[CG] Hypertension, antenatal & daycare guideline

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New Hypertension in Pregnancy
Chronic Hypertension outwith pregnancy

Criteria for referral :

  • BP ≥ 150/90mm Hg
  • DBP ≥90mmHg SBP ≥ 150mm Hg
  • 20 mmHg rise in diastolic BP and ≥ 1 + proteinuria
  • Epigastric pain and headache are potential red flag symptoms and merit medical review

Investigations of referrals

Note importance of Systolic BP (SBP)

  • Check BP Profile (BP x 3 at no less than 15 minute intervals)
  • Routine AN observations
  • Test urine using automated reagent strip reading device; if proteinuria ≥+1 then send urine for urinary Protein Creatinine Ratio (uPCR) for quantification

1. If Normotensive, asymptomatic, <2++proteinuria

  • Return to ANC (No medical review)

2. If initial BP ≥140/90 and proteinuria <+2: follow Table 1 for investigation / management

Table 1.

 

Mild
140-149/90-99mmHg

Moderate
150-159/100-109 mmHg

Severe
≥160/110 mmHg

Admit

No

No

Yes

 Treat BP

If treatment given in daycare, recheck BP in 45 mins

No

Oral Labetalol*

Aim for systolic <150mmHg,
diastolic 80-100mmHg

Oral Labetalol*

Aim for systolic <150mmHg,
diastolic 80-100mmHg

Follow-up BP review frequency

Not more than once / week; unless <32/40 at first review or “high risk” for pre- eclampsia – then twice weekly review

Twice a week

Four times a day

Test proteinuria (Automated strip reader or uPCR)

Each visit

Each visit

Daily

If significant proteinuria (≥+2 on strip or >30mg/mmol) develops then follow Table 2 (pre-eclampsia management)

Blood tests

Only routine AN blood tests

At initial visit: FBC, U&E, LFTs.

Subsequent visits: only if significant proteinuria develops

At presentation & then weekly: FBC,

U&E, LFTs

Scans

If abnormal result – inform consultant

If <34/40: growth, liquor volume, Doppler. If normal scan do not routinely repeat.

If ≥34/40 only scan if clinically indicated

If <34/40: growth, liquor volume, Doppler. If normal scan do not routinely repeat.

If ≥34/40 only scan if clinically indicated

Growth, liquor volume, Doppler. If normal then repeat fortnightly.

CTG monitoring

If not reassuring – inform consultant

Only perform if abnormal fetal activity or abnormal scan findings

Only perform if abnormal fetal activity or abnormal scan findings

Yes

Repeat if develops:

decreased fetal movement, abdominal pain, vaginal bleeding, deterioration in maternal condition

Delivery

By EDD

By EDD

From 37+0 weeks, earlier if indicated

Ideally, the woman’s consultant should be involved in the planning of her antenatal care.

3. If BP ≥140/90 with significant proteinuria (≥+2 on automated reagent strip testing or uPCR >30mg/mmol): follow Table 2 below.

Table 2: Investigation & management of pre-eclampsia  (gestational hypertension & significant proteinuria)

 

Mild 
140-149/90-99mmHg

Moderate
150-159/100-109 mmHg

Severe
≥160/110 mmHg

Admit

Yes

Yes

Yes

 Treat BP

If treatment given in daycare, recheck BP in 45 mins

No

Oral Labetalol*

Aim for systolic <150mmHg, diastolic 80-100mmHg

Oral Labetalol*

Aim for systolic <150mmHg, diastolic 80-100mmHg

BP measurements

At least 4 times / day

At least 4 times / day

4 hourly, depending on clinical circumstances

Test for proteinuria (Automated strip reader or uPCR)

Following initial quantification indicating significant proteinura (>30mg/mmol), do not repeat uPCR.

 Blood tests:

FBC, U&E, LFTs

Twice weekly

Three times a week

Three times a week

 Scans

If abnormal result – inform consultant

Growth, liquor volume, Doppler at diagnosis.

If normal - repeat fortnightly.

Growth, liquor volume, Doppler at diagnosis.

If normal - repeat fortnightly.

Growth, liquor volume, Doppler at diagnosis.

If normal - repeat fortnightly.

CTG monitoring

If not reassuring – inform consultant

Yes

Yes

Yes

Repeat if develops: decreased fetal movement, pain, vaginal bleeding, deterioration in maternal condition

Delivery

Offer delivery from 34+0 to 36+6 weeks depending on maternal / fetal condition, risk factors, availability of NNU cots

Recommend

delivery if ≥34+0 weeks once BP controlled / steroids complete (if appropriate)

Recommend delivery within 24-48 hours if ≥37+0 weeks

 

Inform the on call obstetric consultant of any woman requiring admission.

Antihypertensive treatment*

  • First line drug is Labetalol (unless contraindicated e.g. Asthma)

    Chronic Hypertensives may need small dose only therefore start them on 100 mg b.d. or t.i.d. (depending on build)
    New Hypertensives may be started at 200 mgs t.i.d.
    Stepwise incremental escalation may be employed to maximum of 300 mgs qid. It is at this point that Second line drugs may be considered, after discussion with senior obstetrician.
  • Second Line (as adjunct or when Labetalol contraindicated)

    Nifedipine Retard - 10 mg bd. May be increased incrementally to 20 mg bd.

    Methyldopa - Start at 250 mg bd. (Takes 48 hrs to maximum effect) Increase incrementally to 250mg qid then if necessary to 500mg qid.

 

Postnatal daycare review

  • Patients with PIH who were not on medication prior to discharge do not require daycare review.
  • Methyldopa should be stopped (changed to alternative medication if necessary) within 2 days of delivery due to the increased risk of postnatal depression.
  • Postnatal patients should have 3 BP checks within 1 hour and their medication reduced accordingly.
  • GP follow up suggested if more convenient for the patient.
  • Occasionally ACE inhibitors may be required POST-NATALLY ONLY
  • Occasionally "resistant" hypertensives may require review by Renal or Hypertension Physicians.
  • See separate post natal hypertension guideline.
References

NICE. Hypertension in pregnancy: diagnosis and management. [CG107] August 2010, last updated January 2011.  

Last reviewed: 26 June 2018

Next review: 01 July 2023

Author(s): Dr. V. Brace - Obstetric Consultant

Approved By: Obstetric Guideline Group