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Hypertension in Pregnancy

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Amy McComish

on 18 February 2013

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Transcript of Hypertension in Pregnancy

Hypertension in Pregnancy
NICE Guidelines Hypertension in Pregnancy Scale of the problem
Chronic hypertension in pregnancy
Gestational Hypertension
Long term risks and recurrence Scale of the problem... Hypertension in Pregnancy is still one of the leading causes of maternal death in the UK.
one third of severe maternal morbidity was a consequence of hypertensive conditions

Hypertensive disorders also carry a risk for the baby
5% stillbirths in infants without congenital abnormality occurred in women with pre-eclampsia
half of women with severe pre-eclampsia give birth pre-term
small for gestational age babies are common - 20-25% of preterm births and 14-19% term births in women with pre-eclampsia being <10th centile of birth weight for gestation Types of Hypertension in Pregnancy Chronic Hypertension Hypertension that is present at the booking visit or before 20 weeks or if the woman is already taking antihypertensive medication when referred to maternity services. Can be primary or secondary in origin Gestational Hypertension New hypertension presenting after 20 weeks without significant proteinuria Pre-eclampsia New hypertension presenting after 20 weeks with significant proteinuria Severe Pre-eclampsia Pre-eclampsia with severe hypertension +/- symptoms, +/- biochemical +/- haematological impairment HELLP Syndrome Haemolysis, elevated liver enzymes and low platelet count Eclampsia Convulsive condition associated with pre-eclampsia Chronic Hypertension Advice... ACEi and ARBs increase risk of congenital abnormalites.
As does chlorothiazide.
Limited evidence on other antihypertensive agents has not shown an increased risk of congenital malformations.
Discuss antihypertensive treatment when planning pregnancy.
Encourage low daily dietary sodium intake. Reduce or substitute salt.

If uncomplicated chronic hypertension in Pregnancy
aim BP lower than 150/100mmHg
ideally want diastolic blood pressure not to fall below 80mmHg
If Target organ damage secondary to chronic hypertension
aim BP lower than 140/90mmHg

Timing of Birth
Do not offer women with chronic hypertension whose BP is <160/110mmHg with or without Anti-HTN treatment, birth before 37weeks.

After delivery
Measure BP daily for 1st two days, and then at least once between day 3 and day 5.
Aim BP <140/90mmHg.
Continue antenatal antihypertensive treatment and review long term antihypertensive treatment 2 weeks after birth.
Offer review 6-8 weeks after birth
If taking methyldopa for chronic hypertension in pregnancy - stop within 2 days of birth and restart usual antihypertensive. Gestational Hypertension Risk Factors requiring additional assessment and follow-up Nulliparity
40 years +
Pregancy interval of >10years
FHx Pre-eclampsia
Multiple Pregancy
BMI 35+
Gestational age at presentation
PMHx pre-eclampsia or gestational HTN
Pre-existing valvular disease
Pre-existing Kidney Disease Management of Gestational Hypertension Mild Gestational Hypertension
140/90 - 149/99
no need for treatment
measure BP no more than once per week
test for proteinuria at each visit

Moderate Gestational Hypertension
150/100 - 159/109
Treat with oral labetalol - first line
aim diatolic 80-100mmHg
aim systolic <150mmHg
BP measurements twice weekly
Test for proteinuria at each visit
Check U+E, FBP and LFTs

Severe Gestational Hypertension
admit until BP <159/109
Treat with oral labetalol
Check BP at least QID
Test for proteinuria daily
Test bloods at presentation and then weekly Alternatives to Labetalol include Nifedipine and methyldopa Timing of Birth Do not offer before 37 weeks to women with gestational hypertension whose BP is less than 160/110mmHg with or without Anti HTN Tx
Should be discussed with senior Obstetrician Postnatal Management Measure BP Daily for first 2 days, then at least once between day 3 and 5.
Consider reducing antihypertensive treatment if BP falls below 140/90
Reduce antihypertensive treatment if BP falls below 130/80
Stop Methyldopa within 2 days of birth
Offer review 6-8weeks after the birth Pre-eclampsia

Treat BP if >150/100
Labetalol first line
Aim diastolic 80-100mmHg
Aim systolic <150mmHg
Measure BP at least QID, more if severe pre-eclampsia
Monitor FBP, U+E, LFTs 3x/week if BP >150/100mmHg Manage conservatively until 34 weeks
Document maternal and fetal thresholds for elective birth prior to 34 weeks

Offer birth before 34 weeks (after discussion with neonatal, anaesthetic teams and a course of corticosteroids) if...
Severe HTN refractive to treatment
Maternal or fetal indictations develop

Recommend Birth after 34 weeks for women with pre-eclampsia and severe hypertension when BP adequately controlled and steroid course completed.

Recommend birth within 24-48hours if mild - moderate HTN after 37 weeks Postnatal Care Transfer to community care when...
no symptoms of pre-eclampsia
BP <149/99 (with or without Tx)
Blood results are stable or improving

2 week review if continuing on Antihypertensive treatment
Otherwise 6-8week review
Refer to specialist for HTN assessment if still requiring treatment at postnatal review

Check bloods 48 - 72hrs post birth.
If improving but still abnormal repeat at postnatal review
Check for proteinuria at reveiw - if still present, advise further review at 3 months to assess renal function - may need specialist renal referral Fetal Monitoring Eclampsia Breastfeeding Long term risks Risk Recurrence Reducing the risk Amy McComish
Antrim Cardiology Teaching
Feb 2013 Symptoms...
severe headache
blurred vision
epigastric pain
oedema - facial, hands, feet NICE reccomends all patients with pre-eclampsia be admitted to hospital Chronic Hypertension
USS to assess fetal growth, amniotic fluid volume and doppler umbilical artery
between 28-30 weeks and between 32-34 weeks
CTG only if abnormal fetal activity

Mild - mod Gestational Hypertension
USS if diagnosis is confirmed at less than 34 weeks

Severe Gestational Hypertension or pre-eclampsia
CTG at diagnosis, then weekly if normal
if change in fetal movement, PV bleeding, abdo pain or deterioration in maternal condition - Repeat CTG
USS at diagnosis Avoid diuretics if Breastfeeding or expressing milk

Labetalol, nifedipine, enalapril, Captopril, atenolol, metoprolol
No known adverse effects on babies receiving breastmilk

Insufficient evidence on safety of ARBs, Amlodipine, other ACEi Increased risk of developing hypertension and its complications in later life - CVD and stroke

If pre-eclampsia with no proteinuria and no hypertension at postnatal review - relative risk end-stage renal disease is increased but absolute risk is low. No further follow-up required In women with gestational hypertension
16-47% risk of gestational hypertension recurring in future pregnancies

In women with pre-eclampsia
13-53% risk gestational hypertension in future pregnancies
16% risk pre-eclampsia in future pregnancies
if severe pre-eclampsia 25% risk recurrence
if led to delivery before 28 weeks - 55% risk recurrence If high risk of pre-eclampsia advise women to take 75mg Aspirin OD daily from 12 weeks until birth

High Risk
Hypertensive disease during a previous pregnancy
Autoimmune disease
Chronic Hypertension Summary Although Eclampsia rates have fallen, hypertension in pregnancy remains one of leading causes of maternal death in UK

Hypertensive disorders in pregnancy occur in women with pre-existing primary or secondary chronic hypertension and in women with new onset hypertension in the second half of pregnancy. References

NICE Guidelines - Hypertension in pregnancy
August 2010, modified January 2011


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