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Hypertension in pregnancy
NICE published guidance in 2010 on the management of hypertension in pregnancy.
They also made recommendations on reducing the risk of hypertensive disorders developing in the first place.
Women who are at high risk of developing pre-eclampsia should take aspirin 75mg od from 12 weeks until the birth of the baby. High risk groups include:
hypertensive disease during previous pregnancies
chronic kidney disease
autoimmune disorders such as SLE or antiphospholipid syndrome
type 1 or 2 diabetes mellitus
The classification of hypertension in pregnancy is complicated and varies.
Remember, in normal pregnancy:
blood pressure usually falls in the first trimester (particularly the diastolic), and continues to fall until 20-24 weeks
after this time the blood pressure usually increases to pre-pregnancy levels by term
Hypertension in pregnancy in usually defined as:
systolic > 140 mmHg or diastolic > 90 mmHg
or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic
After establishing that the patient is hypertensive they should be categorized into one of the following groups:
Watch This Video:
A=Pre-existing hypertension :
A history of hypertension before pregnancy or an elevated blood pressure > 140/90 mmHg before 20 weeks gestation No proteinuria, no oedema Occurs in 3-5% of pregnancies and is more common in older women
B=Pregnancy-induced HTN (PIH, also known as gestational HTN):
Hypertension (as defined above) occurring in the second half of pregnancy (i.e. after 20 weeks) No proteinuria, no oedema Occurs in around 5-7% of pregnancies Resolves following birth (typically after one month). Women with PIH are at increased risk of future pre-eclampsia or hypertension later in life
C=Pre-eclampsia:
Pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours) Oedema may occur but is now less commonly used as a criteria Occurs in around 5% of pregnancies
Pre-eclampsia
- Pre-eclampsia is a condition seen after 20 weeks gestation characterised by:
Watch This Video:
Pregnancy-induced hypertension in association with
Proteinuria (> 0.3g / 24 hours).
Oedema used to be third element of the classic triad but is now often not included in the definition as it is not specific
Pre-eclampsia is important as it predisposes to the following problems:
fetal: prematurity, intrauterine growth retardation
eclampsia
haemorrhage: placental abruption, intra-abdominal, intra-cerebral
cardiac failure
multi-organ failure
Risk factors:
> 40 years old
nulliparity (or new partner)
multiple pregnancy
body mass index > 30 kg/m^2
diabetes mellitus
pregnancy interval of more than 10 years
family history of pre-eclampsia
previous history of pre-eclampsia
pre-existing vascular disease such as hypertension or renal disease
Features of severe pre-eclampsia:
hypertension: typically > 170/110 mmHg and proteinuria as above
proteinuria: dipstick ++/+++
headache
visual disturbance
papilloedema
RUQ/epigastric pain
hyperreflexia
platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome Management:
Management:
consensus guidelines recommend treating blood pressure > 160/110 mmHg although many clinicians have a lower threshold
Oral labetalol is now first-line following the 2010 NICE guidelines.
Nifedipine and hydralazine may also be used
Delivery of the baby is the most important and definitive management step. The timing depends on the individual clinical scenario
Eclampsia
Eclampsia may be defined as the development of seizures in association pre-eclampsia.
To recap, pre-eclampsia is defined as:
1) condition seen after 20 weeks gestation
2) pregnancy-induced hypertension
3) proteinuria
Magnesium sulphate is used to both prevent seizures in patients with severe pre-eclampsia and treat seizures once they develop. Guidelines on its use suggest the following:
1) should be given once a decision to deliver has been made
2) in eclampsia an IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour
3) urine output, reflexes, respiratory rate and oxygen saturations should be monitored during treatment
4) treatment should continue for 24 hours after last seizure or delivery (around 40% of seizures occur post-partum)
Other important aspects of treating severe pre-eclampsia/eclampsia include fluid restriction to avoid the potentially serious consequences of fluid overload
Centrally acting antihypertensives
Examples of centrally acting antihypertensives include:
methyldopa: used in the management of hypertension during pregnancy
moxonidine: used in the management of essential hypertension when conventional antihypertensives have failed to control blood pressure
clonidine: the antihypertensive effect is mediated through stimulating alpha-2 adrenoceptors in the vasomotor centre
NICE published guidance in 2010 on the management of hypertension in pregnancy.
They also made recommendations on reducing the risk of hypertensive disorders developing in the first place.
Women who are at high risk of developing pre-eclampsia should take aspirin 75mg od from 12 weeks until the birth of the baby. High risk groups include:
hypertensive disease during previous pregnancies
chronic kidney disease
autoimmune disorders such as SLE or antiphospholipid syndrome
type 1 or 2 diabetes mellitus
The classification of hypertension in pregnancy is complicated and varies.
Remember, in normal pregnancy:
blood pressure usually falls in the first trimester (particularly the diastolic), and continues to fall until 20-24 weeks
after this time the blood pressure usually increases to pre-pregnancy levels by term
Hypertension in pregnancy in usually defined as:
systolic > 140 mmHg or diastolic > 90 mmHg
or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic
After establishing that the patient is hypertensive they should be categorized into one of the following groups:
Watch This Video:
A=Pre-existing hypertension :
A history of hypertension before pregnancy or an elevated blood pressure > 140/90 mmHg before 20 weeks gestation No proteinuria, no oedema Occurs in 3-5% of pregnancies and is more common in older women
B=Pregnancy-induced HTN (PIH, also known as gestational HTN):
Hypertension (as defined above) occurring in the second half of pregnancy (i.e. after 20 weeks) No proteinuria, no oedema Occurs in around 5-7% of pregnancies Resolves following birth (typically after one month). Women with PIH are at increased risk of future pre-eclampsia or hypertension later in life
C=Pre-eclampsia:
Pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours) Oedema may occur but is now less commonly used as a criteria Occurs in around 5% of pregnancies
Pre-eclampsia
- Pre-eclampsia is a condition seen after 20 weeks gestation characterised by:
Watch This Video:
Pregnancy-induced hypertension in association with
Proteinuria (> 0.3g / 24 hours).
Oedema used to be third element of the classic triad but is now often not included in the definition as it is not specific
Pre-eclampsia is important as it predisposes to the following problems:
fetal: prematurity, intrauterine growth retardation
eclampsia
haemorrhage: placental abruption, intra-abdominal, intra-cerebral
cardiac failure
multi-organ failure
Risk factors:
> 40 years old
nulliparity (or new partner)
multiple pregnancy
body mass index > 30 kg/m^2
diabetes mellitus
pregnancy interval of more than 10 years
family history of pre-eclampsia
previous history of pre-eclampsia
pre-existing vascular disease such as hypertension or renal disease
Features of severe pre-eclampsia:
hypertension: typically > 170/110 mmHg and proteinuria as above
proteinuria: dipstick ++/+++
headache
visual disturbance
papilloedema
RUQ/epigastric pain
hyperreflexia
platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome Management:
Management:
consensus guidelines recommend treating blood pressure > 160/110 mmHg although many clinicians have a lower threshold
Oral labetalol is now first-line following the 2010 NICE guidelines.
Nifedipine and hydralazine may also be used
Delivery of the baby is the most important and definitive management step. The timing depends on the individual clinical scenario
Eclampsia
Eclampsia may be defined as the development of seizures in association pre-eclampsia.
To recap, pre-eclampsia is defined as:
1) condition seen after 20 weeks gestation
2) pregnancy-induced hypertension
3) proteinuria
Magnesium sulphate is used to both prevent seizures in patients with severe pre-eclampsia and treat seizures once they develop. Guidelines on its use suggest the following:
1) should be given once a decision to deliver has been made
2) in eclampsia an IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour
3) urine output, reflexes, respiratory rate and oxygen saturations should be monitored during treatment
4) treatment should continue for 24 hours after last seizure or delivery (around 40% of seizures occur post-partum)
Other important aspects of treating severe pre-eclampsia/eclampsia include fluid restriction to avoid the potentially serious consequences of fluid overload
Centrally acting antihypertensives
Examples of centrally acting antihypertensives include:
methyldopa: used in the management of hypertension during pregnancy
moxonidine: used in the management of essential hypertension when conventional antihypertensives have failed to control blood pressure
clonidine: the antihypertensive effect is mediated through stimulating alpha-2 adrenoceptors in the vasomotor centre
