Patients with high blood pressure or hypertension have multiple health risks including cardiovascular disease, chronic kidney disease, and cognitive impairment (Oparil et al., 2018). Cardiovascular risks include coronary heart disease, heart failure, stroke, myocardial infarct, atrial fibrillation, and peripheral artery disease. Hypertension is called a silent killer because many patients do not have discernable symptoms (Oparil et al., 2018). Studies have shown approximately twenty-five percent of adults have hypertension. Modifiable risk behaviors include the accumulation of excessive sodium intake, insufficient potassium intake, obesity, alcohol intake, and physical inactivity. Non-modifiable factors include genetic predisposition, gestational hypertension, or pre-eclampsia (Oparial et al., 2018). Hypertension is now measured as systolic blood pressure greater than or equal to 140 and diastolic blood pressure greater than or equal to 90 in an office setting.
For pregnant patients, hypertension can be dangerous and typically classified as hypertension with or without pre-eclampsia, gestational hypertension, pre-eclampsia, and eclampsia (Luger & Kight, 2022). Women with a history of hypertension, renal disease, DM, OSA, thrombophilia, or autoimmune disease before pregnancy are at greater risk for pregnancy induced hypertension. In turn, pregnancy induced hypertension leads to a greater risk factor for hypertension post pregnancy (Luger & Kight, 2022). Symptoms of gestational hypertension usually with blood pressure greater than 160/110 after 20 weeks includes a persistent headache, edema to extremities, sudden weight gain, blurred vision or double vision, nausea, abdominal pain, and decreased urine output. Pre-eclampsia is all the previous symptoms plus greater than or equal to 300 mg urine protein (Luger & Kight, 2022). Eclampsia is all the previous symptoms plus tonic-clonic seizure activity.
Treatment for pregnancy hypertension, gestational hypertension, pre-eclampsia, and eclampsia includes prophylaxis ASA 81 mg PO daily if warranted, for blood pressure 140/90 or greater is labetalol, hydralazine, nifedipine, and magnesium seizure prophylaxis for severe pre-eclampsia (Luger & Kight, 2022). For pre-eclampsia, monitoring biweekly for intrauterine growth retardation, placental abruption, and poor placental/umbilical blood flow by checking blood pressure and evaluating fetal non-stress test, amniotic fluid, index evaluation, and lab evaluations. Definitive treatment is delivery as early at 34 weeks up to 37 weeks (Luger & Kight, 2022). Delivery is delayed as safely as it can be delayed.
Patients with pregnancy induced hypertension, gestational hypertension, or pre-eclampsia are given dietary education which includes the DASH diet rich in vegetables, fruit, low saturated and total fats, and low sodium (Singh et al., 2021). If the patient is smoking, stress the need for cessation, eliminate alcohol to prevent fetal injury, and limit or eliminate caffeine such as coffee, tea, chocolate, guarana nuts, and energy drinks. Dietary counseling may help the patient understand micro and macro nutrients.
Hypertension in adult patient is multifocal with consideration to the risk factors and treatment. Hypertension in pregnant adults can add another layer of difficulty. Careful monitoring during pregnancy is crucial for a healthy pregnancy and birth. Maintaining a healthy diet before pregnancy may lower the risk for pregnancy induced hypertension, gestational hypertension, or pre-eclampsia.
Reference
Luger, R. K. & Kight, B. P. (2022, October 3). Hypertension in pregnancy. Treasure Island: StatPearls. https://www.ncbi.nlm.gov/books/NBK430839
Oparil, S., Acelajado, M. C., Bakris, G. L., Berlowitz, D. R., Cifkova, R., Dominiczak, A. F., Grassi, G., Jordan, J., Poulter, N. R., Rodgers, A., & Whelton, P. K. (2018, March 22). Hypertension. Nature Review Disease Primer. https://doi.org/10.1038/nrdp.2018.14
Singh, D. K., Sinha, N., Bera, O. P., Saleem, S. M., Tripathi, S., Shikha, D., Goyal, M., & Bhattacharya, S. (2021, September 30). Effects of diet on hypertensive disorders during pregnancy: A cross-sectional study from teaching hospital. Journal of Family Medicine and Primary Care, 10(9), 3268-3272. https://doi.org/10.4103/jfmpc.jfmpc_96_21
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Osteoporosis is a metabolic bone disease characterized by low bone density and deterioration of bone architecture that increases the risk of fractures. In the United States, osteoporosis affects one in four women 65 or older. But younger women can get osteoporosis. And girls and women of all ages need to take steps to protect their bones.
Primary osteoporosis is often associated with age and sex hormone deficiency. Age-related osteoporosis results from the continuous deterioration of the trabeculae in bone. In addition, the reduction of estrogen production in post-menopausal women causes a significant increase in bone loss. Secondary osteoporosis is caused by several comorbid diseases and/or medications. Diseases implicated in osteoporosis often involve mechanisms related to the imbalance of calcium, vitamin D, and sex hormones. Cushing’s syndrome has been found to accelerate bone loss through excess glucocorticoid production. Also, many inflammatory diseases, such as rheumatoid arthritis, may require the patient to be on long-term glucocorticoid therapy and have been associated with secondary osteoporosis. Glucocorticoids are considered the most common medications linked to drug-induced osteoporosis.
Osteoporosis is called a “silent” disease” because there are typically no symptoms until a bone is broken. Symptoms of a vertebral fracture include severe back pain, loss of height, or spine malformations such as a stooped or hunched posture (kyphosis).
Published osteoporosis screening guidelines vary greatly. In general, most organizations recommend that all adults older than 50 years of age with a history of fractures receive BMD screening. The gold standard for diagnosing osteoporosis utilizes BMD measurements, especially in the hip and lumbar spine, with the dual-energy x-ray absorptiometry (DXA) device or the occurrence of nontraumatic hip or vertebral fractures. Resulting T-scores are used to interpret BMD and to correlate results with fracture risk.
AACE/ACE provides evidence-based information for managing postmenopausal osteoporosis (PMO). In those with no prior fragility fractures or moderate fracture risk, alendronate, risedronate, zoledronic acid, or denosumab (Prolia, Amgen) is appropriate as first-line options. At the same time, ibandronate and raloxifene are considered alternatives. In those with prior fragility fractures or indicators of high fracture risk, denosumab, teriparatide (Forteo, Lilly), and zoledronic acid are recommended for first-line use, with alendronate and risedronate as alternatives. Indicators of high fracture risk include advanced age, frailty, glucocorticoids, very low T-scores, and increased fall risk. Teriparatide, denosumab, or zoledronic acid should be considered for those unable to use oral therapy. Raloxifene or ibandronate may be used as initial therapy for spine-specific efficacy. While sequential therapy of teriparatide followed by an antiresorptive medication is supported, combination therapy of osteoporosis medications for treatment or prevention of osteoporosis in postmenopausal women is not recommended due to the limited availability of supportive data, increased cost, and potential increased side effects.
Nonpharmacological management of osteoporosis includes adequate calcium and vitamin D intake, weight-bearing exercise, smoking cessation, limitation of alcohol/caffeine consumption, and fall prevention techniques. The Institute of Medicine (IOM) recommends that dietary calcium intake should be limited to 1,000 mg daily for men 50 to 70 years of age and to 1,200 mg daily for women 51 years of age and older and for men 71 years of age and older.
References:
Osteoporosis. Osteoporosis | Office on Women’s Health. (n.d.). https://www.womenshealth.gov/a-z-topics/osteoporosis
Tu, K. N., Lie, J. D., Wan, C. K. V., Cameron, M., Austel, A. G., Nguyen, J. K., Van, K., & Hyun, D. (2018, February). Osteoporosis: A review of treatment options. P & T : a peer-reviewed journal for formulary management. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5768298/
U.S. Department of Health and Human Services. (2023, June 7). Osteoporosis. National Institute of Arthritis and Musculoskeletal and Skin Diseases. https://www.niams.nih.gov/health-topics/osteoporosis
