PREVENTION STRATEGIES FOR GESTOSIS HDP

PREVENTION STRATEGIES FOR GESTOSIS HDP (HYPERTENSIVE DISORDERS OF PREGNANCY)

Introduction:

Hypertensive disorders of pregnancy are on the rise and prevention and risk assessment could be the first step in reducing the devastating morbidity associated. This has become important as not only is the woman liable to morbidity now she is at high risk of having a lifetime disease soon. Many factors such as age, nutrition, immunological factors, autoimmune disorders, chronic kidney disorders have been identified to be associated. This is a ready reckoner strategy for clinicians to approach HDP.

Preconceptional optimization:

BMI, weight control, hyperlipidemia, insulin resistance, anemia, hyper-homocystenemia, folic acid, B12 and D deficiency, hypothyroidism can be screened for and treated. this period can also be used to update the prospective mother with vaccines such as Hepatitis B and Rubella and replenish calcium, vitamin D, Micronutrient stores by supplements and dietary corrections. Pre-pregnancy physical assessment for any clinical pathology and guidance for physical fitness, avoiding over the counter medications can be given.

The first Antenatal visit after confirmation of the pregnancy :

This is a valuable opportunity which we should make the most of. Following conditions are identified as risk for hypertension disorders.            

Risk factors for HDP GESTOSIS

Woman born as small for gestational age Chronic vascular disease (Dyslipidemia)
Maternal Anemia Excessive weight gain during pregnancy
Age older than 35 years MAP > 85
Age younger than 19 years Gestational diabetes mellitus
Obesity (BMI >30) Multiple Pregnancy
Nulligravida Hypertensive disease during previous pregnancy
Short duration of paternity (cohabitation) Pregestational diabetes mellitus
Family history of preeclampsia Chronic hypertension
Family history of cardiovascular disease Mental disorders (eg. Schizophrenia)
Polycystic Ovary Syndrome Inherited / Acquired Thrombophilia
Inter pregnancy interval more than 5 years Maternal chronic kidney disease
Assisted Reproductive (IVF/ ICSI/0D) Treatment
Maternal Hypothyroidism Autoimmune disease (SLE / APLAS / RA )

EMERGING ISSUES:

Gestational Diabetes, fetal growth restriction, sudden weight gain, appearance of edema need close vigilance Abnormal blood pressure reading and the following conditions define gestosis

PE is defined as systolic blood pressure at ≥140 mm Hg and/or diastolic blood pressure at ≥90 mm Hg on at least two occasions measured 4 hours apart in previously normotensive women
 

Maternal factors, biochemical markers and ultrasound parameters can be used singly or in combination for predictions of HDP gestosis as under : Ultrasound ObstetGynecol2018 ; 51 :743-750

Preventive INTERVENTIONS: evidences

  1. Correction of anemia, hypothyroidism, moderate weight gain and surveillance for diabetes
  2. Micronutrient supplements along with folic acid, calcium Vitamin D
  3. Low dose aspirin in the dose of 75-150 mg daily.

Folic acid and folates : evidence

Supplementation of folic acid has been found to decrease preeclampsia risk. The possibility is that folic acid can affect the levels of hyperhomocysteinemia, which is suggested to damage the vascular endothelium of the developing placenta. Moreover, a folate deficiency may induce the apoptosis of human cytotrophoblast cells, thus possibly affecting trophoblast invasion and placental development. Therefore, the supplementation of folic acid may improve placental implantation and subsequently affect the incidence of hypertensive pregnancy disorders. Decreased preeclampsia risk is related to multivitamin use, but there is no association between the risk of preeclampsia and folic acid supplement alone. Given the biologic rationale of folic acid in reducing the risk of developing preeclampsia, we speculate that folic acid may play a more important role in preeclampsia than other vitamins because the biologic mechanisms of other vitamins in reducing the risk of developing preeclampsia have not been fully explored. Supplementation of multivitamins containing folic acid during pregnancy may reduce preeclampsia risk. Multivitamin supplementation may be considered as a promising prevention strategy for preeclampsia.(Liu, Cheng et al. “Supplementation of folic acid in pregnancy and the risk of preeclampsia and gestational hypertension: a meta-analysis.” Archives of gynecology and obstetrics vol. 298,4 (2018): 697-704. doi:10.1007/s00404-018-4823-4)

Calcium :World Health Organization (WHO) recommends 1500 to 2000 mg elemental calcium supplementation per day for pregnant women IN populations where baseline dietary calcium intake is low to reduce the risk of preeclampsia, particularly among those at higher risk of developing hypertension (2.5 g of calcium carbonate or 4.75 g of calcium citrate contains approximately 1 g elemental calcium).2018 systematic review of 27 randomized trials including over 18,000 pregnant women of whom two-thirds lived in geographic areas where calcium-rich foods were not commonly available or consumed. Calcium supplementation (≥1 gram daily) from mid-pregnancy (20 weeks) to delivery approximately halved the risk of preeclampsia (relative risk [RR] 0.45, 95% CI 0.31-0.65; 13 trials, 15,730 women) and hypertension during pregnancy (RR 0.65, 95% CI 0.53-0.81) compared with placebo/no treatment in the overall cohort (irrespective of the baseline risk of developing hypertension and calcium intake status). The reduction in risk was greatest for women with low baseline calcium intake variously defined but always less than 900 mg/day (RR 0.36, 95% CI 0.20-0.65; 8 trials, 10,678 women) and those at high risk of preeclampsia (RR 0.22, 95% CI 0.12-0.42; 5 trials, 587 women). Preterm birth was also reduced (RR 0.76, 95% CI 0.60-0.97; 11 trials, 15,275 women), but rates of stillbirth, neonatal intensive care admission, and infant death were similar in both groups.

Low dose aspirin : low-dose aspirin (60 to 150 mg/day) diminishes platelet thromboxane synthesis while maintaining vascular wall prostacyclin synthesis. In 2017, a meta-analysis of 45 trials including 20,909 women demonstrated a significant reduction in preeclampsia when aspirin was initiated at ≤16 weeks(RR 0.57, 95% CI 0.49-0.75). There was also a significant reduction in FGR &SPE. When aspirin was initiated after 16 weeks of gestation, the risk reduction for preeclampsia remained significant (RR 0.81, 95% CI 0.66-0.99), but was of a lesser magnitude than with initiation prior to 16 weeks. There was no significant reduction in SPE &FGR with aspirin initiation after 16 weeks. In the ASPRE trial, women were considered high risk based on a combination of clinical factors, uterine artery Doppler as well as biochemical markers (PAPP-A and placental growth factor) and then randomized and initiated on aspirin or placebo between 11 and 14 weeks. The risk reduction for preterm preeclampsia with aspirin was 0.38 (95% CI 0.20-0.74). The authors concluded that this marked and significant reduction in preterm preeclampsia risk supports the earlier initiation of aspirin therapy.

Conclusion :

  • Let’s join hands in reducing pregnancy morbidity and perinatal  mortality
  • Focus on first trimester and optimise health
  • Antenatal care : structured and strategic approach will help reducing GESTOSIS -HDP
  • Assess nutrition and guide them at al opportunities
  • Vaccinate and protect
  • Supplement appropriately

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