1. Ch.45 Chronic Hypertension Adverse Pregnancy Outcome

2. Chronic Hypertension 임신중 많은 내과적 합병증을 야기 임신중 고혈압처치에 대해 많은 혼동을 줌 임신중 고혈압이 개선되는 것처럼 보임 Dangerous worsening sign proteinuria edema convulsion Preclamsia-eclamsia

3. Definitions Treatment Diastolic ≫ 90mmHg Systolic ≫ 160mmHg Benefit Atherosclerotic disease Postmyocardial infarction Renal or cardiac dysfuction Cerebrovascular thrombosis & hemorrhage

4. Diagnosis 임신 20 주 이전에 고혈압 –Transient hypertension – 임신 2 기까지는 혈압이 떨어지나 일시적임 Complication –Hypertensive or ischemic cardiac disease –Renal insufficiency –Cerebrovascular event –Retinal hemorrhage & exudate Relative factor Age, Body weight, DM, Heredity

5. Treatment in Nonpregnant Benefit of antihypertensive Tx –Motarity –Stroke –Myocardiac event Behavior lifestyle modification –Weight loss –Physical activity –Dietary adjustment –Cessation of smoking –Excessive alcohol –Caffeine usage 그러나 이미 고혈압이 있는 환자가 임신시 고혈압치료를 유지하는 것이 옳은 것인가에 대해선 논란이 있다

6. Evaluation Past history disease –Duration of chronic hypertention –Level of blood presure –General health Adverse events –Cerebrovascular accident –Myocardial infarction –Cardiac failure –Renal dysfuction

7. Cardiac function –Left ventricular hypertrophy --> cardiac dysfunction congestive heart failure --> long-term hypertension 환자에서 ecocardiography 실시되어져야 Renal function –Serun creatinine, proteinurea --> fetal loss, hypertensive complication 증가

8. Pulmonary fuction -->baseline pulmonary fuction test longitudinal vital capacity test --> cardiac dysfuction pulmonarycongestion Physical capability Opthalmological evaluation

9. Relative contraindication of pregnancy –Diastolic pressure ≫ 110mmHg –Multiple antihypertensive drug use –Serum creatinine ≫ 2mg/dL Stronger contraindication of pregnancy –Cerebrovascular thrombosis & hemorrhage –Myocardiac infarction & cardiac failure

10. EFFECTS OF CHRONIC HYPERTENSION ON PREGNANCY

11. MATERNAL EFFECT Abruptio placentae –Incidence 1/150 → 임신전고혈압 환자에서 1.5% 로 증가 → preeclamsia 환자에서 1~2% 로 증가 (1.4%) low-dose aspirin 치료중인 환자중 –The risk of abruptio placentae in women with chronic hypertension is 2~3 fold greater than for normotensive women

12. Superimposed preeclamsia –Chronic hypertension 과의 superimposed preeclamsia 와의 관련성은 논란이 많으나 대체적으로 관련성이 있다고 생각된다. →hypertension for at least 4years =preeclamsia during a prior pregnancy –Low dose aspirin therapy 가 Chronic hypertension 이 있는 환자에서 superimposed preeclamsia 를 예방하는 효과는 미미하다.

13. Maternal economic & lifestyle demands – 충분한 자료가 없어서 증명하긴 어려우나 산모의 병원 방문 정도에 영향을 미치거나 일에 대한 스트레스에 대한 차이가 있을 것 같 다.

14. FETAL/NEWBORN EFFECT Fetal growth restriction – 태아발육제한과 고혈압의 위험도와 관련성이 있다. – 하지만 빈도와 심각도가 다른 인자들에 의해 영향을 받 는다. Maternal factors ; age Severity & control; additional antihypertensive End-organ damage; renal & cardiac dysfuction

15. –Because of these factors, there is no data regarding safety or efficacy of treatment of Women with mild chronic hypertension predating pregnanacy –While such treatment is not harmful for the mother, the potential benefits or adverse fetal-neonatal effects have not been determined  Chronic hypertension 과 protein urea 가 있는 산모에서 Small-for-gestational age newborn 의 발생빈도가 증가  fetal growth 와 antihypertensives 와의 관계에서 mean arterial pressure 가 감소할수록 Small-for-gestational age infant 의 발생빈도가 증가한다

16. Other adverseperinatal outcome –Preterm birth 증가 Before 38week 33% Before 35week 18% –Perinatal death 증가