Traditional East Asian Medicine has so much to offer to support patients in maintaining a healthy blood pressure in pregnancy and beyond.
The most common complications of pregnancy, hypertensive diseases range from slightly elevated blood pressure (pregnancy induced hypertension or gestational hypertension) to severe hypertension accompanied by multiple organ and neurological dysfunction (eclampsia.) Rates of hypertensive diseases of pregnancy are reported from 12 -22% of all pregnancies and the maternal mortality rate in the United States has been reported to be over 17% (Chandi et al., 2015).
Pregnancy Induced Hypertension (PIH) is defined as blood pressure readings of at-or-above 140 systolic and/or 90 diastolic after 20 weeks gestation. No other signs or symptoms accompany the elevated blood pressure and blood pressure returns to pre-pregnancy levels after birth.
HELLP syndrome is a complication of preeclampsia that is associated with serious maternal complications such as pulmonary edema, acute renal failure, sepsis, hepatic failure, hemorrhage, and abruptio placenta (Gedik et al., 2017). The pathogenesis is unknown and treatment strategies consist of treating complications, managing the hypertensive state, administering anti-seizure medications and corticosteroids to speed fetal lung maturation, and initiating delivery. HELLP syndrome typically has a rapid onset and the serious nature of this disease warrants early detection and management.
Eclampsia is the most severe form of hypertensive disease in pregnancy and presents with all symptoms related to preeclampsia outlined below, as well as maternal seizures and birth complications. The focus of this paper will be preeclampsia, as this complication describes the pathogenesis of eclampsia and is comprehensive of PIH as well.
The signs and symptoms of preeclampsia (PE) include elevated blood pressure due to vasoconstriction at-or-above 140 systolic and/or 90 diastolic after 20 weeks’ gestation, as in PIH, as well as proteinuria greater than 300 mg in 24 hours, headaches, dizziness, and vision changes (CONNELLY, 2008). Any combination of these signs and symptoms warrant a referral to a neonatologist specializing in high risk pregnancy for further testing and treatment.
PE affects multiple systems and numerous causative factors such as genetics, metabolic syndrome, insulin resistance, and diabetes have been found to affect PE (CONNELLY, 2008). Low pre-pregnancy Vitamin D levels, dyslipidemia, and a previous history of preeclampsia are also risk factors in developing PE (El-Sayed, 2017).
The pathogenesis of PE includes complex systemic changes due to many factors (El-Sayed, 2017). Multisystem vasoconstriction, structural changes of the placenta and placental ischemia, oxidative stress, micro-emboli, endothelial cell dysfunction, and systemic inflammatory response serve to complicate pregnancy outcomes in women with PE. Not only is the development of eclampsia with its accompanying neurological changes a risk of unmanaged preeclampsia, but HELLP (Hemolysis, Elevated Liver enzymes, Low Platelet count) syndrome, the damage done to multiple organs due to restricted blood flow, and fetal growth restriction, fetal morbidity and mortality, and premature birth due to placental hypo-perfusion are major concerns.
Treatment strategies for PE should address the varied mechanisms and systems that are involved. Current clinical practice for managing PE includes anti-hypertensive therapy usually using hydralazine, seizure prophylaxis using magnesium sulfate, and IV fluid management (El-Sayed, 2017). Vasodilators such as sildenafil citrate have been shown to prolong pregnancy by an average of 4 days which is long enough for corticosteroids to have an effect on fetal lung maturation.
Prevention may be the best strategy as treatment or management of PE has only been effective in delaying parturition by a few days. Pre-pregnancy blood testing and supplementation, if indicated, of vitamin D to increase maternal levels to greater than 30 ng/mL is associated with lowering the risk of PE. Supplementation prenatally of even high doses of vitamin D have not been shown to prevent PE (El-Sayed, 2017).
Pre-pregnancy lab work testing triglycerides and the management of diet, weight, and activity level can address the direct correlation between dyslipidemia and PE, as well as unmanaged diabetes and PE.
The use of daily low-dose Aspirin has become a common practice for addressing the micro-emboli that develop in PE, however studies are showing contradictory results. One study outlined a protocol of taking 100mg/day (in the evening) and initiated before 16 weeks gestation in patients at risk for developing PE. This protocol was shown to decrease maternal blood pressure and reduce the incidences of PE (Ayala et al., 2013). However, the use of Aspirin has also been shown to have little to no effect on the development of PE and intrauterine growth restriction (IUGR) (Groom et al., 2017). The safety of low-dose Aspirin use during pregnancy has been established, so it may be a prevention strategy to employ even before more research either confirms or denies its effectiveness.
Vasoconstriction in PE is associated with endothelial nitric oxide deficiency. (El-Sayed, 2017) Nitric oxide donors or precursors (such as L-arginine) have been shown to be effective in preventing PE and significantly reduced the incidence of IUGR. Curcumin can be used to reduce the systemic inflammatory response of PE.
New management strategies are being developed and reviewed that target the underlying mechanisms of PE pathophysiology and may prove to be more effective in defeating this disease when used preventatively in high-risk patients. Many of the experimental treatments address the inflammatory processes and increased circulating cytokines that play a major role in PE and include the use of hydroxychloroquine and apo-lipoprotein (El-Sayed, 2017). Experiments in treatments that address the major role of the hypoxia-induced excessive production of sFlt-1 (tyrosine kinase 1) and sEng (placental endoglin) include the use of statins, esomeprazole, metformin, dextran sulfate apheresis, or recombinant human PLGF (placental growth factor).
Acupuncture is a treatment method that is very under-studied but shows promise in treating PE in an integrated setting (Kocher & Hobbs, 2019). A case report published in 2019 offers an example of how acupuncture can reduce blood pressure and regulate liver function in PE. The ability of acupuncture to increase uterine blood flow warrants further research into the possibility that acupuncture could also increase placental blood perfusion and therefore address the cause of PE rather than attempting to treat symptoms.
The long term sequelae brought about by hypertensive diseases in pregnancy for the offspring include a greater risk of developing cardiovascular disorders, cancer, or neuropsychiatric disorders (Díaz Martínez et al., 2011). Long term health risks for the birthing parent who experiences hypertensive diseases of pregnancy include cardiovascular disease, hypertension, diabetes mellitus, and kidney disease (Kintiraki et al., 2015).
Hypertensive diseases of pregnancy pose a serious health risk to both parent and neonate and management strategies currently in use are insufficient, however treatment possibilities being researched and considered offer significant promise for preventing and defeating these complications of pregnancy.
1. Ayala, D. E., Ucieda, R., & Hermida, R. C. (2013). Chronotherapy With Low-Dose Aspirin for Prevention of Complications in Pregnancy. Chronobiology International, 30(1–2), 260–279. https://doi.org/10.3109/07420528.2012.717455
2. Chandi, A., Sirohiwal, D., & Malik, R. (2015). Association of early maternal hypertriglyceridemia with pregnancy-induced hypertension. Archives of Gynecology & Obstetrics, 292(5), 1135–1143. cin20. https://doi.org/10.1007/s00404-015-3706-1
Connelly, P. (2008). COMPLEMENTARY MEDICINE STRATEGIES IN THE MANAGEMENT OF PRE-ECLAMPSIA. Journal of the Australian Traditional-Medicine Society, 14(4), 217–220. awh.
3. Díaz Martínez, L. A., Díaz Pedraza, N. del M., Serrano Díaz, N. C., & Colmenares Mejía, C. C. (2011). [The prognosis for children of mothers with preeclampsia. Part 2: Long-term effects]. Archivos Argentinos De Pediatria, 109(6), 519–524. mnh. https://doi.org/10.1590/S0325-00752011000600009
4. El-Sayed, A. A. F. (2017). Preeclampsia: A review of the pathogenesis and possible management strategies based on its pathophysiological derangements. Taiwanese Journal of Obstetrics and Gynecology, 56(5), 593–598. https://doi.org/10.1016/j.tjog.2017.08.004
5. Gedik, E., Yücel, N., Sahin, T., Koca, E., Colak, Y. Z., & Togal, T. (2017). Hemolysis, elevated liver enzymes, and low platelet syndrome: Outcomes for patients admitted to intensive care at a tertiary referral hospital. Hypertension in Pregnancy, 36(1), 21–29. cin20. https://doi.org/10.1080/10641955.2016.1218505
6. Groom, K. M., McCowan, L. M., Mackay, L. K., Lee, A. C., Said, J. M., Kane, S. C., Walker, S. P., van Mens, T. E., Hannan, N. J., Tong, S., Chamley, L. W., Stone, P. R., McLintock, C., Groom, K., McCowan, L., Mackay, L., Lee, A., Stone, P., Chamley, L., … Middeldorp, S. (2017). Enoxaparin for the prevention of preeclampsia and intrauterine growth restriction in women with a history: A randomized trial. American Journal of Obstetrics & Gynecology, 216(3), 296.e1-296.e14. https://doi.org/10.1016/j.ajog.2017.01.014
7. Kintiraki, E., Papakatsika, S., Kotronis, G., Goulis, D., & Kotsis, V. (2015). Pregnancy-Induced hypertension. HORMONES, 211–223. https://doi.org/10.14310/horm.2002.1582
8. Kocher, Z., & Hobbs, V. (2019). Integrating Acupuncture for Preeclampsia with Severe Features and HELLP Syndrome in a High-Risk Antepartum Care Setting. Medical Acupuncture, 31(6), 407–415. https://doi.org/10.1089/acu.2019.1399
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