Dr Chris Sexton
FRANZCOG
Acknowledgements
 SOUTH AUSTRALIAN GP OBSTETRIC SHARED
CARE PROTOCOLS
 SA PERINATAL GUIDELINES – Hypertensive
Disorders in Pregnancy
 Based on 10 SC patients per year
Case Study 1
 39 yo Primigravida
 Former model/ TV host/
Actress
 Partner of 13 years her
junior .
 Uncomplicated
pregnancy -”can’t
believe how fast her
bump is growing”
Case Study 1
 34 weeks –puffy but otherwise well
 Good growth and good FM
 Blood pressure 150-140/ 90-95
 Mild 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 1
 Women's Assessment
MW
 Registrar on Call
 Labour Ward
 Paediatric Reg
 2nd on Call
 3rd on Call
Case Study 1
 Tests
 Bloods: FBC, Electrolytes, Renal function tests and Liver
function tests
 Urine Protein /Creatinine Ratio (later sign)
 Review in 2 days
 4/5 chance then next BP is normal
Case Study 1
 Results 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 again
Send her to hospital day unit
Send to hospital for admission
Start her on anti hypertensive
Deliver 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 1
Kept at home, reviewed the next week
 35.5 weeks
 Still feels well
 BP 155/95
 Bloods show elevation of RFT
 Proteinuria now evident
Its all over now – It’s Preeclampsia!
Preeclampsia is a multi-system disorder unique to human
pregnancy characterised by hypertension and involvement of one or more other organ systems and/or the
fetus.
See 1 case very year or two
There is a reduction in blood flow to body organs
It will progress until delivery
35 Week Delivery
Definitions
 Gestational 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 hypertension
 Essential/secondary/white coat
Before 20 weeks, still there after 12 weeks
 Preeclampsia superimposed on chronic hypertension
Case Study 2
 29 yo Primip
 1 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 2
 36 weeks
 Vaguely unwell – back pain, sore abdomen, nausea
 Looks well
 Good fetal HR and movements
 BP 150/ 90 - 95. No proteinuria
 Blood tests and review in 2 days
Case Study 2
 Call from the Lab
 All her LFTS elevated
 Platelets 100
HELLP Syndrome (Haemolysis, Elevated LFTs and low
Platelets)
1% of pregnancies – 1 in 10 years
Straight to Hospital
Expect to be delivered tonight
Always check LFTS!
Postnatal Care
 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 preeclampsia 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