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Essential Hypertension and Pregnancy
Essential Hypertension and Pregnancy WILLIAM J. DIECKMANN, M.D. *
THE term "toxemia of pregnancy" is a composite one for a group of diseases which occur during pregnancy or the early puerperium and are characterized by the appearance of one or more of the following signs: edema, proteinuria, hypertension, convulsions and/or coma. The percentage of toxemic patients with hypertensive disease in pregnancy in eight obstetrical services ranged from 5 to 57 per cent (52 per cent in our hospital in a twenty year period), indicating that there is a difference in the interpretation of the usually accepted criteria for hypertensive disease in pregnancy. Essential hypertension in pregnant patients is classified with the true toxemias of pregnancy because the underlying pathologic lesions tend to be aggravated by the increased physiologic demands of the pregnant state, thus producing signs and/or symptoms, one or more of which may simulate those of preeclampsia-eclampsia. These patients may have hypertension before pregnancy, or it may develop before the twentyfourth week or, in some cases, after the twenty-fourth week. DIAGNOSIS
Most investigators have stated that the blood pressure must be 140/90 or more for some time to establish the diagnosis of hypertensive disease or of preeclampsia. A number of studies have been made to determine the mean and the range of blood pressure for the various decades of life. The most recent study is that by Masters and co-workers. Dieckmannl in his monograph states that one cannot accept a blood pressure greater than 140/90 for all periods of pregnancy and especially for the follow-up studies. Masters and his group state that in women the lowest limit of hypertension is 140 mm. of mercury systolic up to the age of 30 years. From the Department of Obstetrics and Gynecology of the University of Chicago and the Chicago Lying-in Hospital. Supported in part by the Chicago Lying-in 50th Anniversary Fund for Eclampsia.
* Mary Campau Ryerson Professor of Obstetrics and Gynecology and Chairman of the Department, University of Chicago; Chief of Service, Chicago Lying-in Hospital; Attending Gynecologist, Albert Merritt Billings Memorial Hospital. 27
28
William J. Dieckmann
Thereafter it increases 5 to 10 mm. for every five years. The diastolic blood pressure in women is from 60 to 86 up to 30 years; in the age period 35 to 39 years, it is 65 to 90; from 40 to 44 it is 65 to 92; and so on upward. To establish a diagnosis of hypertensive disease, pressure must be in the hypertensive level for the patient's age before pregnancy or must have been elevated to at least this level for twelve or more hours or have been present on three or more days before the twenty-fourth week of pregnancy. In some patients the hypertension develops,after the twentyfourth week. If the onset is during labor, the blood pressure must be continuously over 150/90 for six or more hours during the first stage of labor. Occasionally the patient with a prepregnant hypertension is normotensive during pregnancy. Proteinuria which is present on three or more days or more than 0.3 gm. of protein per twenty-four hours for three or more days is abnormal in the pregnant woman. Edema is present in 75 per cent or more of pregnant women. Edema of the ankle and/or tibia which is present on arising after bed rest, or edema of the face and/or hands is abnormal in pregnancy. Dieckmann states that the patients with essential hypertensive disease can be divided as follows: (1) Prep regnancy hypertension (2) Onset before twenty-four weeks (3) Onset after twenty-four weeks with no rapid gain in weight or marked edema (4) Recurrent toxemia of pregnancy. These patients have had toxemia in one pregnancy, usually the first, which was characterized only by hypertension or [occasionally] by the apparently typical signs of preeclampsia. The blood pressure and renal function were normal between pregnancies and usually in the first months of the next pregnancy. A hypertension develops usually between the sixteenth and thirtieth week in subsequent pregnancies. Eventually [hypertension] and evidence of renal damage persist between the pregnancies. Dieckmann lists the degree of severity for each condition upon the following criteria: 1. Benign a. Mild (1) Blood pressure at hypertensive level for patient's age to 169/99 (2) Proteinuria-0.1 to 0.99 gm. per twenty-four hours (none to trace) (3) Renal function-normal (4) Ophthalmoscopy-no changes or early hypertensive retinal arteriolosclerosis (5) Blood chemistry-normal (6) Symptoms mild and occur in 30 per cent
Essential Hypertension and Pregnancy
29
b. Severe (1) Blood pressure-170/100 or more (2) Proteinuria-2 gm. or more per twenty-four hours (1 to 4 plus) (3) Renal function-low normal to renal failure (4) Ophthalmoscopy-early changes to marked retinal changes of sufficient degree to cause decrease in vision or blindness. (5) Blood chemistry-normal to nitrogen retention; may be anemia and hypoproteinemia (6) Heart size-normal to enlarged (7) Symptoms present in 57 per cent 2. Malignant Occurs very rarely; patients show rapidly progressive hypertension associated with necrotizing arteriolitis, manifested clinically by typical changes in the retina and progressive renal impairment.
Chronic hypertensive disease does not improve during pregnancy. In a small percentage of the cases the blood pressure either does not increase or may occasionally become normotensive. It does not follow that the fetal loss will be less in this type of patient. The incidence of abortion, prematurity, abruptio placentae, cortical necrosis of the kidney, cerebral hemorrhage and cardiac failure is increased in patients with this condition. The fact that only approximately one-third of the patients with chronic hypertensive disease will leave the hospital with a live baby indicates the seriousness of the condition and the care which must be used in determining whether or not the pregnancy should continue. The risk for mother and baby must be explained to the patient and her husband. DIFFERENTIAL DIAGNOSIS
If the hypertension was present before pregnancy or began early in pregnancy, there is no need for differentiating the ,~ondition from preeclampsia-eclampsia. It is not always easy to differentiate hypertensive disease from renal disease, because patients with chronic glomerulonephritis eventually have hypertension and the hypertensive patient ultimately has extensive renal disease. It is possible for the patient with known hypertensive disease to have a superimposed preeclampsia or eclampsia, but I believe that this rarely occurs. The development of edema in the hypertensive patient may merely be the normal edema of pregnancy. Many patients with known hypertensive disease before pregnancy usually after the twenty-eighth week show increasing amounts of protein in the urine. This increase or sudden appearance of proteinuria is frequently associated with increasing hypertension, and it is to these cases that the term "superimposed preeclampsia" has been attached. I believe that the hypertensive patients
William J. Dieckmann
30
had been excreting abnormal amounts of protein per twenty-four hours and that it is only in the last trimester of pregnancy that the amount becomes great enough to be noticed. Similarly, many patients with hypertensive disease may have convulsions and/or coma as a result of their hypertension, but it does not follow that it is eclampsia. The liver and renal lesions described in eclampsia are peculiar to pregnancy, with the highest incidence in patients with clinical evidence of toxemia. But they are not pathognomonic of preeclampsia or eclampsia. COMPLICATIONS
Maternal
The most common complication of hypertensive disease is abruptio placentae with a fetal mortality of 50 per cent or more and a maternal mortality of 5 per cent. The frequency in the hypertensive group was 9.3 per cent. A small percentage of the patients with abruptio placentae have an associated cortical necrosis of the kidney. Most of these patients died, and the diagnosis was based on the pathologic findings. In several cases the diagnosis was made before death, and in 3 patients there was evidence of nitrogen retention associated with oliguria or anuria, but the patients recovered. It is also in this group of patients with abruptio placentae that necrosis of the anterior lobe of the pituitary gland may occur. Cerebral hemorrhage occurs infrequently in pregnant patients with hypertensive disease. In the period 1931-1952, over 70,000 pregnant patients have been treated in our hospital, with death due to cerebral hemorrhage in 4 patients. Autopsy confirmed the hemorrhage in 2 patients. From 1931 to 1952 there have been ninety deaths, of which twentyfour (13 per cent of the total hospital mortality) were in patients wh() had toxemia, a rate of 0.44 per cent for almost 6000 toxemic patients if all deaths of patients with all types of toxemia are included, irrespective of the cause of death. Cardiac failure may occur in the patient with hypertensive disease and is most likely to occur if the hypertension has been of sufficiently long standing to have caused cardiac hypertrophy; the additional load of pregnancy results in decompensation. Does pregnancy cause additional damage to the patient with vascular disease? This is not only a moot point, but it is also difficult to decide whether the increase in the blood pressure levels, in the eyeground findings or in the renal damage has been greater during the forty weeks of the pregnancy than it would have been had the patient not been pregnant. Statistics indicate that many patients with known hypertension have survived the pregnancy and have given birth to living babies. This
Essential H ype:rtension and Pregnancy
31
does not indicate that the pregnancy has been beneficial to the patient. An analysis of some 3500 pregnancies which occurred in over 1600 patients who had had two or more pregnancies in our hospital or in the New York Lying-in Hospital indicated that there was increasing damage . from each pregnancy if the patient had vascular disease, as evidenced by a higher abortion rate, a higher mean blood pressure, a higher incidence and greater amounts of protein in the urine, and, in a small percentage of the patients, increased evidence on ophthalmoscopic examination of greater advance in the retinal change. Fetal
There are fetal complications, as evidenced by a higher rate of abortion. The usual incidence of abortion for all patients is 4.3 per cent in our hospital. In the patients with known mild hypertensive disease it was 9.7 per cent, and with severe hypertensive disease, 18.2 per cent aborted before the twenty-eighth week. If the patient does not abort, there is a high incidence of fetal death in utero, and at delivery one finds evidence of old infarction of the placenta of varying stages, recent retroplacental hematoma or even abruptio placentae. Our usual incidence of premature delivery for fetuses weighing from 1000 to 2500 gm. is 6.6 per cent. In the patients with known mild hypertensive disease the rate was 11.4 per cent, and 31.9 per cent for the severe group. Our overall premature, neonatal mortality is 13.5 per cent, but it was 30 per cent in the mild and 35 per cent in the severe group. Many of the patients with known hypertensive disease are delivered by elective cesarean section at thirty-two weeks or more in pregnancy. In a disappointingly large number of these babies, fetal death occurs, and the autopsy reveals a hyaline-like membrane in the lungs and an increased amount of fluid in the meninges. A small percentage of the babies when they are six months or more old are found to have retrolental fibroplasia. We have found no way of preventing either of these conditions except by permitting the patient to approach as close to term as possible. However, with increasing proteinuria or increasing blood pressure one is faced with the usual fetal death in utero, and the decision has to be made whether one wishes a live premature with its increased risks, or an older baby, dead in uterb- a decision which offers no choice.
TREATMENT Diet
Many of these patients with essential hypertension are obese, and our policy has been to try to restrict their weight gain to 7 to 8 kg. or even less. We have not tried to reduce these patients while pregnant. They are placed on an 1800 calorie diet containing a minimum of 96 gm. of pro-
32
William J. Dieckmann
tein, 198 gm. of carbohydrate and 67 g;m. of fat. The overweight patient will not gain if she adheres to this caloric intake. If the patient is cooperative, the sodium intake should be limited to 1.5 gm. per day throughout pregnancy. She should be instructed to measure the urine for twenty-four hours once a week and drink sufficient fluids to insure a twenty-four hour output of approximately 2000 milliliters. If the patient is first seen before pregnancy or early in pregnancy, an ophthalmoscopic examination should be made, the urea clearance or concentrating ability of the urine determined, an Addis count made and the twenty-four hour excretion of protein in the urine determined. If the ophthalmoscopic examination does not show extensive retinal changes, and if the clearance is 50 per cent or higher, or if the concentrating ability is 1.020 or more, and the Addis count is not too abnormal, and the twenty-four hour excretion of protein is less than 0.3 gm. for twenty-four hours, in general the patient should be advised that the pregnancy can be continued, but the risks to her and the probability that there is one chance out of three of obtaining a live baby should be explained to her and her husband. The patient should be seen everyone or two weeks, depending on the severity of the condition and the period of pregnancy. After the twentysixth week she should be seen at weekly intervals. At each visit the blood pressure, weight, and a twenty-four hour determination of the urine protein should be made. The patient should be instructed to rest one hour in the morning and one hour in the afternoon and to regulate her work and activities. No sedative should be used for the ambulatory patient except what is necessary to insure six to eight hours' sleep at night. If the blood pressure, edema or proteinuria should increase, or dyspnea develop, the patient should be hospitalized for five or more days for study and treatment. Unless there is extensive edema or evidence of cardiac failure, the patient is permitted to have bathroom privileges. Drug Therapy
Digitalis is given if there is cardiac decompensation or cardiac hypertrophy. Minimum amounts of sedation are given at night, such as phenobarbital, 0.06 to 0.12 gm. Sedatives are not given during the day because of the possibility of masking the various symptoms and signs of abruptio placentae, convulsions, and the like. In a limited number of patients, veratrum alkaloids given intramuscularly over a period of several days have had no effect other than to decrease the level of the blood pressure; the proteinuria has remained the same. Whether or not one could salvage some of the babies by prolonged intramuscular injection of veratrum alkaloids is not known. The oral
Essential Hypertension and Pregnancy administration has not been effective over a prolonged period of time.
III
33 lowering the blood pressure
Surgical Procedures
Smithwick and the late Peet and their respective co-workers have perfor'med special sympathectomy operations for the relief of hypertensive disease in 42 patients who subsequently became pregnant. There were forty-nine pregnancies with thirty-nine live babies, a loss of 26 per cent. In general, the patient who has vascular disease of sufficient severity warranting some type of sympathectomy should not undergo pregnancy. Termination of Pregnancy. Once the decision to permit the pregnancy to continue has been made, no interruption should be instituted before the thirty-second week or later, if possible. The sudden increase in the twenty-four hour proteinuria to 3 gm. or more, of 30 mm. or more in the systolic or 15 mm. or more of mercury in the diastolic blood pressure, or retinal pathology, or oliguria, or hematuria, warrants termination of the pregnancy. This is done by rupture of the membranes if the cervical findings on sterile vaginal examination indicate that delivery will occur within twenty-four hours. Intramuscular injection of 50 per cent magnesium sulfate in amounts of 6 to 12 milliliters each four to six hours (total of 40 milliliters in twenty-four hours) is given. Sedatives are withheld if the baby is premature. Delivery is under local, general or spinal anesthesia. The twenty-four hour limit is set because a longer period entails increased morbidity and mortality for mother and baby. Intravenous injections of 20 per cent dextrose solution in 1000 milliliter amounts are given in thirty to forty minutes only if there is an oliguriaanuria or the onset of cerebral or visual symptoms. If cesarean section is selected, local or local and general anesthesia is best if the baby is premature. Continuous spinal or a single intraspinal injection of procaine is warranted if the other types of anesthesia cannot be carried out. REFERENCE 1. Dieckmann, W. J.: Toxemias of Pregnancy. 2d Ed. St. Louis, C. V. Mosby Company, 1952. Acknowledgement is made to the publishers for permission to quote certain paragraphs from the above book.
THE term "toxemia of pregnancy" is a composite one for a group of diseases which occur during pregnancy or the early puerperium and are characterized by the appearance of one or more of the following signs: edema, proteinuria, hypertension, convulsions and/or coma. The percentage of toxemic patients with hypertensive disease in pregnancy in eight obstetrical services ranged from 5 to 57 per cent (52 per cent in our hospital in a twenty year period), indicating that there is a difference in the interpretation of the usually accepted criteria for hypertensive disease in pregnancy. Essential hypertension in pregnant patients is classified with the true toxemias of pregnancy because the underlying pathologic lesions tend to be aggravated by the increased physiologic demands of the pregnant state, thus producing signs and/or symptoms, one or more of which may simulate those of preeclampsia-eclampsia. These patients may have hypertension before pregnancy, or it may develop before the twentyfourth week or, in some cases, after the twenty-fourth week. DIAGNOSIS
Most investigators have stated that the blood pressure must be 140/90 or more for some time to establish the diagnosis of hypertensive disease or of preeclampsia. A number of studies have been made to determine the mean and the range of blood pressure for the various decades of life. The most recent study is that by Masters and co-workers. Dieckmannl in his monograph states that one cannot accept a blood pressure greater than 140/90 for all periods of pregnancy and especially for the follow-up studies. Masters and his group state that in women the lowest limit of hypertension is 140 mm. of mercury systolic up to the age of 30 years. From the Department of Obstetrics and Gynecology of the University of Chicago and the Chicago Lying-in Hospital. Supported in part by the Chicago Lying-in 50th Anniversary Fund for Eclampsia.
* Mary Campau Ryerson Professor of Obstetrics and Gynecology and Chairman of the Department, University of Chicago; Chief of Service, Chicago Lying-in Hospital; Attending Gynecologist, Albert Merritt Billings Memorial Hospital. 27
28
William J. Dieckmann
Thereafter it increases 5 to 10 mm. for every five years. The diastolic blood pressure in women is from 60 to 86 up to 30 years; in the age period 35 to 39 years, it is 65 to 90; from 40 to 44 it is 65 to 92; and so on upward. To establish a diagnosis of hypertensive disease, pressure must be in the hypertensive level for the patient's age before pregnancy or must have been elevated to at least this level for twelve or more hours or have been present on three or more days before the twenty-fourth week of pregnancy. In some patients the hypertension develops,after the twentyfourth week. If the onset is during labor, the blood pressure must be continuously over 150/90 for six or more hours during the first stage of labor. Occasionally the patient with a prepregnant hypertension is normotensive during pregnancy. Proteinuria which is present on three or more days or more than 0.3 gm. of protein per twenty-four hours for three or more days is abnormal in the pregnant woman. Edema is present in 75 per cent or more of pregnant women. Edema of the ankle and/or tibia which is present on arising after bed rest, or edema of the face and/or hands is abnormal in pregnancy. Dieckmann states that the patients with essential hypertensive disease can be divided as follows: (1) Prep regnancy hypertension (2) Onset before twenty-four weeks (3) Onset after twenty-four weeks with no rapid gain in weight or marked edema (4) Recurrent toxemia of pregnancy. These patients have had toxemia in one pregnancy, usually the first, which was characterized only by hypertension or [occasionally] by the apparently typical signs of preeclampsia. The blood pressure and renal function were normal between pregnancies and usually in the first months of the next pregnancy. A hypertension develops usually between the sixteenth and thirtieth week in subsequent pregnancies. Eventually [hypertension] and evidence of renal damage persist between the pregnancies. Dieckmann lists the degree of severity for each condition upon the following criteria: 1. Benign a. Mild (1) Blood pressure at hypertensive level for patient's age to 169/99 (2) Proteinuria-0.1 to 0.99 gm. per twenty-four hours (none to trace) (3) Renal function-normal (4) Ophthalmoscopy-no changes or early hypertensive retinal arteriolosclerosis (5) Blood chemistry-normal (6) Symptoms mild and occur in 30 per cent
Essential Hypertension and Pregnancy
29
b. Severe (1) Blood pressure-170/100 or more (2) Proteinuria-2 gm. or more per twenty-four hours (1 to 4 plus) (3) Renal function-low normal to renal failure (4) Ophthalmoscopy-early changes to marked retinal changes of sufficient degree to cause decrease in vision or blindness. (5) Blood chemistry-normal to nitrogen retention; may be anemia and hypoproteinemia (6) Heart size-normal to enlarged (7) Symptoms present in 57 per cent 2. Malignant Occurs very rarely; patients show rapidly progressive hypertension associated with necrotizing arteriolitis, manifested clinically by typical changes in the retina and progressive renal impairment.
Chronic hypertensive disease does not improve during pregnancy. In a small percentage of the cases the blood pressure either does not increase or may occasionally become normotensive. It does not follow that the fetal loss will be less in this type of patient. The incidence of abortion, prematurity, abruptio placentae, cortical necrosis of the kidney, cerebral hemorrhage and cardiac failure is increased in patients with this condition. The fact that only approximately one-third of the patients with chronic hypertensive disease will leave the hospital with a live baby indicates the seriousness of the condition and the care which must be used in determining whether or not the pregnancy should continue. The risk for mother and baby must be explained to the patient and her husband. DIFFERENTIAL DIAGNOSIS
If the hypertension was present before pregnancy or began early in pregnancy, there is no need for differentiating the ,~ondition from preeclampsia-eclampsia. It is not always easy to differentiate hypertensive disease from renal disease, because patients with chronic glomerulonephritis eventually have hypertension and the hypertensive patient ultimately has extensive renal disease. It is possible for the patient with known hypertensive disease to have a superimposed preeclampsia or eclampsia, but I believe that this rarely occurs. The development of edema in the hypertensive patient may merely be the normal edema of pregnancy. Many patients with known hypertensive disease before pregnancy usually after the twenty-eighth week show increasing amounts of protein in the urine. This increase or sudden appearance of proteinuria is frequently associated with increasing hypertension, and it is to these cases that the term "superimposed preeclampsia" has been attached. I believe that the hypertensive patients
William J. Dieckmann
30
had been excreting abnormal amounts of protein per twenty-four hours and that it is only in the last trimester of pregnancy that the amount becomes great enough to be noticed. Similarly, many patients with hypertensive disease may have convulsions and/or coma as a result of their hypertension, but it does not follow that it is eclampsia. The liver and renal lesions described in eclampsia are peculiar to pregnancy, with the highest incidence in patients with clinical evidence of toxemia. But they are not pathognomonic of preeclampsia or eclampsia. COMPLICATIONS
Maternal
The most common complication of hypertensive disease is abruptio placentae with a fetal mortality of 50 per cent or more and a maternal mortality of 5 per cent. The frequency in the hypertensive group was 9.3 per cent. A small percentage of the patients with abruptio placentae have an associated cortical necrosis of the kidney. Most of these patients died, and the diagnosis was based on the pathologic findings. In several cases the diagnosis was made before death, and in 3 patients there was evidence of nitrogen retention associated with oliguria or anuria, but the patients recovered. It is also in this group of patients with abruptio placentae that necrosis of the anterior lobe of the pituitary gland may occur. Cerebral hemorrhage occurs infrequently in pregnant patients with hypertensive disease. In the period 1931-1952, over 70,000 pregnant patients have been treated in our hospital, with death due to cerebral hemorrhage in 4 patients. Autopsy confirmed the hemorrhage in 2 patients. From 1931 to 1952 there have been ninety deaths, of which twentyfour (13 per cent of the total hospital mortality) were in patients wh() had toxemia, a rate of 0.44 per cent for almost 6000 toxemic patients if all deaths of patients with all types of toxemia are included, irrespective of the cause of death. Cardiac failure may occur in the patient with hypertensive disease and is most likely to occur if the hypertension has been of sufficiently long standing to have caused cardiac hypertrophy; the additional load of pregnancy results in decompensation. Does pregnancy cause additional damage to the patient with vascular disease? This is not only a moot point, but it is also difficult to decide whether the increase in the blood pressure levels, in the eyeground findings or in the renal damage has been greater during the forty weeks of the pregnancy than it would have been had the patient not been pregnant. Statistics indicate that many patients with known hypertension have survived the pregnancy and have given birth to living babies. This
Essential H ype:rtension and Pregnancy
31
does not indicate that the pregnancy has been beneficial to the patient. An analysis of some 3500 pregnancies which occurred in over 1600 patients who had had two or more pregnancies in our hospital or in the New York Lying-in Hospital indicated that there was increasing damage . from each pregnancy if the patient had vascular disease, as evidenced by a higher abortion rate, a higher mean blood pressure, a higher incidence and greater amounts of protein in the urine, and, in a small percentage of the patients, increased evidence on ophthalmoscopic examination of greater advance in the retinal change. Fetal
There are fetal complications, as evidenced by a higher rate of abortion. The usual incidence of abortion for all patients is 4.3 per cent in our hospital. In the patients with known mild hypertensive disease it was 9.7 per cent, and with severe hypertensive disease, 18.2 per cent aborted before the twenty-eighth week. If the patient does not abort, there is a high incidence of fetal death in utero, and at delivery one finds evidence of old infarction of the placenta of varying stages, recent retroplacental hematoma or even abruptio placentae. Our usual incidence of premature delivery for fetuses weighing from 1000 to 2500 gm. is 6.6 per cent. In the patients with known mild hypertensive disease the rate was 11.4 per cent, and 31.9 per cent for the severe group. Our overall premature, neonatal mortality is 13.5 per cent, but it was 30 per cent in the mild and 35 per cent in the severe group. Many of the patients with known hypertensive disease are delivered by elective cesarean section at thirty-two weeks or more in pregnancy. In a disappointingly large number of these babies, fetal death occurs, and the autopsy reveals a hyaline-like membrane in the lungs and an increased amount of fluid in the meninges. A small percentage of the babies when they are six months or more old are found to have retrolental fibroplasia. We have found no way of preventing either of these conditions except by permitting the patient to approach as close to term as possible. However, with increasing proteinuria or increasing blood pressure one is faced with the usual fetal death in utero, and the decision has to be made whether one wishes a live premature with its increased risks, or an older baby, dead in uterb- a decision which offers no choice.
TREATMENT Diet
Many of these patients with essential hypertension are obese, and our policy has been to try to restrict their weight gain to 7 to 8 kg. or even less. We have not tried to reduce these patients while pregnant. They are placed on an 1800 calorie diet containing a minimum of 96 gm. of pro-
32
William J. Dieckmann
tein, 198 gm. of carbohydrate and 67 g;m. of fat. The overweight patient will not gain if she adheres to this caloric intake. If the patient is cooperative, the sodium intake should be limited to 1.5 gm. per day throughout pregnancy. She should be instructed to measure the urine for twenty-four hours once a week and drink sufficient fluids to insure a twenty-four hour output of approximately 2000 milliliters. If the patient is first seen before pregnancy or early in pregnancy, an ophthalmoscopic examination should be made, the urea clearance or concentrating ability of the urine determined, an Addis count made and the twenty-four hour excretion of protein in the urine determined. If the ophthalmoscopic examination does not show extensive retinal changes, and if the clearance is 50 per cent or higher, or if the concentrating ability is 1.020 or more, and the Addis count is not too abnormal, and the twenty-four hour excretion of protein is less than 0.3 gm. for twenty-four hours, in general the patient should be advised that the pregnancy can be continued, but the risks to her and the probability that there is one chance out of three of obtaining a live baby should be explained to her and her husband. The patient should be seen everyone or two weeks, depending on the severity of the condition and the period of pregnancy. After the twentysixth week she should be seen at weekly intervals. At each visit the blood pressure, weight, and a twenty-four hour determination of the urine protein should be made. The patient should be instructed to rest one hour in the morning and one hour in the afternoon and to regulate her work and activities. No sedative should be used for the ambulatory patient except what is necessary to insure six to eight hours' sleep at night. If the blood pressure, edema or proteinuria should increase, or dyspnea develop, the patient should be hospitalized for five or more days for study and treatment. Unless there is extensive edema or evidence of cardiac failure, the patient is permitted to have bathroom privileges. Drug Therapy
Digitalis is given if there is cardiac decompensation or cardiac hypertrophy. Minimum amounts of sedation are given at night, such as phenobarbital, 0.06 to 0.12 gm. Sedatives are not given during the day because of the possibility of masking the various symptoms and signs of abruptio placentae, convulsions, and the like. In a limited number of patients, veratrum alkaloids given intramuscularly over a period of several days have had no effect other than to decrease the level of the blood pressure; the proteinuria has remained the same. Whether or not one could salvage some of the babies by prolonged intramuscular injection of veratrum alkaloids is not known. The oral
Essential Hypertension and Pregnancy administration has not been effective over a prolonged period of time.
III
33 lowering the blood pressure
Surgical Procedures
Smithwick and the late Peet and their respective co-workers have perfor'med special sympathectomy operations for the relief of hypertensive disease in 42 patients who subsequently became pregnant. There were forty-nine pregnancies with thirty-nine live babies, a loss of 26 per cent. In general, the patient who has vascular disease of sufficient severity warranting some type of sympathectomy should not undergo pregnancy. Termination of Pregnancy. Once the decision to permit the pregnancy to continue has been made, no interruption should be instituted before the thirty-second week or later, if possible. The sudden increase in the twenty-four hour proteinuria to 3 gm. or more, of 30 mm. or more in the systolic or 15 mm. or more of mercury in the diastolic blood pressure, or retinal pathology, or oliguria, or hematuria, warrants termination of the pregnancy. This is done by rupture of the membranes if the cervical findings on sterile vaginal examination indicate that delivery will occur within twenty-four hours. Intramuscular injection of 50 per cent magnesium sulfate in amounts of 6 to 12 milliliters each four to six hours (total of 40 milliliters in twenty-four hours) is given. Sedatives are withheld if the baby is premature. Delivery is under local, general or spinal anesthesia. The twenty-four hour limit is set because a longer period entails increased morbidity and mortality for mother and baby. Intravenous injections of 20 per cent dextrose solution in 1000 milliliter amounts are given in thirty to forty minutes only if there is an oliguriaanuria or the onset of cerebral or visual symptoms. If cesarean section is selected, local or local and general anesthesia is best if the baby is premature. Continuous spinal or a single intraspinal injection of procaine is warranted if the other types of anesthesia cannot be carried out. REFERENCE 1. Dieckmann, W. J.: Toxemias of Pregnancy. 2d Ed. St. Louis, C. V. Mosby Company, 1952. Acknowledgement is made to the publishers for permission to quote certain paragraphs from the above book.