Education presentation: Hypertensive disorders of pregnancy · Learning outcomes . The participant...
Transcript of Education presentation: Hypertensive disorders of pregnancy · Learning outcomes . The participant...
Translating evidence into best clinical practiceTranslating evidence into best clinical practice
Queensland Health
Hypertensive disorders of pregnancy
45 minutes
Towards CPD Hours
Clinical Guideline Presentation v2.0
References: The Queensland Clinical Guideline Hypertensive disorders of pregnancy is the primary reference for this package. Recommended citation: Queensland Clinical Guidelines. Hypertensive disorders of pregnancy clinical guideline education presentation E15.13-1-V2-R20 Queensland Health. 2015. Disclaimer: This presentation is an implementation tool and should be used in conjunction with the published guideline. This information does not supersede or replace the guideline. Consult the guideline for further information and references. Feedback and contact details: M: GPO Box 48 Brisbane QLD 4001 | E: [email protected] | URL: www.health.qld.gov.au/qcg Funding:
Queensland Clinical Guidelines is supported by the Queensland Health, Healthcare Improvement Unit. Copyright: © State of Queensland (Queensland Health) 2016 This work is licensed under a Creative Commons Attribution Non-Commercial No Derivatives 3.0 Australia licence. In essence, you are free to copy and communicate the work in its current form for non-commercial purposes, as long as you attribute the Queensland Clinical Guidelines Program, Queensland Health and abide by the licence terms. You may not alter or adapt the work in any way. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/3.0/au/deed.en For further information contact Queensland Clinical Guidelines, RBWH Post Office, Herston Qld 4029, email [email protected], phone (+61) 07 3131 6777. For permissions beyond the scope of this licence contact: Intellectual Property Officer, Queensland Health, GPO Box 48, Brisbane Qld 4001, email [email protected], phone (07) 3234 1479. Images are property of State of Queensland (Queensland Health) unless otherwise cited.
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Learning outcomes
The participant will be able to outline, in relation to hypertensive disorders of pregnancy (HDP):
• Definitions and classification • Risk factors for and diagnosis of preeclampsia • Initial screening and testing recommendations • Treatment of moderate and severe hypertension • Indications for the use of Magnesium Sulfate • Management of eclampsia • Antenatal surveillance of mother and baby • Intrapartum and postpartum management • Discharge and follow-up advice
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Hypertension definitions
Term Definition
Hypertension sBP ≥ 140 and/or dBP ≥ 90 mmHg
Moderate Hypertension
sBP ≥ 141─159 and/or dBP ≥ 91─109 mmHg
Severe Hypertension
sBP ≥ 160 and/or dBP ≥ 110 mmHg
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Hypertension classifications
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Classification Definition
Gestational New onset after 20 weeks without features of preeclampsia
Preeclampsia Hypertension and involvement of one or more other organ systems and/or the fetus
Chronic hypertension in pregnancy (essential and secondary)
Hypertension confirmed pre-conception or prior to 20 weeks
Preeclampsia superimposed on chronic
Preexisting hypertension with systemic features of preeclampsia after 20 weeks gestation
Diagnosis of preeclampsia
• Raised BP is common but not always first manifestation
• Proteinuria is common but not mandatory for clinical diagnosis
• Pre-existing hypertension is a strong risk factor
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Features of Preeclampsia
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Organ/System Feature Proteinuria protein: creatinine ratio ≥ 30 mg/mmol
Renal serum or plasma creatinine ≥ 90 micromol/L or oliguria
Haematological thrombocytopenia, haemolysis, raised bilirubin, raised LDH, decreased haptoglobin, DIC
Liver raised transaminases, severe right upper quadrant pain
Pulmonary: pulmonary oedema
Uteroplacental fetal growth restriction
Neurological severe headache, visual disturbances, hyperreflexia convulsions (eclampsia), stroke
Risk assessment
• Assess all women with new hypertension after 20 weeks for signs and symptoms of preeclampsia
• The earlier the presentation and the more severe the hypertension, the higher is the likelihood of progression to preeclampsia
• Currently, no accurate predictive tool for preeclampsia
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Risk factors for preeclampsia • Antiphospholipid
syndrome • Previous history of
preeclampsia • BP > 130/80 at
booking • Pre-existing diabetes
• Multiple pregnancy • Renal disease • > 10 years since last
pregnancy • Chronic autoimmune
disease • Nulliparity • Chronic hypertension • Raised BMI • > 40 years of age
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Risk reduction • Assess all women for risk factors • If moderate to high risk, recommend
◦ Aspirin 100 mg daily before 16 weeks until 37 weeks or birth
• Advise women to seek advice immediately if they have signs and symptoms of preeclampsia
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Initial investigations
• Accurate BP measurement • Screen for proteinuria each visit (dipstick)
◦ Quantify if > 2+ or repeated 1+ proteinuria • Blood tests
◦ FBC, ELFT including LDH and urate • CTG and USS
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Moderate hypertension
• Consider drug therapy if: ◦ sBP 140-160 and/or dBP 90-100 mmHg ◦ Signs of preeclampsia are present
• Target BP: no clear evidence - suggested
◦ sBP < 140 mmHg and dBP < 90 mmHg
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Oral antihypertensive drugs
• ACE inhibitors and angiotensin receptor blockers are contraindicated in pregnancy
• First line drugs: ◦ Methyldopa, Labetalol, Oxprenolol
• Second line drugs: ◦ Hydralazine, Nifedipine, Prazosin,
Clonidine
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Severe hypertension
• Commence drug therapy if severe hypertension (sBP ≥ 160 or dBP ≥ 100 mmHg)
• Target BP– aim for gradual lowering ◦ sBP 130─150 mmHg / dBP 80─90 mmHg
• sBP ≥ 170 with or without dBP ≥ 110 mmHg is a medical emergency
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Preeclampsia
• Severity, timing, progression and onset unpredictable – lose surveillance required
• Birth is the definitive management • Increased severity indicated by
difficulty controlling BP, HELLP syndrome, impending eclampsia, worsening fetal growth and wellbeing
• Independent risk factor for VTE Queensland Clinical Guideline: Hypertensive disorders of pregnancy 15
Magnesium Sulfate
• Drug of choice for prevention and treatment of eclampsia
• Indications to commence: ◦ Eclampsia ◦ Severe preeclampsia ◦ Preeclampsia with ≥ one sign of CNS irritability ◦ Transfer to higher
service level required
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HELLP Syndrome
• Variant of severe preeclampsia • Includes:
◦ Thrombocytopenia (common) ◦ Haemolysis (rare) ◦ Elevated liver enzymes (common)
• Magnesium Sulfate may be indicated • Consider platelet transfusion • Plan birth if > 34 weeks gestation
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(Haemolysis Elevated Liver enzymes Low Platelet)
• Imminent eclampsia: ≥ 2 or more of following symptoms ◦ Frontal headache ◦ Visual disturbance ◦ Altered level of consciousness ◦ Hyperreflexia ◦ Epigastric tenderness
Imminent eclampsia
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Eclampsia
• Resuscitation DRSABCD • Goals of treatment
◦ Terminate the seizure ◦ Prevent reoccurrence ◦ Control hypertension ◦ Prevent maternal and fetal hypoxia
• Magnesium Sulfate is the anticonvulsant drug of choice
• Plan birth (if antepartum) asap Queensland Clinical Guideline: Hypertensive disorders of pregnancy 19
Ongoing surveillance
• Plan care and document in health record • Serial surveillance of maternal and fetal
wellbeing
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• Frequency, intensity and modality depends on individual clinical circumstances
• Incorporate holistic review of the fetus that includes USS, CTG and maternal wellbeing
Birth
• Multidisciplinary team approach • Except where there is acute fetal
compromise, stablise the woman before birth ◦ Control or prophylaxis against eclampsia ◦ Control severe hypertension ◦ Correct coagulapathy ◦ Attention to fluid status
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Timing and mode of birth
• Recommend vaginal birth unless CS indicated for other obstetric indications
• Moderate hypertension: ◦ If otherwise well expectant management
beyond 37 weeks • Preeclampsia:
◦ Dependent of severity and gestation • HELLP: Plan birth as soon as feasible
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Intrapartum monitoring
• Close clinical surveillance required • Minimum ½ hourly BP • Continuous CTG • IV access • Multidisciplinary involvement
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Intrapartum care
• 2nd stage: ◦ If BP is within target range: usual care ◦ If BP not responsive to initial drug therapy,
advise assisted/operative birth • 3rd Stage
◦ Active management as increased risk of PPH ◦ Do not give Ergometrine or Sytometrine
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Postpartum • Hypertension and pre/eclampsia may
develop for the first time postpartum • Continue close monitoring (4 hourly or
more frequently) • Ask frequently about the presence
of headaches, epigastric pain • Actively consider VTE prophylaxis
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Postpartum drug therapy
• Continue antenatal antihypertensives • Cease or reduce when hypertensive
changes are resolving ◦ Avoid abrupt withdrawal
• If BP persistently elevated start antihypertensives
• NSAID not recommended • Methyldopa associated with depression
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Discharge
• First and second line drugs are compatible with BF
• If taking ACE inhibitors, discuss contraception
• Recommend follow-up screening after 6 weeks to ensure resolution/ascertain need for ongoing care
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Discharge advice
• Advise to avoid smoking, maintain healthy weight and of the benefits of exercise
• Encourage overweight women to attain healthy BMI
• Discuss assessment for traditional cardiovascular risk markers (e.g. annual BP, serum lipids, blood glucose)
• Risk reduction for future pregnancy (e.g. Aspirin, change from ACE inhibitors)
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