Open Journal of Preventive Medicine, 2014, 4, 860-867

Published Online November 2014 in SciRes. http://www.scirp.org/journal/ojpm

http://dx.doi.org/10.4236/ojpm.2014.411097

Study of the Prevalence of Hypertension

and Complications of Hypertensive
Disorders in Pregnancy
Shahla Khosravi1, Soheila Dabiran2*, M. Lotfi3, Mohammad Asnavandy2
1
Reproductive Health and Community Medicine, Faculty of Medical Sciences, Tehran University of Medical
Sciences, Tehran, Iran
2
Department of Community Medicine, Tehran University of Medical Sciences, Tehran, Iran
3
Islamic Azad University of Varamin, Varamin, Iran
Email: *[email protected]

Received 21 September 2014; revised 22 October 2014; accepted 18 November 2014

Copyright 2014 by authors and Scientific Research Publishing Inc.

This work is licensed under the Creative Commons Attribution International License (CC BY).
http://creativecommons.org/licenses/by/4.0/

Abstract
Introduction: Hypertension is one of the common problems associated with pregnancy that may
be followed by eclampsia, acute renal failure, maternal death, premature delivery, intra-uterine
growth restriction and other. This study was conducted to determine the results of pregnancies
associated with hypertension in patients visiting in the Delivery Ward of Valiasr Hospital. Methods:
A descriptive study was conducted on all the patients admitted to the aforementioned department
and who possessed the inclusion criteria for hypertensive pregnancy. Results: Among the 1694
delivery cases examined, 173 cases had hypertension (9.8%). Among these, 75 (45%) had gesta-
tional hypertension; 24 (14.8%) had preeclampsia-eclampsia; 30 (18%) had preeclampsia supe-
rimposed on chronic hypertension; 21 (13.5%) cases had chronic hypertension; and 13 (8%) had
pregnancy-aggravated chronic hypertension. Ninety-six point three percent (96.3%) had a systolic
blood pressure (BP) of 140 - 190 mmHg, and 3.7% had a systolic BP greater than 190 mmHg.
Whereas 61.1% of diastolic blood pressure 90 - 110 mmHg and 38.9% of the mothers had diastolic
BP greater than 110 mmHg. The HELLP (Hemolysis, Elevated Liver enzymes & Low Platelet count)
syndrome was present in 4.9% of cases; 52.6% experienced premature delivery; 7.4% had IUFD
(intra uterine fetal death); 9.9% had IUGR (intrauterine growth retardation); and 17.3% had LBW
babies. Conclusions: Based on our results, hypertensive mothers who are younger and have lower
weight babies at birth experience more perinatal complications. The unpleasant effects of hyper-
tension in pregnancy warrant the need for training, routine prenatal care, the early detection and
treatment of hypertension at younger ages of pregnancy, and follow-up after delivery.

*
Corresponding author.

How to cite this paper: Khosravi, S., Dabiran, S., Lotfi, M. and Asnavandy, M. (2014) Study of the Prevalence of Hyperten-
sion and Complications of Hypertensive Disorders in Pregnancy. Open Journal of Preventive Medicine, 4, 860-867.
http://dx.doi.org/10.4236/ojpm.2014.411097
 S. Khosravi et al.

Keywords
Hypertension, Pregnancy Induced Hypertension, Preeclampsia, Eclampsia, Chronic Hypertension

1. Background
Hypertensive disorders of pregnancy are among the leading causes of maternal and perinatal deaths in develop-
ing countries, and many studies have been conducted in this field [1]. Hypertension is a common medical prob-
lem that affects 20% - 30% of the adult population and more than 5% - 8% of all pregnancies in the world [2]
[3]. Hypertensive disorders of pregnancy rank high among the causes of maternal mortality and morbidity.
Hypertension in pregnancy is defined as a systolic BP of 140 mmHg and higher, and a diastolic BP of 90 mmHg
and higher. Being the second leading cause of maternal death in the USA, almost 15% of maternal deaths are
related to hypertension (HTN). Severe HTN raises the risk of heart attacks, cardiac failure, cerebrovascular ac-
cidents and renal failure in the mothers. The fetuses of hypertensive mothers are also at increased risks, such as:
inappropriate placental oxygen transfer, IUGR, premature delivery, placental abruption, stillbirth, and neonatal
death [2]. The hypertensive disorders of pregnancy affect 5% - 22% of all pregnancies. Hypertension, bleeding
and infection are the triad of lethality that greatly contributes to maternal mortality and morbidity [4]-[7].
The American College of Obstetricians and Gynecologists (ACOG) has classified pregnancy induced hyper-
tension (PIH) into four groups of disorders: gestational hypertension, where resting BP is 140/90 mmHg or
higher after the 20th week of gestation; chronic hypertension, that exists before pregnancy or begins in the first
20 weeks of gestation; preeclampsia (raised BP and edema or proteinuria)/eclampsia (preeclampsia and sei-
zures); and preeclampsia superimposed on chronic hypertension [3] [4]. In spite of the high incidence and out-
comes of hypertensive disorders of pregnancy, their pathogenesis, clinical manifestations and clinical courses
greatly vary and at times complicate the diagnosis [8]. Decades of extensive research on the subject have failed
to explain its onset or aggravation, and it is still the most significant unsolved problem in midwifery. Among the
theories proposed so far, the most important is the immunologic one. Based on this theory, an immunologic dis-
order leads to an unnatural implantation and secretion of substances that activate vascular endothelial cells, or
damage them, leading to vascular constriction and eventually a raised BP.
PIH is more commonly seen in nulliparous women, and older women (owing to the risk of chronic HTN) are
at greater risk of preeclampsia being superimposed. Evidence shows that discrete pathophysiological changes
begin from the moment fertilization takes place. And if delivery does not take place these changes lead to the
involvement of multiple organs and present with dangerous clinical signs in both the mother and fetus [4].
Pregnancies induced with hypertension are associated with increased risks of serious outcomes such as prema-
ture delivery, IUGR, perinatal mortality & morbidity, acute renal failure (ARF), acute hepatic failure, bleeding
at the time of delivery and postpartum bleeding, maternal mortality & morbidity following harms such as
HELLP, disseminated intravascular coagulation (DIC) and seizures [2]-[4] [9]. The hazards of these outcomes
depend on its severity, gestational age (GA) at the onset of HTN, and GA at the time of delivery. According to
literature, women who are affected with PIH before their 37th week of gestation have poorer perinatal results as
compared to women who are affected at term. Moreover, IUGR and placental abruption are more common in
preterm deliveries. Mothers who have had a history of preeclampsia (17.9%) are at a greater risk than nullipar-
ous women (5.3%) (p < 0.00001) [9]. Hypertensive mothers usually give birth to preterm babies, who in turn
will most likely need Neonatal Intensive Care Unit (NICU) care as a result of their IUGR and low birth weight
(LBW) [10].
The prevalence of preeclampsia has been reported at 5%, but it is influenced by parity, race, ethnicity, envi-
ronmental factors, socio-economic status, multiple pregnancies, maternal obesity etc. Hence different statistical
results have been obtained in research. This study aimed to investigate the consequences of high blood pressure
in pregnancy.

2. Methods
A cross-sectional descriptive study was conducted in Imam Khomeini Hospital (IKH), a teaching hospital affi-
liated with Tehran University of Medical Sciences. This hospital is also considered a tertiary care center. All

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hypertensive pregnant mothers (with a BP of 140/90 mmHg or more) who had visited the hospital for delivery
during one year went under study, regardless of when their BP had risen. Among the 1694 cases of delivery 173
had hypertension (9.8%), 11 of which who were excluded because of incomplete data. The maternal variables
studied were: age, gestational age, number of deliveries, status of mothers BP, type of delivery, time of occur-
rence of HELLP based on lab findings and doctors diagnosis, and maternal death. Neonatal variables included:
weight at birth, first minute and fifth minute Apgar scores, IUGR, IUFD and neonatal death. Data were extracted
upon referring to mothers and neonates existing files, and gathered by completing the studys data collection
questionnaire.
Sampling: All hypertensive patients visiting the delivery ward were studied as a census. The reason for
choosing IKH was its NICU ward and its proximity to the delivery ward and hence the possibility to follow-up
the newborns. The inclusion criteria were: delivery at IKH, existence of adequate data in the mothers and neo-
nates files, and existence of HTN (with respect to our set criteria).
In our study hypertension was considered as a systolic BP of 140 mmHg and higher and a diastolic BP of 90
mmHg and higher. Based on the signs & symptoms of disease and a history of HTN before pregnancy, the pa-
tients were classified into groups of gestational hypertension, chronic HTN, pregnancy-aggravated chronic
HTN, preeclampsia-eclampsia and preeclampsia superimposed on chronic hypertension. The data existing
in the files have been registered upon a physicians diagnosis. Thenceforward the data were fed into a designed
database and analyzed by SPSS software.

3. Results
Among the 1694 mothers who had delivered in the hospital 173 had HTN (9.8%), 11 of which were excluded
because of incomplete data, hence leaving us with 162 cases. Most mothers fell in the 21 - 30 years age-group
(55.6%). Nine point four percent (9.4%) were aged under 20 and 32.3% were aged over 30 years. 38.6% were
nulliparous and only 3.1% had over 5 pregnancies. The study populations demographic data are displayed in
Table 1.

Table 1. Demographic characteristics of the population and their newborn infants of mothers with hypertension.
Variables Number Percent (%)
<20 15 12.2
Maternal age 21 - 30 90 55.6
>30 57 32.2
1 52 32
2 44 27.1
Parity
3-5 59 36.4
6 6 3.7
20 - 29 12 7.4
Gestational 30 - 36 93 57.4
37 57 35.1
NVD 53 32.7
Type of delivery
Cesarean section 109 67.3
700 - 1499 9 5.5
1500 - 2400 19 11.8
Birth weight
2500 - 3499 123 81.5
3500 12 1.2
40 - 30 cm 13 8
Birth height 49 - 41 cm 77 47.5
53 - 50 cm 53 32.7
<7 32 20.9
First minute Apgar score
7 121 79.1
Fetuses born dead, weight, and Apgar score has not been calculated.

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More than half the mothers (52.6%) GA at delivery (spontaneous, induced and/or elective section) was under
37 weeks and gave birth to preterm babies. Among these 7.4% (12) babies were born at 20 - 28 weeks GA,
where viability is very poor. Among the latter 28.1% were LBW babies or had IUGR.
Eighteen point three percent (18.3%) of the newborns (28 cases) were LBW babies, weighing less than 2500 g.
Among these, 32.1% (9 newborns) weighed less than 1500 g, i.e. were very LBW babies. The stillborn cases
were however not measured for weight and height. Only two babies weighed 3500 g or higher in this study. Fif-
ty-five percent (90 newborns) measured less than 50 cm in height, 8% (13) of which measured less than 40 cm.
The stillborn cases or those who had early death were either not measured and/or had not been registered any-
where.
The frequency distribution of systolic and diastolic BP in hypertensive mothers is illustrated in Table 2. Ac-
cording to the results, the percentage of very high diastolic BPwhich is an indicator of the severity of dis-
easewas more than the percentage of very high systolic BP in these individuals.
In hypertensive mothers, 7.4% of newborns (12 cases) were born at a GA of 20 - 28 weeks, 45.2% (73) cases
were born at 29 - 36 weeks GA, and 37.4% (77 cases) were born at 37 - 42 weeks GA. Hence the highest per-
centage was of those born at 29 - 36 weeks GA. Beginning with the third semester, PIH had posed as a serious
threat and had led to the termination of pregnancy.
Upon examining the first minute Apgar score, 2.5% (4) of newborns scored lower than 4, 19.8% (32) scored
between 5 - 6, and 74.4% (121) scored between 7 - 10. The fifth minute Apgar score was lower than 7 in 1.9%
(3) cases, and 7 or more in 98.1% cases.
Table 3 shows the frequency distribution of different types of PIH.
The maternal and fetal complications of HTN raise the possibility of perinatal and neonatal mortality and
morbidity. Preterm delivery was the most prevalent among such outcomes. Some of these cases were the result
of induction or elective termination of pregnancy as the most important measures in controlling and managing
hypertensive disorders and reducing the risks to mother and fetus. Table 4 shows the frequency of these com-
plications.
Table 2. Distribution of systolic and diastolic blood pressure values.
Diastolic blood pressure (mmHg) Number Percent Systolic blood pressure (mmHg) Number Percent
90 - 110 99 61.1 140 - 190 156 96.3
110 - 140 63 38.9 191 - 230 6 3.7
Total 162 100 Total 162 100

Table 3. Prevalence types of hypertensive disorders in the study population.

Disorders Number Percent (%)
Gestational hypertension 74 45
Preeclampsia-eclampsia 24 14.8
Preeclampsia superimposed on chronic hypertension 30 18
Chronic hypertension 21 13.5
Pregnancy-aggravated chronic hypertension 13 8
Total 162 100

Table 4. Prevalence of maternal and fetal outcomes in the study population.

Complications Number Percent (%)
HELLPs syndrome 8 4.9
Preterm labor 85 52.6
Cesarean section 109 67.3
LBW 28 17.3
IUGR 16 9.8
IUFD 9 5.5
Infant death 10 6.1
Mother death 0 0

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Thirty-two percent (53) mothers had natural vaginal deliveries (NVD), and 67.3% went under cesarean sec-
tion. Termination of pregnancy was done by induction in 38.3% (62) cases, 5.6% of which ended up in cesarean.
Elective cesarean was performed in 60.5% (98) cases.

4. Discussion
Maternal and fetal complications increase with an increase in PIH, but appropriate maternal and perinatal care
can prevent dangerous outcomes such as eclampsia and maternal death.
In a population-based study, Roberts et al. (2005) examined hypertensive pregnancy disorders in 250,173
pregnant women and their newborns in Sydney-Australia. On the whole, 9.8% of the mothers had PIH disorders;
6% of these had chronic HTN, 4.2% were affected with preeclampsia, 0.3% had preeclampsia superimposed on
chronic HTN, and 4.3% had gestational HTN. Mothers affected with hypertensive disorders were more exposed
to maternal mortality and morbidities as compared to those who were not affected [10]. Another study con-
ducted in Nigeria on 2393 deliveries found 127 (5.3%) cases affected with PIH disorders. Gestational HTN,
preeclampsia superimposed on chronic HTN and preeclampsia/eclampsia were observed in 26.2%, 19.7% and
54.1% cases, respectively. All the cases that had had chronic HTN before pregnancy had experienced superim-
posed preeclampsia or eclampsia during pregnancy [11].
In our study, 1694 mothers visiting IKHs delivery department during one year were studied. 173 cases had
HTN (9.8%). Among these, 60.5% had preeclampsia-eclampsia, 30 (18%) had preeclampsia superimposed on
chronic HTN, 21 (13.5%) cases had chronic HTN and 13 (8%) had pregnancy-aggravated chronic HTN.
A study in Madrid (2004) examined the outcomes of chronic HTN in the second half of pregnancy in 154
mothers. Seventy-two percent (72%) had had chronic HTN before pregnancy and the remainder had been af-
fected with it during the first half of pregnancy. Seventy-eight percent (78%) had experienced aggravation of
HTN during pregnancy. Their mean gestational age was 34 4.6 weeks, and most of them had undergone cesa-
rean [12].
Dr. Jain of Chicagos Illinois University conducted a study on 109,428 deliveries. During the study 8019
mothers had PIH, among which 74.5% had preeclampsia and 25.5% had chronic HTN. Hypertension was asso-
ciated with unpleasant outcomes in pregnancy, such that in this study chronic HTN was associated with preterm
delivery and IUGR more as compared to PIH alone [13]. A third of women who have chronic HTN are affected
with preeclampsia in pregnancy and this phenomenon usually takes place between 26 - 34 weeks GA [2]. In our
study, 39.5% of the mothers had chronic HTN prior to pregnancy, 18% of which were affected with preeclamp-
sia. Eclampsia superimposed on chronic HTN doubles the risk of IUGR and preterm delivery [2] [12].
The risk of premature birth in mothers with PIH is approximately 25% - 30% [12]. Preeclampsia usually oc-
curs in the 32nd week and after. Ninety-four percent (94%) of the cases Saleh et al. (2003) followed had been af-
fected with PIH at the 32nd week and onwards [14]. Whereas, preeclampsia superimposed on chronic HTN
usually occurs in the 26 - 33 weeks GA, and raises the risk of premature birth and its outcomes [2]. In Bozhino-
va et al.s study (2004) the severe forms of preeclampsia/eclampsia were seen to begin in the 25 - 30 weeks of
pregnancy in 60% of cases, whereas the semi-severe forms of the disease began during 31 - 36 weeks in 50% of
cases [15]. Among the 760 mothers kept under observation in Moodley et al.s study (1999) in South Africa,
46.3% had preterm deliveries [16]. In our study however, 52.6% of the pregnancies ended up in preterm delive-
ries, 7.4% of which was terminated between 20 - 29 weeks. However, some of these deliveries were the result of
induction. The definitive treatment of preeclampsia is termination of pregnancy, which is done in spite of the
prematurity of the baby [2].
A case control study in Buenos Aires (1999) hospitals examined the type of deliveries and found that the
number of cesarean (cases with PIH) were 3.8 times the controls, concluding that PIH was clearly associated
with increased cesarean [17]. The greater the severity of HTN the more are the complications associated with it
during pregnancy, and hence, the greater the possibility of pregnancy termination [1] [13]. Granguly et al. re-
ported a 34.3% rate of cesarean section among hypertensive mothers [18]. Zibaeenezhad et al. reported a 45.8%
rate [19]. In our study, 67.3% of pregnancies had been terminated by cesarean. Although the rate of cesarean is
high among PIH mothers, the higher figures in our studyas opposed to othersis because the overall rate of
cesarean in our country is many times the ideal figure. Like many other countries, Iran too has witnessed an
alarming increase in the cesarean rate; 48% of all deliveries in 2009 were performed through cesarean [20]. This
is in spite the fact that the World Health Organization (WHO) has announced the normal cesarean rate at 10% -

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15% of all deliveries.

Induction of delivery is used to terminate pregnancy in hypertensive mothers. In our study 38.3% (62) moth-
ers were induced to deliver, 5.6% of which ended up in cesarean. While in Yadavs study where 250 cases (PIH
women) and 400 controls were observed, 52.8% and 3.25% of cases and controls, respectively, were induced to
deliver. Among those induced to deliver, 14.8% and 3.5% of cases and controls, respectively, underwent cesa-
rean [21].
One of the serious complications associated with severe preeclampsia is the HELLP syndrome. This syn-
drome is a group of symptoms including hemolysis, elevated liver enzymes, and low platelet count. There were
4.9% cases of HELLP syndrome in our study, whereas Vigil observed the HELLP syndrome, ARF, pulmonary
edema and hypertensive-induced encephalopathy following delivery in 8.4%, 8.4%, 3.9%, 1.3% and 1.3% of
cases [12]. Moodley reported HELLP syndrome at 3.2% [16], and Arif Khan reported it at 3.8% in Agha Khans
Hospital. In Ben et al.s study the frequency of this syndrome in mothers affected with severe preeclampsia
and/or eclampsia was reported as 9.7% (167 cases), 14 of which occurred before and 2 of which occurred after
delivery. Nine cases had acquired it before the 32nd week of pregnancy [21]. Osmanagaoglu (2004) found a sig-
nificant association between the occurrence of HELLP syndrome and maternal mortality and morbidity [22].
However, we found no case of maternal mortality in our study, although Moodley reported it as 0.8%.
The mean birth weight of babies born to hypertensive mothers is lower than normal [9]. The mean birth
weight of babies born to chronically hypertensive mothers is also lower than pregnancy-induced hypertensive
mothers (with a difference of 184 g) [12]. In our study 17.3% of the babies born to hypertensive mothers had
birth weights less than 2500 g, which is greater than the normal population. Out of this 17.3%, 5.5% weighed
less than 1500 g. The study conducted by Moodley in South Africa (1999) divided the 322 nulliparous that con-
sisted of 161 hypertensive cases and 161 controls into two groups: a) those with proteinuria, and b) those with-
out proteinuria. The mean birth weight in the control group was 3.02 kg. It was 2.4 kg and 2.8 kg in groups a
and b respectively. There were 9 cases of perinatal death, all of which were observed in the hypertensive
group [16].
Preeclampsia superimposed on chronic hypertension usually occurs between weeks 26 - 34, and doubles the
risk of preterm delivery and IUGR [13]. A study conducted by Fernandes on the Italian Hospital in Buenos Air-
es showed that SGA (small for gestational age) babies were born 7.08 times more to mothers with PIH, than in
the control group [17]. The frequency of IUGR was 9.8% in our study, and 6.6% in Moodley and others studies.
The higher rate of IUGR in our study is probably a consequence of economic conditions and poor nutrition dur-
ing pregnancy. The greatest rate of IUGR was observed in the 21 - 30 years old group (62%).
Elevation of BP in the mother increases the risk of perinatal mortality and morbidity. There were 9 (5.6%)
such cases (IUFD and neonatal death) among the 161 hypertensive nulliparous observed in Moodleys study
[16]. Jains study reported 4.8% perinatal mortality and morbidity in PIH mothers, as opposed to 2.9% in chron-
ically hypertensive mothers [12]. We estimated IUFD at 5.5% and neonatal death at 6.1%. We had 9 cases of
IUFD and/or neonatal deaths, all of which took place in hypertensive mothers who had proteinuria. Yadav also
reported higher IUFD rates in hypertensive mothers, where it was 4.8%, as opposed to 0.25% in the control
group. Perinatal deaths were observed in 14.8% of hypertensive mothers, as opposed to 1% in the control group,
hence necessitating special neonatal care in the hypertensive group [21]. Hadavi et al. studied the causes of
death in a two-year study and found PIH to be one of the most common causes of perinatal mortality and mor-
bidity at a rate of 8.9% [23]. Elsewhere Babaee et al. examined 445 mothers and neonates and looked for the
causes of mortality and morbidity in premature babies, and found that 21% of LBW babies had been born to
mothers with PIH [24].

Limitations
The most important limitation of this study was the availability of information in the hospital files, which did not
allow for their further examination.

5. Conclusion
Pregnancy-induced hypertension is associated with multiple complications in the mother and baby, and particu-
larly preterm delivery. Complications such as HELLP syndrome can sometimes prove fatal to mother and fetus.

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Therefore, the timely diagnosis of PIH and provision of specialized antenatal maternal care could reduce the
impacts of such complications.

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