The detection, investigation and management of hypertension in pregnancy

Hypertension in pregnancy Definitions

systolic BP (SBP) 140 mmHg
and/or

diastolic BP (DBP) (Korotkoff V) 90 mmHg

confirmed by readings over several hours in day assessment unit or after rest in hospital

Recording blood pressure in pregnancy (1)

sitting, feet supported, for 2 minutes
appropriate size cuff

palpate systolic BP at brachial artery and inflate cuff to >20 mmHg above
deflate cuff slowly, 2 mmHg per sec mercury sphygmomanometer

Recording blood pressure in pregnancy (2)

measure systolic BP
measure diastolic BP K5 (sounds disappear)
or K4 (sounds muffle) if K5 inaudible

measure BP in both arms at first visit

(refer if different >20 mmHg)

avoid use of automatic BP machines

Classification
Gestational hypertension (GH)
Pre-eclampsia (PE) Chronic hypertension
Essential Secondary

Pre-eclampsia superimposed on chronic

hypertension

Gestational hypertension Diagnosis

de novo hypertension after 20 weeks no other features of multisystem disease resolution within 3 months post partum

Pre-eclampsia
a multisystem disorder
usually first detected by hypertension proteinuria common but not essential for a clinical diagnosis of pre-eclampsia in the presence of other organ involvement, including feto-placental unit

Pre-eclampsia: Diagnosis
de novo hypertension after 20 weeks and new onset of one or more of: proteinuria renal insufficiency liver disease neurological problems haematological changes pulmonary oedema IUGR

Pre-eclampsia: common features

proteinuria
>300 mg/24h or 30 mg/mmol creatinine (spot urine)

renal insufficiency
creatinine >0.09 mmol/L or oliguria

hyperuricaemia
serial assays: rapid rise predicts progression normal ranges differ at different stages of pregnancy

Pre-eclampsia: common features

liver disease
ALT and/or severe RUQ/epigastric pain

neurological problems
convulsions (eclampsia) ankle clonus severe headache and hyper-reflexia visual scotomata

Pre-eclampsia: common features

haematological disturbance
thrombocytopenia haemolysis

DIC

pulmonary oedema

IUGR

Beware!
other disorders
eg: acute fatty liver of pregnancy (AFLP) haemolytic uraemic syndrome (HUS) thrombotic thrombocytopenic purpura (TTP) cholecystitis

oedema is NOT diagnostic! urine dipsticks are NOT reliable for diagnosing or excluding proteinuria

Chronic hypertension: Diagnosis

Essential hypertension
pre-conception or before 20 weeks 140 mmHg systolic 90 mmHg diastolic without apparent underlying cause

Secondary hypertension
renal renovascular endocrine aortic coarctation

Pre-eclampsia superimposed on chronic hypertension: Diagnosis

Chronic hypertension
with one or more systemic features of pre-eclampsia after 20 weeks gestation diagnosis may be difficult in women with chronic renal disease and pre-existing proteinuria: needs other features, eg ALT or platelets

Gestational hypertension
outcome generally much better than for pre-eclampsia
assessment: usually in a day-stay unit admit if BP 170/110 mmHg exclude pre-eclampsia

close watch for development of pre-eclampsia

antihypertensive drugs as necessary

Pre-eclampsia: At risk
primigravida primipaternity prior pre-eclampsia by same partner renal disease essential hypertension diabetes autoimmune disease, esp. SLE, antiphospholipid FH pre-eclampsia syndrome multiple pregnancy thrombophilia obesity alloimmunisation

Pre-eclampsia: Assessment
primigravidae: standard ANC
others: frequent assessment no fall of BP in mid-pregnancy? de novo proteinuria after 20 weeks?

Pre-eclampsia: a multisystem disorder

Pre-eclampsia: Assessment Clinical features

some women mainly maternal some women mainly fetal some women both maternal and fetal

Pre-eclampsia: Assessment Important factors

gestational age
fetal growth maternal organ dysfunction

Pre-eclampsia: Assessment Laboratory testing

haemoglobin, haematocrit, platelets, film coags: only if platelets or haemolysis serum uric acid serum creatinine LFTS: transaminase, albumin MSSU: urinalysis and microscopy urine protein quantitation
spot urine protein/creatinine ratio 24 hr collection

Pre-eclampsia Rare Birds pre-20 weeks

hydatidiform mole
multiple pregnancy

fetal triploidy
antiphospholipid syndrome

other thrombophilia
severe renal disease

Pre-eclampsia: Management Maternal

admission to hospital: YES!

bed rest: NO!

diet: NO!

Pre-eclampsia: Management Antihypertensive drugs

Acute treatment:
oral nifedipine
im/iv hydralazine

SBP >170 mmHg DBP >110 mmHg

iv diazoxide/labetalol

Pre-eclampsia: Management Antihypertensive drugs

Acute treatment: SBP >170 mmHg DBP >110 mmHg

oral agents unless symptomatic or features of

impending eclampsia initial SBP 20-30 mmHg DBP 10-15 mmHg continuous CTG consider plasma expansion with vasodilators

Pre-eclampsia: Management Antihypertensive drugs

Ongoing treatment
methyldopa ?atenolol?
IUGR pre-32w

oxprenolol
nifedipine labetalol clonidine prazosin

NOT ACE-inhibitors
fetal death/renal failure

NOT diuretics
plasma volume

Pre-eclampsia: Management Antihypertensive drugs

Mild to moderate hypertension
controversial! primary benefit to the mother
protection from complications(?) suppresses an important sign

secondary benefit to the fetus

reduces incidence of severe hypertension as an indication for early delivery compromising fetal perfusion?

Pre-eclampsia: Management Antihypertensive drugs

Mild to moderate hypertension
a compromise view
initiate treatment if DBP >90 mmHg maintain SBP 120-140 mmHg maintain DBP 80-90 mmHg

develop protocols and report data!

Pre-eclampsia: Management Volume manipulation

BEWARE PULMONARY OEDEMA!
maternal plasma volume
capillary permeability

Pre-eclampsia: Management Volume manipulation

initial load up to 500 ml
prefilling for vasodilator therapy/epidural severe oliguria

PULMONARY OEDEMA KILLS!

Pre-eclampsia: Management Invasive monitoring

CVP monitoring may NOT be helpful!
poor correlation between CVP and PCWP

PA catheters have risks!

rare indications:
pulmonary oedema resistant to diuretics oliguric renal failure despite volume expansion

Pre-eclampsia: Management Neurological problems

eclampsia can occur with only moderate BP elevation delivery does not reduce the risk immediately!

Pre-eclampsia: Management Eclampsia treatment

seizures are usually short-lived
if prolonged, give diazepam iv bolus and watch for respiratory depression

treat hypertension MgSO4 for prophylaxis of further seizures

Pre-eclampsia: Management Eclampsia prophylaxis

controversial!

await the outcome of MAGPIE

randomise appropriately!

Pre-eclampsia: Management Hepatic problems

consider delivery for rising ALT

post partum imaging for ongoing pain

is there another diagnosis?

Pre-eclampsia: Management Haematological problems

consider delivery for
progressive platelets
microangiopathic haemolysis

consult for antiphospholipid syndrome

Pre-eclampsia: Management Renal problems

hyperuricaemia and proteinuria are NOT indications for delivery per se consider delivery for progressive renal impairment (creatinine >0.09 mmol/L) care with fluids (pulmonary oedema can kill!)

Pre-eclampsia: Management Fetal considerations

steroids for lung maturation
<34 weeks delivery expected within a week

early maternal transfer to a tertiary centre for early onset pre-eclampsia

Pre-eclampsia: Management Fetal assessment: ultrasound

growth scan every 2 weeks

assess cord Doppler and liquor volume

?fetal karyotyping for severe IUGR,

normal/excess liquor and severe PE

Pre-eclampsia: Management Fetal assessment: CTG

needs expert interpretation in the very pre-term fetus a non-reactive trace in the pre-term fetus indicates need for more detailed monitoring a non-reactive trace in the mature fetus may indicate delivery late decelerations and reduced variability are usually an indication for delivery

Pre-eclampsia: Delivery Indications

pre-eclampsia at term (>37 weeks) failure to control BP despite adequate Rx deteriorating liver function deteriorating renal function progressive thrombocytopenia neurological complications or imminent eclampsia abruption concern for fetal welfare

Pre-eclampsia: Delivery Management

in pre-eclampsia close to term, the fetus will usually tolerate labour and vaginal delivery

continuous FHR monitoring during labour

in severe pre-eclampsia, especially pre-term or if the indication for delivery is fetal, Caesarean section is usually in the best interests of both fetus and mother

Pre-eclampsia: Delivery Management of hypertension

SBP 170 mmHg or DBP 110 mmHg need parenteral therapy

continue oral agents unless <120/70 mmHg

consider epidural anaesthesia and volume expansion check BP every 30 minutes NO ergometrine/Syntometrine!

Pre-eclampsia: Delivery Anaesthetic considerations (1)

pre-labour/delivery assessment if possible LEA: helps BP control improves utero-placental blood flow gives good operating conditions SAB: usually suitable

LEA/SAB contraindicated in coagulopathy and for fetal distress requiring immediate delivery
low dose aspirin OK if platelets are normal

Pre-eclampsia: Delivery Anaesthetic considerations (2)

GA for severe fetal distress needing immediate delivery, haemodynamic compromise with abruption, difficult surgical access Avoid pulmonary aspiration
antacids H2 antagonists/metoclopramide

avoid supine hypotension

pre-oxygenation

Attenuate hypertension at induction

Pre-eclampsia: Post partum

all features resolve eventually new complications may occur up to 1 wk postpartum delivery for maternal indications warrants high dependency care postpartum with frequent lab tests monitor fluid balance! oliguria may indicate onset of postpartum renal failure

cease routine bloods with clinical improvement

continue antihypertensive drugs and wean as BP reassessment at 3m postpartum, esp. if early onset

Chronic hypertension: Assessment

is there an underlying cause?
secondary hypertension may have other implications for the pregnancy apart from the blood pressure

Chronic hypertension: Assessment

renal disease: prognosis? degree of impairment? systemic disease, eg diabetes, SLE: what organs are involved?
think of phaeochromocytoma!

Chronic hypertension: Risks

exacerbation of maternal hypertension
superimposed pre-eclampsia utero-placental insufficiency; IUGR; abruption

all risks if renal disease/impairment

complications may be if BP controlled

Chronic hypertension: Laboratory tests

urinalysis for protein, blood, glucose
sediment microscopy: casts, RBC, WBC midstream urine culture quantitate proteinuria serum chemistry, inc. blood glucose full blood count ?urinary catecholamines

Chronic hypertension: Monitoring

urinalysis every visit ambulatory BP monitoring NOT proven early confirmation of gestational age monitor fetal growth blood/urine at 20-24w, 25-28w, 33-36w admit (?day unit) for BP >160/100 mmHg or de novo proteinuria assessment by obstetric anaesthetist

Chronic hypertension: Drugs

as for pre-eclampsia
avoid atenolol before 3rd trimester

Chronic hypertension: Delivery

if BP well controlled and no other problems,
aim for vaginal delivery at term

if BP cannot be controlled, delivery to protect

against maternal cerebral haemorrhage

mode of delivery as for pre-eclampsia

Chronic hypertension: Post partum

BP may be unstable for 7-14 days and may
need additional therapy (inc. ACE inhibitors)

watch for superimposed pre-eclampsia

taper drugs as BP settles

Chronic hypertension and superimposed pre-eclampsia

occurs in 20% of women with chronic
hypertension

maternal and fetal risks are higher than for

chronic hypertension alone management as for pre-eclampsia

Follow-up
recurrence of PE and GH is likely in up to 50%, especially if early-onset disease, though often milder
recurrent GH may herald chronic hypertension investigate for underlying disease if early-onset or recurrent pre-eclampsia or significant placental vasculopathy there is no established therapy to prevent recurrence of pre-eclampsia: further trials are required