Hypertension in Pregnancy: Diagnosis and Management NICE ...
Transcript of Hypertension in Pregnancy: Diagnosis and Management NICE ...
Hypertension in Pregnancy:
Diagnosis and Management
NICE Guideline NG133
Dr Fran Conti-Ramsden, ST3 O&G, ACF, King’s College London
BACKGROUND
• Hypertensive disorders of pregnancy (HDP) are estimated to affect 1 in 10 pregnancies
• HDP are responsible for approximately 10% of preterm births
• Associated with high rates of maternaland fetal morbidity
GOOD NEWS IN THE UK
Conti-Ramsden et al, Reducing maternal deaths from hypertensive disorders, BMJ, 2019.
CAN WE DO BETTER?
• 2019 MBRRACE report (reporting
period 2015-2017):
• 6 deaths from pre-eclampsia in the UK &
Ireland.
• In 4 out of 6 cases, improvements in
care may have led to a different
outcome
• 4 had indication for aspirin. One
woman was prescribed aspirin appropriately,
one started late, two never.
ABROAD…
• A: Territory according to land area
• B: Territory according to population
• C: Territory according to proportion of
maternal deaths (HDP approx. 10-15%)
• Global burden of disease study estimated
~30,000 maternal deaths due to HDP
in 2013
• 42% Sub-Saharan Africa
• 36% South Asia
Dudley, The Global Impact of eclampsia and pre-eclampsia, Semin. Perinat, 2009.
DEFINITIONS
DEFINITIONS
DEFINITIONS
HYPERTENSION IN PREGNANCY: DIAGNOSIS
AND MANAGEMENT
NICE Guideline NG133 June 2019
HYPERTENSION IN PREGNANCY: DIAGNOSIS
AND MANAGEMENT
1.1 Reducing the risk of hypertensive disorders in pregnancy
1.2 Assessment of proteinuria in hypertensive disorders of pregnancy
1.3 Management of chronic hypertension in pregnancy
1.4 Management of gestational hypertension
1.5 Management of pre-eclampsia
1.6 Fetal monitoring
1.7 Intrapartum care
1.8 Medical management of severe hypertension, severe pre-eclampsia or
eclampsia in a critical care setting
1.9 Antihypertensive treatment during the postnatal period, including
during breastfeeding
1.10 Advice and follow-up at transfer to community care
1.1 REDUCING THE RISK
• Advice: • If any symptoms, advise women to see a Health care
professional immediately • Give the same advice on rest, exercise and work to
women with chronic hypertension or at risk of hypertensive disorders during pregnancy as healthy pregnant women.
• Aspirin: from 12/40 until birth in women with risk factors
• Do not use/recommend:
• Nitric oxide donors / progesterone / diuretics / LMWH / Magnesium / folic acid / antioxidants
• Reducing salt intake (except in chronic HTN)
1.1 REDUCING THE RISK
High Moderate
Previous hypertensive disease
Chronic kidney disease
Autoimmune disease
Type 1 / 2 diabetes
Chronic hypertension
1st baby
Age ≥ 40 years
Pregnancy interval > 10 years
BMI ≥ 35
FHx PET
Multiple pregnancy
Aspirin 75-150mg/day from 12 weeks
for women with:
• 1 high risk factor
• 2 moderate risk factors
1.2 ASSESSING PROTEINURIA
• Use automated machine in secondary care
• Interpret measurements in context of full clinical review
• If dipstick ≥ 1+ protein use PCR or ACR quantification:
PCR: Cut off 30 mg/mmol
ACR: Cut off 8mg / mmol
Repeat PCR / ACR if uncertainty about diagnosis
• Do not use 1st morning void
• Do not not routinely use 24 hour collections
1.6 ADDITIONAL FETALMONITORING
• In women who had previous:
• Severe OR early onset PE requiring delivery <34/40
• PE with birth weight <10th centile
• Intrauterine death
• Placental abruption
Arrange USS for growth, fluid volume and umbilical artery doppler
velocimetry at 28/40 (or at least 2 weeks before gestational age of onset if earlier
than 28/40) and repeat 4 weeks later
1.3 CHRONIC HYPERTENSION
Hypertension that is present at the booking visit, or before 20/40, or if
the woman is already taking antihypertensive medication when referred
to maternity services
1.3 CHRONIC HYPERTENSION
PRE-PREGNANCY ADVICE
• Pre-conception counselling
• Refer to a specialist in HDP to discuss risks / benefits of treatment and decide
on most appropriate treatment
• ↑risk of congenital abnormalities if ACE inhibitors or ARBs are taken
during pregnancy
• Possibly ↑risk of congenital abnormalities and neonatal complications if
thiazide / thiazide-like diuretics are taken during pregnancy
• No evidence of increased risk with antihypertensives other than ACEi, ARBs,
thiazide and thiazide-like diuretic
If pregnant STOP ACEi/ARBs and offer alternatives
1.3 CHRONIC HYPERTENSION
MANAGEMENT
• Lifestyle advice: weight management, exercise, diet, lowering salt intake in line
with non-pregnant advice
• Antihypertensives:
• Continue existing antihypertensive therapy if safe in pregnancy or switch to
an alternative
• Discontinue antihypertensives if systolic BP <110 or diastolic <70 or
symptomatic hypotension
• Commence treatment if sustained readings above: systolic BP >140 or
diastolic BP > 90
• TARGET: 135/85mmHg
1.3 CHRONIC HYPERTENSION
MANAGEMENT
• Antihypertensives:
• Aspirin 75-150mg from 12/40 until birth
• Placental Growth Factor testing in suspected pre-eclampsia between 20-
35 weeks.
1.3 CHRONIC HYPERTENSION
MANAGEMENT
• Antenatal Appointments
• Individualised plan.
• Weekly if poorly controlled
• 2-4 weekly if well controlled
• Timing of Birth
• Do not offer delivery <37/40 if BP <160/110 with or without
treatment if there are no other medical indications
• Timing of birth after 37/40 should be agreed with the woman and
her obstetrician
• If planned early delivery is necessary offer antenatal corticosteroids
and MgSo4 if indicated in line with guidance on pre term birth
1.3 CHRONIC HYPERTENSION
FETAL MONITORING
• USS for fetal growth, amniotic
fluid volume and Umbilical
artery doppler velocimetry at
28, 32 and 36/40
• CTG only if clinically indicated
1.3 CHRONIC HYPERTENSION
POSTNATAL CARE
• BP measures: BP daily for 2/7 post birth, once between day 3-5
• Target BP: <140/90
• Antihypertensive agent:
• Stop / change methyldopa within 2 days of delivery
• Follow up:
• Review antihypertensive treatment after 2 weeks (GP / Specialist)
• Medical review at 6-8 weeks PN with GP / specialist
1.4 GESTATIONAL HYPERTENSION
New hypertension presenting after 20 weeks of pregnancy without
significant proteinuria
1.4 GESTATIONAL HYPERTENSION
ASSESSMENT
• Full assessment in 2* care by a Healthcare professional trained in HDP
Admit?
Tx?
1.4 GESTATIONAL HYPERTENSION
Mum
Baby
ASSESSMENT
PlGF!
1.4 GESTATIONAL HYPERTENSION
TIMING OF BIRTH
• Do not offer delivery <37/40 if BP lower than 160/110mmHg unless there are
other indications
• Timing of birth after 37/40 should be agreed between the woman and senior
obstetrician
• If planned early delivery is necessary corticosteroids and magnesium sulfate
should be offered in line with NICE guidance
1.4 GESTATIONAL HYPERTENSION
POSTNATAL CARE
• BP measures: BP daily for 2/7 post birth, once between day 3-5
• Target BP: <140/90
• Antihypertensive agent:
• Stop / change methyldopa within 2 days of delivery
• Continue antihypertensives if required, advise duration of Tx
similar to antenatal duration
• Reduce if BP < 130/80
• Start if not on Tx and BP >= 150/100
1.4 GESTATIONAL HYPERTENSION
POSTNATAL CARE
• Follow up:
• Care plan on discharge to community including:
• Who will provide follow up care including medical review if
required
• Frequency of BP checks
• Thresholds for stopping treatment
• Indications for referral to primary care
• If on antihypertensives, review treatment after 2 weeks (GP /
Specialist)
• Medical review at 6-8 weeks PN with GP / specialist
CHOOSING ANTIHYPERTENSIVES
PLACENTAL GROWTH FACTOR
PLACENTAL GROWTH FACTOR
Angiogenic (promotes
formation of new blood
vessels)
PLACENTAL GROWTH FACTOR (PLGF)
PlGF: PARROT study
• 11 maternity centres across the UK, recruited 1035 women with suspected pre-
eclampsia between 20 weeks to 36+6
• Revealed vs concealed testing
• Primary outcome: time from presentation with suspected pre-eclampsia to
documented diagnosis of pre-eclampsia
• Findings:
• Median time to pre-eclampsia diagnosis: 4.1 days with concealed testing
versus 1.9 days with revealed testing (time ratio 0·36, 95% CI 0·15–0·87;
p=0·027).
• Where PlGF was revealed there was lower incidence of adverse outcomes
(adjusted odds ratio 0·32, 95% CI 0·11–0·96; p=0·043)
• Consistent with targeted, increased surveillance
1.5 PRE-ECLAMPSIA
New onset hypertension >140/90 after 20/40 and the coexistence of 1 or
more of the following new onset conditions: proteinuria, other maternal
organ dysfunction, uteroplacental dysfunction
1.5 PRE-ECLAMPSIA
ASSESSMENT
• Full clinical assessment by professional trained in hypertensive disorders of
pregnancy
• Offer admission if concerns for mother or baby e.g.
• Consider using fullPIERS or PREP-S risk prediction models to guide
decisions about appropriate place of care, timing of delivery and
thresholds for intervention
Sustained systolic BP >160mmHg Suspected fetal compromise
Biochemical concern
(creatinine >90, ALT >70, PLTs <150,000)
Signs of impending pulmonary oedema,
eclampsia
Signs of severe pre-eclampsia Any other clinical signs that cause concern
PREP-S PREDICTION MODEL
OVERVIEW
• Aims to predict the risk of MATERNAL (no baby!!) adverse outcomes at 48
hours (PREP-S) and by discharge (PREP-L) in EARLY ONSET PRE-
ECLAMPSIA (up to 34/40)
• Model developed in UK, validated in multi-national and Netherlands cohorts
• Which adverse outcomes?
• Maternal death, neurological (GCS <13, stroke, cortical blindness), hepatic (INR >1.2,
hepatic haematoma, rupture), cardiorespiratory (inotropic support, MI, intubation,
pulmonary oedema), renal (AKI, dialysis) or haematological complications (transfusion,
PPH 1L+), or delivery before 34 weeks
• Factors in the model include: Age, gestational age, medical comorbidities, clinical
features, biochemical measures and treatment
See: https://www.evidencio.com/models/show/1038
FULLPIERS PREDICTION MODEL
OVERVIEW
• Aims to predict the risk of MATERNAL (no
baby!!) adverse outcomes within 48 hours in pre-
eclampsia (any gestational age).
• Model developed and validated in multi-national
cohorts (high income)
• Which adverse outcomes?
• One or more of Maternal death, or serious
nervous system, cardiorespiratory,
hepatic, renal or haematological
morbidity.
See: https://pre-empt.bcchr.ca/evidence/fullpiers
1.5 PRE-ECLAMPSIA
MANAGEMENT
1.5 PRE-ECLAMPSIA
• Repeat CTG if:
• Change in fetal movements
• PV bleeding
• Abdominal pain
• Deterioration in maternal condition
MANAGEMENT
1.5 PRE-ECLAMPSIA
Gestation Timing of Birth
Before 34/40 Continue surveillance unless there are indications for early
delivery
34-36+6/40 As above
When considering option of planned early delivery take into
account woman’s and baby’s condition, risk factors, co morbidities
and the availability of neonatal unit beds
37/40+ Initiate Birth within 24-48 hours
• Involve senior obstetrician in any decisions on timing of birth
• Involve anaesthetists and neonatal teams
• Offer IV Magnesium sulfate and a course of corticosteroids as appropriate
TIMING OF DELIVERY
1.5 PRE-ECLAMPSIA
TIMING OF DELIVERY
Chappell et al, Planned early delivery or expectant management.., Lancet, 2019.
1.5 PRE-ECLAMPSIA
Example maternal and fetal thresholds for
delivery before 37/40Inability to control BP despite using 3 agents (appropriately)
Mat pulse oximetry <90%
Progressive deterioration of LFTS, U&Es, haemolysis or platelets
Ongoing neurological features (eclampsia, intractable headache, repeated
visual scotomata)
Placental abruption
Reversed EDF in umbilical artery, an abnormal CTG or stillbirth
Other features not listed may also be considered
TIMING OF DELIVERY
1.5 PRE-ECLAMPSIA
POSTNATAL CARE: Did not take antihypertensives
• BP measures: QDS whilst I/P, at least once Day 3-5, alternate days until
normal.
• Clincal review: Ask about headaches and epigastric pain at every visit
• Antihypertensive agents:
• Start if not on Tx and BP >= 150/100
1.5 PRE-ECLAMPSIA
POSTNATAL CARE: Did take antihypertensives
• BP measures: QDS whilst I/P, every 1-2 days for up to 2 weeks until woman
is off treatment and has no hypertension.
• Clincal review: Ask about headaches and epigastric pain at every visit
• Antihypertensive agents:
• Stop / change methyldopa within 2 days of delivery
• Continue antihypertensive treatment
• Reducing treatment:
• Consider if BP < 140/90
• Reduce if BP < 130/80
1.5 PRE-ECLAMPSIA
POSTNATAL CARE: Biochemistry monitoring
• In women who had pre-eclampsia with hypertension or after step down from
critical care:
• FBC, U&Es & LFTs 48-72 hours after delivery or step down
• DO NOT REPEAT if these results are normal
• If abnormal repeat as clinically indicated until return to normal
• Urine dip for protein at 6-8 weeks after delivery
• If ≥ + protein at 6-8 weeks. Review with U&Es at 3 months and refer to renal
specialist if remain abnormal
1.5 PRE-ECLAMPSIA
POSTNATAL CARE: Transfer to Community
• Criteria:
• No symptoms of pre-eclampsia
• BP with or without treatment is ≤150/100
• Blood tests are stable or improving
• Write a care plan to include
• Frequency of BP checks
• Thresholds for reducing / stopping medication
• Indications for referral to primary care
• Self monitoring for symptoms
• GP / specialist review in 2 weeks and at 6-8 weeks after delivery
1.7 INTRAPARTUM CARE
Blood Pressure Every 15-30 minutes until <160/110 then hourly
Continue antenatal antihypertensives in labour
Haematological &
Biochemical tests
Determine the need for tests using same criteria as in
antenatal period
Care during epidural
analgesia
Do not pre load with IV fluids
Management of 2nd
stage
Do not routinely limit the 2nd stage if BP is controlled
Consider operative or assisted birth for women with
severe hypertension if have not responded to
treatment
1.8 SEVERE HYPERTENSION, SEVERE PRE-ECLAMPSIA,
ECLAMPSIA
- Severe Hypertension: systolic BP >160 or diastolic > 110mmHg
- Severe Pre-eclampsia: Pre-eclampsia with severe hypertension that does not
respond to treatment or is associated with ongoing / recurring severe headaches,
visual scotomata, nausea / vomiting, epigastric pain, oliguria, progressive
deterioration of blood results or failure of fetal growth or abnormal doppler
studies.
- Eclampsia: A convulsive condition associated with pre-eclampsia
1.8 SEVERE DISEASE
ANTICONVULSANTS
• Indication for anticonvulsant therapy (Magnesium Sulfate):
• Give MgSo4 if: Critical care setting and severe hypertension, severe pre-
eclampsia or previously had an eclamptic fit
• Consider MgSo4 if:
• delivery planned within 24 hours OR
• need for MgSo4 if 1 or more of the following:Ongoing / recurring severe
headaches
Epigastric pain
Visual Scotomata Oliguria with severe HTN
Nausea / vomiting Progressive deterioration of
blood tests
1.8 SEVERE DISEASE
ANTIHYPERTENSIVES
• Treat women with severe hypertension (AN/PN) in critical care with:
• Oral / IV labetalol
• Oral nifedipine
• IV hydralazine
• Monitor response to treatment to:
• Ensure BP falls
• Identify adverse effects for mum and baby
• Modify treatment according to response
1.8 SEVERE DISEASE
STEROIDS & FLUID BALANCE
• If early delivery is considered within 7 days offer steroids for fetal lung
maturation in line with preterm birth guidance
• Do not use dex/betamethasone for treatment of HELLP syndrome
• Limit fluids to 80ml/hour unless there are other ongoing fluid losses
• Mode of delivery according to clinical circumstances and woman’s
preference
1.9 POSTNATAL CARE
1.9 POSTNATAL CARE
ANTIHYPERTENSIVE AGENTS (AHA)
• Breastfeeding is okay!
• AHA can cross into breastmilk, but levels likely very low, lack of
testing means we have little data!
• Consider monitoring baby BP, especially preterm, who have
symptoms of low BP
• Monitor babies for drowsiness, lethargy, pallor, cold peripheries
and poor feeding
So which drug?
1.9 POSTNATAL CARE
ANTIHYPERTENSIVE AGENTS
• In line with treatment of non-pregnant hypertensive patients (NICE), or if
breastfeeding:
• Consider Enalapril: MONITOR RENAL FUNCTION + K+
• For black African / Caribbean women consider nifedipine/amlodipine
• Use combination therapy if BP not well controlled:
• Enalapril + nifedipine / amlodipine
• Add on atenolol / labetalol
• Consider choosing once daily dosing if possible.. Adherence is an
issue!
• Involve women in decision making about treatment
• Avoid diuretics and angiotensin receptor blockers
1.10 ADVICE & FOLLOW UP
1.10 ADVICE
RECURRENCE RATES in FUTURE PREGNANCIES
Overall risk is 1 in 5.
1.10 ADVICE
RECURRENCE RATES in FUTURE PREGNANCIES
Overall risk is 1 in 5.
Type of Hypertension current pregnancy
Prevalence of hypertension
in future pregnancy
Any HTN Pre-eclampsia Gestational
Any HTN 21% (1 in 5) 20% (1 in 5) 22% (1 in 5)
Pre-eclampsia 14% (1 in 7) 16% ( 1in 6) 7% (1 in14)
Gestational HTN 9% (1 in 11) 6-12% (up to 1
in 8)
11-15% (up to
1 in 7)
Chronic HTN N/A 2% (1in 50) 3% (up to 1 in
34)
1.10 ADVICE
LONG TERM CARDIOVASCULAR RISK
Type of Hypertension
Risk of
cardiovascular
Disease
Any HTN Pre-eclampsia Gestational Chronic
Major adverse
event
2x 1.5-3x 1.5-3x 1.7x
Cardiovascular
mortality
2x 2x No data No data
Stroke 1.5x 2-3x ? increased 1.8x
Hypertension 2-4x 2-5x 2-4x N/A
1.10 ADVICE
HOW DO WE REDUCE RISK?
• Advise to see GP or specialist to discuss, consider:
• Avoid smoking
• Maintain healthy lifestyle
• Maintain healthy weight (target BMI 18.5-24.9)
• Other considerations:
• Likelihood of recurrence increases if interbirth interval >10 years
• Re. long term risk of end-stage kidney disease, low risk if no HTN or
proteinuria at 6-8 week check
• Pre-pregnancy counselling for women who delivered <34/40 due to HDP
SUMMARY
NICE GUIDELINE
NG133 2019
WHAT HAS CHANGED?
• Definition of Pre-eclampsia
• Lower threshold to initiate treatment: 140/90 mmHg
• Lower Target BP: 135/85 mmHg or less
• Categories of hypertension:
• simplified to hypertension and severe hypertension (vs mild / moderate /severe)
• 24 hour urine collection no longer recommended
• Individualised risk assessment: Place of care
• Pharmacological management now reflects treatment for adults but
adapted for breastfeeding women
• Includes recurrence rates and long term cardiovascular risks
WHAT DO WE NOT KNOW?
• Which Drug (AN)?
• In women who need treatment for chronic hypertension in pregnancy, what is the
effectiveness and safety of antihypertensive agents (compared in head-to-head trials) in
improving maternal and perinatal outcomes?
• In women who need treatment for hypertension in pregnancy, what are the adverse neonatal
outcomes associated with maternal use of beta blockers (or mixed alpha-beta blockers)?
• Which Drug (PN)?
• In women who need treatment for high blood pressure after birth, what is the effectiveness
and safety (including in breastfeeding women) of antihypertensive agents in achieving adequate
blood pressure control?
• Place of care?
• In which women with pre-eclampsia is inpatient management associated with better outcomes
for women and babies?
TO CONCLUDE
• Patient information and involvement
• New thresholds for treatment
• PN follow up and communication
• Appropriate referrals
• Professional education and awareness
FOOTNOTES
Optimal aspirin dosing for preeclampsia prevention
Anna Lene Seidler, MSc, Lisa Askie, PhD
American Journal of Obstetrics & Gynecology
Volume 219, Issue 1, Pages 117-118 (July 2018) DOI: 10.1016/j.ajog.2018.03.018
Copyright © 2018 Elsevier Inc. Terms and Conditions
Figure
American Journal of Obstetrics & Gynecology 2018 219, 117-118DOI: (10.1016/j.ajog.2018.03.018)
Copyright © 2018 Elsevier Inc. Terms and Conditions