HIPERTENZIJA I TRUDNOĆA

JOSIP ĐELMIŠ

Trudnoća u hipertenziji nije jedinstven entitet i danas postoji nekoliko klasifikacija. Najčešće se rabi osuvreme­njena klasifikacija Američkog društva ginekologa i opstetričara, koja klasificira hipertenziju na kroničnu hipertenziju, preeklampsiju-eklampsiju, preeklampsiju superponiranu na kroničnu hipertenziju i gestacijsku hipertenziju. Preeklampsija se javlja u oko 7% trudnica. Povišen rizik od nastanka preeklampsije imaju primigravide. Učestalost preeklampsija u sestara iznosila je 37%, u kćeri 26%, u unučica 16%, a u snaha samo 6%, što upućuje na čvrstu povezanost s naslijeđem. Iako se osnovne kliničke promjene u preeklampsiji događaju tek u drugom dijelu trudnoće, određene se hemodinamske i bioke­mijske promjene u trudnice mogu uočiti ranije. Osim hemodinamskih promjena u majke jedno od glavnih obilježja pre­eklampsije jest insuficijencija uteroplacentarnog krvotoka i posljedični intrauterini zastoj rasta. Osnovne se promjene kod preeklampsije događaju zbog neodgovarajuće migracije trofoblasta i izostale fiziološke pretvorbe spiralnih arterija. U preeklampsiji ostaje očuvan muskuloelastični sloj spiralnih arteriola, zbog čega njihov lumen ostaje uzak tijekom cijele trudnoće, a stijenka osjetljiva na vazokonstriktorne čimbenike. Danas je najuvjerljivija i najobuhvatnija hipoteza o generali­ziranoj disfunkciji endotela kao osnovnome patofiziološkome mehanizmu. Preeklampsija je bolest zbog vazokonstrikcije i smanjene perfuzije, posebice esencijalnih organa. HELLP sindrom je multisistemska bolest čija patogeneza do danas nije potpuno razjašnjena. Kod HELLP sindroma dolazi do vaskularnog oštećenja endotelnih stanica, što posljedično uzrokuje intravaskularnu aktivaciju trombocita. Učestalost HELLP sindroma otprilike je 0,2–0,6% svih trudnoća te 4–12% onih s preeklampsijom. HELLP sindrom je akronim u engleskom jeziku koji označava: H=»haemolysis«/hemolizu, EL=»elevated liver enzymes«/povišeni jetreni enzimi te LP=»low platelet count«/niski trombociti. Rizični čimbenici su multiparitet, dob majke veća od 25 godina, bijela rasa te loš perinatalni ishod u prethodnim trudnoćama. Terapija eklampsije velik je izazov za svakog liječnika, ali istodobno i predmet brojnih rasprava budući da još nema jedinstvenog stajališta koji bi lijek bio najbolji za liječenje i prevenciju eklampsije. Općenito je prihvaćeno mišljenje daje granična vrijednost arterijskog tlaka kod koje treba početi antihipertenzivnu terapiju vrijednost dijastoličkog tlaka viša od 110 mmHg, ali pritom vodeći računa da se tlak ne snizi ispod vrij ednosti od 90 do 100 mmHg kako se ne bi ugrozio uteroplacentarni protok krvi koj i j e kod preeklampsij e i eklampsije ionako znatno reduciran. Porođaj je definitivna terapija preeklampsije i eklampsije.

Summary. Pregnancy in hypertension is not a single entity, and currently several classifications exist. Most often used is the updated classification of the American College of Obstetricians and Gynecologists, which classifies hypertension into chronic hypertension, preeclampsia-eclampsia, preeclampsia superposed on chronic hypertension, and gestational hyper- tension. Preeclampsia occurs in about 7% of pregnant women. Primigravida have increased risk for preeclampsia. Preeclampsia frequency in sisters was 37%, in daughters 26%, in granddaughters 16%, an in daughters in law only 6%, which points to the strong hereditary association. Although basic clinical changes in preeclampsia appear in the second part of pregnancy, some haemodynamic and biochemical abnormalities may be observed earlier. Besides haemodynamic abnor- malities in the mother, one of the main characteristics of preeclampsia is uteroplacental circulation insufficiency, and conse- quent intrauterine growth restriction. Basic alterations in preeclampsia occur due to inadequate trophoblast migration and lack of spiral artery physiologic transformation. In preeclampsia, musculoelastic layer of spiral arterioles is preserved, there- fore their lumen stays narrow during the entire pregnancy, ad their wall sensitive to vasoconstrictive factors. Currently, the most convincing and most comprehensive is the hypothesis on generalized endothelial dysfunction as the underlying pathophysiological mechanisms. Preeclampsia is an illness that develops due to vasoconstriction and reduced perfusion, particularly in essential organs. HELLP syndrome is a multiple system disease whose pathogenesis has not yet been com- pletely explained. In HELLP syndrome endothelial vascular cells are damaged, resulting in intravascular platelet activation. Frequency of HELLP syndrome is about 0.2–0.6% of all pregnancies, and 4–12% of those with preeclampsia. HELLP syn- drome is an acronym for H = haemolysis, EL = elevated liver enzymes and LP = low platelet count. Risk factors are multiple pregnancy, mother’ age over 25 years, white race, and poor perinatal outcome in previous pregnancies. Preeclampsia treat- ment is a great challenge for every physician, but also the subject of numerous discussion because there is no consensus on which drug would be the best for the treatment and prevnetion of preeclampsia. Generally accepted opinion is that the cut-off blood pressure level, when antihypertensive therapy should be initiated, is diastolic blood pressure over 110 mmHg. How- ever, it should not be decreased below 90–100 mmHg in order not to jeopardize uteroplacental circulation, which is in preeclampsia and eclampsia already significantly reduced. Termination of pregnancy is the definitive treatment for preeclampsia and eclampsia