NICE - hypertension in pregnancy: diagnosis and management. 2019 Flashcards
What are the “high” risk factors for pre-eclampsia
Hypertensive disease in a previous pregnancy
Chronic kidney disease
Autoimmune disease such as SLE or APS
Type 1 or 2 diabetes
Chronic hypertension
What are the “moderate” risk factors for pre-eclampsia
Nulliparity
Age >40
Pregnancy interval more than 10 years
BMI >35 at booking
FHx of pre-eclampsia
Multiple pregnancy
Who should aspirin be offered to?
Those with 1 high risk factor or 2 moderate risk factors.
At which level (trace, 1+, 2+,3+) on dipstick, should PCR be used to quantify proteinuria?
1+ or more
What is the diagnostic threshold for PCR ratio for significant proteinuria
30mg/mmol
What is the diagnostic ratio for significant proteinuria if using albumin creatinine ratio
8mg/mmol
What might be the effect of taking ACE-inhibitors or angiotensin II receptor antagonists in pregnancy
Associated with renal dysfunction, oligohydramnios, neonatal anuria, skull ossification defects.
Also with cardiovascular malformation, CNS malformation
What may be the side effects of thiazides/thiazide like drugs if used in pregnancy
Lower birth weight,
preterm delivery,
malformations
fetal/neonatal electrolyte abnormalities,
jaundice
thrombocytopenia
When using medication for HTN in pregnancy aim for BP of
135/85
Offer PLGF based testing to rule out pre-eclampsia between ___ weeks and ___ /40 if women with chronic HTN are suspected of developing pre-eclampsia
between 20 weeks and 36+6
What is the monitoring schedule suggestion from NICE in women with chronic hypertension
weekly if poorly controlled
Appointments ever 2-4 weeks if HTN well controlled.
TOB for women with chronic hypertension
Do not offer planned early birth before 37 weeks to women with chronic hypertension whose BP is lower than 160/110 with or w/o medication unless other indications.
Postnatal monitoring for women with chronic hypertension.
Measure BP daily for first 2 days
Once between D3 and D5
or as clinically indicated if treatment is changed after birth.
BP aim for postnatal management of women with chronic hypertension.
below 140/90
In PIH what are the parameters of “hypertension” and “severe” hypertension.
HTN - 140/90 - 159/109
severe HTN - 160/110 or greater.
How often should dipstick proteinuria testing occur in PIH and severe PIH
Once or twice a week for PIH
Daily whilst admitted severe PIH
How often should bloods be taken for both PIH and severe PIH?
at presentation and then weekly.
In PIH (not severe) how often should fetal US assessment occur
at diagnosis and, if normal, repeat every 2-4 weeks if clinically indicated.
In severe PIH how often should fetal US assessment occur?
At diagnosis and, if normal, every 2 weeks if severe hypertension persists
TOB for PIH
Do not offer planned early birth before 37 weeks to women with PIH whose BP is lower than 160/110.
Postnatal monitoring BP with PIH
Daily D1 and D2
Once between D3 and D5
As clinically indicated if treatment changed after birth.
postnatal management of women with PIH. Reduce treatment if BP falls below
130/80
When should methydopa be stopped
Within 2 days after birth.
What is the BP treatment threshold for women with PIH who did not take antihypertensive treatment and have given birth.
150/100
For women with PET when reviewed, offer admission if there are concerns such as:
Sustained SBP 160 or >
New or persistent CR>90 or ALT >70 or fall in plt count <150
signs of impending eclampsia
Signs of pulm. oedema
Signs of severe pre-eclampsia
Suspected fetal compromise
How often should bloods be checked in PET and PET with severe hypertension (FBC, LFT, UE)
PET - twice a week
Severe hypertension PET - 3 times a week
How often should US assessment of the fetus occur in PET and PET with severe hypertension
At diagnosis and, if normal, every 2 weeks.
TOB in PET. Considerations for planned early birth could include (not limited to) the following features of severe pre-eclampsia
Inability to control BP despite x3 or more classes of antiHTN medication in appropriate doses.
Mat SpO2 <90%
Progressive biochemical deterioration (HELLP)
Ongoing neurological features - severe intractable headache, visual scotoma
Placental abruption
Reversed EDF or abnormal CTG
TOB in PET
Surveillance to 36+6
Initiate birth from 37 weeks
How should BP be monitored in women with pre-eclampsia postnatally if they did NOT require any treatment.
QDS whilst inpatient
at least once between D3 and D5
On alternate days until normal if abnormal D3-D5
How should BP be monitored in women with pre-eclampsia postnatally if they required treatment.
QDS whilst inpatient
every 1-2 days for up to 2 weeks after transfer to community care until she is off treatment and has no hypertension.
At what threshold should antihypertensives be reduced postnatally
<130/80
Consider transfer to community care postnatally if all of the criteria have been met.
No symptoms of pre-eclampsia
BP with or without treatment <150/100
Blood tests stable or improving.
In chronic hypertension. What should the AN USS schedule be?
US for growth LV and doppler at 28, 32 and 36 weeks
In women with PIH when should they have an US?
US growth LV doppler at diagnosis, and, if normal every 2-4 weeks
When should women with PET or severe PIH have US growth LV and doppler?
At diagnosis and if continuing with surveillance then every 2 weeks
Consider serial US growth LV doppler between 28-30 weeks (or at least 2 weeks before previous gestational age of onset) in women with previous:
severe pre-eclampsia
Pre-eclampsia resulting in birth before 34 weeks
PET with baby below the 10th centile
IUFD
Abruption
Consider the need for MgSO4 if 1 or more of the following symptoms of severe PET are present
Ongoing or recurring severe headaches
Scotomata
Nausea or vomiting
Epigastric pain
oliguria and severe hypertension
Progressive biochemical deterioration.
What is the recommended regimen for MgSO4
Loading dose 4g over 5-15mins
Maintenance 1g/hr for 24hours
How long should the MgSO4 infusion be continued after the last fit?
24hours after the last fit
How should recurrent fits be treated whilst on MgSO4 infusion
A further loading dose 2-4g given IV over 5-15minutes.
What are the potential side effects of prolonged or repeated MgSO4 administration 5-7days in pregnancy?
Skeletal adverse effects
hypocalcaemia and hypermagnesaemia in neonates
In severe PET, what should the fluids be restricted to?
80ml/hr
Unless there are ongoing fluid losses.
Can breastfeeding mothers take ACE-i or ARBs
Not recommended but not absolutely contra-indicated. not in the first few weeks.
With ACE-i: although the levels transferred are unlikely to be clinically relevent there is insufficient date to exclude a possible risk of profound neonatal hypotension.
What should women with hypertensive disorder of pregnancy be advised about the overall risk of recurrence of any hypertensive disease
Overall risk is ~21% or 1in 5
Risk of recurrence of PET if PET in previous or current pregnancy
Overall 16%
If birth was at 28-34 weeks - 33%
If birth 34-37 - 23%
Risk of PET in future if PIH in current or previous pregnancy
7% or 1 in 14
Risk of PIH in future pregnancy if PIH currently
Between 11-15%
Risk of chronic hypertension if PET in current or previous pregnancy
2% or 1 in 50
Risk of chronic hypertension if PIH in current pregnancy or previous
3% or up to 1in 34
