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Hypertension in Pregnancy BCRCP OBSTETRIC GUIDELINE 11 HYPERTENSION IN PREGNANCY June, 2006 Inside Summary_______________________ 2 9. Management of Severe The TESS Ad Hoc Advisory Pre-Eclampsia_______________9-10 Working Group _________________ 2 9.1 For Pharmacological Management of Severe 1. Introduction _________________ 3 Hypertension see Section 10.2 9.2 General Measures 2. Relevance __________________3-4 9.3 Basic Investigations 2.1 Adverse Maternal Outcome 9.4 Maternal assessment / Monitoring 2.2 Adverse Neonatal Outcome 9.5 Fetal Assessment 9.6 Thromboprophylaxis 3. Risk Factors__________________ 4 10. Pharmacological Treatment of 4. Classification _______________4-5 Hypertensive Disorders in Pregnancy ______________10-12 4.1 Measurement of Blood Pressure 10.1 Initiation of Antihypertensive 4.2 Current Canadian Drug Treatment Hypertension Society (CHS) 10.2 Acute Management of Severe Definitions Hypertension 5. Pathophysiology_____________6-7 10.3 Recommended Treatment of Non-severe Hypertension 5.1 Placental Involvement in Pregnancy 5.2 HELLP Syndrome, Liver and Peripheral Vascular 11. Anticonvulsant Therapy: Magnesium Involvement Sulphate (MgSO4) __________12-13 5.3 Kidney Involvement 11.1 Prophylaxis 5.4 Central Nervous System Involvement 11.2 Management of Eclampsia 5.5 Cardiovascular: Left 11.3 Management of Recurrent Ventricular Failure Seizures 5.6 Pulmonary Oedema 11.4 Magnesium Sulphate Protocol 6. Indications for Outpatient 12. Delivery Guidelines ________14-15 Assessment and Office 12.1 Steroids Management __________________7 12.2 Mode of Delivery British Columbia 12.3 Anaesthsia and Fluids Reproductive Care 7. Indications to Consider 12.4 Indications for Central Venous Program Hospitalization ______________7-8 Pressure (CVP) Monitoring F5 – 4500 Oak Street 7.1 Indications for Conservative Vancouver, BC Hospital Management 13. Postpartum__________________ 15 Canada V6H 3N1 7.2 Conservative Management 13.1 Fuid Management Tel: 604.875.3737 13.2 Analgesia Web: www.rcp.gov.bc.ca 8. Severe Pre-Eclampsia_________8-9 8.1 Definitions 14. Special Problems (Antenatal and Postnatal) _________________15-16 While every attempt has been 8.1.1 Adverse Conditions made to ensure that the in- 8.1.2 Severe Systolic 14.1 Oliguria formation contained herein is Hypertension 14.2 Dropping O2 Saturations clinically accurate and current, 8.1.3 Eclampsia 14.3 Blood Products the BCRCP acknowledges that 8.1.4 HELLP syndrome many issues remain controver- (partial/complete) 15. Stabilization Before Transfer __ 16 sial, and therefore may be sub- ject to practice interpretation. 8.1.5 Other signs of CNS disturbance 16. Outcome Indicators __________ 16 16.1 Maternal 16.2 Newborn © References _____________________ 16 BCRCP, 2006 Appendix A ____________________18 Summary This guideline reflects both the variable presentation The BC Women’s Maternal-Fetal Medicine & Obstetric and the systemic nature of gestational hypertension Anaesthesia Teams are available to give advice as with proteinuria and/or adverse conditions needed. Telephone: 604-875-2161 (referred to as pre-eclampsia in this guideline)1 and the other hypertensive disorders of pregnancy. THE TESS AD HOC ADVISORY WORKING GROUP Recommendations for the comprehensive evaluation This document is an update of the previous BCRCP and management of organ dysfunction associated Hypertension in Pregnancy guideline (2000) and with pre-eclampsia are included. includes a local adaptation of the Yorkshire Obstetric The main points in the guideline are: Critical Care Group Regional Guidelines for the n Pre-eclampsia is a systemic disorder that may Management of Severe Pre-eclampsia. The prior work affect many organ systems of the Yorkshire group, and their willingness to share n For pre-eclampsia remote from term (<34 their document with us, is gratefully acknowledged. weeks), expectant management is associated This document is part of a research project titled with improved perinatal outcomes. Expectant “Translating Evidence-based Surveillance and management requires obsessive surveillance to Treatment Strategies” (TESS) which is designed to mitigate maternal risks and is a “package”. influence outcomes in all women with a hypertensive n Initial assessment and ongoing surveillance of disorder of pregnancy admitted to a BC healthcare women with a hypertensive disorder of pregnancy facility. TESS project information is available at should include assessment of all vulnerable www.obstgyn.ca/mfmresearch/guidelines. maternal organs as well as the fetus. A set of standardized orders is included in Appendix A. The members of the ad hoc TESS Advisory Working n Initiate antihypertensive drug treatment: Group that produced this document were: • Immediately (in the absence of pre-pregnancy Peter von Dadelszen (Chair) renal disease or diabetes) Consultant Obstetrician, o sBP >160 mmHg or dBP >110 mmHg BCWHHC & CFRI/UBC Centre for o sBP 140-159 mmHg and/or dBP 85-109 Healthcare Innovation and mmHg, based on practitioner preference, Improvement (CHIi) training, and experience Susan Barker Provincial Perinatal Analyst, • In the presence of pre-pregnancy renal disease or BCRCP Database Registry diabetes Sheryll Dale Manager, BCRCP Database • sBP >140 mmHg or dBP >90 mmHg Registry n Recommended treatment of non-severe hypertension in pregnancy Joanne Douglas Obstetrical Anaesthesiologist, • Treatment goal: dBP 80-105 mmHg (depending BCWHHC on practitioner preference) William Ehman Family Practitioner & Consultant, o First choice agent: Methyldopa (Aldomet) Nanaimo General Hospital o Second choice agents: Labetalol Sarah Gilgoff TESS Coordinator, BCWHHC (Trandate); Nifedipine (Adalat PA or XL) Sherry Hamilton Director, High Risk Antepartum o Special indications (renal or cardiac Program, BCWHHC & CHIi diseases): diuretics Anthony Human Consultant Obstetrician, Royal • Drugs to avoid: angiotensin-converting enzyme Inland Hospital, Kamloops inhibitors; angiotensin II receptor antagonists; Shoo K. Lee Director, iCARE, University of atenolol Alberta, Edmonton n Acute management of severe hypertension Robert M. Liston Consultant Obstetrician, BCWHHC • Reduce dBP by 10 mmHg in the first instance and & CHIi maintain the blood pressure at or below that Laura A Magee Consultant Obstetric Internist, level. BCWHHC & CHIi o First choice agent: Nifedipine Craig Mitton Faculty Scientist (Health o Second choice agent: Labetalol Outcomes and Health Economics), n Anticonvulsant therapy CHIi • Prophylaxis: MgSO (4g IV stat, then 1g/hr) 4 Pauline Robertson Director, Decision Support, • Management of eclampsia: MgSO (4g IV stat, 4 BCWHHC then 1g/hr) Diane Sawchuck Perinatal Nurse Consultant, • Management of recurrent seizures: MgSO (2g IV 4 BCRCP & CHIi stat, then increase to 1.5g/hr) Karen Vida Director, Newborn Care Program n Fluids: total intake should not exceed 80 ml/hr; and Transport & Project Director, tolerate urine outputs as low as 10 ml/hr. Provincial Specialized Perinatal Services Program 2 British Columbia Reproductive Care Program 1. INTRODUCTION O10: Pre-existing hypertension complicating This guideline has been developed to reflect both pregnancy, childbirth and the puerperium the variable presentation and the systemic nature of O11: Pre-existing hypertensive disorder with pre-eclampsia1 and the other hypertensive disorders of superimposed proteinuria pregnancy.2-4 The recommendations are derived from the pattern of investigation used in other centres of O13: Gestational [pregnancy-induced] hyperten- excellence, in response to international guidelines,5-8 sion without significant proteinuria in response to current practice across Canada,9,10 and O14: Gestational [pregnancy-induced] hyperten- preliminary evidence that it may be possible to predict sion with significant proteinuria those women most at risk of doing poorly.11 It must be remembered that up to 40% of women who develop O15: Eclampsia eclampsia (seizures) will not have had both hyperten- The provincial rates for hypertensive disorders of sion and proteinuria in the week preceding their first pregnancy (HDP) by fiscal year were 5.5% in 2001/02, seizure.12 Therefore, to proffer the greatest safety to 5.7% in 2002/03, and 5.7% in 2003/04. As expected, women, we should consider (and continue to consider) due to increasing maternal age at first pregnancy, pre-eclampsia in all women presenting with either frequency of multiple births, and rates of obesity (all hypertension or proteinuria in pregnancy, as well as independent risk factors for the HDP), BC experienced those women who present with the symptoms of pre- an increased incidence in the HDP from fiscal years eclampsia in the absence of both hypertension and 2001/02 to 2003/04. proteinuria. Pre-eclampsia remains the most common cause of maternal mortality in North America, and it is appar- ent that the surveillance of women with suspected or confirmed pre-eclampsia is variable between practi- tioners.9,10 In an era of effective blood pressure con- 13,14 trol, it is end organ failure (especially hepatic and respiratory complications) that most commonly causes women to die from pre-eclampsia.4,15 This guideline includes recommendations for the comprehensive evaluation of organ dysfunction. The pattern of investigations presented in this guideline aims to standardize the approach to care within British Columbia, with consideration that the choice of Mondays to Thursdays provides the Of the 6,691 pregnancies which were complicated best timing for delivery of infants (away from Friday by hypertension during this three-year period,
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