Presentation on theme: "HYPERTENSION IN PREGNANCY"— Presentation transcript:
1 HYPERTENSION IN PREGNANCY Dr Chris SextonFRANZCOG
2 Acknowledgements SOUTH AUSTRALIAN GP OBSTETRIC SHARED CARE PROTOCOLS SA PERINATAL GUIDELINES – Hypertensive Disorders in PregnancyBased 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 FMBlood pressure / 90-95Mild peripheral oedema – (like 50-80% of all mothers)Hypertension in PregnancySystolic blood pressure greater than or equal to 140 mmHg and/orDiastolic 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 Reg2nd on Call3rd on Call
7 Case Study 1TestsBloods: FBC, Electrolytes, Renal function tests and Liver function testsUrine Protein /Creatinine Ratio (later sign)Review in 2 days4/5 chance then next BP is normal
8 Case Study 1Results all normal (ALP elevated). No proteinuria BP 140/90Gestational 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 outcomeThere 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 unitSend to hospital for admissionStart her on anti hypertensiveDeliver herGestational 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 tdsSlow onset of action over 24 hours. Dry mouth, sedation, depression, blurred visionLabetolol mg tdsBradycardia, bronchospasm, headache, nausea, scalp tingling, which usually resolves within 24 to 48 hours (labetalol only)Nifedipine SR 60mg BdSevere 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 wellBP 155/95Bloods show elevation of RFTProteinuria now evidentIts 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 twoThere is a reduction in blood flow to body organsIt will progress until delivery
15 Definitions Gestational HT Preeclampsia – eclampsia After 20 weeks, gone by 12 weeks post partum. No features of:Preeclampsia – eclampsiaAfter 20 weeks, gone by 12 weeks post partumNeurological, renal , liver involvementChronic hypertensionEssential/secondary/white coatBefore 20 weeks, still there after 12 weeksPreeclampsia superimposed on chronic hypertension
16 Case Study 2 29 yo Primip 1 previous marriage, No children Pregnant with new partnerOccupation – 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 wellGood fetal HR and movementsBP 150/ No proteinuriaBlood 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 yearsStraight to HospitalExpect to be delivered tonightAlways check LFTS!
19 Postnatal CareHypertension 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 CareWomen 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