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Hypertension in Pregnancy:
Diagnosis and Management
(NICE NG 133 - Jun…
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Anti-Hypertensive Therapy
First-line: Labetalol
Second-line: Nifedipine (if labetalol not suitable)
Third-line: Methydopa (if labetalol and nifedipine not suitable)
Methyldopa: Risk of postnatal depression
Nifedipine: Risk of headache
Pre-eclampsia: New onset hypertension after 20 weeks and the coexistence of 1 or more of the following conditions
- Proteinuria (urine PCR of =/>30 mg/mmol OR ACR =/>8 mg/mmol OR at least 1 g/litre [2+] on dipstick testing)
- Maternal organ dysfunction
- Renal insufficiency (creatinine =/> 90)
- Liver involvement (elevated transaminases >40) with or without RUQ or epigastric pain
- Neurological complications: Eclampsia, altered mental status, blindness, stroke, clonus, severe headaches, persistent visual scotomata
- Haematological complications: Thrombocytopenia (platelets <150), disseminated intravascular coagulation or haemolysis
- Uteroplacental dysfunction: Fetal growth restriction, abnormal umbilical artery Dopplers, stillbirth
Severe pre-eclampsia: Pre-eclampsia with severe hypertension that does not respond to treatment or is associated with ongoing or recurring severe headaches, visual scotomata, nausea or vomiting, epigastric pain oliguria and severe hypertension, as well as progressive deterioration in laboratory blood tests such as rising creatinine or liver transaminases or falling platelet count, or failure of fetal growth or abnormal Dopplers.
Management of PET
(Hypertension BP 140/90 to 159/109)
- Admission: Admit if any clinical concerns or high risk of adverse events suggested by risk prediction models
- Treatment: Offer anti-hypertensive treatment if BP persistently >140/90
- Target BP: =/<135/85
- Monitoring: At least every 48 hours; more if admitted
- Dipstick proteinuria: Only if clinically indicated
- Bloods: FBC, LFTs, U&Es twice a week
- Fetal assessment: FHR antenatal appointment, ultrasound at diagnosis and if normal 2 weekly ultrasound, CTG at diagnosis then only if clinically indicated
Management of PET
(Severe Hypertension BP 160/110 or More)
- Admission: Admit, but if BP <160/110 manage as for hypertension
- Treatment: Offer anti-hypertensive treatment to all women
- Target BP: =/<135/85
- Monitoring: 15-30 minutes until BP <160/110, then QDS while admitted
- Dipstick proteinuria: Only if clinically indicated
- Bloods: FBC, LFTs, U&Es thrice a week
- Fetal assessment: FHR antenatal appointment, ultrasound at diagnosis and if normal 2 weekly ultrasound, CTG at diagnosis and if clinically indicated