P2010/0477-001 WACSClinProc1.

14 / 07 Title: Replaces: Description: Target Audience: Key Words: Policy Supported: P2010/0509-001 Management of Eclampsia P2010/0510-001 Intravenous Hydralazine for Severe Hypertension in Pregnancy P2010/0491-001 Magnesium Sulphate (MgSO4) Infusion Purpose: Hypertension during pregnancy may develop as a result of the pregnancy or follow preexisting hypertension. Hypertension arising for the first time after 20 weeks gestation may be an isolated finding ie: gestational hypertension or part of a multisystem disorder such as pre-eclampsia. Definition: Hypertension in pregnancy is diagnosed when systolic blood pressure is 140mmHg and/or diastolic blood pressure is 90mmHg on two occasions at least six hours apart. Recording Blood Pressure in Pregnancy An appropriate sized cuff should be used (standard cuff for arms 33cm circumference, large cuff for arms > 33cm). Systolic blood pressure should be palpated at the brachial artery and the cuff inflated to 20mmHg above this level. This cuff should be deflated slowly, at approximately 2 mmHg per second Blood pressure should be recorded with a mercury sphygmomanometer Diastolic blood pressure is recorded as the phase V Korotkoff sound (when sounds disappear). If phase V is not present, Korotkoff IV (when sounds muffle) should be recorded. Blood pressure should be recorded on both arms at the first antenatal visit and thereafter on the right arm if, as anticipated, there is little difference in the blood pressure between arms. If a significant difference is found, an opinion should be sought from a consultant physician. Classification of Hypertensive Disorders of Pregnancy Gestational Hypertension Pre-eclampsia Chronic Hypertension o Essential o secondary Pre-eclampsia superimposed on chronic hypertension
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Hypertension in Pregnancy New guideline Management of women with hypertension in pregnancy Midwives and medical officers, QVMU Gestational hypertension, pre-eclampsia, essential hypertension

Gestational Hypertension Gestational hypertension is hypertension arising in pregnancy after 20 weeks gestation without any other features of the multi-system disorder pre-eclampsia and which resolves within 3 months postpartum. Pre-eclampsia Pre-eclampsia is usually first detected by the measurement of high blood pressure but features other than hypertension are required to make the diagnosis. A clinical diagnosis of pre-eclampsia can be made when the following criteria are fulfilled: Hypertension arising after 20 weeks gestation and the new onset after 20 weeks gestation of one or more of the following: Proteinuria 300mg/24h Renal insufficiency serum/plasma creatinine 0.9mmol/L or oliguria Liver disease raised serum transaminases and/or sever epigastric/right upper quadrant pain Neurological excitation convulsions (eclampsia), hyperreflexia with clonus, severe headaches with hyperreflexia, persistent visual disturbances (scotomata) Haematological disturbances thrombocytopenia, disseminated intravascular coagulation, haemolysis Fetal growth restriction Chronic Hypertension Essential hypertension; blood pressure 140 mmHg systolic and/or 90 mmHg diastolic pre-conception or in the first half of pregnancy without an apparent underlying cause. It may also be diagnosed in those women presenting in pregnancy taking antihypertensive medications with no apparent underlying cause. Secondary hypertension: hypertension associated with renal, renovascular and endocrine disorders and aortic coarctation. Pre-eclampsia superimposed on chronic hypertension In women with chronic hypertension, superimposed pre-eclampsia is diagnosed when one or more of the systemic features of pre-eclampsia develop after 20 weeks gestations. In women with chronic renal disease a diagnosis of superimposed pre-eclampsia is often more difficult. In such women, sudden increase in proteinuria and hypertension should lead to increased surveillance for pre-eclampsia but the diagnosis is not secure without the development of other features eg. abnormal liver function, thrombocytopenia or neurological abnormalities. PRE-ECLAMPSIA Risk factors for Pre-eclampsia Nulliparity, adolescent pregnancy, family history of pre-eclampsia, obesity, multiple pregnancy, pre-eclampsia in a previous pregnancy, poor outcome in a previous pregnancy (placental abruption, IUGR, fetal death in utero), pre existing medical conditions (chronic hypertension, diabetes, renal disease, thrombophilias, antiphospholipid syndrome, protein C and S, antithrombin III and Factor V Leiden). Baseline Assessments Maternal History and physical examination FBC, EUC, LFT, uric acid Urinalysis
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24hr urine collection if 1+ protein on urinalysis Fetal CTG and/or biophysical profile, doppler studies Fortnightly USS for growth Assessment of Severity in Pre-eclampsia All women with pre-eclampsia must be regarded as being at risk of major maternal and fetal complications, but there are certain indictors of particular concern, when they occur in a woman with definite pre-eclampsia: HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) Severe hypertension refractory to usual treatment Renal impairment serum creatine greater than 0.09mmol/L Massive oedema beware laryngeal oedema Pulmonary oedema Persistent neurological symptoms headache/altered mental state/clonus Severe epigastric pain and/or vomiting, usually associated with abnormal liver enzymes Fetal growth restriction. Pre-eclampsia usually pursues a course of deterioration, sometimes slowly and sometimes quickly. It may evolve from mild to severe over a period of hours or day and requires frequent reassessment by medical staff. Management Acute treatment of severe hypertension - BP > 170 systolic or > 110 diastolic Oral therapy should be used initially unless the woman is symptomatic or has features of impending eclampsia. The agent of choice for the acute treatment of severe hypertension is oral nifedipine. This is administered as 10mg oral dose initially with a repeat dose of 10mg if there is inadequate response after 30 minutes. Headaches are a frequent side effect of this medication. The second choice for acute treatment is intravenous hydralazine, as per the Intravenous Hydralazine for Severe Hypertension in Pregnancy clinical guideline. Continuous CTG monitoring must be initiated to ensure that lowering the blood pressure does not cause fetal distress. Maintenance treatment of hypertension/ treatment of mild hypertension Methyldopa administered orally commencing at 250mg BD increasing to a maximum of 750mg QID Labetalol administered orally commencing with 100mg BD and increasing to a maximum 300mg QID. Other agents that can be used include nifedipine, other beta blockers, oral hydralazine, clonidine. Timing of delivery The only definitive treatment for the hypertensive complications of pregnancy is delivery. The decision to delivery should take into account the maternal and fetal status and fetal maturity. Women at term with any degree of hypertensive complications should be delivered.
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Other indications for delivery include: Preterm pregnancy with severe preeclampsia Eclampsia Maternal deterioration IUGR or evidence of fetal intolerance of the intrauterine environment Delivery may be delayed if the cervix is unfavourable and: Blood pressure is mildly elevated There is minimal proteinuria There is no evidence of end-organ compromise Disease improves with interim therapy There is no evidence of fetal compromise Except in the situation of acute fetal compromise, urgent delivery is not helpful in preeclampsia and the mother must be resuscitated before being subjected to the delivery process. In severe pre-eclampsia, delivery must be preceded by: Control of severe hypertension Attention to fluid status Correction of coagulopathy Control of eclampsia or prophylaxis against eclampsia. Corticosteroids should be administered for fetal lung maturation if pre-eclampsia is established below 34 weeks gestation and delivery is anticipated within one week. Postpartum All features of pre-eclampsia will eventually resolve postpartum Blood pressure can take 6 weeks to return to normal New maternal complications may occur up to a week post delivery Careful monitoring of fluid balance Oliguria should alert concern for developing postpartum renal failure In the woman showing clinical improvement, blood tests are not routinely indicated post partum Antihypertensives are usually continued but can be weaned as the blood pressure settles. Potential for chronic renal failure and acute liver failure GESTATIONAL HYPERTENSION Women whose pregnancies are complicated by gestational hypertension alone have very good pregnancy outcomes compared to women who develop pre-eclampsia. Maternal and fetal investigations must be performed to exclude pre-eclampsia. Antihypertensives may be required to maintain the blood pressure between 110 and 140 mmHg systolic and 80 to 90 mmHg diastolic without inducing undue side effects. Management can be on an outpatient basis. CHRONIC HYPERTENSION In all women with chronic hypertension an underlying cause for hypertension should be considered, as essential hypertension is at present a diagnosis of exclusion. Secondary hypertension may have implications for the pregnancy unrelated to the level of blood pressure.
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Renal Disease Assessment of the underlying prognosis of the renal disease and the degree of renal impairment is important in determining risk in relation to pregnancy which may be much higher than that associated with the degree of hypertension Systemic Disease with Renal Manifestation (eg. Diabetes, systemic lupus erythematosus0 The extent of other organ involvement will also determine the degree of risk associated with the pregnancy. Endocrine Disorders Phaeochromocytoma, though rare, has grave prognostic implications for both maternal and fetal welfare and must be considered in all cases of hypertension in pregnancy. Significance of chronic hypertension in pregnancy The risks of chronic hypertension are: Exacerbation of maternal hypertension Superimposed pre-eclampsia Uteroplacental insufficiency, IUGR, abruption

Outpatient Monitoring of Women with Hypertension Outpatient monitoring of hypertension may be appropriate for women in whom: There are no complications There are no geographic contraindications There is no evidence of fetal compromise The woman is able to return to the Pregnancy Assessment Unit for monitoring. Criteria for referral to the Pregnancy Assessment Unit BP > 140/90 or Women commenced on antihypertensive treatment BP < 170/110 Assessment Every visit: BP monitoring half hourly x 4 Urinalysis CTG Weekly: FBC, LFTs, U&E, Urate 24 hr urine collection AFI, doppler studies Fortnightly: USS for fetal growth

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Attachments Attachment 1 Attachment 2

PAC Algorithm for Assessment and Monitoring of Blood Pressure References

Performance Indicators: Evaluation of compliance with guideline to be achieved through medical record audit annually by clinical Quality improvement Midwife WACS Review Date: Annually verified for currency or as changes occur, and reviewed every 3 years via Policy and Procedure working group coordinated by the Clinical and Quality improvement midwife. November 2009 Midwives and medical staff WACS Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Stakeholders: Developed by:

Dr A Dennis Co-Director (Medical) Womens & Childrens Services

Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Date: _________________________

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ATTACHMENT 1 Pregnancy Assessment Unit Algorithm for Assessment and Monitoring of Hypertension in Pregnancy Criteria for referral: BP > 140/90 or on antihypertensives BP < 170/110

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ATTACHMENT 2 REFERENCES Abalos, E, Duley, L, Steyn, D & Henderson-Smart, D. Antihypertensive drug therapy for mild to moderate hypertension during pregnancy. Cochrane Database of Systematic Reviews 2001, Issue 2. Art.No.: CD002252. DOI: 10.1002/14651858.CD002252. Australasian Society for the Study of Hypertension in Pregnancy (ASSHP) 2000 The detection, investigation and management of hypertension in pregnancy: full consensus statement. Online: http://www.racp.edu.au/asshp/news.htm Duley L, Henderson-Smart DJ, Meher S. Drugs for treatment of very high blood pressure during pregnancy. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD001449. DOI 10.1002/14651858.CD001449.pub2.

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PATHOLOGY Full Blood Count Thromobcytopenia platelet counts considered consistent with severe pre-eclampsia are those <100000/mL excessive bleeding associated with trauma or surgery is uncommon unless the platelet count is <50 000/mL significant spontaneous bleeding may occur with platelet counts < 10000/mL. Liver Function Tests Test Levels deemed to be elevated ALT >35 AST >34

Electrolytes, Urea & Creatinine Sodium Potassium Chloride Bicarbonate Creatinine Urea

Urates

24hr Urine Collection

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