Management Of Hypertension In Pregnancy

Management of Genital Tract sepsis

Management Of Ectopic Pregnancy

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MANAGEMENT OF HYPERTENSION IN PREGNANCY

DR JUDITH KUNDODYIWA

Table of content

3. Gestational Hypertension without proteinuria

5. Significant proteinuria without hypertension

6. Reference

Definitions Of Terms Used

Chronic hypertension – Hypertension present at booking visit or before 20 weeks, or that is being treated at time of referral to maternity services.

Gestational Hypertension – New hypertension presenting after 20 weeks without significant proteinuria

Pre-eclampsia – is new hypertension presenting after 20 weeks with significant proteinuria.

Eclampsia – Convulsive condition associated with pre-eclampsia

Severe Pre-eclampsia – pre-eclampsia with severe hypertension and/or with symptoms, and/or biochemical and/or haematological impairment.

Significant Proteinuria – Presence of proteinuria 1+ or more on automated reagent –strip .or if the urinary protein:creatinine ratio is greater than 30 mg/mmol

HELLP syndrome – is haemolysis, elevated liver enzymes and low platelet count.

Degrees of hypertension

Mild: 140-149/90-99mmHg

Moderate: 150-159/100-109mmHg

Severe: >160/>110mmHg

Risk Factors

Pre-eclampsia/severe eclampsia in any previous pregnancy
Intra uterine fetal death
Abruption
Multiple pregnancy
BMI>35
Medical conditions eg chronic hypertension, booking diastolic of >90mmHg, renal disease, proteinuria at booking, diabetes, autoimmune disease
Family history of pre-eclampsia, primiGRAVIDA, >10yrs since last baby or >40 yrs old

All pregnant women should be aware that after 20 weeks gestation, pre-eclampsia may develop between antenatal assessments, and it is appropriate for them to self-refer at any time if they have.

Severe headache
Problems with vision
Epigastric pain and/or vomiting
Sudden swelling of face, hands or feet

If a woman reports any of the above symptoms, arrange full antenatal assessment such as:-

History & risk assessment
Bloods including FBC, LFTs, U&Es, Urate
BP profile (correct cuff size)
Computerised CTG
Urine dipstick for protenuria

Gestational Hypertension Without Proteinuria

Mild/moderate – refer to Antenatal day unit for BP profile
Severe – ANDU or Central delivery suite if symptomatic

Mild with normal profile –

community antenatal assessment in 1 week If profile abnormal – repeat in 2 days
If 2 abnormal profiles – refer to consultant clinic
If <32/40 or high risk with raised BP on profile refer to consultant clinic

Moderate with normal profile –

Community antenatal assessment in 1 week
If profile abnormal – treat with labetalol or nifedipine MR and consider admission
Do BP profile twice weekly on ANDU
No further bloods if no proteinuria

Severe –

Treat with labetalol/nifedipine SR
BP 4 hourly
Do urine dip stick daily
FBC,LFTs, Urea and Electrolyte, Urates on admission
Twice weekly BP profile on ANDU after discharge
Weekly bloods only

Growth scan not indicated in mild/moderate if diagnosed after 34 weeks unless clinically indicated.
Refer to consultant clinic within 7 days for further management plan and mode of delivery discussion
If possible with good control of blood pressure manage till 37 weeks before considering delivery

Pre Eclampsia

(New onset hypertension with significant proteinuria or ≥1+)

History, bloods(FBC, Electrolyte and Urea, Urates, LFTs, BP profile, uPCR, computerised CTG
Do not use uPCR for quantification at every visit for management of PET

Mild Twice weekly BP profile & bloods

Refer consultant clinic within 5 days

Moderate

Admit M2
Treat BP – aim below 149/99mmHg
4 hourly BP
Bloods 3 times per week
If symptoms appear, transfer to delivery suite/labour ward
Do Twice weekly BP profile on ANDU after discharge

Severe

Refer to Central delivery suite urgently & follow severe pre-eclampsia protocol
Before 34 weeks – conservative management, consultant to document plan for antenatal monitoring, steroids, document maternal & fetal indications for elective delivery before 34 weeks.
34+0 – 36+6 weeks -Offer delivery if blood pressure is difficult to control, if bloods are derranged or fetal growth restriction/ abnormal dopplers, abnorml CTG, symptomatic patient with headache , flashes of light or epigastric pain
Offer birth if pre-eclampsia with mild/moderate hypertension depending on maternal/fetal condition, risk factors and neonatal ICU availability.
>37+0

Recommend birth within 24-48 hours in women with confirmed pre-eclampsia with mild or moderate hypertension.

Significant proteinuria without hypertension

In many cases this is attributable to a urinary tract infection, but it may also herald the development of pre-eclampsia.

About 50% of women with isolated proteinuria develop pre-eclampsia and importantly, even in the absence of hypertension, these women are at significantly increased risk of adverse pregnancy outcomes such as fetal growth restriction and placental abruption.

1+Send MSU, if normal repeat antenatal check in 1 week

If 1+ in a week, send uPCR

If normal uPCR and normal BP – routine care

>1+ with symptoms of PET

Send MSU & uPCR

Refer for BP profile

If all normal – repeat BP profile in 3 days if symptoms persist

>1+ without symptoms

Send MSU & uPCR

If all normal – repeat BP profile in 3 days

If raised uPCR only – consultant clinic within 5 days

If raised uPCR & raised BP – follow pre-eclampsia guidelines

uPCR is reported the same day and it is the responsibility of the requestor to check and act on the result.