Essential Hypertension

Question 1

Define essential hypertension in pregnancy

Answer 1

finding of established chronic hypertension prior to pregnancy, or the finding of hypertension prior to 20 weeks’ gestation during regular prenatal visits
Primary hypertension > 140/90 before 20 weeks (as BP falls during first trimester)

Question 2

Epidemiology of essential hypertension

Answer 2

Approximately 1-5% of pregnancies are complicated by essential hypertension
More common in older women

Question 3

Define gestational hypertension

Answer 3

Hypertension (>140/90) occurring in the second half of pregnancy (>20 weeks) with NO proteinuria and NO oedema

Question 4

What investigations should be done for essential hypertension

Answer 4

Usually pre-diagnosed, Investigations are required to assess baseline function of organ symptoms
Bedside: urine dip, urinalysis, 24-urine for protein
Bloods: FBC, U&Es, glucose tolerance
Other: Echo, Ophthalmoplegic evaluation (poor BP control)

*be aware that women with chronic HTN may exhibit BP within normal range due to the physiological drop in BP

Question 5

What is the antenatal management for essential hypertension

Answer 5

1. Lifestyle: weight, diet (esp. salt), exercise
2. Review anti-hypertensive medications
   - Change ACEi/ARBs and thiazide-like diuretics → labetalol/nifedipine
   - Stop statins
   - Consider stopping anti-HTN if BP < 110/70 or there is symptomatic hypotension
3. Start aspirin from 12 weeks-birth (75mg)
4. Continue to dipstick urine at every visit
5. Consultant-led care
6. Safety net on PET warning signs
7. Serial US growth scans

Question 6

What are the complications for essential hypertension in pregnancy

Answer 6

Maternal:
Pre-eclampsia
Placental abruption
Pulmonary oedema
Stroke (2x)
Adverse cardiovascular event (1.7x)
Retinopathy
Renal dysfunction or failure
Hypertensive encephalopathy
Cerebral haemorrhage

Foetal: pre-term delivery, FGR, perinatal death

Question 7

What is the prognosis for essential hypertension in pregnancy

Answer 7

The risk for preterm delivery is < 15% (severe 60%)
Likelihood for the infant requiring admission to the neonatal intensive care unit is < 5%
Perinatal survival is almost 100%.

Question 8

What is the intrapartum management for essential hypertension in pregnancy

Answer 8

Continuous monitoring of BP changes, fluid intake-output, resp. symptoms
Continuous CTG
Analgesia
Epidural: May be given if platelets >70-80 | If LFTs are abnormal → check clotting
If haemorrhage → avoid ergometrine

Question 9

What is the postpartum management for essential hypertension

Answer 9

Consider LMWH within 6 hours of delivery to reduce significant risk of thromboembolism
Expect:
- A transient deterioration in clinical state following delivery (BP peaks day 3-6)
- Spontaneous diuresis, preceded by a period of oliguria (especially with prolonged oxytocin use)
Atenolol 50-100mg OD, nifedipine 10-20mg BD or amlodipine 5-10mg OD
Discuss options for birth in following pregnancies
Avoid NSAIDs
Complicated low-risk HTN → monitor BP and control for 48 hours

Question 10

What are the indications for delivery in essential hypertension

Answer 10

Uncontrollable BP
Rapidly worsening biochemistry/haematology e.g. platelets <100, coagulopathy, deteriorating liver or renal function, albumin <20
Maternal symptoms
Foetal distress, severe IUGR
Development of complications: Pre-eclampsia, Significant deterioration in renal function, Congestive heart failure

Question 11

What is the management for mild, moderate, and severe gestational hypertension

Answer 11

Mild: BP weekly, urine dip weekly, bloods weekly (FBC, U&Es, LFTs, bilirubin)
ModerateL: BP 2x a week, urine dip 2x a week, bloods weekly
Severe: admit and monitor, BP every 15-30mins, urine daily, bloods weekly

Question 12

What is the post-partum management for gestational hypertension

Answer 12

Measure BP: Daily for first 2 days and at least once between day 3-5

Medical
Continue use of antenatal antihypertensive treatment
As indicated if antihypertensive treatment changes after birth
- Reduce antiHTN dose if BP falls < 140/90mmHg
- Reduce antiHTN dose if BP falls < 130/80mmHg
- If on methyldopa- STOP within 2 days

Anti-HTNs used postnatally include amlodipine, atenolol, labetolol, anamipril
All hypertensive diseases should resolve within 6 weeks postnatally
Can come into MAS up to 4 wks after delivery