HYPERTENSION IN PREGNANCY Dr Chris Sexton FRANZCOG

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

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”

Case Study 1 34 weeks –puffy but otherwise well Good growth and good FM Blood pressure 150-140/ 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)

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.

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

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

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

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

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 140-160 mmHg systolic and / or 90-100 mmHg diastolic on more than one occasion. Methyl dopa 250 – 750mg tds Slow onset of action over 24 hours. Dry mouth, sedation, depression, blurred vision Labetolol 200-400mg 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

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.

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!

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

35 Week Delivery

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

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.

Case Study 2 36 weeks Vaguely unwell – back pain, sore abdomen, nausea Looks well Good fetal HR and movements BP 150/ 90 - 95. No proteinuria Blood tests and review in 2 days

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!

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”

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