Dr Chris Sexton FRANZCOG. Acknowledgements SOUTH AUSTRALIAN GP OBSTETRIC SHARED CARE PROTOCOLS SA...
-
Upload
kayley-barnaby -
Category
Documents
-
view
217 -
download
1
Transcript of Dr Chris Sexton FRANZCOG. Acknowledgements SOUTH AUSTRALIAN GP OBSTETRIC SHARED CARE PROTOCOLS SA...
HYPERTENSION IN PREGNANCY
Dr Chris SextonFRANZCOG
Acknowledgements
SOUTH AUSTRALIAN GP OBSTETRIC SHARED CARE PROTOCOLS
SA PERINATAL GUIDELINES – Hypertensive Disorders in Pregnancy
Based on 10 SC patients per year
Case Study 139 yo PrimigravidaFormer model/ TV
host/ ActressPartner of 13 years
her junior . Uncomplicated
pregnancy -”can’t believe how fast her bump is growing”
Case Study 134 weeks –puffy but otherwise well Good growth and good FMBlood pressure 150-140/ 90-95Mild 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 1Women's
Assessment MWRegistrar on Call
Labour WardPaediatric Reg2nd on Call3rd on Call
Case Study 1Tests
Bloods: FBC, Electrolytes, Renal function tests and Liver function tests
Urine Protein /Creatinine Ratio (later sign)
Review in 2 days4/5 chance then next BP is normal
Case Study 1Results 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 againSend her to hospital day unitSend to hospital for admissionStart her on anti hypertensiveDeliver 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 1Kept at home, reviewed the next week35.5 weeksStill feels wellBP 155/95
Bloods show elevation of RFTProteinuria now evident
Its all over now – It’s Preeclampsia!
Preeclampsia is a multi-system disorder unique to human pregnancy characterised by hypertension and involve ment 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
35 Week Delivery
DefinitionsGestational HT
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 hypertensionEssential/secondary/white coat
Before 20 weeks, still there after 12 weeks
Preeclampsia superimposed on chronic hypertension
Case Study 229 yo Primip1 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 236 weeksVaguely unwell – back pain, sore abdomen,
nauseaLooks wellGood fetal HR and movementsBP 150/ 90 - 95. No proteinuriaBlood tests and review in 2 days
Case Study 2Call from the Lab
All her LFTS elevatedPlatelets 100
HELLP Syndrome (Haemolysis, Elevated LFTs and low Platelets)
1% of pregnancies – 1 in 10 yearsStraight to HospitalExpect to be delivered tonight
Always check LFTS!
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”
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