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How to manage pregnancy induced hypertension?

Q: My wife is 27 years old. The first pregnancy ended up in IUD (placenta abruption due to the high BP) at 25th week. The BP was found to be normal during the earlier check ups. It was also found that there was excess protein in urine, which became normal after delivery. BP became normal after 3 months with medication and medication was stopped thereafter. Six months later she conceived again. Doctor prescribed Aspirin (delayed released, 75 mg per day) this time from first month onwards. However it too ended in missed abortion during 10th week. As a follow up, blood antibodies were checked and it is normal; but reason for these is not known. Could aspirin have caused this? What are the risks involving taking aspirin? Should it be taken again in the next pregnancy? Are these two miscarriages related? Will they recur & what precautions are needed for the next time?

A:Pregnancy induced hypertension, especially if associated with protein in the urine (proteinuria) can be a cause of intrauterine death and placental abruption. Though one would think that 25 weeks is a bit too early to have a complication like that especially if the blood pressure was mild to moderate. However if it has happened in the first pregnancy, she is certainly more likely to have high blood pressure in the later pregnancies, though they may be less harmful to the pregnancy next time. By and large pregnancy induced hypertension gets better with each pregnancy. Of course there no hard and fast rules in medicine, and the reverse may be true in some cases. The role of Aspirin in pregnancy induced hypertension is controversial. It is certainly not indispensable. Aspirin has been recently reported to be associated with a high risk of earlier abortions, and so your concern is justified. The exact risk in an individual case is difficult to determine as early abortions are common anyway. Whether your wife needs aspirin in the next pregnancy will have to be decided by the treating physician but I'd like to add that it is neither essential nor extremely harmful. So I guess once she's pregnant next time you would have to take the decision right then. Needless to say that Aspirin is not the end all of management of hypertension in pregnancy. In fact due to its complicated mode of action it may actually be associated with higher risk Of early abortions and placental abruption. Certainly there is no need to give Aspirin in the first few months of pregnancy. Once a live pregnancy is established by ultrasound examination, after the sixteenth week or so, one can consider using low dose Aspirin, and that too only if blood flow seems to be less than adequate. However if you choose not to use Aspirin at all I can assure you that it would not harm the pregnancy in any way. The role of Aspirin in these cases has only been speculated and has not yet been proven beyond doubt. As far as precautions are concerned there is nothing specific that you can do in the next pregnancy except keep a close watch on the blood pressure and the amount of protein in the urine. you may need to monitor the blood flow through the placental and fetal vessels By doppler studies. No specific precautions as a change of lifestyle like avoiding travel, and work, are required. In fact, she should be lead as normal a life as possible. This will give her more confidence and increase the chances of having a normal pregnancy. Needless to say, in case she develops hypertension in the next pregnancy or show signs of passing protein in the urine she would require treatment for blood pressure and the pregnancy must be looked after by an expert trained to look after high-risk pregnancies. And there is nothing to suggest that the two pregnancy losses are related to each other in any way. Early abortions generally occur when the fetus (the conceptus) itself is less than perfectly formed. Nature does not preserve abnormal fetuses and this leads to an early abortion, while placental abruption and hypertension occur during late pregnancy and are worse in the first pregnancy. Subsequently the risk of developing hypertension is there but is generally a milder type and causes less damage to the fetus. To completely answer your question as to whether the two miscarriages were related, one would have to do a few tests on your wife to find out what went wrong. She would require a complete work up with a complete blood count, blood sugar to rule out diabetes, check the kidney functions, exclude infections and exclude anti phospholipid syndrome (APLS) by doing lupus anticoagulant and anticardiolipin tests. If all these tests do not reveal any abnormalities, one can safely presume that the two abortions were because of independent reasons and she should go ahead with a positive frame of mind and plan the next pregnancy. I wish you all the luck for the next pregnancy.

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