to the hypothesis that adverse nutritional experiences in utero have a powerful influence on the development of degenerative diseases in adulthood. Poor fetal growth appears to be a strong predictor of hypertension, diabetes, hyperlipidemia, alteration in clotting factors, syndrome X (the combination of noninsulin-dependent diabetes, hypertension, and hyperlipidemia), and mortality from cardiovascular disease and chronic obstructive airway disease. The theory of fetal origins of adult disease proposes that early defects in the development, structure, and function of organs lead to programmed susceptibility, which interacts with later diet and environmental stresses to cause overt disease many decades after the original insult.

Use of rapidacting insulin analogs in pregnancies complicated by diabetes

The report also indicated that both women maintained a mean blood glucose level of < 108 mg dL. A pregnant woman's target blood glucose should be < 90 mg dL fasting and < 120 mg dL postprandially.29 If the women measured their fasting blood glucose only, the reported mean is obviously too high. If postprandial measurements were also taken into account, the mean is still too high, although less so. These women would be categorized as being at high risk for bearing infants with malformations. Throughout pregnancy, the second mother was being treated for hypertension and if the malformations were due to a medication it is perhaps

2113 Monoaminoxidase inhibitors MAOIs

Hypertension is a common complication of pregnancy, and is often insidious in onset. MAOIs can exacerbate this condition and may lead to alterations in placental blood How. particularly placental hypoperfusion, which may have serious consequences for fetal growth and development (Mortola 1989). Recommendation. The limited data available on the safety of MAOI use in pregnancy and the potential for interacting with other medication and certain food substances mean that MAOIs are not recommended for use during pregnancy. They can exacerbate hypertension, and may interfere with drugs used at delivery. They should be avoided unless all other treatments have failed. Nevertheless, exposure to MAOIs in the first 3 months of pregnancy is not an indication for termination of a pregnancy. Detailed fetal ultrasonography may be offered in such cases to control normal development. Furthermore, a pregnant patient who is stable with these drugs should not be changed to another drug, because this may...

2124 Selective immunosuppressants

Discussed elsewhere (sec Chapter 2.17). Certain advantages and disadvantages of tacrolimus in pregnancy are discussed compared to cyclosporine rejection and hypertension are less common with tacrolimus, and the necessary dosage of prednisolone is lower. On the other hand, gestational diabetes occurs more often, as does transient hyperkalemia and transient reduction of kidney function in the newborn. Jain (1997) even reported on a newborn with anuria which lasted 36 hours. As with other immunosuppressant drugs, pre-eclampsia, prematurity, low birth weight, and cesarian births were seen at greater incidence.

33 Antipsychotic Agents

Cated by the development of hypertension and pre-eclampsia in the mother (61). Very few case reports have been written regarding in utero use of clozapine. These limited case reports to date have not shown a clear teratogenic effect (62-64). Several studies have suggested an increased risk for hyperglycemia in pregnant women related to using atypical antipsychotic therapy during gestation (65). One study in schizophrenic women suggested that atypical antipsychotics are associated with a higher risk of neural tube defects in the infants of 21 women with schizophrenia (66). However, in another study (67), women who had been exposed to atypical antipsychotics were matched to a comparison group of pregnant women who had not been exposed to these agents. The study evaluated 151 pregnancy outcomes that involved 60 exposures to olanzapine, 49 exposures to risperidone, 36 exposures to quetiapine, and 6 exposures to clozapine. Rates ofmalformation were 0.9 . Thus, in this controlled study...

Lana K Wagner Larry Leeman and Sarah Gopman

Summary Preeclampsia is a multi-organ disease that is specific to pregnancy and is characterized by the development of proteinuria and hypertension. It complicates 5-7 of pregnancies and specific criteria must be met for diagnosis. The exact etiology or pathophysiology of preeclampsia is poorly understood and as such, there are no well-established methods of primary prevention or of reliable and cost-effective screening. Calcium and aspirin may have a role in preventing preeclampsia in certain subpopulations, and research continues regarding these and other possible nutritional interventions. Preeclampsia is associated with increased maternal mortality and morbidity, and childbirth is the only known cure. Women with preeclampsia need to have regular surveillance. The associated hypertension may warrant treatment under certain conditions and magnesium sulfate is the drug of choice for the prevention and treatment of eclamptic seizures. Keywords Preeclampsia, Eclampsia, Hypertensive...

112hypertensive disorders of pregnancy

Complications from hypertension are a leading cause of pregnancy-related deaths, ranking third behind hemorrhage and embolism 2 . Hypertensive disorders that may be found during pregnancy include chronic hypertension, preeclampsia- eclampsia, preeclampsia superimposed on chronic hypertension, and gestational hypertension 3 . Chronic hypertension is hypertension that exists outside of the pregnancy. As such, it will predate the pregnancy, be documented prior to 20 weeks, or will still be present 12 weeks after delivery 3 . Treatment of mild-to-moderate chronic hypertension during pregnancy has not been shown to prevent preeclampsia and has shown no proven fetal benefit 4-6 . Preeclampsia-eclampsia is the onset of hypertension with proteinuria that occurs after 20 weeks of pregnancy. Eclampsia, which occurs in less than one percent of women with preeclampsia 1 , is the new onset of seizures during preeclampsia. If a patient has chronic hypertension but develops new or worsened...

113diagnosis of preeclampsia

As mentioned previously, both proteinuria and hypertension after 20 weeks of gestation must be present for a diagnosis of preeclampsia to be made. The diagnostic criteria for preeclampsia are presented in Table 11.1. Blood pressures should be measured with an appropriately sized cuff, with the patient in an upright position 8 . Edema and blood pressure elevations above the patient's baseline are no longer included in diagnostic criteria 3, 7 .

114pathophysiology and risk factors

Theories of pathophysiology include genetic predisposition 11-14 , abnormal placental implantation 15, 16 , angiogenic factors 17 , exaggerated inflammatory responses 18 , inappropriate endothelial activation 18 , vasoconstriction 19 , and coagulation cascade defects 19 . Although hypertension and proteinuria are the criteria by which preeclampsia is diagnosed, the pathophysiologic changes associated with preeclampsia affect virtually every organ system. Microthrombi from activation of the coagulation a Both hypertension and proteinuria components must be present b One or more must be present in addition to criteria for preeclampsia c Taken on two occasions at least 6 h apart Chronic hypertension

Pheochromocytoma in pregnancy

Pheochromocytoma accounts for approximately 0.1 cases of hypertension in the general population. There have been at least 200 cases diagnosed in pregnancy, and the estimated prevalence at term is approximately 1 in 54,000 83,84 . Pheochromocytoma is associated with sustained or paroxysmal episodes of hypertension, pallor, headaches, and palpitations 84 . Other presentations include chest pain, dyspnea, abdominal pain, seizure, or even sudden death 85 . Although antenatal diagnosis is associated with improved outcomes, pheochromocytoma can be missed because of unexpectedly normal blood pressure during gestation 83,85 . A recent case illustrated the Untreated pheochromocytoma is associated with increased fetal and maternal morbidity and mortality. The maternal mortality rate was 48 before 1969 and 26 in the 1970s, and subsequently it fell to 17 87-89 . Since 1990, approximately 85 of cases have been diagnosed antenatally, perhaps because of increased awareness 84 . In one series,...

115prevention and nutrition

However, calcium and aspirin may have a role in preventing preeclampsia in certain subpopulations, though the optimal treatment regimens will require further research. Calcium supplementation in high-risk women and in women with low dietary calcium intakes reduced the risk of hypertension and preeclampsia 25 . Also, calcium supplementation has been shown to decrease the incidence of neonatal mortality and severe maternal morbidity due to hypertensive disorders when given to normotensive nullipa-rous women 26 . Low-dose aspirin was shown to have small to moderate benefits for prevention of preeclampsia within certain groups of women. A Cochrane analysis demonstrated that in women at increased risk for preeclampsia, 69 women would need to be treated with low-dose aspirin to prevent one case of preeclampsia 27 . However, in the subgroup of women at highest risk for preeclampsia (because of histories of previous severe preeclampsia, diabetes, chronic hypertension, renal disease, or...

116management of preeclampsia

The hypertension of preeclampsia only warrants treatment if the systolic blood pressure is above 160 mmHg or the diastolic blood pressure is above 110 mmHg 3 . If these pressures occur near term, then the blood pressure may be managed with intravenous hydralazine or labetalol until delivery 32 . Women with severe preeclampsia undergoing expectant management may have their blood pressure controlled with oral labetalol, methyldopa, or nifedipine 3 . Magnesium sulfate is the drug of choice for the prevention and treatment of eclamptic seizures 33 . All women with severe preeclampsia need intravenous magnesium in labor and for 24 h postpartum 34 . The use of magnesium

2147 Magnesium sulfate

Magnesium sulfate, although not actually an antihypertensive, has proved valuable in the treatment of pre-eclampsia. Magnesium sulfate is the drug of choice for the prevention and treatment of seizures in eclampsia. Intravenous administration of the drug as an initial loading dose of 4-6 g, followed by an infusion of 2-3.5 g h, was found not to be harmful. A significantly lower risk of repeated convulsions in eclampsia has been reported.

Breast Feedinq Summary

Hypertensive crisis associated with the use of ritodrine and betamethasone has been reported (35). Systolic blood pressure was above 300 mm Hg with a diastolic pressure of 120 mm Hg. Although the hypertension was probably caused by ritodrine, it is not known whether the corticosteroid was a contributing factor.

2159 Diabetes mellitus and pregnancy

The vast majority of type II or gestational diabetes occurs within the bounds of metabolic syndrome X (obesity, hyperlipidemia, hypertension, impaired glucose tolerance), in the beginning, there is insulin resistance of the insulin-dependent tissues. Therefore, an elevated insulin concentration is necessary for utilization of glucose. Hyperinsulinemia again intensifies the feeling of being hungry, which results in eating more and more, which leads to further weight gain, and so on - a vicious circle. Weight reduction results in lower insulin levels, and an increasing sensibility and amount of insulin receptors. Ideally, a body mass index of 27 kg m2 and below should be achieved prior to pregnancy Regarding the risk of pre-existing obesity for a pregnancy, see Chapter 2.5.

Hypertensive Disorder of Pregnancy Preeclampsia

This condition is characterized by the development of high blood pressure (> 140 90 mmHg), swelling of the extremities and proteins in the urine during pregnancy from > 20 weeks of pregnancy onwards. Those who are primiparas (never delivered before), above 35 years of age, with twins or triplets or have pre-existing hypertension or diabetes are at a higher risk of developing this condition. In some instances, this condition has been known to arise during labor or after the delivery of the baby. Many other organ systems can also be affected and notably seizures (eclampsia) can occur in severe cases. When the organ systems are severely affected, they can pose a danger to the mother and fetus.

Womens rights and the antenatal environment

Three months after the publication of Ballantyne's article, the first hospital bed for the treatment of pregnant women was endowed in the Edinburgh Royal Maternity Hospital, and named the Hamilton bed after the founder of the hospital, Alexander Hamilton. Subsequently, home visits were organised for expectant mothers who were booked in for delivery at the hospital, and by 1915 outpatient antenatal consultations had been instituted there. The concept of antenatal care had been accepted, and slowly the ideas were put into practice, if not quite in the form Ballantyne had envisaged (in-patient beds specifically for pregnant women were never instituted on a large scale). Ballantyne wanted pregnant women to be given basic advice on diet and exercise and to be tested for albuminuria (the presence of albumin in the urine, which is associated with hypertension and had been linked with pre-eclampsia in the late nineteenth century). These goals began to be met initially in the context of...

General and local anesthetics and muscle relaxants

In spite of the fact that there have been very few epidemiological studies on specific and individual anesthetic agents, there have been several relatively large-scale studies looking at the effects of surgery (including anesthesia) in pregnancy, often using a combination of different anesthetic agents. As a general rule, none of these studies has demonstrated significant damaging effects on the outcome of pregnancy (Ebi 1994, Mazze 1989, Duncan 1986). An increased rate of spontaneous abortions was demonstrated in some reports (Brodsky 1980), but it is difficult to attribute that to the direct effects of the anesthetic agents. Therefore, we can conclude from the current state of knowledge that none of the commonly used anesthetics produces an increase in congenital malformations. However, anesthetic complications involving compromise of the mother's breathing or circulation (i.e. pulmonary hypertension) or anesthetic-associated malignant hyperthermia have been described, and might...

2164 Injectable anesthetics

It seems preferable not to use ketamine during pregnancy. As ketamine can increase blood pressure, it is especially contraindi-cated in cases of hypertension or pre-edampsia in pregnancy, and with uterine hyperactivity or suspicion of fetal hypoxia during labor.

IVF pregnancy complications

A recent study from Canada (Allen et al 2006) which reviewed articles from 1995 to 2005 on the effect of ART on perinatal outcomes and obstetric risk showed that there is a definite link to a higher risk of perinatal complications, due mainly to the higher incidence of multiple pregnancies. These include pregnancy-induced hypertension, preterm birth, low birthweight, abruptio placentae and placenta praevia. The outcomes of that study and others have lead to a push from the medical world for single embryo transfer in ART, especially at blastocyst stage (Jansen & Sullivan 2006, Pinborg et al 2004). However, the study stated 'it remains unclear if these increased risks are attributable to the underlying infertility, characteristics of the infertile couple, or use of the assisted reproductive techniques' (Allen et al 2006).

Intrauterine factors in metabolic syndrome The fetal origin of adult disease

DM.15,16 It was also found to be associated with high blood pressure (BP) in childhood17,18 and adult life.19 The evidence was strongest for blood pressure and glucose tolerance,20 which could be measured earlier in life and for which more data, and sometime also prospective data, were available.19,21 The evidence was weaker, though still convincing for heart disease, for which data were sparse and often confined to men. The findings in the few studies on stroke, particularly the hemorrhagic type, were consistent.14 formulated the hypothesis of incorrect statistical interpretations because of chance, artifacts, or confounding factors in later life, but these have been resolved.34 Nevertheless, it should be emphasized that support for the hypotheses comes mainly from studies in rodents35 which cannot rule out environmental causes, particularly those associated with socioeconomic status,36,37 genetic predisposition to low birthweight or hypertension and hypertension-related diseases,...

Mechanisms underlying metabolic syndrome

Insulin resistance now appears to be the epidemiological link between high BP and obesity. Insulin resistance induces hypertension via mechanisms at the cellular, circulatory, and neurological levels, as well as via possible polygenic factors. Acquired or transient insulin resistance is associated with certain physical conditions, such as pregnancy, obesity, oral contraceptive use, and severe distress. Type 2 DM is a state of increased insulin secretion caused by the physiological resistance of insulin action and a lower-than-normal beta-cell reserve. Diabetes in pregnancy or gestational DM (GDM) may precede the clinical expression of Type 2 DM in the nonpreg-nant state, even by several years. Pre-eclampsia and other hypertensive disorders, which are known to have a higher incidence in GDM, can be linked to increased insulin resistance.47

The dyslipidemia component

Several other metabolic disturbances, such as elevated levels of triglycerides, decreased levels of high-density lipoproteins (HDL), high cholesterol level, glucose intolerance, and hyperuricemia, have also been related to hyperinsulinemia.56 The metabolic consequences of these disturbances include changes in the lipid profile resulting in atherosclerosis, increased deposition of body fat, and proliferation of vascular smooth muscle cells, which place the hypertensive, hyperinsu-linemic individual at increased risk of cardiac complications and stroke.57 Studies of the evolution of the clinical and biological disturbances in women with a polycystic ovary (PCO) support the view that insulin resistance, dyslipidemia, and hypertension are all manifestations of a single syndrome. Often obese, these women have hyperinsulinemia which disrupts sex hormone production,58 resulting in androgenization and clinical manifestations of hirsutism and infertility. During pregnancy, they have more...

Clinical consequences of insulin resistance

Insulin resistance impairs glucose tolerance while promoting dyslipidemia, obesity, hypertension, and atherosclerosis. Its effects on salt handling by the kidneys predisposes the individual to renal dysfunction. Obesity, glucose intolerance, hyperinsu-linemia, hypertension, and dyslipidemia represent cumulative risk factors that generate an escalating cycle of vascular compromise and collapse. Patients with three or more of these risk factors have an increased incidence of stroke, nephropathy, ischemic heart disease, and peripheral vascular disease.82 Long-term diabetic complications are the most common cause of blindness, renal failure, and limb amputation in the United States today. Meticulous glycemic control has been shown to decrease the incidence of eye disease among diabetic patients. Antihypertensive therapy, specifically with angiotensin converting enzyme inhibitors (ACE-I), is effective in reducing the rate of progression of diabetic kidney disease. To prevent the peripheral...

Gestational diabetes and hypertensive disorders

Hypertension Dyslipidemia Insulin Hyperinsulinemia Pre-existing resistance jt hypertension combination of insulin resistance and a genetic predisposition (Figure 41.4). A genetic predisposition to PIH was described in southwestern Navajo Indians, who like other Native Americans, are also at increased risk of hypertension, obesity, and DM.107 Pre-eclampsia was also reported to be associated with increased fasting plasma insulin levels in African-American women.108 However, these findings have not been confirmed in more het-erogenous populations.109

Pregestational diabetes and hypertensive complications

In most cases, pregestational diabetes refers to Type 1 DM. The incidence of Type 1 DM in pregnancy ranges from 0.2 to 0.5 .119,120 Affected women contribute a heterogenous group in terms of duration of diabetes, White's classification, presence of hypertension, and end-organ damage, especially to the eye (retinopathy) and kidney (nephropathy). Pregnancy in women with Type 1 DM is associated with increased risks of pre-eclampsia, IUGR, neonatal morbidity, and perinatal mortality.110-127 The diagnosis of pre-eclampsia is difficult in women with preexisting hypertension and proteinuria,120 and women with chronic hypertension are at increased risk of superimposed pre-eclampsia independent of the presence of diabetes.128 The rate of hypertensive disorders (PIH and pre-eclampsia) in the various studies ranged from 9 to 66 . The lowest rate occurred in women with milder forms of DM (class B), and the highest in women with diabetic nephropa-thy. Table 41.1 summarizes the reported rates of...

Breast Feeding Summary

Class Antihypertensive Risk Factor CM* The prodrug, candesartan cilexetil, is hydrolyzed to the active drug, candesartan, during absorption from the gastrointestinal tract. Candesartan is a selective angiotensin II receptor antagonist that is used, either alone or in combination with other antihypertensive agents, for the treatment of hypertension. It blocks the vasoconstrictor and aldosterone-secreting effects of angiotensin II by preventing angiotensin II from binding to AT receptors. No reports describing the use of candesartan cilexetil during human pregnancy have been located. The antihypertensive mechanisms of action of candesartan and angiotensin converting enzyme (ACE) inhibitors are very close. That is, the former selectively blocks the binding of angiotensin II to AT receptors, whereas the latter No reports describing the use of candesartan cilexetil during human lactation have been located. The drug is excreted into rat milk (1). Because the molecular weight of the active...

Treatment of diabetic retinopathy

Control of hypertension, a risk factor for diabetic retinopathy, appears to delay the progression of retinopathy in patients with Type 2 diabetes.16,21,101 High serum lipid levels are associated with increased risk of hard exudates, macular edema, and proliferative retinopathy.102,103 Normalization of lipid levels may reduce this risk.

Impact of pregnancy on the development and progression of diabetic retinopathy

Rosenn et al.137 reported a progression rate of 33 in a prospective study of 154 pregnant women with Type 1 diabetes. They have found that hypertension, either chronic or pregnancy-induced, was a significant and independent risk As mentioned earlier, hypertension is a risk factor for the progression of diabetic retinopathy.11,14,16,20,21,137 Hypertensive disorders are common in diabetic pregnancies, complicating up to 40 of pregnancies in Type 1 diabetic women.146 Thus, hypertension may contribute to the progression of retinopa-thy during pregnancy. hypertension

Management of diabetic retinopathy during pregnancy

Patients with diabetes who are planning to become pregnant should be given a thorough explanation on the risk of development or progression of diabetic retinopathy during pregnancy, and the importance of glycemic control throughout pregnancy. Patients with high-risk characteristics (longstanding diabetes, severe retinopathy, coexisting hypertension, poor glycemic control) should be identified and followed appropriately. Glycemic control should be achieved prior to conception in order to reduce the risk of progression of retinopathy, as well as to avoid the adverse maternal and fetal outcome associated with poorly controlled diabetes during pregnancy. One goal is to achieve a glycosylated hemoglobin level of less than 6 standard deviations above normal prior to conception.138 In the presence of proliferative or severe nonproliferative retinopathy, normalization of blood glucose levels should be achieved gradually over a period of weeks to months in order to avoid progression of...

Pathophysiology and treatment of diabetic nephropathy

Diabetic nephropathy is a progressive disease that affects approximately 30 of patients with diabetes and it is the most common cause of end stage renal disease in USA. The first clinical sign is increased excretion of albumin in the urine, so called microalbuminuria in the range 30-300 mg 24 h, corresponding to a spot urine albumine to creatinine ratio of 30 mg g. Untreated microalbuminuria progresses to overt diabetic nephropathy characterised by persistent proteinuria, hypertension and a relentless decline in glomerular filtration rate.4 Histological changes in the glomeruli with increased basal membrane thickness and glomerulosclerosis are characteristics, but universal leakage of albumin over the endothelium in the whole body is also present. Progression to end stage renal disease occurs with a median duration of 7 years after onset of diabetic nephropathy, if let untreated. The introduction of inhibition of the renin-angiotensin system in combination with other antihypertensive...

Effects of pregnancy on diabetic nephropathy

Few studies have examined the long-term effect of pregnancy on renal function in women with diabetic nephropathy after strict antihypertensive treatment has been widely used and improved the survivial. The most recent is a case-control study including 26 pregnant women with diabetic nephropa-thy and normal serum creatinine followed for up to 13 years and the decline in kidney function was compared to women with diabetic nephropathy who did not became pregnant in the study period.8 The women were offered strict antihypertensive treatment as routine treatment.during the whole study period. They found that in women with serum creatinine within the normal range, pregnancy did not accelerate the

Effect of diabetic nephropathy on pregnancy outcome

The risk of perinatal mortality in pregnancies complicated by diabetic nephropathy is now close to that of women with Type 1 diabetes without diabetic nephropathy.1-3 The rate of pre-eclampsia in women with diabetic nephropathy is high 53-64 1,2,3,11 especially when reduced kidney function,12 hypertension at onset of pregnancy or severe nephrotic pro-teinuria is present.2,3 Moreover, also women with Type 1 diabetes and microalbuminuria have increased risk of developing pre-eclampsia compared to women with Type 1 diabetes and normal urinary albumin excretion.12 Pre-eclampsia often leads to preterm delivery11 and preterm delivery before week 34 has been reported in up to 45 of the cases.11,13 Severe handicap of the children born to mothers with diabetic nephropathy has been described. In a follow-up of 35 children born between 1982 and 1992, the majority were normally developed but seven (20 ) had psychomotor retardation when examined at a mean age of 4.5 years.13 The risk of...

Treatment of women with diabetic nephropathy during pregnancy

Blood pressure recording has not been shown to be of benefit in the care of these women.15 Early onset and strict antihypertensive treatment as in the nonpregnant state might improve the outcome. In patients with microalbuminuria introduction of early onset antihypertensive treatment with methyldopa in normotensive pregnant women with Type 1 diabetes and microalbuminuria resulted in a significant reduction in preterm delivery before gestational week 34.16 Furthermore, early onset and strict antihypertensive treatment in women with diabetic nephropathy most likely also reduce the severity of pre-eclampsia end preterm delivery. Our center recommends initiating antihypertensive treatment in pregnant women with diabetes and elevated urinary albumin excretion at one of the following clinical indications blood pressure exceeding 135 85 a doubling of urinary albumin excretion or urinary albumin excretion exceeding 300 mg 24 h.16 ACE inhibitors or angiotensin receptor blockers used before...

Counseling women with diabetic nephropathy

Careful counseling of the woman and her partner of the risk for herself and the newborn is important before the couple can take a well-considered decision regarding pregnancy. An updated diabetes status including hemoglobin A1c, risk of hypoglycemia, degree of retinopathy, serum creatinine, blood pressure, and proteinuria is necessary to estimate the risk for complications during pregnancy. The number of antihypertensive drugs to control the blood pressure sufficiently prior to pregnancy is also of importance, since there has to be room for further intensification of antihypertensive treatment in late pregnancy, if necessary. ACE inhibition was discontinued immediately after the positive pregnancy test and only four out of 24 women delivered preterm. Severe handicap or late infant death was seen in two cases.3 However, treatment with ACE inhibitors in early pregnancy has recently been shown to be associated with increased risk of congenital malformations.18 Furthermore ACE inhibition...

Data that may support higher GDM rate in multiples

Fetal macrosomia, birth trauma, unexplained antepartum fetal demise, pregnancy-induced hypertension, and placental abruption. Specifically, a retrospective population-based study of twins conceived by in vitro fertilization (IVF) found that patients who developed severe pre-eclampsia were more likely to have GDM.7 Using the 1995 to 1997 Multiple Birth File of the United States, Wen et al.16 compared the maternal morbidity and obstetric complications of 152,238 twins, 5491 triplets and 432 quadruplets or more pregnancies. After an adjustment for important confounding factors, the risk of pregnancy-associated hypertension and eclampsia, anemia, diabetes mellitus, abruptio placenta, premature rupture of membrane, and Cesarean delivery was increased in women with triplet pregnancies and higher-order multiple pregnancies than in women with twin pregnancies. A dose-response relationship was observed for GDM (as well as for pregnancy-associated hypertension and placental abruption). Newman...

Euthyroid chronic thyroiditis

Patients with Hashimoto's thyroiditis are at greater risk of developing hypothyroidism very early in pregnancy because of the increase demand in thyroid hormones if not properly managed they are at risk of developing the same complications as poorly treated hypothyroid mothers, mainly spontaneous abortions, preterm delivery, and pregnancy-induced hypertension (PIH). One recent study showed a significant decrease of miscarriages and preterm delivery in euthyroid chronic thyroiditis women treated with levo-thy-roxine in the first 10 weeks of gestation as compared to euthy-roid chronic thyroiditis mothers receiving no treatment and a control population.13 In the untreated women a significant number of them developed subclinical hypothyroidism. Therefore it appears reasonable to treat euthyroid and subclinical hypothyroidism mothers with levo-thyroxine before or very early in pregnancy to prevent the above complications.

1 If you are diabetic during pregnancy

Diabetes during pregnancy increases the risk of certain health problems like high blood pressure during pregnancy (pre-eclampsia), big baby leading to difficult delivery and higher chance of needing a cesarean section. Hence, it is important for women with pre-existing diabetes before pregnancy, and those newly diagnosed during pregnancy (i.e. gestational diabetes) to control their

62 Fetal Effects of Cocaine

Nonetheless, cocaine diffuses across the placenta and affects the blood supply to the fetus. Cocaine increases maternal and fetal blood pressure. Maternal hypertension may affect blood flow to the placenta, which can decrease oxygen to the fetus. Adverse fetal outcomes may result from cycles of relative ischemia, rebound vasodilation, and hyperperfusion that may develop from vasoconstrictive effects within the placenta (55). Vasoconstriction is presumed to cause disruption ofplacental adherence to the uterine wall and thereby increases the risk of placental abruption. A meta-analysis of 33 epidemiological studies found that the risks of placental abruption and premature rupture of membranes were significantly associated with cocaine use (56). In this analysis, the rates of major malformations, low birthweight (LBW), and prematurity among children of mothers who used cocaine prenatally were not higher than among children exposed prenatally to other drugs of abuse. However, the...

37 Medications that affect lactation

Medications with an antidopamine effect, such as phenothiazine, haloperidol, and other neuroleptics, such as sulpiride and risperidone, as well as the antihypertensive a-methyldopa, and medications used to stimulate intestinal peristalsis, domperidone and metoclopramide, can, as a result of increasing the secretion of prolactin, stimulate milk production. The sympathicoiytic action of reserpine can have the same effect. Growth hormone and thyrotrophin-releasing hormone can also enhance milk production. Domperidone and metoclopramide are occasionally used for this purpose - for example. 10 mg metoclopramid three times a day (for a maximum of 7-10 days) and then tapering off the dosage for 2-5 days is sometimes recommended. Domperidone (not available in the USA) is less capable of crossing the blood-brain barrier, and therefore the risk of extrapyramidal symptoms is remote. Due to a molecular mass of 426, protein binding > 90 , and poor oral bioavailability, the relative dose for a...

Growth of SGA infants

In the pre-insulin era, most infants of diabetic mothers were of low birthweight due to maternal starvation that was then the way to reduce serum glucose levels and avoid intrauterine fetal death.5 Since the introduction of insulin, low birthweight in infants of mothers with PGD is usually a sign of severe diabetic vascular complications and is observed in increasing frequencies in women with PGD and hypertension, renal disease or with malformed infants.5,9,32 It is interesting to note that in studies assessing the in utero early embryonic and fetal growth of diabetic mothers, early fetal growth retardation was accompanied by an increased rate of congenital anomalies.32 However, overzeallous treatment of diabetes causing periods of reduced blood glucose levels may cause low birthweight. Langer et al.15 have found that the rate of LBW in women with GD and mean gestational blood glucose levels below 87 mg was 20 , significantly lower, than in controls that had only 11 of LBW infants....

Seth Guller Yuehong Ma and Men Jean Lee Abstract

Although the etiology of intrauterine growth restriction (IUGR) and preeclampsia (PE) remains unclear, most investigators attribute the initial insult to poor utero-placental perfusion due to defective trophoblast invasion that ultimately compromises fetal well-being.13 The resultant hypoxia curtails the remodeling of uterine vessels by invasive cytotrophoblasts in the second trimester.1,2 Our results suggest that mediators of fetal stress i.e., glucocorticoids (GC) may in fact alter placental gene expression and contribute to the destruction of the placental villous network in pregnancies with IUGR PE. We will present a molecular model through which GC, induced in response to fetal stress, promotes the placental villous damage observed in pregnancies associated with IUGR PE. This model incorporates the roles of trophoblast plasminogen activator inhibitor (PAI)-l, mesenchymal extracellular matrix (ECM) proteins, and their regulation by transforming growth factor (TGF)-(3. We will...

Covering special issues for moms with multiples

Hypertension and preeclampsia Hypertension (high blood pressure) is more common in multi-fetal pregnancies. The risk is proportional to the number of fetuses present. Some women develop hypertension alone, without other symptoms or other physical signs. Others develop a condition unique to pregnancy called preeclampsia, which involves high blood pressure in association with either edema (swelling) or spilling protein in the urine (see the description of preeclampsia in Chapter 16). Forty percent of mothers carrying twins and 60 percent or more with triplets develop some form of hypertension during pregnancy. For this reason, your practitioner keeps a close eye on your blood pressure.

Reducing Blood Pressure Naturally

Reducing Blood Pressure Naturally

Do You Suffer From High Blood Pressure? Do You Feel Like This Silent Killer Might Be Stalking You? Have you been diagnosed or pre-hypertension and hypertension? Then JOIN THE CROWD Nearly 1 in 3 adults in the United States suffer from High Blood Pressure and only 1 in 3 adults are actually aware that they have it.

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