1. HYPERTENSION IN PREGNANCY
Dr Chris Sexton
FRANZCOG

2. Acknowledgements SOUTH AUSTRALIAN GP OBSTETRIC SHARED CARE PROTOCOLS
SA PERINATAL GUIDELINES – Hypertensive Disorders in Pregnancy
Based on 10 SC patients per year

3. Case Study 1 39 yo Primigravida Former model/ TV host/ Actress
Partner of 13 years her junior .
Uncomplicated pregnancy -”can’t believe how fast her bump is growing”

4. Case Study 1 34 weeks –puffy but otherwise well
Good growth and good FM
Blood pressure / 90-95
Mild peripheral oedema – (like 50-80% of all mothers)
Hypertension in Pregnancy
Systolic blood pressure greater than or equal to 140 mmHg and/or
Diastolic blood pressure greater than or equal to 90 mmHg (Korotkoff 5)
20% of patients have an episode in pregnancy (2 per year)
5% get pre-eclamsia (1 every second year)

5. Shared Care Guidelines
A diagnosis of Pre-eclampsia dictates immediate referral to the participating hospital. It is recommended in this instance, the GP contact the participating hospital and discuss referral with the on call Obstetric Registrar.

6. Case Study 1 Women's Assessment MW Registrar on Call Labour Ward
Paediatric Reg
2nd on Call
3rd on Call

7. Case Study 1
Tests
Bloods: FBC, Electrolytes, Renal function tests and Liver function tests
Urine Protein /Creatinine Ratio (later sign)
Review in 2 days
4/5 chance then next BP is normal

8. Case Study 1
Results all normal (ALP elevated). No proteinuria BP 140/90
Gestational hypertension - the new onset of hypertension after 20 weeks gestation without any maternal or fetal features of preeclampsia, followed by return of blood pressure to normal within 3 months post-partum.
Gestational hypertension near term is associated with little increase in the risk of adverse pregnancy outcomes . The earlier the gestation at presentation and the more severe the hypertension, the higher is the likelihood that the woman with gestational hypertension will progress to develop preeclampsia or an adverse pregnancy outcome
There is about a 25% chance she will get worse and develop Preeclampsia

9. So What To Do? What could you do? Repeat the tests & see her again
Send her to hospital day unit
Send to hospital for admission
Start her on anti hypertensive
Deliver her
Gestational HT – repeat bloods weekly and urinalysis 1-2 weekly

10. What Hypertensive?
The intention in treating mild to moderate hypertension is to prevent episodes of severe hypertension and allow safe prolongation of the pregnancy for fetal benefit.
It is reasonable to consider antihypertensive treatment when systolic blood pressure reaches mmHg systolic and / or mmHg diastolic on more than one occasion.
Methyl dopa – 750mg tds
Slow onset of action over 24 hours. Dry mouth, sedation, depression, blurred vision
Labetolol mg tds
Bradycardia, bronchospasm, headache, nausea, scalp tingling, which usually resolves within 24 to 48 hours (labetalol only)
Nifedipine SR 60mg Bd
Severe headache associated with flushing, tachycardia Peripheral oedema, constipation

11. What About An Ultrasound?
An appropriately grown fetus in the third trimester in women with well-controlled hypertension without superimposed preeclampsia generally is associated with a good perinatal outcome.
Fetal monitoring using methods other than continued surveillance of fetal growth and amniotic fluid volume in the third trimester is unlikely to be more successful in preventing perinatal mortality / morbidity.

12. Cases Study 1 Kept at home, reviewed the next week 35.5 weeks
Still feels well
BP 155/95
Bloods show elevation of RFT
Proteinuria now evident
Its all over now – It’s Preeclampsia!

13. Preeclampsia is a multi-system disorder unique to human pregnancy characterised by hypertension and involve­ment of one or more other organ systems and/or the fetus.
See 1 case very year or two
There is a reduction in blood flow to body organs
It will progress until delivery

14. 35 Week Delivery

15. Definitions Gestational HT Preeclampsia – eclampsia
After 20 weeks, gone by 12 weeks post partum. No features of:
Preeclampsia – eclampsia
After 20 weeks, gone by 12 weeks post partum
Neurological, renal , liver involvement
Chronic hypertension
Essential/secondary/white coat
Before 20 weeks, still there after 12 weeks
Preeclampsia superimposed on chronic hypertension

16. Case Study 2 29 yo Primip 1 previous marriage, No children
Pregnant with new partner
Occupation – Oxfam ambassador, Nanny Magicians assistant and currently Agent for S.H.I.E.L.D.

17. Case Study 2 36 weeks Vaguely unwell – back pain, sore abdomen, nausea
Looks well
Good fetal HR and movements
BP 150/ No proteinuria
Blood tests and review in 2 days

18. Case Study 2 Call from the Lab All her LFTS elevated Platelets 100
HELLP Syndrome (Haemolysis, Elevated LFTs and low Platelets)
1% of pregnancies – 1 in 10 years
Straight to Hospital
Expect to be delivered tonight
Always check LFTS!

19. Postnatal Care
Hypertension may persist for days, weeks or even up to three months and will require monitoring and slow withdrawal of antihypertensive therapy.
Resolution is still assured if the diagnosis was pre-eclampsia and there is no other underlying medical disorder.
“Quick on – quick off”

20. Postnatal Care
Women diagnosed with preeclampsia/gestational hypertension are at increased risk of subsequent cardiovascular morbidity including hypertension and coronary heart disease.
They should be counselled that they will benefit from avoiding smoking, maintaining a healthy weight, exercising regularly and eating a healthy diet.
It is recommended that all women with previous preeclampsia or hypertension in pregnancy have an annual blood pressure check and regular (5 yearly or more frequent if indicated) assessment of other cardiovascular risk factors