King Edward Memorial Hospital

Obstetrics & Gynaecology

CLINICAL PRACTICE GUIDELINE

Hypertension in pregnancy: Medical management

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Contents
Medical Management ............................................................................2
Key Point................................................................................................................. 2
Definitions ............................................................................................................... 2
Recording Blood pressure in pregnancy ................................................................. 4
Classification of Hypertension in pregnancy ........................................................... 4
Risk Factors for Pre Eclampsia1, 16 ......................................................................... 6
Investigation Of New Onset Hypertension after 20 Weeks Gestation ..................... 6
Assessment of Severity in Pre Eclampsia ............................................................... 8
Management of pre-eclampsia and gestational hypertension...........8
Outpatient management ....................................................................................... 11
Inpatient management .......................................................................................... 11
Special management issues for hypertensive crises (BP of  170/110). .............. 11
Drug Therapy ........................................................................................................ 12
Fetal surveillance in pregnant women with hypertension ...............15
Eclampsia ............................................................................................ 15
Management of eclampsia .................................................................................... 15
Prevention of eclampsia in the woman with preeclampsia .................................... 16
Administration of Magnesium Sulphate ................................................................. 16
HELLP syndrome ................................................................................ 18
Management of HELLP Syndrome ....................................................................... 18
Chronic hypertension .........................................................................19
Baseline assessments .......................................................................................... 19
Oral Drug Therapy ................................................................................................ 20
Post-partum management of women with chronic hypertension ........................... 20
Chronic hypertension with superimposed preeclampsia ....................................... 20
Preconception counselling ................................................................ 21
Key points ............................................................................................................. 21
Significant risk factors for developing pre-eclampsia57.......................................... 21
Risk factors associated with preeclampsia6 .......................................................... 22
Women recommended to attend preconception counselling ................................ 22
Management Strategies for prevention of pre-eclampsia ...................................... 22
References .......................................................................................... 23

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 Hypertension: Medical management

Medical Management
Aim
The aim of this guideline is to standardise the approach to the management of
severe pre-eclampsia and eclampsia in the immediate pre- and post- delivery
interval in order to improve the outcome for the mother and child1.

Background
Hypertensive disorders during pregnancy occur in women with pre-existing primary
or secondary chronic hypertension, and in women who develop new-onset
hypertension in the second half of pregnancy. Hypertensive disorders during
pregnancy carry risks for the woman and the baby. Although the rate of eclampsia in
the United Kingdom (UK) appears to have fallen, hypertension in pregnancy remains
one of the leading causes of maternal death in the UK2.
In Western Australia alone, Hypertension occurs in 4.0% of all pregnancies, 2.7 %
due to Pre-Eclampsia and 13.6% due to Essential Hypertension. 2.4 % of Perinatal
Deaths are due to Hypertension in pregnancy3, 4.

Key Point

Transfer to a tertiary setting is indicated for:

 All pre term pregnancies with severe pre eclampsia, eclampsia or HELLP
syndrome
 All term pregnancies complicated by eclampsia or HELLP syndrome
 Any pregnancy in which the health care provider believes his/her health care
facility would be unable to manage the complications of hypertension in
pregnancy.
Note: MgSO4 therapy should be considered prior to transfer in women with severe
pre eclampsia, eclampsia or HELLP syndrome5, provided that the women will be
accompanied in transfer by a Medical Practitioner (in case of respiratory
arrest).

Definitions

Hypertension in pregnancy6
1. Systolic blood pressure greater than or equal to 140 mmHg and/or
2. Diastolic blood pressure greater than or equal to 90 mmHg (Korotkoff 5)

These measurements should be confirmed by repeated readings over several

hours6.

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Normal pregnancy is characterized by a fall in blood pressure, detectable in the first

trimester and usually reaching a nadir in the second trimester. Blood pressure rises
towards pre-conception levels towards the end of the third trimester.
Detecting a rise in blood pressure from ‘booking’ or preconception blood pressure (>
30/15 mmHg), rather than relying on an absolute value, has in the past been
considered useful in diagnosing pre-eclampsia in women who do not reach systolic
blood pressures of 140 mmHg or diastolic blood pressures of 90 mmHg6. Available
evidence however, does not support the notion that these women have an increased
risk of adverse outcomes.7, 8 Nevertheless such a rise may be significant in some
women, particularly in the presence of hyperuricemia and proteinuria. Further data
are required and in the meantime, closer monitoring of pregnant women with an
increment in blood pressure of ≥30 mmHg systolic and/or 15 mmHg diastolic is
appropriate.

Severe hypertension in pregnancy

Systolic blood pressure greater than or equal to 170 mmHg and/or diastolic
blood pressure greater than or equal to 110 mmHg.

This represents a level of blood pressure above which the risk of maternal morbidity
and mortality is increased. It is generally acknowledged that severe hypertension
should be lowered promptly, albeit carefully, to prevent cerebral haemorrhage and
hypertensive encephalopathy6, 9. This degree of hypertension requires urgent
assessment and management. It is important to acknowledge that systolic as well as
diastolic hypertension increases the risk of cerebral haemorrhage.

White Coat Hypertension

Defined as hypertension in a clinical setting with normal blood pressure away from
this setting when assessed by 24 hour ambulatory blood pressure monitoring or
home blood pressure monitoring using an appropriately validated device. Women
with this condition present early in pregnancy with apparent chronic hypertension,
but their outcomes are better than those of women with true chronic hypertension.
They may generally be managed without medication by using repeated ambulatory
or home blood pressure monitoring. A small proportion will go on to develop
preeclampsia10.

Proteinuria
Defined as the urinary excretion of ≥0.3 g protein in a 24-hour specimen. This will
usually correlate with ≥30 mg/dL (≥1+ reading on dipstick) in a random urine
determination with no evidence of urinary tract infection9, 11.

Oedema
Oedema is no longer included in the definition of pre-eclampsia as it occurs equally
in women with and without this condition. Nevertheless rapid development of
generalised oedema should alert the clinician to screen for preeclampsia6.

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Recording Blood pressure in pregnancy

The woman should be seated comfortably with her legs resting on a flat surface. In
labour, the blood pressure may be measured in the left arm in lateral recumbency.
The supine posture should be avoided because of the supine hypotension
syndrome. Measurement of blood pressure should be undertaken in both arms at the
initial visit to exclude rare vascular abnormalities such as aortic coarctation,
subclavian stenosis and aortic dissection. Generally the variation in blood pressure
between the upper limbs should be less than 10 mmHg.
The systolic blood pressure is accepted as the first sound heard (K1) and the
diastolic blood pressure the disappearance of sounds completely (K5)(8-10). Where
K5 is absent, K4 (muffling) should be accepted. Correct cuff size is important for
accurate blood pressure recording. A large cuff with an inflatable bladder covering
80% of the arm circumference should be used if the upper arm circumference is
greater than 33 cm. This helps to minimise over-diagnosis of hypertension during
pregnancy 6, 12, 13.

Classification of Hypertension in pregnancy

This classification of the hypertensive disorders in pregnancy reflects the
pathophysiology of the constituent conditions as well as the risks and potential
outcomes for both mother and baby. The following clinical classification has been
adopted by numerous International and National bodies, differing predominantly in
whether they require proteinuria or not for the diagnosis of pre eclampsia. The
International Society for the Study of Hypertension in Pregnancy (ISSHP) guideline
no longer requires proteinuria for the diagnosis of pre eclampsia, leaving on the
British NICE guideline with this requirement17.

The classification is as follows:

 Preeclampsia – eclampsia
 Gestational hypertension
 Chronic hypertension
 essential
 secondary
 white coat
 Preeclampsia superimposed on chronic hypertension6, 14

Pre eclampsia
This is a multi-system disorder characterised by hypertension and involvement of
one or more other organ systems and/or the fetus. Raised BP is commonly but not
always the first manifestation. Proteinuria is also common but should not be
considered mandatory to make the clinical diagnosis6
Diagnosis can be made when:

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1. hypertension arises after 20 weeks gestation

2. accompanied by one or more of the following signs of organ involvement:
 Renal involvement
 Significant proteinuria – a spot urine protein / creatinine ration > 30mg /
mmol
 Serum or plasma creatinine greater than or equal to 90 micromol/L or
 Oliguria < 80mL / 4 hours
 Haematological involvement
 Thrombocytopenia < 100,000 /µL
 Haemolysis :schistocytes or red cell fragments on blood film, raised
bilirubin, raised lactate dehydrogenase > 600mIU/L, decreased haptoblobin
 DIC
 Liver involvement
 Raised transaminases
 Severe epigastric or right upper quadrant pain
 Neurological involvement
 Convulsions (Eclampsia)
 Persistent visual disturbances (photopsia, scotomata, cortical blindness,
posterior reversible encephalopathy syndrome, retinal vasospasm)
 Persistent, new headache
 Stroke
 Pulmonary oedema
 Fetal growth restriction (FGR)

Gestational hypertension
 New onset of hypertension arising after 20 weeks gestation
 No additional maternal or fetal features of preeclampsia
 Resolves within 3 months postpartum

The earlier the gestation at presentation and the more severe the hypertension, the
higher the likelihood of developing preeclampsia or an adverse pregnancy outcome 6, 14.

Chronic hypertension
Pre-existing hypertension is a strong risk factor for the development of preeclampsia
and requires close clinical surveillance.
1- Essential
BP greater than 140/90 mmHg preconception or prior to 20 weeks without an
underlying cause15
or

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BP less than 140/90 entering pregnancy on antihypertensives

2- Secondary

Hypertension due to:

 chronic kidney disease (e.g. glomerulonephritis, reflux nephropathy and adult
polycystic kidney disease)
 renal artery stenosis
 systemic disease with renal involvement (e.g. diabetes mellitus, systemic
lupus erythematosus)
 endocrine disorders (e.g. phaeochromocytoma, Cushing’s syndrome and
primary hyperaldosteronism)
 coarctation of the aorta

Preeclampsia superimposed on chronic hypertension

This is diagnosed when a woman with pre-existing hypertension develops systemic
features of preeclampsia, after 20 weeks gestation. Worsening or accelerated
hypertension should increase surveillance for preeclampsia but is not diagnostic.

Risk Factors for Pre Eclampsia1, 16

Moderate risk
 Age 40 years or more
 First pregnancy
 Multiple pregnancy
 Interval since last pregnancy of more than 10 years
 Body mass index of 35 or more at presentation
 Family history of pre-eclampsia

High risk
 Chronic hypertension
 Chronic kidney disease
 Hypertensive disease during a previous pregnancy
 Diabetes
 Autoimmune disease

Investigation Of New Onset Hypertension after 20 Weeks Gestation

Any woman presenting with new hypertension after 20 weeks gestation should be
assessed for signs and symptoms of preeclampsia. Initially assessment and
management in a day assessment unit may be appropriate. If features of
preeclampsia are detected, admission to hospital is indicated. The presence of
severe hypertension, headache, epigastric pain, oliguria or nausea and vomiting are

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ominous signs which should lead to urgent admission and management, as should
any concerns about fetal wellbeing.

Maternal
 The following investigations should be performed in all women with new onset
hypertension after 20 weeks gestation.
 Spot urine PCR
 FBP
 Urea, creatinine, electrolytes
 Liver function tests
 Ultrasound assessment of fetal growth, amniotic fluid volume and umbilical
artery Doppler assessment
If features of preeclampsia are present, additional investigations should include:
 Urinalysis for protein and urine microscopy on a carefully collected mid-
stream urine sample.
 If there is thrombocytopenia or a falling haemoglobin, investigations for
disseminated intravascular coagulation and / or haemolysis are indicated
Table 1
Test Age Levels deemed to be
Group elevated (KEMH Lab)
LDH >16 years > 618u/L
ALT >15 years > 35 u/L
AST >15 years > 32 u/L
Uric Acid >15 years > 0.36 mmol/L

Notes:
 Patients with severe early onset preeclampsia warrant investigation for
associated conditions e.g. systemic lupus erythematosus, underlying renal
disease, antiphospholipid syndrome or thrombophilias. The timing of these
investigations will be guided by the clinical features.
 Acute Fatty Liver can also present itself as HELLP syndrome.
 Although a very rare disorder, undiagnosed phaeochromocytoma in
pregnancy is potentially fatal and may present as preeclampsia17, 18 .
Measurement of fasting plasma free metanephrines/normetanephrines or 24
hour urinary catecholamines should be undertaken in the presence of very
labile or severe hypertension.
 Subsequent management will be based on the results of ongoing blood
pressure measurement and these investigations – see table 2 below6
 Amongst women referred for assessment of new onset hypertension, a
number will have normal blood pressure and investigations. These women are

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considered to have transient or labile hypertension. Repeat assessment

should be arranged within 3-7 days as many will subsequently develop pre-
eclampsia
Table 2 Ongoing Investigation of women with hypertension in pregnancy

Classification Modality Frequency

Chronic Hypertension Urinalysis for protein* Each visit

Pre Eclampsia bloods If sudden increase in BP or
new proteinuria
Gestational Hypertension Urinalysis for protein 1-2 x per week
Pre Eclampsia bloods Weekly

Pre Eclampsia Urinalysis for protein At time of diagnosis: if non-

proteinuric, repeat daily
Pre Eclampsia bloods Twice weekly or more
frequent if unstable

Assessment of Severity in Pre Eclampsia

All patients with pre eclampsia must be regarded as being at risk of major maternal
and fetal complications. However, there are certain indicators of particular concern
when they occur in a woman with definite pre eclampsia:
 HELLP syndrome – any component (see section on HELLP Syndrome Page 14)
 Severe hypertension refractory to usual treatment
 Renal impairment – creatinine greater than 106µmol/L
 Pulmonary oedema
 Persistent neurological symptoms – headache / altered mental state / clonus
 “Pre eclamptic angina” – severe epigastric pain and/or vomiting with abnormal
liver enzymes
 Fetal growth restriction
Pre eclampsia usually pursues a course of deterioration, sometimes slowly and
sometimes quickly. It may evolve from mild to moderate to severe over a period of
hours or days, and requires frequent reassessment by medical staff.

Management of pre-eclampsia and gestational

hypertension
Preeclampsia is a progressive disorder that will inevitably worsen if pregnancy
continues. Current therapy does not ameliorate the placental pathology nor alter the

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pathophysiology or natural history of preeclampsia. Delivery is the definitive

management and is followed by resolution, generally over a few days but sometimes
much longer. Obstetric consultation is mandatory in all women with severe pre
eclampsia. In those women with preeclampsia presenting at extreme preterm
gestations consultation with KEMH should be arranged. At mature gestational age,
delivery should not be delayed. Even so, it is important to control severe
hypertension and other maternal derangements before subjecting the woman to the
stresses of delivery6.
Prolongation of pregnancy in the presence of preeclampsia carries no benefit for the
mother but is desirable at early gestations to improve the fetal prognosis as in
general, fetal outcome is proportional to gestational age at delivery18. In cases of
preterm preeclampsia before 34 weeks, delivery should be delayed for at least 24-48
hours if maternal and fetal status permit, to allow fetal benefit from antenatal
corticosteroids administered for lung maturation19. Continuation of pregnancy carries
fetal risk and some stillbirths will occur despite careful monitoring.
The management of women with preeclampsia between gestational ages of 24-32
weeks should be restricted to those centres with appropriate experience and
expertise. Clear “endpoints” for delivery should be defined for each patient (Table 3),
such that the decision to terminate the pregnancy is based on agreed criteria. In
many cases, the timing of delivery will be based upon a number of factors, maternal
and/or fetal rather than a single absolute indication for delivery.

In the presence of HELLP syndrome, expectant management is harmful with a 6.3%

incidence of maternal death and an increased risk or placental abruption. In such
cases delivery should be planned as soon as feasible.

Table 3 Indications for delivery in women with preeclampsia or gestational

hypertension6

Maternal Fetal
Gestational Age >37weeks Severe fetal growth restriction
Inability to control hypertension Non-reassuring fetal status
Deteriorating platelet count
Deteriorating liver function
Deteriorating renal function
Placental abruption
Persistent neurological symptoms
Eclampsia
Persistent epigastric pain, nausea or
vomiting with abnormal liver function tests

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Acute pulmonary oedema

Table 4 Timing of Delivery and gestation of presentation of preeclampsia

Gestation Pre-viable 23 – 31+6 32 – 36+6 37+ 0

at onset <23 onwards
weeks

Aim to prolong Plan delivery on

Consult with Consult and pregnancy best day in best
KEMH: likely to transfer to where possible, way
need KEMH: likely to deliver in an
Delivery termination of need preterm institution with
Plan pregnancy or delivery. Aim to appropriate
extreme prolong paediatric care.
preterm pregnancy
delivery. where possible.
High risk
patient

Except in the situation of acute fetal compromise, urgent delivery is not helpful in pre
eclampsia and the mother must be resuscitated before being subjected to the
delivery process. Therefore, in severe pre eclampsia, delivery must always be
preceded by:
 control of severe hypertension
 attention to fluid status
 correction of coagulopathy (usually thrombocytopenia)
 control of eclampsia, or prophylaxis against eclampsia if indicated (see below)

A team approach, involving obstetrician, midwife, neonatologist, anaesthetist and

physician provides the best chance of achieving a successful outcome for mother and
baby. Regular and ongoing reassessment of both the maternal and fetal condition is
required. Careful daily assessment for clinical symptoms and signs should be
complemented by regular blood and urine tests as indicated (Table 1 and 3).

The only controlled studies of bed rest for preeclampsia have shown no significant
maternal or fetal benefit20 . However, admission to hospital allows close supervision
of both mother and fetus as progress of the disorder is unpredictable. Outpatient
monitoring may be appropriate in milder cases after a period of initial observation.

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Outpatient management
Women with mild gestational hypertension can be cared for at home, in as long as:
 there are no obstetric contraindications
 there are no geographic contraindications
 there is no evidence of fetal compromise
 the patient has her blood pressure monitored regularly either at home by a
visiting midwife with obstetrician back up or in MFAU 21
 the patient visits the clinic 1-2 times per week
Note: Any evidence of maternal and or fetal compromise or failure to respond to
outpatient treatment requires hospitalisation.

Inpatient management

Maternal
 Evaluate patient to determine if the admission should be to Labour and Birth
Suite or to the ward.
 Perform baseline laboratory evaluations (FBP, Serum creatinine, LDH, ALT,
AST, Uric Acid and PCR)
 Review by obstetric registrar/ Consultant, at least daily (including weekends and
public holidays) to evaluate the patient for evidence of maternal deterioration
(headaches, visual changes, or epigastric distress)

Fetal
 Fetal surveillance by biophysical Profile, Doppler studies and cardiotocography
as appropriate.
 Administer betamethasone 11.4 mg IM x 2 doses, 24 hours apart, if appropriate.
Corticosteroid therapy in pregnancies between 23 and 36+6 weeks accelerates
fetal lung maturity, decreases Respiratory Distress Syndrome (RDS),
intraventricular haemorrhage (IVH) and the risk of fetal death in these
pregnancies.

Special management issues for hypertensive crises (BP of 

170/110).
 Admit to the Adult Special Care Unit/Labour and Birth Suite for close observation
and antepartum care. Manage in the Adult Special Care Unit postpartum until the
crisis has resolved.
 Evaluate and stabilize with frequent maternal and continuous fetal surveillance.
 Consider MgSO4 therapy for seizure prophylaxis.
Magnesium sulphate should be considered for women with pre-eclampsia for
whom there is concern about the risk of eclampsia. This is usually in the context
of severe pre-eclampsia once a delivery decision has been made and in the

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immediate postpartum period. In women with less severe disease the decision is
less clear and will depend on individual case assessment1.
 Anaesthesia: May consider epidural/spinal anaesthesia if maternal platelet count
is > 100,000 and platelet function is normal.

Drug Therapy

Antihypertensive Therapy
Evidence suggests that antihypertensive drug therapy confers no clear benefit to
women with mild pre eclampsia22-24. Randomized control trials of women with mild
pre eclampsia remote from term, which compared antihypertensive drug therapy with
no medication or a placebo, have been reported. In some of these trials, the
frequency of proteinuria, progression to severe disease, and neonatal respiratory
distress syndrome were higher in the women not treated.25-28 These observations
however have not been confirmed in other trials.29-31
In the absence of compelling evidence, treatment of mild to moderate hypertension
in the range 140-160/90-100 mm Hg should be considered an option and will reflect
local practice. Above these levels, treatment should be considered mandatory6.

In women with severe pre eclampsia, or those who have received treatment for
hypertensive crisis, maintenance control of BP is essential to reduce the risk of
cerebral events and to prolong the pregnancy for fetal benefit where possible.
However, the maternal blood pressure must not be lowered too drastically because
inadequate placental perfusion may occur where placental circulation has adapted to
a higher blood pressure.

Acute Treatment of Severe Hypertension

Antihypertensive treatment should be commenced in all women with a systolic blood
pressure ≥170 mm Hg or a diastolic blood pressure ≥110 mm Hg because of the risk
of intracerebral haemorrhage and eclampsia 22. Whilst there is no controlled trial to
determine how long severe hypertension may be left untreated, it is recommended
that treatment be administered promptly aiming for a gradual and sustained lowering
of blood pressure.
A recent systemic review of the literature regarding antihypertensive agents used for
the management of severe hypertension acknowledged that each medication had
benefits and risks.56 Both intravenous and oral agents may be used depending on
the clinical situation.
The agent of choice for the acute treatment of hypertension is oral nifedipine. This is
administered as a 10mg oral dose initially, with a repeat dose of 10mg if there is
inadequate response after 30 minutes. Headache is frequently a side effect.

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Intravenous labetalol is the agent of choice for intravenous administration. This is

administered as a 20-80mg bolus dose over 2 minutes. Associated side effects may
be bradycardia, bronchospasm and headache.

The third agent of choice is hydralazine. This is administered as an intravenous or

intramuscular dose of 5-10mg every 20-30 minutes to control hypertension of >170
systolic and / or 110 diastolic.

Table 4 - Acute blood pressure lowering for severe hypertension32-35

Medication Dose Route Onset of action

Nifedipine 10mg IR tablet Oral 30-45 minutes. Repeat after 45
Maximum 40mg minutes if response is
inadequate
Labetalol 20-80mg IV bolus over 2 Maximal effect usually occurs
minutes. within 5 minutes of each dose.
Max 80mg/dose36 Repeat every
10 minutes prn
Hydralazine 5-10mg IV bolus over 2 20 minutes. May be repeated
(First dose 5mg if minutes after 20 minutes.
fetal IM injection
compromise)

Diazoxide 15-45mg Rapid IV bolus 3-5 minutes , repeat after 5

Max 300mg total minutes

Note: Blood pressure should not be allowed to fall below a level of 140/80.

Ongoing treatment for hypertension

In terms of lowering blood pressure in preeclampsia, a number of drugs have
demonstrated safety and efficacy (Table 4). First line drugs include methyldopa, and
labetalol 37-39. Second line agents are hydralazine, nifedipine and prazosin40-43.
Angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers
are contraindicated in pregnancy. Their use in the third trimester has been
associated with fetal death and neonatal renal failure. All of the drugs in Table 4
along with enalapril, captopril and quinapril are considered compatible with
breastfeeding 44.

Antihypertensive therapy should be considered:

 When the SBP  150 mm Hg at least twice in a 24 hour period separated by
four hours.
 When DBP  95 mm Hg at least twice in a 24 hour period separated by four hours
 Following the acute treatment of severe hypertension (170/110) 22

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Table 5. Guidelines for selecting antihypertensive drug treatment in pregnancy6

Drug Dose Action Contraindications Practice points

Methyldopa 250-750 mg Central Depression Slow onset of action
tds over 24 hrs. Dry
mouth, sedation,
depression, blurred
vision.
Withdrawal
effects:rebound
hypertension

Labetalol 100-400 mg Β blocker Asthma, Chronic Bradycardia,

tds with mild airways limitation bronchospasm,
alpha headache, nausea,
vasodilator scalp tingling which
effect usually resolves
within 24-48 hrs
(labetalol only)

Nifedipine 20 mg SR Calcium Aortic Stenosis Severe Headache

once a day to channel associated with
a maximum antagonist flushing and
of 60mg SR tachycardia.
once a day Peripheral oedema,
constipation
Prazosin 0.5-5mg tds Alpha First dose effect-
blocker orthostatic
hypotension
Hydralazine 25-50 mg tds Vasodilator Flushing, headache,
nausea, lupus-like
syndrome

It is important to control severe hypertension at any gestation and post-partum.

Induction of labour or Caesarean section does not control hypertension even though
delivery begins the process of resolution of preeclampsia. Thus, antihypertensive
medication will usually be required even when delivery has been arranged 6.
When either of these has been unsuccessful, consider consultation with Obstetric
Physician. In some cases of severe hypertension, it is necessary to add a second or
even third agent.

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Fetal surveillance in pregnant women with hypertension

Hypertension Modality Frequency

Chronic  Early dating ultrasound  First trimester

hypertension  U/s for fetal growth /AFV/ doppler  3rd trimester: repeat as
indicated

Gestational  U/s for fetal growth / AFV/ doppler  At time of diagnosis and 3
hypertension – 4 weekly

Preeclampsia  U/s for fetal growth/ AFV/ doppler  At time of diagnosis.

+ / - fetal growth Subsequent frequency is
restriction  Cardiotocography dependent on the clinical
progression of the disease.

AFV = Assessment of amniotic fluid volume

Eclampsia
Eclampsia remains rare in Australia. There are no reliable clinical markers to predict
eclampsia and conversely, the presence of neurological symptoms and/or signs is
rarely associated with seizures6, 45. Seizures may occur antenatally, intra-partum or
postnatally, usually within 24 hours of delivery but occasionally later. Hypertension
and proteinuria may be absent prior to the seizure and not all women will have
warning symptoms such as headache, visual disturbances or epigastric pain 46.
The further from delivery that the seizure occurs, the more carefully should other
diagnoses be considered. Cerebral venous thrombosis in particular may occur in the
first few days of the puerperium. It should be remembered that eclampsia is not the
commonest cause of seizures in pregnancy and the differential diagnosis includes
epilepsy and other medical problems that must be considered carefully, particularly
when typical features of severe preeclampsia are lacking.

Management of eclampsia
There are four main aspects to care of the woman who sustains eclampsia 6.

1. Resuscitation
Resuscitation requires institution of intravenous access, oxygen by mask,
assuring a patent airway and institution of intravenous access6. Intravenous
Midazolam (0.1 – 0.2mg /kg IV or IM) may be given if the seizure is long.

Intravenous Magnesium Sulphate is the agent of choice.

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See Loading dose- 4gm over 20 mins (rate 150 mL/hr for 20 mins only = 50mL).

2. Prevention of further seizures

Following appropriate resuscitation, treatment should be continued with
Magnesium Sulphate.

Ref. Administration of Magnesium sulphate

3. Control of hypertension
Control of severe hypertension to levels below 160/100 mmHg by parenteral
therapy is essential as the threshold for further seizures is lowered after
eclampsia, likely in association with vasogenic brain oedema. In addition, the
danger of cerebral haemorrhage is real.

4. Delivery
Arrangements for delivery should be decided once the woman’s condition is
stable. In the meantime, close fetal monitoring (continuous CTG) should be
maintained. There is no role, with currently available treatment, for continuation of
pregnancy once eclampsia has occurred, even though many women may appear
to be stable after control of the situation has been achieved.

Prevention of eclampsia in the woman with preeclampsia

The drug of choice for the prevention of eclampsia is magnesium sulphate 47.
Although there is good evidence for the efficacy of this therapy, the case for its
routine administration in women with preeclampsia in countries with low maternal
and perinatal mortality rates is less than compelling48.

Evidence indicates that magnesium sulphate is the superior drug to use in the
prevention and the treatment of eclamptic seizures.18,19
In the patient with known renal disease or myasthenia gravis however, phenytoin
sodium is the anti-seizure medication of choice. Phenytoin sodium is administered in
a total dose of 15mg/kg at an infusion rate of 40mg/min with continuous cardiac and
blood pressure monitoring.

Administration of Magnesium Sulphate

See Clinical Guideline Magnesium Sulphate Anticonvulsant Therapy
Magnesium Sulphate should not be prescribed for the prevention of eclampsia
without discussion with the Consultant Obstetrician on call.
Magnesium sulphate therapy is recommended for use antepartum, intrapartum and
within the first 24 hours postpartum for severe pre eclampsia (as defined on page 2)
when the following factors are present:

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 persistently elevated blood pressure despite adequate hypotensive therapy

and appropriate fluid management,
 evidence of CNS dysfunction, thrombocytopenia or liver disease 2, 5, 15.

Before discontinuation of MgSO4 therapy:

 the blood pressure should be stable (consistently below 150/100)
 the patient should have adequate diuresis
 the patient should be clinically improved (absence of headache, epigastric pain).

Postpartum Management
 Monitor the patient in the Adult Special Care Unit49 or Labour and Birth Suite until
she begins to recover.
 Continue magnesium sulphate until stabilisation and adequate diuresis is
achieved.
 Antihypertensive therapy should be commenced if the BP is >150 mmHg
systolic or >100 mmHg diastolic in the first four postpartum days. Options for
antihypertensive therapy include:
o Labetalol 100mg TDS to start
o Atenolol 50mg daily. On rare occasions, may need increasing to
100mg/day.
o Nifedipine SR 20mg BD to start.
o Enalapril 5-10mg daily.

Resolution of preeclampsia
After delivery, all clinical and laboratory derangements of preeclampsia recover, but
there is often a delay of several days, and sometimes longer, in return to normality.
On the first day or two after delivery, liver enzyme elevations and thrombocytopenia
will often worsen before they reverse. Hypertension 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. The woman and her
family are often overwhelmed and distressed from their experience and appropriate
counselling post partum should include psychological and family support.
All women who develop preeclampsia and gestational hypertension are at risk of
these disorders in future pregnancies and should receive appropriate counselling
before embarking upon another pregnancy6.

NOTE: Magnesium Sulphate may also be used antenatally prior to preterm birth for
Neuro Protection of the fetus post birth- to reduce the incidence of cerebral palsy.
See Preterm Birth guideline

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HELLP syndrome
HELLP Syndrome is a variant of severe preeclampsia (Haemolysis, Elevated Liver
enzymes and Low Platelet) count. Maternal mortality is reported to be as high as 1-
2%
The elements of this variety of severe pre eclampsia are:
 thrombocytopenia (common)
 haemolysis (rare) and
 elevated liver enzymes (ALT, LDH - common).

Epigastric or right upper quadrant pain in a woman with preeclampsia often

represents hepatic involvement. This is called ‘Pre eclamptic Angina’ 43. The pain
responds poorly to analgesia but both the pain and associated increases in liver
enzymes (AST, ALT) may subside (albeit temporarily) after blood pressure lowering,
particularly with vasodilators. If the cause of epigastric or right upper quadrant pain is
not clear, close ongoing assessment is required, with careful review of all indicators
of maternal and fetal wellbeing and appropriate imaging of the liver and gallbladder 6.
Thrombocytopenia is the commonest hematologic abnormality seen in preeclampsia;
the lower limit of the normal platelet count in pregnancy is approximately 140x10 9/L
but the risk of spontaneous bleeding is not significantly increased until the count falls
below 50 x 109/L. Even so, there are concerns with central neuraxial anaesthesia
and analgesic techniques at higher levels (50-75 x 109 /L), and surgical bleeding
may be increased even with moderate thrombocytopenia6.

In a woman with pre eclampsia, the presence of any one of the following is an
indicator of severe disease, even if not suggested on other criteria such as
severity of hypertension:
 a maternal platelet count of <100,000 x 10 9/L
 a transaminase level or LDH more than double the normal upper limit
 haemolysis of any quantity

Management of HELLP Syndrome

Antenatal management
If the platelet count is sufficiently low to present a hazard for operative delivery, a
platelet transfusion should be considered6 (consult with Consultant Haematologist or
Obstetric Physician).

Postpartum management
If there is significant bleeding attributed to pre-eclamptic thrombocytopenia at any
time in the puerperium a platelet transfusion should be given6 (consult with
Consultant Haematologist or Obstetric Physician).

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In the absence of bleeding, consider a platelet transfusion in the first 72 hours only if
the count falls below 40,000 and there is concern of possible bleeding (e.g. after
Caesarean Section).
If the count remains below 40,000 after 72 hours from delivery without significant
bleeding and without sign of impending recovery, consultation with the Consultant
Haematologist or Obstetric Physician is indicated.

Chronic hypertension
Hypertension affects up to 13.6% of the West Australian adult population4, the
prevalence increasing with age. The diagnosis can be difficult in women whose
blood pressure before pregnancy or early in the first trimester is unknown. Very
rarely preeclampsia can present before 20 weeks’ gestation and the physiological fall
in blood pressure in the second trimester can obscure pre-existing chronic
hypertension6.
Women with chronic hypertension have an increased risk of accelerated
hypertension in the third trimester, superimposed preeclampsia, fetal growth
restriction, placental abruption, premature delivery and stillbirth. These events are
seen more often in women who develop preeclampsia and are not correlated with
actual blood pressure levels37, 45. The exception to this appears to be uncontrolled
hypertension in the first trimester when later fetal and maternal morbidity and
mortality are markedly increased 9. Other indicators of poor prognosis include a
failure of blood pressure to normalize in the second trimester, the presence of
secondary hypertension, a history of longstanding severe hypertension, and
concurrent cardiovascular and/or renal disease.
The woman with chronic hypertension, whether essential or secondary, should be
observed frequently during pregnancy by an obstetrician and by a physician familiar
with the management of hypertension in pregnancy6.
Benefits of therapy for the treatment of mild chronic hypertension in pregnancy have
not been proven. In general, treatment is considered when systolic blood pressure
exceeds 150 mm Hg and/or diastolic pressure exceeds 95 mm Hg on several
occasions. Possible benefits include reduction in hospital admission (when the
hypertension is not due to pre-eclampsia) and prolongation of gestation when
uncontrolled hypertension would result in delivery. For agents used, see below.

Baseline assessments

Maternal
 Ophthalmic examination.
 Spot urine protein: creatinine ratio where there is doubt about proteinuria on
dipstick, i.e., +1 or +2 proteinuria.
 Serum electrolytes.
 ECG (if not done recently).
 24 hour urine catecholamines if there is severe hypertension.

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 Hypertension: Medical management

Fetal
 Baseline ultrasound for the assessment of fetal anatomy.
 Follow-up ultrasound at 26-28 weeks.
 From 28 weeks, ultrasound every 2-3 weeks to evaluate fetal growth.
 Weekly non-stress tests from 30 weeks.

Oral Drug Therapy

Methyldopa: a centrally acting adrenergic agonist is the most commonly prescribed
medication for the treatment of hypertension in pregnancy. Start at a
dose of 250mg TDS, increasing to a maximum of 750mg TDS as
required.
Labetalol: is an alpha and beta-blocking agent. Commence at a dose of 100mg
TDS, increasing up to 400 mg TDS as required
Nifedipine: a calcium channel blocker that can be used in acute hypertensive
situations. Nifedipine may be added as a second line agent to either
labetalol or methyldopa. Commence at 20mg SR once a day increasing
to a maximum dose of 60mg SR once a day as required.

Atenolol and other highly selective beta blocker drugs are not recommended for
prolonged use in pregnancy as they have been associated with fetal growth
restriction39, 50, 51. The use of ACE-inhibitors and angiotensin receptor blockers is
contraindicated in pregnancy. They have been associated with an increased risk of
fetal, particularly cardiovascular, malformations in early pregnancy in one study and
are known to cause adverse sequelae for the fetus in late pregnancy52 . Diuretics,
although not teratogenic, may restrict the natural plasma volume expansion of
pregnancy and are not recommended for the treatment of hypertension.

Post-partum management of women with chronic hypertension

In many women with chronic hypertension or superimposed pre-eclampsia, blood
pressure is unstable for 1-2 weeks after delivery and may be difficult to control. It
may be particularly high on the third to the sixth day after delivery and it is often
necessary to increase or commence antihypertensive medication at that time. All of
the agents mentioned earlier are compatible with breast feeding, as are the ACE
inhibitors enalapril, captopril and quinapril6.

Chronic hypertension with superimposed preeclampsia

As already mentioned, the main risk of chronic hypertension in pregnancy is the
development of superimposed preeclampsia in the second half of pregnancy which
occurs in about 20% of women. This is of considerable concern as the risks to both
mother and fetus are greater than those of chronic hypertension alone. Management
of superimposed preeclampsia should be as outlined above for pre-eclampsia unless
specific diagnostic issues, such as some secondary causes of hypertension, are
present6. It is recommended that all women with a hypertensive complication of

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 Hypertension: Medical management

pregnancy have a postpartum hypertension follow-up. Depending on the severity of

the hypertension this follow-up should be 2-6 weeks after discharge from hospital.

Preconception counselling
For women with a history of, or significant risk factors for pre-eclampsia

Background
The risk of recurrence of pre-eclampsia depends on the presence of absence of risk
factors, gestational age at the time of onset, and the severity of pre-eclampsia in the
previous pregnancy13.

Pre-eclampsia complicates 2–3% of all pregnancies53 and the risk of recurrent pre-
conception Counsellingeclampsia in a second pregnancy was found to vary
according to the gestational age at delivery in the first pregnancy. The risk is
progressive, with the greatest risk attributed to those women who were delivered
earliest in the previous pregnancy54.

Key points
1. All women with significant risk factors for developing pre-eclampsia planning a
future pregnancy should be counselled appropriately about risk factors,
symptoms and management53.
2. Women at significant risk of developing pre-eclampsia should be offered
calcium55 and low dose Aspirin53, 56 supplements.
3. Women planning a pregnancy who are at significant risk for developing pre-
eclampsia should receive preconception counselling by appropriate
obstetrician or obstetric physician.

Significant risk factors for developing pre-eclampsia57

It is likely that development of preeclampsia requires a combination of underlying
susceptibility and a triggering event. Many susceptibility factors for preeclampsia
have been identified (see Table below) but to date no accurate predictive tool, using
either clinical or laboratory markers, has been developed58. Such a tool applied early
in pregnancy would allow intervention that might modify outcomes 6.

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 Hypertension: Medical management

Risk factors associated with preeclampsia6

Risk Factor Relative Risk [95% CI]

Previous history of pre-eclampsia 7.19 [5.85, 8.83]
Antiphospholipid antibodies 9.72 [4.34, 21.75]
Pre-existing diabetes 3.56 [2.54, 4.99]
Multiple pregnancy 2.91 [2.04, 4.21]
Nulliparity 2.91 [1.28, 6.61]
Family history of pre-eclampsia 2.90 [1.70, 4.93]
Elevated BMI >25 2.47 [1.66, 3.67]
Maternal age ≥ 40 1.96 [1.34, 2.87]
Diastolic BP ≥ 80mmHg at booking 1.38 [1.01, 1.87]

A number of other factors are also associated with an increased risk of preeclampsia
including chronic hypertension, pre-existing renal disease, autoimmune disease, >10
years since previous pregnancy, short sexual relationship prior to conception, other
thrombophilias e.g. Factor V Leiden and possibly periodontal disease12, maternal
age < 20 yrs or ≥ 35 yrs4, 13.

Women recommended to attend preconception counselling

(or as early as possible if pregnant)

Preconception counselling and early pregnancy referral6 to KEMH is recommended

for women with:
 a history of pre-eclampsia prior to 34 weeks gestation or severe early onset pre-
eclampsia < 28 weeks gestation.
 thrombophilias12 (acquired or congenital)
 severe pre-gestational diabetes (Type 1 or Type 2)
 connective tissue disease e.g. systemic lupus erythematosus 12(SLE),
rheumatoid arthritis
 chronic renal disease12

Management Strategies for prevention of pre-eclampsia

Calcium Supplementation
Calcium supplement supplementation appears to almost halve the risk of pre-
eclampsia and reduces the rare occurrence of the composite outcome ‘death or
serious morbidity’ 55. There were no other clear benefits, or harms.

Offer all women at increased risk of pre-eclampsia (particularly women with a low
dietary calcium intake) calcium supplements of 1200mg – 2000mg daily.

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 Hypertension: Medical management

Low Dose Aspirin

Low dose aspirin (100mg) has moderate benefits when used for prevention of pre-
eclampsia and its consequences, and is safe to use in pregnancy56. In view of this
potential benefit, and the relative absence of maternal or neonatal complications, low
dose aspirin is indicated for the secondary prevention of pre-eclampsia in women at
increased risk. In most cases, aspirin may be ceased at 37 weeks gestation
although continuation beyond this period is not unsafe.

Use of Clexane with Aspirin

Clexane is used with aspirin2 for patients with Antiphospholipid syndrome in
consultation with the Maternal Fetal Medicine specialist or the Obstetric Physician.

Antioxidants59
Vitamin C, vitamin E48, 53, 60, Fish Oil, Selenium and Lycoprene provide no benefit59.

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Related WNHS policies, procedures and guidelines

Hydralazine
Hypertension in Pregnancy: Midwifery Care
Magnesium Sulphate Infusion

Keywords: Hypertension, pre-eclampsia, PE, eclampsia, convulsions, HELLP,

thrombocytopenia, platelets, magnesium sulphate, hydralazine, labetalol,
nifedipine, diazoxide, methyldopa, gestational, fetal, chronic hypertension,
hypertension in pregnancy, preconception counselling
Document owner: OGID
Author / Reviewer: A / Medical Director Obstetrics
Date first issued: November 2003 (Medical Management) & April 2012 (Preconception Counselling)
Last reviewed: January 2015 (amend Aug 2016 & Nov 2017) Next review date: January 2018

Obstetrics & Gynaecology Page 26 of 27

 Hypertension: Medical management

Endorsed by: OGID Management Committee Date: 20.9.2016

Standards Applicable: NSQHS Standards: 1 Clinical Care is Guided by Current Best Practice
4- Medication Safety; 9 Clinical Deterioration,
Printed or personally saved electronic copies of this document are considered uncontrolled.
Access the current version from the WNHS website.

Obstetrics & Gynaecology Page 27 of 27