Pressão alta na gravidez , Pré-Eclâmpsia e eclâmpsia

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Prê-eclêmpsia

O que é pressão alta na gravidez? (Hipertensão na Gestação)

 

pressão alta na gestação

Hipertensão (pressão alta) na gestação é uma pressão maior ou igual 140/90 mmHg.

Pode ser só a sistólica alta (pressão maior ou igual a 140, ex.:145/80 mmHg) ou só a diastólica alta (maior ou igual a 90, ex.: 135/95 mmHg), em duas ocasiões, idealmente com intervalo de 4h entre as medidas, em mulheres normotensas até 20 semanas.

Ou seja, são consideradas gestantes hipertensas quando se tem pressão maior ou igual 140/90 mmHg, medida por 2 vezes com intervalo de 4h, acima de 20 semanas de gestação.

Contudo,  se uma gestante que na primeira consulta ou em qualquer consulta que apresenta pressão maior que 140/90 mmHg antes de 20 semanas, já deveria ter o diagnóstico de hipertensão antes da gestação, mesmo que não soubesse dessa condição.

Até 50% das mulheres que são diagnosticadas com hipertensão na gestação (pressão alta na gravidez) antes 34 semanas, acabam evoluindo para pré-eclâmpsia, por isso é importante fazer exames laboratoriais e de urina de tempos em tempos.

O que é Pré-Eclâmpsia?

É a síndrome hipertensiva (pressão maior que 140/90 mmHg, acima de 20 semanas, em pelo menos duas medidas com intervalo de 4h entre elas) + proteinúria (presença de proteína na urina).

Como diferenciar doença hipertensiva na gestação de pré-eclâmpsia?

Se perde proteína é pré-eclâmpsia, se não perde proteína é síndrome hipertensiva na gestação.

Nesse sentido, para diferenciar uma doença hipertensiva na gravidez de pré-eclâmpsia, precisamos de outros exames de rastreamento, além do valor da pressão, como:

  • Exames de urina de 24h ou relação proteína/creatina ( para avaliar proteína na urina)
  • Ácido úrico maior que 5.2 mg/dL
  • Média da pressão arterial sistólica maior que 135 mmHg (MAPA)
  • Doppler das artérias uterinas está ou esteve alterados

Esses resultados mostram que essas mulheres tem maiores chances de desenvolver Pré-eclâmpsia.

Como diagnosticar a pré-eclâmpsia?

O mais exame mais comum de rastreamento é o exame proteinúria de 24h (exame de urina por 24h), que verifica a quantidade de proteína.

Ou seja, se encontrar mais de 300 mg em 24h, é considerado patológico e essa mulher é diagnosticada com pré-eclâmpsia.

Além disso, outra maneira mais simples, de rastreamento inicial é a coleta de uma única amostra de urina.

É dosada na amostra de urina a relação entre proteína e creatina, se essa relação vier maior que 0,3, é considerado uma proteinúria significativa e pode ser dado o diagnóstico de pré-eclâmpsia, quando associado a síndrome hipertensiva na gestação.

Ainda assim, outro fator de diagnóstico para pré eclâmpsia quando uma mulher está hipertensa, acima de 20 semanas de gestação, são sinais de doenças graves (sinais de lesão de órgãos maternos), como:

  • Síndrome HELLP,
  • Edema pulmonar,
  • Alterações cerebrais ou visual (escotomas cintilantes, dor de cabeça importante ou associado com perda de campo visual, irritabilidade muito intensa)

Podem ser sinais de lesão de órgãos alvo. Esses também são sinais que isso não é apenas uma hipertensão, mas sim uma pré-eclâmpsia.

Existe tratamento para a pré-eclâmpsia na gestação?

A pré-eclâmpsia é uma doença placentária e só acaba com a retirada da placenta (após o parto), não existe nenhum remédio para tratar a pré-eclâmpsia.

O remédio hipertensivo não trata pré- eclâmpsia, apesar disso ele diminui os riscos de complicações maternas, como picos de pressão que podem causar AVC, edema agudo de pulmão, descolamento prematuro da placenta, mas não evitam o desenvolvimento da doença, não evitam a eclâmpsia, não evitam a síndrome HELLP, o acompanhamento clínico é que irá prever essas complicações ou tratar, assim que elas aparecerem.

Em outras palavras, o tratamento da hipertensão não previne evolução da pré -eclâmpsia, mas é importante para prevenir picos de pressão, que podem complicar a saúde da mãe.

Dá para evitar a pré-eclâmpsia?

O uso do AAS, iniciados até 16 semanas de gestação, diminui a chance de pré-eclâmpsia ou tende a uma doença menos grave e menos precoce.

Acima de tudo, a profilaxia é indicada para mulheres que têm o risco aumentado de desenvolver pré-eclâmpsia na gestação, como histórico gestacional anterior, histórico familiar, gestação múltipla e mulheres que têm alteração do doppler no primeiro trimestre.

Sinais de gravidade da Pré- eclâmpsia

  • Pressão igual maior de 160/110 mmHG
  • Plaqueta menor de 100 mil/mm3
  • Creatinina aumentada (maior que 1.1 mg/dL) 
  • Dobro dos valores de transaminases (TGO/TGP)
  • Edema Pulmonar
  • Sintomas cerebrais ou visuais persistentes (cefaleia intensa, perda de campo visual, irritabilidade intensa)

Em outras palavras, se uma gestante se encontra com pressão 160/110 mmHG, mal estar, dor de cabeça, turvação na visão, já pode receber o diagnóstico de pré-eclâmpsia grave, mesmo sem a dosagem de proteína na urina.

Importante:

A hipertensão na gravidez (sem proteína alterada), evolui para pré-eclâmpsia em até 50% dos casos, principalmente quando diagnosticada antes de 34 semanas de gestação.

Nesses casos, as gestantes precisam ser muito bem vigiadas ao longo da gestação com exames regulares, pois podem evoluir.

Então, as gestantes precisam comprar aparelho para medir pressão pelo menos 2 vezes ao dia, sentada em repouso com braço esticado, preferencialmente com aparelho digital de braço e não de pulso, por não tem tanta precisão.

OBS.: Se a pressão não está controlada a gestante deve ser internada e medicada (pressão igual ou maior de 160/110 mmHg).

Eclâmpsia, o que é?

Quando a pré-eclâmpsia não é bem controlada ou se tem o diagnóstico tardio, a mulher pode complicar com a eclâmpsia, que é a crise convulsiva decorrente da doença hipertensiva na gestação.

Ou seja, uma situação gravíssima na obstetrícia e infelizmente é a doença que mais mata gestantes nesse país e no mundo.

Nem sempre as gestantes seguirão essa ordem cronológica de evolução, algumas gestantes não apresentam muitos sintomas e já apresentam eclâmpsia, que é a complicação e evolução da pré-eclâmpsia e é exclusiva da gestação.

Primordialmente, sempre que uma gestante convulsiona, até que se prove o contrário, consideramos que essa gestante apresenta eclâmpsia e tem que ser tratada como eclâmpsia.

Síndrome HELLP

A síndrome HELLP é caracterizada por hemólise (destruição das hemácias no sangue da mãe).

  • DHL maior que 600 UI/L
  • Transaminases aumentadas 2x (TGO/TGP)
  • Plaqueta baixa (menores que 100)

Acima de tudo, a síndrome HELLP pode não estar associada com o aumento da pressão, por isso é importante rastrear a gestante com hipertensão na gestação, mesmo levemente hipertensas, com exames laboratoriais.

Existem mulheres com síndrome HELLP que não apresentaram aumento significativo da pressão.

Tenho pressão alta e engravidei, e agora…

A hipertensão prévia da gravidez aumenta o risco de desenvolver pré-eclâmpsia na gravidez.

Todavia, o diagnóstico para diferenciar a pressão alta X pré-eclâmpsia é a  presença de proteína na urina, além da avaliação da função hepática, renal, hemácias e plaquetas.

Tive pressão alta na primeira gestação, posso ter na próxima?

Mulheres que tiveram síndrome hipertensiva na gestação têm 22% de chance de ter novamente na próxima gestação. 

Ainda assim, mulheres que tiveram hipertensão na gestação, têm mais chances de se tornarem mulheres hipertensas ao longo da vida. Precisam ficar mais atentas à pressão ao longo da vida.

Quando deve se utilizar remédio para pressão?

Up to date (fev/2021) mostra que mulheres com pressão maior de 145/95 mmHg, a recomendação é que usem remédio para que a pressão fique mais ou menos por aí, pois se a pressão diminuir muito, pode-se prejudicar o fluxo de sangue para o bebê.

Primordialmente, o alvo é manter uma pressão 140/90 mmHg, então só se medica pressões maiores de 145/95 mmHg.

Nascimento do bebê, quando ele deve acontecer?

Em primeiro lugar, a decisão pelo parto busca o benefício da maturidade do bebê e ao mesmo tempo evitar complicações na mãe. E precisa se botar na balança os riscos materno X fetais.

Hipertensão gestacional sem pré eclâmpsia:

  • Se a sua pressão tem o controle ruim, se em algum horário sua pressão fica maior que 145/95 mmHg recorrentemente, o seu parto deve acontecer quando o bebê deixar de ser prematuro (37 semanas).

 

  • Se sua pressão está bem controlada, raramente faz pressão maior que 140/90 mmHg, não tem fator de risco (não é obesa, o bebê não tem restrição de crescimento, por exemplo), o momento do parto pode ser individualizado. Podemos pensar no nascimento entre 38 e 39 semanas, porém 39 semanas e 0 dias é o limite.

Sobretudo, pressão maior de 160/100 mmHg acima de 34 semanas, principalmente se tem sintomas de doença grave, dor de cabeça, dor no estômago, vista brilhando, exames de sangue alterados, não existe benefícios que justifique que o bebê fique na barriga. É o momento de ajudar o bebê nascer.

 

Pré-eclâmpsia (pressão alta com proteína na urina)

  • Pressão normal, mesmo sem medicação -> 37 semanas é hora de indicar o parto, isso diminui 30% mal desfechos maternos e fetais.
  • Se a mãe tem doença grave de pré-eclâmpsia e mais de 34 semanas é indicação de nascimento.
  • Entre 24 a 34 semanas a conduta é expectante, enquanto não existem sinais de doença grave. A partir do momento que  se apresenta algum sinal de doença grave, é importante pensar no nascimento do bebê. É individualizado caso a caso.

Parto Vaginal X Cesárea

Acima de tudo, não existe contra indicação do parto vaginal em doença hipertensiva da gestação ou na pré-eclâmpsia e o parto pode ser induzido, depende do protocolo da maternidade e condução do obstetra.

Agora, doença de evolução grave, por ex. se sua pressão está alterada, exames alterados, você precisa ser estabilizada e depois ser operada.

Exemplo: Mulher que chega no hospital com emergência hipertensiva ( 180/145 mmHg), precisa ser compensada, baixar pressão, usar remédio para prevenir convulsões e só depois pensar na via de nascimento.

  • Em gestações com menos de 32 semanas com mulheres com pré-eclâmpsia grave, devem ser orientadas sobre o tempo de indução, que pode aumentar a chance de desenrolar complicações relacionadas à pré-eclâmpsia.
  • Mulheres com mais de 32 semanas têm mais chances do parto induzido e é completamente viável o parto normal, se o bebê estiver bem (o doppler estiver bom).

 

Como saber se o bebê está bem?

Antes de mais nada, quando temos doença hipertensiva na gestação, a avaliação com o DOPPLER no ultrassom é muito importante.

  • Síndrome Hipertensiva na Gravidez: 1 doppler pelo menos a cada 15 dias;
  • Pré-eclâmpsia mais grave, pelo menos 1 vez por semana;

Acima de tudo, o controle do bebê pelo DOPPLER no ultrassom diminui em até 30% o risco de morte perinatal

 

Iminência de eclâmpsia

Em primeiro lugar, mulheres com pressão de 160/110 mmhg ou mais, dor de cabeça intensa, escotomas cintilantes, escurecimento de um campo visual, muita irritabilidade, dor embaixo da costela direita, dor no estômago, precisam ser internadas para tratar a pressão alta com medicação endovenosa, e precisam fazer profilaxia da eclâmpsia, que é o sulfato de magnésio e se a gestante estiver acima de 34 semanas a gestação será interrompida. 

 

Recomendações finais:

Não é necessário repouso absoluto, nem dieta livre de sódio, não existe evidência científica sobre isso.

Para as mulheres que estão inchando demais, drenagem linfática pode ajudar e exercícios metabólicos orientados por um fisioterapeuta especialista também.

OBS.: Mulheres que têm hipertensão, devem planejar a gestação para que troquem de remédio, que tomem remédios compatíveis com a gestação.

A doença é hereditária?

Sim, se uma irmã da paciente tiver pré-eclâmpsia/eclâmpsia, a chance dela ter é de 30%. Se a mãe da paciente tiver a doença, a chance é de 25%.

A doença só afeta quem tem problema de pressão alta?

Não. Pacientes com diabetes, obesidade,  primeiro filho, gravidez de gêmeos, doenças renais, relações sexuais a pouco tempo com o parceiro e mães  que estão gestantes através de inseminação artificial têm maiores chances.
Este artigo pertence ao http://gestavida.blogspot.com/
Plágio é crime e está previsto no artigo 184 do Código Penal.

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