In this report, we present the terminology, definition and classification of pregnancy induced hypertension (PIH) by the Japan Society for the Study of Hypertension in Pregnancy (JSSHP). PIH is classified as gestational hypertension (GH), preeclampsia (PE), superimposed preeclampsia (S-PE) or eclampsia (E). Subclassifications by symptoms (severity and gestational age at onset) are also shown.

View full abstract

We present a brief review of pregnancy induced hypertension (PIH) guidelines provided by the Japan Society for Study of Hypertension in Pregnancy (JSSHP) in 2009. This review aims to compare the Japanese standards of diagnosis, treatment, and management of hypertensive disorders in pregnancy with those of other countries, as well as to present a resource for Japanese clinical studies or case reports published internationally.

View full abstract

This is the report of the Committee on cerebrovascular disorders, including eclampsia and emergency medical services, of the Japan Society for the Study of Hypertension in Pregnancy (JSSHP). Based on blood pressure (BP) analyses of eclamptic patients, it was concluded that BP variability was important for the onset of eclampsia. Furthermore, the Committee established guidelines for antihypertensive treatment that recommend a sliding scale of antihypertensive drug administration for hypertensive emergencies during both antepartum and postpartum periods.

View full abstract

Aim: A survey of anticoagulation and anesthesia during cesarean section in patients with severe pregnancy induced hypertension (PIH) in Japan was conducted by a committee of the Japan Society for the Study of Hypertension in Pregnancy (JSSHP) to investigate 1) prophylactic anticoagulation for venous thromboembolism (VTE) after cesarean section in patients with PIH and 2) heparin treatment for disseminated intravascular coagulation (DIC) in patients with PIH and related disorders.Methods: Surveys including questionnaires for obstetricians and anesthesiologists were separately conducted among 127 eligible regional leading institutes and hospitals of maternal-fetal medicine with neonatal intensive care units (NICUs) throughout Japan in order to analyze the participants’ perspectives on anticoagulation for VTE and DIC in patients with PIH and related disorders.Results: Sixty-six (52.2%) of the 127 eligible institutes and hospitals ultimately responded. Prophylactic anticoagulation after cesarean section was administered in 82% of the hospitals for patients without PIH to prevent various risks. However, the dose of prophylactic anticoagulation for VTE after cesarean section was not optimized for each patient with PIH in 73% of the hospitals. Anesthesiologists at approximately 74% of the hospitals used neuraxial regional anesthesia in patients with PIH who underwent cesarean section. They selected general anesthesia rather than regional anesthesia if they judged the effects of anticoagulation to be greater than the level indicated for regional anesthesia remaining during surgery. Approximately 30% of the hospitals used anticoagulants, including heparin and/or antithrombin, at the onset of DIC for prophylaxis of VTE after cesarean section in patients with PIH.Conclusions: Most recommendations, worldwide as well as in Japan, in guidelines for prophylactic anticoagulation during cesarean section are based on observational studies and lack statements or recommendations on the use of anesthesia and appropriate anticoagulation during cesarean section in patients with PIH. The JSSHP needs to be encouraged to design studies to obtain better evidence for the use of anticoagulation in patients with severe PIH and to publish a clinical practice bulletin as soon as possible.

View full abstract

Aim: Classification of pregnancy induced hypertension (PIH) according to the Japan Society of Obstetrics and Gynecology defines early onset PIH as that which develops before 32 weeks of gestation, and late onset PIH as that which occurs thereafter. The present study aimed to validate this cut-off point.Methods: Clinical characteristics of the patients from 59 domestic tertiary settings of perinatal medicine were analyzed. Women with multiple pregnancies and/or any medical complications were excluded. Subgroups of mild and severe PIH were created according to the severity of hypertension.Results: Numbers of patients with preeclampsia (PE) and gestational hypertension (GH) were 619 and 194, respectively. Severe cases accounted for 379 (333 for PE and 46 for GH) and mild cases accounted for 434 (286 for PE and 148 for GH). The difference in patterns of distribution of onset time between severe and mild cases of PIH was more remarkable than those between PE and GH. Discriminate analysis showed 32.3 weeks of gestation to be the optimal cut-off point at which severe forms of PIH were distinguishable from mild forms. Receiver operating characteristic (ROC) curve analysis of assumptive diagnostic efficacy for predicting severe hypertension with time of disease onset was most predictive at 32 weeks of gestation.Statistical analyses revealed that the cases presenting before 32 weeks were not significantly different from the severely hypertensive cases in terms of maternal and offspring outcomes. Comparison of PIH cases occurring after 32 weeks with cases of mild hypertension were also very similar.Conclusions: It is considered appropriate to regard 32 weeks of gestation as an optimal cut-off point for subclassification of early and late onset types of PIH.

View full abstract

Aim: The aim of this study was to assess the rate of eclampsia in Japanese women and to determine differences in the pathogenesis of eclampsia between women with pregnancy induced hypertension (PIH) but without severe proteinuria showing rapid changes in high blood pressure during delivery and women with PIH and severe proteinuria from early stages of pregnancy.Methods: We used the perinatal database of the Japan Society of Obstetrics and Gynecology to access 330,399 deliveries after 22 weeks of gestation across 125 centers of the perinatal network between 2005 and 2009. A total of 246 women with eclampsia were identified. The main outcome measures used were incidence, maternal age, body mass index (BMI), parity, gestational age at delivery, and mortality rate. We compared gestational age at incidence between women with PIH but without severe proteinuria (HT group) and women with PIH and severe proteinuria (PE group). Data were analyzed using Welch’s t-test or the Mann-Whitney U-test.Results: We identified a total of 246 cases of eclampsia which corresponded to an incidence of 7.4/10,000 deliveries with a mean age of onset of 30.7±5.8 years. The proportion of primiparous women was 81.3%, and the mean gestational age at delivery was 36.7±4.0 weeks. Four maternal deaths were identified in the PE group. The gestational age at incidence was significantly higher in the HT group compared to the PE group (36.8±4.9 weeks for the HT group vs. 34.3±4.9 weeks for the PE group, t=3.3443, P=0.0009).Conclusions: The present study identified potential differences in the pathogenesis of eclampsia between HT and PE groups, due to the fact that the PE group was observed throughout pregnancy, while observation of individuals in the HT group increased after 34 weeks of gestation.

View full abstract

Aim: It was reported that eclampsia might be caused by vasogenic edema from broken autoregulation in cerebral blood flow, potentially due to elevated systemic blood pressure (BP). This study retrospectively investigated the severity of BP elevation and oscillation amplitude of systemic BP just before eclampsia onset.Methods: Five eclamptic and 4 non-eclamptic women with complications of preeclampsia were enrolled. Three eclamptic and 4 non-eclamptic women with severe hypertension received antihypertensive drugs. Systolic and diastolic BPs, mean arterial pressure (MAP), and oscillation amplitude of BP (ΔBP) before eclampsia onset were evaluated.Results: Maximum MAPs in eclamptic women did not significantly differ from that of non-eclamptic women (130±17 mmHg vs. 116±8 mmHg, respectively). The systolic and diastolic ΔBP in eclamptic women were higher than that in non-eclamptic women (45±15 mmHg vs. 16±6 mmHg, P=0.03, and 25±6 mmHg vs. 9±2 mmHg, P=0.004, respectively).Conclusions: Our results indicate that a large ΔBP could influence eclampsia onset.

View full abstract

Aim: Our aim was to establish a therapeutic strategy for eclampsia and stroke during pregnancy.Methods: We performed a questionnaire-based study of eclampsia and stroke during pregnancy from 2005 to 2009 that targeted all obstetric institutions in Aichi Prefecture. The survey inquired about characteristics of eclampsia and stroke during pregnancy, management of hypertension during labor, and the current situation surrounding the maternal transport system as well as that for collaboration with neurosurgeons.Results: Our survey revealed that 66% of deliveries, 40% of eclampsia episodes, and 31% of stroke incidents occurred at primary medical institutions. With the exception of strokes, most cases were diagnosed by brain magnetic resonance imaging (MRI) and/or computed tomography (CT) at intensive medical institutions. Most medical institutions measured blood pressure during labor. However, other management strategies, including those involving the use of hypotensors, varied by institution.Conclusions: The present study is the first long-term etiological research project to address eclampsia and pregnancy-associated stroke in Japan. From our survey data, we were able to obtain detailed information and assess several issues regarding the maternal transport system, blood pressure management during labor, and collaboration with neurosurgeons.

View full abstract

Aim: Endothelial progenitor cell (EPC) proliferation may contribute to the maintenance of normal pregnancy (NOR) with angiogenic factors, which can be generated by nucleated red blood cells (NRBCs) from fetal blood. In this study, we investigated the effect of NRBCs on EPC proliferation in normal pregnancy and preeclampsia (PE).Methods: NRBCs were collected using a cell sorter with anti-CD71 antibody from umbilical venous blood. Following incubation with or without erythropoietin (EPO), vascular endothelial growth factor (VEGF) concentration in the supernatant was measured using an enzyme-linked immunosorbent assay kit. Mononucleated cells excluding NRBCs were cultured with or without NRBCs. On day 7, acLDL- and lectin-positive cells were counted as EPCs using flow cytometry.Results: In PE, the number of NRBCs and the VEGF production was significantly increased (P<0.05), while the number of EPCs decreased significantly (P<0.05). NRBCs significantly decreased EPC proliferation in NOR (P<0.05). EPO significantly increased VEGF production by NRBCs in NOR (P<0.05). Low concentrations of EPO significantly increased EPC proliferation with NRBCs in PE.Conclusions: In PE, increased NRBCs in the fetal circulation may inhibit fetal EPC proliferation; however, EPO could have a favorable influence on placental vasculature through EPC proliferation.

View full abstract

Aim: The present study examined Japanese women who had preeclampsia 10 or more years earlier, and documented the frequency of hypertension as well as their current clinical and chemical characteristics.Methods: We recruited 119 women for whom 10 or more years had passed since an indexed pregnancy (58 with a history of severe preeclampsia and 61 with normal pregnancies). A physical examination assessed blood pressure, weight, abdominal circumference (AC) and other compositional indices. Fasting blood samples were examined for glucose, total cholesterol (TCHOL), high and low density lipoprotein cholesterol (HDLC, LDLC), and triglycerides (TG). A questionnaire was used to collect demographic data. Data were analyzed using the Student’s t-test.Results: The frequency of hypertension later in life was significantly higher in the preeclampsia group compared to the control (53.4% versus 11.5%, P=0.013). Body mass index (BMI), AC, and levels of TCHOL, TG and LDLC were significantly higher in the group of patients with preeclampsia who did not have hypertension later in life (P<0.05), and there were no significant differences in the levels of glucose and HDLC. Despite the lack of evidence for hypertension, metabolic abnormalities were observed later in life in those who experienced preeclampsia during pregnancy.Conclusions: Since hypertension after preeclampsia was associated with metabolic abnormalities, those who experienced preeclampsia should schedule regular check-ups to monitor for clinical manifestations of hypertension.

View full abstract