NICE - hypertension in pregnancy: diagnosis and management. 2019

Question 1

What are the “high” risk factors for pre-eclampsia

Answer 1

Hypertensive disease in a previous pregnancy
Chronic kidney disease
Autoimmune disease such as SLE or APS
Type 1 or 2 diabetes
Chronic hypertension

Question 2

What are the “moderate” risk factors for pre-eclampsia

Answer 2

Nulliparity
Age >40
Pregnancy interval more than 10 years
BMI >35 at booking
FHx of pre-eclampsia
Multiple pregnancy

Question 3

Who should aspirin be offered to?

Answer 3

Those with 1 high risk factor or 2 moderate risk factors.

Question 4

At which level (trace, 1+, 2+,3+) on dipstick, should PCR be used to quantify proteinuria?

Answer 4

1+ or more

Question 5

What is the diagnostic threshold for PCR ratio for significant proteinuria

Answer 5

30mg/mmol

Question 6

What is the diagnostic ratio for significant proteinuria if using albumin creatinine ratio

Answer 6

8mg/mmol

Question 7

What might be the effect of taking ACE-inhibitors or angiotensin II receptor antagonists in pregnancy

Answer 7

Associated with renal dysfunction, oligohydramnios, neonatal anuria, skull ossification defects.
Also with cardiovascular malformation, CNS malformation

Question 8

What may be the side effects of thiazides/thiazide like drugs if used in pregnancy

Answer 8

Lower birth weight,
preterm delivery,
malformations
fetal/neonatal electrolyte abnormalities,
jaundice
thrombocytopenia

Question 9

When using medication for HTN in pregnancy aim for BP of

Answer 9

135/85

Question 10

Offer PLGF based testing to rule out pre-eclampsia between ___ weeks and ___ /40 if women with chronic HTN are suspected of developing pre-eclampsia

Answer 10

between 20 weeks and 36+6

Question 11

What is the monitoring schedule suggestion from NICE in women with chronic hypertension

Answer 11

weekly if poorly controlled
Appointments ever 2-4 weeks if HTN well controlled.

Question 12

TOB for women with chronic hypertension

Answer 12

Do not offer planned early birth before 37 weeks to women with chronic hypertension whose BP is lower than 160/110 with or w/o medication unless other indications.

Question 13

Postnatal monitoring for women with chronic hypertension.

Answer 13

Measure BP daily for first 2 days
Once between D3 and D5
or as clinically indicated if treatment is changed after birth.

Question 14

BP aim for postnatal management of women with chronic hypertension.

Answer 14

below 140/90

Question 15

In PIH what are the parameters of “hypertension” and “severe” hypertension.

Answer 15

HTN - 140/90 - 159/109
severe HTN - 160/110 or greater.

Question 16

How often should dipstick proteinuria testing occur in PIH and severe PIH

Answer 16

Once or twice a week for PIH
Daily whilst admitted severe PIH

Question 17

How often should bloods be taken for both PIH and severe PIH?

Answer 17

at presentation and then weekly.

Question 18

In PIH (not severe) how often should fetal US assessment occur

Answer 18

at diagnosis and, if normal, repeat every 2-4 weeks if clinically indicated.

Question 19

In severe PIH how often should fetal US assessment occur?

Answer 19

At diagnosis and, if normal, every 2 weeks if severe hypertension persists

Question 20

TOB for PIH

Answer 20

Do not offer planned early birth before 37 weeks to women with PIH whose BP is lower than 160/110.

Question 21

Postnatal monitoring BP with PIH

Answer 21

Daily D1 and D2
Once between D3 and D5
As clinically indicated if treatment changed after birth.

Question 22

postnatal management of women with PIH. Reduce treatment if BP falls below

Answer 22

130/80

Question 23

When should methydopa be stopped

Answer 23

Within 2 days after birth.

Question 24

What is the BP treatment threshold for women with PIH who did not take antihypertensive treatment and have given birth.

Answer 24

150/100

Question 25

For women with PET when reviewed, offer admission if there are concerns such as:

Answer 25

Sustained SBP 160 or > New or persistent CR>90 or ALT >70 or fall in plt count <150 signs of impending eclampsia Signs of pulm. oedema Signs of severe pre-eclampsia Suspected fetal compromise

Question 26

How often should bloods be checked in PET and PET with severe hypertension (FBC, LFT, UE)

Answer 26

PET - twice a week Severe hypertension PET - 3 times a week

Question 27

How often should US assessment of the fetus occur in PET and PET with severe hypertension

Answer 27

At diagnosis and, if normal, every 2 weeks.

Question 28

TOB in PET. Considerations for planned early birth could include (not limited to) the following features of severe pre-eclampsia

Answer 28

Inability to control BP despite x3 or more classes of antiHTN medication in appropriate doses. Mat SpO2 <90% Progressive biochemical deterioration (HELLP) Ongoing neurological features - severe intractable headache, visual scotoma Placental abruption Reversed EDF or abnormal CTG

Question 29

TOB in PET

Answer 29

Surveillance to 36+6 Initiate birth from 37 weeks

Question 30

How should BP be monitored in women with pre-eclampsia postnatally if they did NOT require any treatment.

Answer 30

QDS whilst inpatient at least once between D3 and D5 On alternate days until normal if abnormal D3-D5

Question 31

How should BP be monitored in women with pre-eclampsia postnatally if they required treatment.

Answer 31

QDS whilst inpatient every 1-2 days for up to 2 weeks after transfer to community care until she is off treatment and has no hypertension.

Question 32

At what threshold should antihypertensives be reduced postnatally

Answer 32

<130/80

Question 33

Consider transfer to community care postnatally if all of the criteria have been met.

Answer 33

No symptoms of pre-eclampsia BP with or without treatment <150/100 Blood tests stable or improving.

Question 34

In chronic hypertension. What should the AN USS schedule be?

Answer 34

US for growth LV and doppler at 28, 32 and 36 weeks

Question 35

In women with PIH when should they have an US?

Answer 35

US growth LV doppler at diagnosis, and, if normal every 2-4 weeks

Question 36

When should women with PET or severe PIH have US growth LV and doppler?

Answer 36

At diagnosis and if continuing with surveillance then every 2 weeks

Question 37

Consider serial US growth LV doppler between 28-30 weeks (or at least 2 weeks before previous gestational age of onset) in women with previous:

Answer 37

severe pre-eclampsia Pre-eclampsia resulting in birth before 34 weeks PET with baby below the 10th centile IUFD Abruption

Question 38

Consider the need for MgSO4 if 1 or more of the following symptoms of severe PET are present

Answer 38

Ongoing or recurring severe headaches Scotomata Nausea or vomiting Epigastric pain oliguria and severe hypertension Progressive biochemical deterioration.

Question 39

What is the recommended regimen for MgSO4

Answer 39

Loading dose 4g over 5-15mins Maintenance 1g/hr for 24hours

Question 40

How long should the MgSO4 infusion be continued after the last fit?

Answer 40

24hours after the last fit

Question 41

How should recurrent fits be treated whilst on MgSO4 infusion

Answer 41

A further loading dose 2-4g given IV over 5-15minutes.

Question 42

What are the potential side effects of prolonged or repeated MgSO4 administration 5-7days in pregnancy?

Answer 42

Skeletal adverse effects hypocalcaemia and hypermagnesaemia in neonates

Question 43

In severe PET, what should the fluids be restricted to?

Answer 43

80ml/hr Unless there are ongoing fluid losses.

Question 44

Can breastfeeding mothers take ACE-i or ARBs

Answer 44

Not recommended but not absolutely contra-indicated. not in the first few weeks. With ACE-i: although the levels transferred are unlikely to be clinically relevent there is insufficient date to exclude a possible risk of profound neonatal hypotension.

Question 45

What should women with hypertensive disorder of pregnancy be advised about the overall risk of recurrence of any hypertensive disease

Answer 45

Overall risk is ~21% or 1in 5

Question 46

Risk of recurrence of PET if PET in previous or current pregnancy

Answer 46

Overall 16% If birth was at 28-34 weeks - 33% If birth 34-37 - 23%

Question 47

Risk of PET in future if PIH in current or previous pregnancy

Answer 47

7% or 1 in 14

Question 48

Risk of PIH in future pregnancy if PIH currently

Answer 48

Between 11-15%

Question 49

Risk of chronic hypertension if PET in current or previous pregnancy

Answer 49

2% or 1 in 50

Question 50

Risk of chronic hypertension if PIH in current pregnancy or previous

Answer 50

3% or up to 1in 34