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Antihypertensive drugs avoided in pregnancy.

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Reprinted from Hypertensive disorders in Women, Sibai BM, Severe preeclampsia and eclampsia, page 42,with permission of Elsevier Science gained a mean of 9. Babies of these women had greater birth weights, stayed shorter in the neonatal intensive care unit and had fewer neonatal complications.

All the women who were managed by early intervention recovered with no severe complications. Magas vérnyomás kockázata 4 fok 2 case required temporary renal dialysis.

In Rotterdam plasma volume expansion was used with central haemodynamic monitoring control. Antihypertensive medication was given when diastolic blood pressure was mmHg or more. Methyldopa was the drug of choice.

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In both groups the pregnancy was prolonged with days. A low maternal morbidity was seen in both groups and there were no complications of hemodynamic monitoring.

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Gestational age at delivery was Perinatal mortality was 7. Neonatal ventilation and patent ductus arteriosus occurred significantly more in the study group, but they had fewer growth retarded babies.

In a subsequent study Visser and Wallenburg 11 reviewed their temporising management in consecutive patients with severe pre-eclampsia, remote from term, from to The antihypertensive drugs avoided in pregnancy prolongation of pregnancy was 14 days with a range of 0 to 62 days.

The mean gestational age at delivery was Perinatal morbidity was From these studies it is clear that conservative management of severe early pre-eclampsia enables one to postpone the delivery of the fetus by one or two weeks with subsequent reduction in neonatal complications and improvement in the perinatal mortality rate.

However, expectant therapy should only be performed in tertiary centres where the obstetricians have adequate experience in obstetric intensive or high-risk care. One should be aware that deterioration of the maternal or fetal condition could occur rapidly.

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Careful monitoring of the condition of both the mother and fetus is therefore absolutely essential. It is also important to take the severity of the pre-eclampsia into account, the prevalence in underlying hypertension, patient compliance and delay in referral to a tertiary center.

The latter is of utmost importance as it is more difficult to treat patients with an advanced stage of severe pre-eclampsia expectantly As maternal and fetal complications can develop very rapidly, good facilities for monitoring the mother and fetus should be available.

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Where such antihypertensive drugs avoided in pregnancy do not exist, and when the fetus is not yet viable, it may be safer for the mother to have the pregnancy terminated soon after the diagnosis of severe pre-eclampsia is certain. Fetal viability, is also a relative term as it mainly depends on neonatal intensive care facilities, adequately trained people and the financial resources to support these tertiary care facilities.

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At Tygerberg Hospital, a gestational age of 28 weeks or rarely antihypertensive drugs avoided in pregnancy or 27 weeks is accepted for fetal viability. However, in developed countries fetal viability may start at 22 weeks or, in many developing countries, at weeks.

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As mentioned earlier, expectant management succeeded in prolonging the pregnancy with a mean of 7. It may therefore be unrealistic to introduce expectant management much longer than two weeks before fetal viability.

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On the other hand, the upper range of the prolongation of pregnancy may be as high as 62 days Too early termination of pregnancy will therefore sometimes deprive a patient from having a baby. This very difficult decision whether and when expectant management should be started, should always be individualised and discussed with the patient, her family and the neonatologist.

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Care should be taken to explain all the advantages and disadvantages to the patient and involve her in the decision-making. The upper limit of gestational age at which a patient does not antihypertensive drugs avoided in pregnancy for expectant management also differs. At Tygerberg Hospital a gestational age of 34 weeks is recommended as the neonatal survival at later deliveries is not better and worse when delivered at 33 weeks or earlier 4.

Sibai et al 7 used 32 weeks as the upper limit for entry in their study, but delivered at 34 weeks.

Thirty-two weeks was also accepted as 79 the upper limit for entering to their study by Olah et al 9while Visser et al 10 accepted 35 weeks. After a gestational age of weeks has been reached, delivery is safer for the mother and safe for the fetus.

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The main reason for this is that the condition of the mother or the fetus can change suddenly, necessitating speedy delivery. Severe placental insufficiency and abruptio placentae are the two most common causes of intrauterine death in patients with severe pre-eclampsia, but can be detected by the abnormal fetal heart rate FHR pattern they cause.

It is also necessary to exclude fetal distress before any antihypertensive therapy is initiated, because drugs such as dihydralazine may cause sudden hypotension and therefore worsen the fetal distress.

Parenterally administered drugs are usually used, although oral nifedipine can also be used Table 2. Intravenous hydralazine is the parenteral drug of choice in many units. Patients with severe pre-eclampsia are often hypovolemic, therefore intravenous administration of hydralazine may occasionally cause severe hypotension with subsequent fetal distress To prevent this ml fluid should be given intravenously prior to the administration of this drug.

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As an alternative to dihydralazine, nifedipine may also be used. It has the advantage that it may be given orally Table 2.

Treatment of severe acute hypertension I. Hydralazine mg doses at minute intervals IV initial dose 5 mg or 25 mg in ml normal saline, starting at 3. Give 1 ml 1. Nifedipine mg orally. Repeat after 30 minutes.

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Although experience with nifedipine is less than that with dihydralazine there seem to be few disadvantages. A third drug that is often used for the acute control of blood pressure is labetalol It is seldom used at Tygerberg Hospital because many of the patients with severe preeclampsia have intrauterine growth retardation.

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Labetalol possesses both alpha and beta-adrenoceptor blocking properties. However, it appears to be a more potent inhibitor of beta-adrenoceptors Betablocking agents may inhibit the fetal adaptation to stress and cause neonatal hypoglycemia In addition, it has been shown that black patients do not respond well on beta-adrenegic blocking agents Although there was initial concern regarding its safety for the fetus when administered to patients with severe pre-eclampsia, later studies failed to confirm these observed risks for fetal magas vérnyomás kezelés ápoló anya. Administration of glucocosteroids to patients with pregnancy induced hypertension also did not have an aggravating effect on maternal blood pressure Kirsten 34 followed up neonates, born to mothers with early onset severe pre-eclampsia.

Multiple logistic regression to determine the association between RDS and various categories of the umbilical artery flow velocity waveforms, adjusting for many confounding variables, showed that only birth weight above g, gestational age above 30 weeks and antenatal steroids reduced the likelihood of RDS. These findings once again support the beneficial effects of the antenatal administration of steroids on fetal lung maturity.