Alicia M. Lapidus, MD

Originally published as a review article in Gynaecology 			Forum Vol 4 Nº1, 1999. 
 			Permission granted for re-publication.

High blood pressure complicates almost 10 percent of all pregnancies, and the incidence is higher if the women are nulliparous or carrying multiple fetuses.

Preeclampsia is a major cause of maternal mortality in developed and developing countries. It is also a major cause of perinatal morbidity and mortality, and it is very strongly associated with fetal growth retardation.

Women who have or develop high blood pressure during pregnancy are all at increased risk of complications antenatally, intrapartum and in the puerperium. The increased risk applies to the mother as well to the fetus. Pregnant women with hypertension can be divided into two groups: normotensive women who develop the preeclamptic syndrome, which is characterised by hypertension, proteinuria, and edema; and women with chronic hypertension who become pregnant and are at a higher risk of developing superimposed preeclampsia. The impact of preeclampsia affects both mother and fetus, but it is important to differentiate between the complications of the disease from those inevitably associated to the drugs used for its treatment.

Preeclampsia is the most serious form of hypertensive pregnancy complications, but it is not primarily a hypertensive disease; it is a disorder induced by factors based on the presence of placenta. Preeclampsia is initiated by abnormal placentation and, therefore, a low perfunded placenta, release of cytokines and other toxins, and vasoconstriction and platelet activation; so it is a syndrome of generalized endothelial dysfunction,and the complications are associated with the vascular system. Fundamentally, these complications are 1- intravascular coagulation, bleeding and 2- organ failure (hepatic and renal) following poor perfusion.

1- There is a direct relationship between the decreased antithrombin III (ATIII) levels and the severity of the patient's clinical condition, especially after gestational weeks 30-32.

Blood volume, by measurement of red blood cell and plasma volumes, is reduced and has altered distribution in preeclampsia.

2- In hypertensive pregnancy, there is still controversy over the levels of proteinuria that should be considered pathological.

As we have observed, preeclampsia has quite an impact on renal function (Table 1). Preeclampsia may be complicated by seizures: eclampsia. The greatest compromise occurs with the development of the HELLP syndrome (hemolysis, elevated liver enzimes and low platelet count). The HELLP syndrome, alongside preeclampsia, accounts for most maternal deaths associated with hypertension (Table 2).

The process is completely reversed by the delivery of the fetus and placenta, but intrauterine growth retardation and premature delivery pose major threats to the fetus and may require care in a tertiary care center. Treatment of preexisting or pregnancy-induced hypertension does not prevent or reverse the process, but is justified to prevent maternal cardiovascular complications, especially during labor and delivery. The fetus is at increased risk due to growth retardation and hypoxia following placental damage.

The majority of patients with mild chronic hypertension have successful pregnancy outcomes. Most perinatal morbidity is secondary to superimposed preeclampsia. Antihypertensive therapy does not appear to significantly affect pregnancy outcome, or the incidence of superimposed preeclampsia in mild chronic hypertensives. Maternal and fetal risks are considerably higher in severe chronic hypertension and in those patients with target organ disease. These patients should ideally be counseled regarding their risks prior to pregnancy

Perinatal outcome is strongly influenced by gestational age and the severity of hypertension as expressed by the need for antihypertensive treatment, irrespective of the underlying syndrome. Severe preeclampsia is associated with different degrees of fetal injury.

The main impact on the fetus is undernutrition as a result of utero-placental vascular insufficiency, which leads to growth retardation.

There are short and long-term effects. The immediate impact observed is altered fetal growth resulting in greater fetal liability. Fetal health as well as its weight are highly compromised, leading to various degrees of fetal morbidity, and fetal damage may be such as to cause fetal death.

Long-term follow up studies have demonstrated that babies who suffered intrauterine growth retardation are more likely to develop hypertension, coronary artery disease, and diabetes in adult life. There is growing evidence to suggest that patterns of early growth and other life course factors play an important role in the origins and development of cardiovascular disease (CVD), but understanding the processes which mediate these effects is limited.

Unusual perinatal complications involving anoxia or catecholamine release in the mother, fetus, or newborn may predispose the baby to the development of precocious coronary atherosclerosis later in life

Many fetuses have to adapt to a limited supply of nutrients. In doing so, they permanently change their structure and metabolism. These 'programmed' changes may be the origin of a number of diseases in later life, including coronary heart disease and related disorders: stroke, diabetes and hypertension.

Babies who are small or disproportionate at birth, or who have altered placental growth are now known to have increased rates of coronary heart disease, hypertension and non-insulin-dependent diabetes in adult life. These associations are thought to result from fetal 'programming', whereby a stimulus or insult at a critical, sensitive period of early life has permanent effects on the body's structure, physiology and metabolism. Small size at birth and disproportion in head size, length and weight appear to be surrogate markers for the actual influences that programme the fetus. These observations have prompted a re-evaluation of the maternal regulation of human fetal development. Recent studies suggest that the fetus may be considerably more sensitive to the materno-placental supply of nutrients than previously imagined. Adult cardiovascular disease may be a consequence of fetal adaptations invoked when the materno-placental nutrient supply fails to match the fetal nutrient demand.

It has been demonstrated that intrauterine growth retardation, defined as birth weight below the 10th percentile, gives rise to a reduction in nephron number. Oligonephropathy has been suggested to increase the risk for systemic and glomerular hypertension in adult life as well as enhance risk for expression of renal disease after exposure to potentially injurious renal stimuli.

With the present available evidence there is a need to address the key issues of possible confounding factors of perinatal and early life and those in later life in relation to CVD risk. It is also necessary to replicate studies and establish new ones by assembling cohorts where indicators of prenatal and postnatal growth have been previously recorded from different populations living under different conditions.

Effect of hypertension in pregnancy on uric acid

    1. Churchill D; Perry IJ; Beevers DG. Ambulatory blood pressure in pregnancy and fetal growth. Lancet 1997; 349:7-10.

    2. Voto LS, Margulies M. HipertensiÃ³n en el embarazo. Buenos Aires, El Ateneo, 1997.

    3. Visser W, Wallenburg HC. Maternal and perinatal outcome of temporizing management in 254 consecutive patients with severe pre-eclampsia remote from term. Eur J Obstet Gynecol Reprod Biol 1995; 63:147-54

    4. Riaz M, Porat R, Brodsky NL, Hurt H. The effects of maternal magnesium sulfate treatment on newborns: a prospective controlled study. J Perinatol 1998; 18:449-54

    5. Lindheimer MD, Katz AI: The kidney and hypertension in pregnancy. In Brenner BM, Rector FC eds. The Kidney. Philadelphia: WB Saunders, 1990.

    6. Dunlop W, Davison JM: Renal Haemodynamics and tubular function in human pregnancy. Balliere's Clin. Obstet. Gynaecol, 1987; 1: 769-87.

    7. Baylis C, Davison J: The urinary system. In Hytten F, Chamberlain G eds.: Clinical Physiology in Obstetrics. Oxford, Blackwell, 1990.

    8. Neerhof MG; Pregnancy in the chronically hypertensive patient. Clin Perinatol 1997; 24 :391-406

    9. Piper JM; Langer O; Xenakis EM; McFarland M; Elliott BD; Berkus MD . Perinatal outcome in growth-restricted fetuses: do hypertensive and normotensive pregnancies differ? Obstet Gynecol 1996; 88:194-9

Articles

Effects of preeclampsia on the mother, fetus and child

Effect of HELLP syndrome on laboratory tests values

Originally published as a review article in Gynaecology Forum Vol 4 NÂº1, 1999.Permission granted for re-publication.

1.    Churchill D; Perry IJ; Beevers DG. Ambulatory blood pressure in pregnancy and fetal growth. Lancet 1997; 349:7-10.

2.    Voto LS, Margulies M. HipertensiÃ³n en el embarazo. Buenos Aires, El Ateneo, 1997.

3.    Visser W, Wallenburg HC. Maternal and perinatal outcome of temporizing management in 254 consecutive patients with severe pre-eclampsia remote from term. Eur J Obstet Gynecol Reprod Biol 1995; 63:147-54

4.    Riaz M, Porat R, Brodsky NL, Hurt H. The effects of maternal magnesium sulfate treatment on newborns: a prospective controlled study. J Perinatol 1998; 18:449-54

5.    Lindheimer MD, Katz AI: The kidney and hypertension in pregnancy. In Brenner BM, Rector FC eds. The Kidney. Philadelphia: WB Saunders, 1990.

6.    Dunlop W, Davison JM: Renal Haemodynamics and tubular function in human pregnancy. Balliere's Clin. Obstet. Gynaecol, 1987; 1: 769-87.

click             here for RealAudio version

       "We're at the 9th Congress of Ultrasound in Obstetrics and       Gynecology, and I want to introduce myself: I'm Dr. Alicia Lapidus. I'm       Director of 

,       and we're here with Terry Dubose. This is a great Congress, we are       enjoying it. We have about 1,500 attending. It has great conferences -       it's just great. What do you think?"
       
       

 "Yes,       it's world-class and the atmosphere in Buenos Aires is much more European       than I had expected. It has been very pleasant, a good atmosphere all away       around."
       
       

       "Yes, Buenos Aires is a nice city. I hope everybody can come here and       get to know Buenos Aires. We have a European city here, with wide avenues       full of sun."
       
       

 "This       is the first Congress held in South America, isn't it?"
       
       

       "Yes, it's the first World Congress in South America, and I hope       there will be another one soon because we enjoy doing it and working on       it. I worked all this month because I'm also on the Organizing Committee,       so we have a lot of work with the Congress. But I think everything is       going perfectly, and we are happy to see that everybody's enjoying it and       participating and working. There are a lot of papers being presented, and       everybody's very enthusiastic about that."
       
       

       "Alicia, tell us how you became involved with 

       and what you've done there."
       
       

       "That's funny because       when I began with the OBGYN list I was, I think, the only Argentine doctor       that was on that list."
       
       

 "That       was before the web site?"
       
       

       "Yes, before the web       site."
       
       

,       it was the OBGYN-L."
       
       

       "Yes, I'm old enough,       and afterward when Roberta began the web project, I was asked to be the       International Representative for Argentina. I accepted, and some months       passed and I began to think that it would be a good idea to have some       things in Spanish because in the States you have a lot of Spanish-speaking       people, and all of South America speaks Spanish. So I began to make some       translations, and Dr. Agustin Olmos began to work with me. We both thought       there should be a page just in Spanish, with some things that are       necessary for South America or Latin America, so we're working on that new       page. It's not so new, now; it's been two years. We are translating some       papers and putting our own writings, and a lot of doctors from all over       Latin America are sending their work in, so we are also sharing with all       those doctors by putting some things on the page. I think it's a good       place to share ideas. Patients go there a lot, and the information has       been reviewed because we see all that's put there. We read it, we send it       back, and back and forth…"
       
       

 "And       editing, yes."
       
       

       "Yes, all the editing,       and we ask for quality. That's our goal - quality and education, and for       women and to share... a place for all Spanish-speaking doctors to learn.       For example, in Argentina there aren't very many doctors that speak       English, so I think it's very important. They always say to me that they       are happy to have a place on the Internet to look for information in their       own language."
       
       

 "Dr.       Lapidus, we thank you very much. You've done a wonderful job helping to       organize this."
       
       

 "I       really appreciate all that you've done to help me and show me around       Buenos Aires."
       
       

       "Thank you very much."
       
       

OBGYN.net Conference CoverageFrom 9th World Congress On Ultrasound in Obstetrics & Gynecology, November, 1999 - Buenos Aires, Argentina

The Meaning of the 9th World Congress of ISUOG to Argentina

 “We are here at FIGO 2000 in Washington, and  we’re very proud to have with us Dr. Tisne and Dr. Miranda.  They are  the President and the Vice-President of the Organizing Committee for  FIGO 2003 in Chile.  What does Chile have to offer everybody that’s  going to be there?”
       
       

 “You know the  Scientific Committee is organizing here from FIGO but we are going to  have a lot of people from Latin America that are going to be involved in  that.  But most people go to these Congresses not only for the  scientific organization but also as tourists and to make friends, and in  Chile there are a lot of possibilities.  You are going to have the  driest desert in the north, and you’re going to have the Easter Islands,  which are very well known all over the world.  In the south you’re  going to have some landscape and rivers that you can go rafting on.  You  can have the snow one hour away from Santiago, and if you came back  quickly you can go one hour to the beach.  Santiago has two parts; one  that is old and very colonial and the other one, which is the most  important, is where people live, and more or less known for the same  things as in the states.  So there is the modern part and the ancient  part, and you know that at night you are going to have a lot of fun.  We  know that FIGO is very proud of the Scientific Committee but people  have to have some amusement also.  That’s why I think most of the people  from Latin America and from all the countries from all over the world  are going to come here.  Another thing that you’re going to have is some  other countries that are very near like Buenos Aires, Machupicchu in  Peru and Brazil.  It’s a great part of our country where you can stay  more than one week when you go to Santiago.”
       
       

 “Yes, we  think FIGO 2003 is the best combination of a very good scientific  program and very wide specialties for tourists.  In a way, we have a  long country with a variety of different climates, different sports, and  different things for tourists to do.”
       
       

 “And you also have great wines.”
       
       

 “Yes, the best wines, apples, fruits, and chips.”
       
       

 “And they are inexpensive; Chile is inexpensive.”
       
       

 “Chile  is inexpensive.  Chile has had a stable economy in the last ten years,  and the prices are very low in comparison with North America and in  Europe.”
       
       

  “We are  going to have a really great time with all the Chilean guys there.   Thank you very much for this interview, and we’re going to meet at FIGO  2003.  Thank you.”
       
       

  “We’re waiting for you.”         

OBGYN.net Conference CoverageFIGO 2000 INTERNATIONAL FEDERATION of GYNECOLOGY & OBSTETRICS Washington DC, USA