Treatments to Reduce the Effects of Pregnancy Induced Hypertension and Preeclampsia

Preeclampsia (PE) is a dominant cause of mortality and disease among pregnant women

(Khan, Hafeez, & Nasrullah, 2017). This disease affects 2-8% of all pregnancies and 25% of

maternal and perinatal mortality (Khan et al., 2017). Antihypertensive drugs and vitamin

supplements are being tested to treat the symptoms of pregnancy induced hypertension. Studies

show that the effects of PE can be suppressed if treatment is administered at the proper time and

dosage.

My goal is to become a registered nurse and to work in perinatal care. I know a nurse

who works with high risk pregnancies and I find it fascinating how severe health issues will

always occur, yet there are many ways to solve them. My background knowledge about

contributing factors of PE will help me better inform my pregnant patients of this disease. This

research is important because there are risk factors that can help detect this disease. Women who

are planning to become pregnant or are pregnant should be aware of PE and its preventive

measures, as well as treatment options. Some factors that contribute to the development of

preeclampsia are diabetes, chronic hypertension, and obesity, prior to pregnancy (Behjat Sasan,

Zandvakili, Soufizadeh, & Baybordi, 2017). If women with these risk factors are made more

aware of their costs, they may be able to better control them and thus reduce the risk for PE.

Preeclampsia can be deadly for the mother and baby, leading to eclampsia which results in

maternal seizures, reducing the chance of survival for both mother and baby (Preeclampsia,

2017). The more people know about this disease and possible risk factors ahead of time, the

more that can be done to prevent it.

 PE reduces blood supply to the placenta by altering the process of remodeling uterine

blood vessels (​Atallah et al., 2017)​. During pregnancy, in order for blood to flow sufficiently to

the placenta, and thus the fetus, the uterine blood flow circulation is remodeled (​Osol &

Mandala, 2009).​ PE interrupts this process and is caused by clinically visible symptoms of severe

high blood pressure and protein in urine; however, these symptoms are silent until after or

around twenty weeks of gestation (Ding, Kang, Fan, 2017).

Many predictions about the origin of PE have been considered, one in particular is

vitamin D deficiency. According to some clinical studies, an important association among

preeclampsia and vitamin D levels has been found (Behjat Sasan et al., 2017). Preeclampsia

occurs in two main stages. The first, reduces blood flow from the mother to the fetus through

spaces in the placenta (Behjat Sasan et al., 2017). This leads to the second stage in which an

inflammatory reaction within the veins causes the inner linings of blood vessels to malfunction

(Behjat Sasan et al., 2017). This result of poor blood flow to the placenta is not the principal

cause of PE, but it does make it much more likely to occur (Behjat Sasan et al., 2017).

Hypertension during pregnancy may result in PE if not treated as soon as possible, and continued

hypertension can put the mother at risk for cerebral stroke and other organ complications ​(​Khan

et al., 2017). If PE is detected and treated soon enough, the baby can be delivered and live

healthily with minor complications (such as a lower birth weight) (Preeclampsia, 2017).

However, if it is not controlled, PE can precede eclampsia, liver failure, or kidney failure

(Preeclampsia, 2017).

Vitamin D supplements have been used to treat PE in a 2017 clinical study by Bejhat

Sasan et al., with women who have a history of PE. In this study, 72 patients were placed in a
control group and given a placebo, and 70 patients were placed in an intervention group which

received a 50,000 IU (1.25mg) vitamin D3 supplement (Behjat Sasan et al., 2017). Both groups

were given their respective drug once every two weeks until the 36th week of gestation (Behjat

Sasan et al., 2017). This study by Behjat Sasan et al. (2017) was conducted to determine if

vitamin D supplements could reduce the probability of developing PE in women who had PE

during a previous pregnancy. This study was completed in Iran, an Islamic country where

women receive much less sunlight due to their minimal body surface exposed to the sun (Behjat

Sasan et al., 2017). These women’s bodies produce much less vitamin D because they do not

receive UV-B rays from sun exposure due to governmental rules and traditional norms and

customs (Behjat Sasan et al., 2017). Vitamin D deficiency occurs throughout the world, studies

have demonstrated that pregnant women with low vitamin D levels have a higher risk of

developing PE (Behjat Sasan et al., 2017). Women in the intervention group resulted in having a

much lower probability of preeclampsia than women in the control group, Behjat Sasan et al.

expresses that the placebo controlled group was 1.94 times more at risk of developing PE than

the vitamin D intervention group (2017). Results from the study by Behjat Sasan et al. (2017),

support conclusions that vitamin D supplements can reduce the risk of PE in pregnant women,

especially those who have a history of this disease.

Antihypertensive drugs being used to reduce pregnancy induced hypertension and related

diseases bring many concerns and controversy (​Atallah et al., 2017). In the review article by

Atallah et al. (2017), reports of serious, although rare side effects such as abnormal blood flow or

bleeding resulted from administered Aspirin for the treatment of pregnancy induced

hypertension, while it is a widely used drug to treat cardiovascular diseases. A clinical study by
Khan et al. (2017), tested the efficacy of the antihypertensive drugs hydralazine and labetalol.

Both of these drugs used by Khan et al. (2017), are widely used in treating hypertension during

pregnancy, being top drugs of choice to use; however they had unfavorable side effects, the most

concerning is neonatal bradycardia. In the study by Khan et al. (2017), these two

antihypertensive drugs were compared in their efficacy to lower severe hypertension in

pregnancy. In this study, 78 women in Karachi, Pakistan were randomly divided equally into two

groups, either labetalol or hydralazine and given determined amounts of their respective drug

until the desired effect was attained ​(​Khan et al., 2017). For the labetalol group, 20 mg was

administered intravenously, if it was not effective in 20 minutes, then 40 mg was administered. If

the desired effect was not present yet after another 20 minutes, then 80 mg was administered

every 20 minutes for a maximum of three doses ​(​Khan et al., 2017). In contrast, the hydralazine

group was administered 5 mg intravenously every 20 minutes until the proper effect was reached

with a maximum of three doses ​(​Khan et al., 2017). During the trials, all patients’ blood

pressures were taken and recorded every 15 minutes to check the progress of the medication

(​Khan et al., 2017). Patients in both trial groups reported side effects such as headaches and

tachycardia, a heart rate greater than the normal resting rate of 100 beats per minute; however,

these occurred more often in the hydralazine group than in the labetalol group ​(​Khan et al.,

2017). Results from the study by Khan et al. (2017) show that by a narrow margin, blood

pressure is controlled better by labetalol than by hydralazine. The authors state that “A balance

between safety profile of a drug and a given dosage is of crucial importance. Therefore until

conclusive results are obtained regarding superiority of hydralazine or labetalol, choice of drug

should be on clinicians’ experience and discretion”, ​(​Khan et al., 2017, p. 470). This helps
demonstrate that these drugs control high blood pressure and thus reduce the risk of pregnancy

induced hypertension and diseases such as PE, however not one or the other has specifically

proven a clinical advantage ​(​Khan et al., 2017).

Other antihypertensive drugs have been used to treat pregnancy induced hypertension and

PE. The clinical trial by Ding et al. (2017) tested the effectiveness of resveratrol (RESV) as a

supplement to the first-line antihypertensive drug nifedipine (NIFE). Resveratrol has shown

advantageous effects in treating cardiovascular diseases such as hypertension (Ding et al., 2017).

A total of 349 women in Zhejiang, China were randomly assigned to two treatment groups,

either NIFE+RESV or NIFE+placebo (Ding et al., 2017). The NIFE+RESV group was

administered a NIFE capsule which contained 10mg plus a RESV capsule which contained 50

mg every 15 minutes up to five doses or until the desired blood pressure was reached (Ding et

al., 2017). The NIFE+placebo group was administered a NIFE capsule of 10 mg in addition to a

50mg glucose capsule as the placebo every 15 minutes up to five doses or until the desired blood

pressure is reached (Ding et al., 2017). The results from the study by Ding et al. (2017), show

that the supplement of RESV in addition to NIFE significantly reduced hypertension quicker and

with fewer doses, as well as maintained control of hypertension longer, than the NIFE+placebo

group did. In addition to the positives of the NIFE+RESV treatment, there were no severe

adverse side effects due to the RESV supplement to either the maternal or neonatal PE patients

(Ding et al., 2017).

In all three studies, each of them were able to prove a successful treatment in reducing

pregnancy induced hypertension and the risk of PE. In comparison within each antihypertensive

drug study, the trials done by Ding et al. (2017) had a much more significant difference of the
independent variable than the trials of Khan et al. (2017). The results in the trial by Khan et al.,

(2017) were measured by the reduction of blood pressure passed a certain point in a set amount

of time, in contrast to the time it took to reduce blood pressure to a certain point as it did in the

study by Ding et al. (2017). This causes somewhat difficulty in comparing results among drug

treatments. Both drug treatment studies and the vitamin D supplement study showed that these

treatments reduce pregnancy induced hypertension with minimal adverse side effects. The

vitamin D supplement to treat PE resulted in a significant decrease in risk of recurrent PE in

patients with a deficiency of vitamin D. All three treatments were successful in their efficacy of

reducing, controlling, and preventing severe pregnancy induced hypertension and PE.

All of the three trials utilized viable methods in selecting participants through vigorous

eligibility requirements. The ages of participating women were appropriate and close in range as

to not cause the data to result in inaccurate results such as an older age which puts them at a

higher risk for complications during pregnancy anyway. The gestational ages and blood pressure

or risk factor of all the women were appropriate to each of their studies. Each study had a control

group so the data was measurable and valid. Clinical studies done by Ding et al. (2017) and

Khan et al. (2017) were quick and measured within minutes or hours. In contrast, the clinical

study done by Behjat Sasan et al. (2017) with vitamin D supplements, was measured over

multiple weeks in which you had to wait longer to see results. The study with the most

participants was done by Ding et al. (2017) comparing NIFE+RESV against NIFE+placebo with

349 eligible patients. The least amount of participants was the study done by Khan et al. (2017)

comparing hydralazine and labetalol which had 78 eligible patients. With more participants in all

of the studies, results may have been more accurate and they could have had stronger
associations shown by their trials. The results and conclusions are clear and match the studies

done by Ding et al. (2017) and Behjat Sasan et al. (2017) explaining which group produced the

better results in the study. However, in the study by Khan et al. (2017), the margin between the

results of labetalol and hydralazine were very narrow, and although labetalol showed better

control of hypertension, their conclusions could have been stronger if the number of participants

was much greater than only 78 women.

All of the treatments I researched showed positive results in treating pregnancy induced

hypertension and PE. However, some questions arose while I researched. Are there ways to stop

eclampsia if PE is not controlled? What are the advantages and disadvantages to quicker

treatment options such as the antihypertensive drugs, versus the long term treatments like

vitamin supplements? Although vitamin D deficiency may be a factor to cause PE, is there a

density of pregnancies with PE in a certain part of the world that receives a lot of skin exposure

to the sun? I was not able to determine which treatment was the best overall because the results

were unclear in comparison to each other. In my future career as a perinatal nurse, I will educate

my patients on the risks and treatments for pregnancy induced hypertension and related diseases.

This research will help me support my patients by providing background knowledge on the

matter. I can provide them with the benefits of different types of treatments as well as the

adverse effects of antihypertensive drugs or supplements. Depending on the situation of the

patient and other factors, I can have an understanding of the better plan for them. For example

they may not be able to afford a first-line antihypertensive drug, but are willing to try a vitamin

D supplement to improve and prevent their condition. I hope that in the near future
antihypertensive drugs will become widely accepted and used more extensively worldwide along

with vitamin D supplements to prevent and control preeclampsia.

References

Atallah, A., Lecarpentier, E., Goffinet, F., Doret-Dion, M., Gaucherand, P., & Tsatsaris, V.

(2017). Aspirin for prevention of preeclampsia. ​Drugs​, ​77, ​1819-1831.

doi10.1007/s40265-017-0823-0

Behjat Sasan, S., Zandvakili, F., Soufizadeh, N., & Baybordi, E. (2017). The effects of vitamin D

supplement on prevention of recurrence of preeclampsia in pregnant women with a

history of preeclampsia. ​Obstetrics and Gynecology International​, ​2017​, 5.

doi.org/10.1155/2017/8249264

Ding, J., Kang, Y., Fan, Y., & Chen, Q. (2017). Efficacy of Resveratrol to supplement oral

Nifedipine treatment in pregnancy-induced preeclampsia. ​Endocrine connections​, ​6​(8),

595-600. doi: 10.1530/EC-17-0130

Khan, A., Hafeez, S., & Nasrullah, F. D. (2017). Comparison of Hydralazine and Labetalol to

lower severe hypertension in pregnancy. ​Pakistan journal of medical sciences​, ​33​(2),

466. doi.org/10.12669/pjms.332.12243

Osol, G., & Mandala, M. (2009). Maternal uterine vascular remodeling during pregnancy.

Physiology​, ​24​(1), 58-71. doi:10.1152/physiol.00033.2008

Preeclampsia: Symptoms, Risks, Treatment and Prevention. (2017, April 04). Retrieved from

http://americanpregnancy.org/pregnancy-complications/preeclampsia