Pregnancy Induced Hypertension And Ayurveda


                                 

Today is World Health Day and this year focus is on Hypertension .

Hypertension is one of the common medical complication of pregnancy and contributes significantly to  the maternal and perinatal morbidity and mortality .

Pregnancy induced hypertension  ( PIH ) , Transient hypertension of pregnancy or Gestational hypertension are terms used to describe new hypertension which appears after midterm ( 20 weeks ) and resolves after delivery .

Chronic Hypertension is used to describe the condition of long term high blood pressure .The usual cause is ‘ essential hypertension ‘, meaning an inherited condition with no underlying  pathology .

The threshold for diagnosing Hypertension in pregnancy is 140/90 mm Hg . In second half of pregnancy cut off is 170 / 110 mm Hg . However 170 / 110 or higher is considered to be severe Hypertension ( Davey & MacGillivray 1988 ) .

Thus hypertension in pregnancy has three possible aetiologies :

1)      It may be caused by pregnancy itself

2)      It may be long term problem present before pregnancy began

3)      It may be a new medical problem by chance coinciding with pregnancy

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PRE-ECLAMPSIA :

Pre-eclampsia , pre – eclamptic toxaemia ( PET) or gestosis are roughly synonymous terms, a common syndrome that becomes detectable in the second half of pregnancy ( although origins may lie in the first half ) and  which is defined in terms of the new development of hypertension and proteinuria . It is common , dangerous to both mother and baby .

The cause of pre-eclampsia is not yet known but must lie within the       gravid uterus . Hence , although pre – eclampsia is conventionally defined as hypertension is not primarily a hypertensive disease . The signs of pre-eclampsia  are therefore best considered as secondary to a uteroplacental disorder affecting specific maternal target systems . The targets include the maternal         cardiovascular , renal , coagulation and hepatic systems .

Definition of Pre-eclampsia as accepted by the International Society for the Study of Hypertension  ( Davey & MacGillivray 1988 ) is :

Hypertension : Diastolic pressure :

                              ≥ 90 mm Hg o two or more consecutive occasions  ≥ 4 hr apart or  ≥ 110 mm Hg once

Proteinuria :  24 hr urine collection : ≥ 300 mg protein ;

                         Or two MSU ( mid stream urine ) sample collected more than 4 hr apart with ≥   + 1 on stick test .

Pre – eclampsia : New hypertension and new proteinuria developing after 20 weeks gestational age and regressing remotely after delivery .

RISK FACTORS FOR PRE-ECLAMPSIA :

MATERNAL FACTORS :

  • Primigravidity

  • Primipaternity ( There is partner specificity about the occurance of pre-eclampsia . Hence , it is not simply the first pregnancy that is an important risk factor but the first by the current partner) .

  • Short period of co habitation ( Stable co habitation with a single partner seems to reduce the risk of pre – eclampsia in the first pregnancy by the partner ) .

  • Increasing maternal age

  • Previous pre – eclampsia

  • Obesity ( Syndrome X , PCOS )

  • Medical disorders :  Diabetes , Chronic Hypertension , Chronic Renal disease , Antiphospholipid antibody syndrome & thrombophilia , Migraine , Asthma .

  • Family history of Pre – eclampsia

  • Stressful job

PLACENTAL / FETAL FACTORS :

  • Advancing gestational age

  • Poor placentation

  • Multiple pregnancy

  • Hyaditiform mole

  • Triploidy

  • Trisomy 13

  • Trisomy 16 mosaic

  • Placental hydrops

RECOGNITION OF THE PRE – ECLAMPTIC SYNDROME :

MATERNAL SIGNS :

  • PIH

  • Excessive weight gain ( > 1.0 kg / wk )

  • Generalized oedema

  • Evidence of haemoconcentration : Increased haematocrit

  • Disturbance of Renal function : Hyperuricaemia , Proteinuria , Raised plasma creatinine – reduced creatinine clearance , Hypocalciuria

  • Increased circulatory markers of endothelial dysfunction : Plasma vonWillbrand factor , Plasma cellular fibronectin

  • Laboratory evidence of excessive activation of the clotting system : Reduced plasma concentration of anti thrombin III , Thrombocytopenia , Increased circulating fibrin D-dimer

  • Increased circulating concentrations of liver enzymes .

FETAL SYNDROME :

  • Intra uterine growth restriction

  • Intra uterine hypoxaemia

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COMPLICATIONS OF PRE – ECLAMPSIA :

Central Nervous System :

  • Eclamptic convulsions

  • Cerebral haemorrhage

  • Cerebral oedema

  • Cortical blindness

  • Retinal oedema

  • Retinal detachment

Renal System :

  • Renal cortical necrosis

  • Renal tubular necrosis

Respiratory System :

  • Laryngeal oedema

  • Pulmonary oedema

Liver :

  • Jaundice

  • Hepatic infarction

  • HELLP Syndrome

  • Hepatic rupture

Coagulation System :

  • DIC

  • Microangiopathic haemolysis

Placenta :

  • Placental infarction

  • Retroplacental bleeding and Abruptio placentae

MANAGEMENT OF PRE-ECLAMPTIC HYPERTENSION AND ASSOCIATED PROBLEMS

The principles of management are :

  • Screening of the symptomless patient , diagnosis and well timed delivery .

  • In general , symptomatic pre-eclampsia ( symptoms , hypertension and proteinuria ) justifies an emergency admission .

  • Symptomless proteinuric pre- eclampsia demands urgent admission on the day of diagnosis .

  • Pre – eclampsia without proteinuria , which has been confirmed by biochemical testing ( eg hyperuricaemia ) is usually best managed in a day assessment unit where frequent detailed checks are routine .

  • Mild hypertension with no other complicating factor can be managed conservatively from routine clinics .

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AYURVEDA :

Though there is no direct mention of PIH in Ayurveda , but some symptoms as complication of pregnancy have been described . It can be termed as Garbhajanya Vishamayataa .The main symptoms are :

Shopha ( Oedema )

Paad Shotha  ( Pedal oedema )

Mutra alpata ( Oliguria )

Aakshepa ( Convulsions )

Sangyanasha ( Coma )

MANAGEMENT :

In PIH , Ayurveda helps in limiting the maternal and fetal complications . Herbs are helpful as a supportive treatment along with the modern medicine under supervision .

Herbs : Garlic ( Allium sativum ) , Punarnava ( Boerhavia diffusa ) ,   Gokshur      ( Tribulus terrestris ) , Shatavari ( Asparagus racemosus ) ,                       Jatamansi            ( Nordostachys jatamansi ) , Brahmi ( Centella asiatica ) etc can be given under supervision .

Other activities such as walk , meditation , deep breathing etc are also helpful .

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