Education And Debate

Fortnightly Review: The hypertensive disorders of pregnancy

BMJ 1995; 311 doi: (Published 02 September 1995) Cite this as: BMJ 1995;311:609
  1. F Broughton Pipkin, professor of perinatal physiologya
  1. a Department of Obstetrics and Gynaecology, University Hospital, Queen's Medical Centre, Nottingham NG7 2UH

    Summary points

    • Pre-eclampsia remains the single most common cause of maternal death in the United Kingdom. Its cause is still unknown so it cannot be prevented or treated rationally

    • The rise in blood pressure that occurs in late pregnancy without other symptoms may initially be compensatory for fetoplacental hypoxia and therefore physiological. This compensatory mechanism may explain the high incidence of hypertension during pregnancy

    • In some women the compensation breaks down and severe multisystem disease occurs resulting in pregnancy induced hypertension and pre-eclampsia

    • Lipid peroxidation and consequent endothelial damage are probably involved in pathogenesis

    • Calcium excretion is reduced and intracellular free calcium concentrations increased, which could contribute to the greater pressor responsiveness

    • Most of the cardiovascular changes occur during the second half of pregnancy and are hormonally driven rather than mediated by the sympathetic nervous system

    • Women at risk of developing pre-eclampsia can be detected early in pregnancy by asking whether their mother developed the condition; by measuring blood pressure using a standardised method; and by checking for proteinuria

    The hypertensive disorders of pregnancy remain an enigma. Biologically speaking, pregnancy is the time when women are the most important to the species. One feels instinctively that any condition that occurs in between 1 in 7 and 1 in 10 women during the course of their first pregnancy cannot be all bad. And yet, successive reports on confidential inquiries into maternal deaths in the United Kingdom have identified hypertension in pregnancy as the most frequently cited cause of maternal death.

    I cannot cover the pathophysiology of eclampsia in this brief review. Eclampsia occurs unexpectedly in about one in 2000 maternities in the United Kingdom1 and is therefore difficult to study systematically. More than one third of cases occur before the classic warning signs of both proteinuria and hypertension have been documented, and …

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