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Diagnosis
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Pregnancy onset hypertension (BP ≥ 140/90 MMHg) on two occasions, 4 hours apart, usually after 20 weeks gestation
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OR
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>160/110 on one occasion
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Associated with one of:
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- Proteinuria >300mg in 24 hours
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- Se Creatinine >0.09 units and/or oliguria
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- Raised transaminases / RUQ pain
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- Neurological symptoms (fitting, hypereflexia, clonus, visual changes, severe headache)
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- Platelets <100x109, DIC, haemolysis.
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- Intra uterine growth restriction (IUGR)
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Antenatal Management
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Indication for In patient admission:
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- BP ≥ 150/100 on 2 occasions
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- Concern for fetal well-being
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Antenatal Ward
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- FBE & Film, U&E's, urate, LFT, coag profile (APTT, PT, fibrinogen) (if platelets Platelets <100x109) - alternate days
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- MSU MC&S, 24 hour urine:- creatinine clearance and protein - weekly
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 | | - AFI, Doppler, CTG -2-3 times per week
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- Antihypertensive if BP >160/100 MMHg (maintain BP at 130-140/80-90 MMHg ) usually first line drugs are methyl dopa or labetolol.
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- Steroids if <34 weeks - 11.4 mg IM Celestone Chronodose (Betamethasone). Daily for two (2) days.
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Delivery if any of the following:
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- BP uncontrolled despite treatment
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- Deterioration in LFT and/or RFT
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- Progressive decrease in platelets
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- Neurological symptoms / eclampsia
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Mode of delivery:
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Will depend on maternal and fetal factors (gestation, presentation)
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Birthing Suite Management
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The management of PE in birthing suite is multi-disciplinary and may involve the obstetrician, midwife, anaesthetist, physician, haematologist and paediatrician.
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1. Full physical examination with respect to potential complications of PE is to be undertaken on admission and thereafter at regular intervals
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2. IV access, group & save, PE screen (FBE & film, U&E, urate, LFT, coag profile (APTT, PT, fibrinogen) (if platelets <100x109)
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Hypertension
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Patient may continue oral antenatal medication unless BP <120/70 MMHg
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BP >170/110 requires prompt treatment
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Acute control:
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- 5-10mg Hydralazine, given intravenously as a bolus over 5-10 minutes, then by continuous infusion at 5mg/hr, with adjustment of rate to maintain BP <160/100 every 30 minutes until BP 140/90 to 160/100
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- Reactive tacchycardia with hydralazine may necessitate use of IV beta blockers. Occasionally hypertension resistant to hydralazine requires other drugs, e.g. Nitraproside, GTN
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Neurological instability
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Prophylaxis with magnesium sulphate should be considered where there are premonitory signs of eclampsia (increased reflexes associated with clonus and or severe headache, visual changes)
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- MgSO4 commenced (as per protocol) and continued as an infusion
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- Magnesium levels may be adequately assessed clinically (reflexes, respiratory rate) unless there is renal impairment / oliguria when serum levels should be performed 6 hourly.
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Fluid Balance
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Indwelling urinary catheter and urine output measured hourly, fluid balance chart
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Urine output <30mL/hour is considered abnormal
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In general:
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- Give Hartmanns 250 mL boluses X 2
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- If no response in urine output, give Gelofusine 500 mL over 1 hour
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- Continuing oliguria requires CVC insertion: aim for CVP 2-4 cm H20
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- CVP values correlate poorly with left heart pressures in PE
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- CVP >+4 cm H20 with oliguria may indicate diuretic use (e.g. frusemide 20 mg IV)
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- Persisting oliguria may require ICU transfer
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BEWARE - Pulmonary oedema
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Epidural
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If no other contra-indications and platelets >100 x 10 9/L
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Other maternal complications
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- DIC: involve the haematologist on call
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- RUQ pain: consider haematoma / liver capsule rupture (CT scan, MRI)
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Fetal monitoring
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Continuous CTG in labour
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Remember the IUGR fetus will have less tolerance of labour than a well-grown healthy fetus
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Fetal blood sampling (FBS) is appropriate where indicated
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Delivery
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No assistance is routinely required for the second stage but may be necessary if the BP is poorly controlled, woman has symptoms of imminent fit, or progress is inadequate
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Oxytocin 10 IU (i.e. ten international units) bolus IV for third stage - should be actively managed
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Refer CPG Management of third stage of labour
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NOTE: Do not give ERGOMETRINE OR SYNTOMETRINE
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Postpartum
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Most women will show signs of recovery within the first 24 hours of delivery; however a minority will remain unstable or deteriorate after delivery. Close monitoring should therefore continue until:
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- Diuresis has occurred and urine output has normalised
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- MgSO4 usually can be stopped 24-36 hours postpartum but may be prolonged if clinically indicated.
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- Blood investigations are stable / improving
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Postnatal follow-up
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May require discharge on antihypertensive medication and arrangements should be made for ongoing outpatient monitoring.
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Obstetric and physician review routinely at six weeks, though in some cases earlier and/or later follow up may be required.
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Hypertension that has not resolved after three months requires further investigation [consider renal disease, systemic disease (SLE, diabetes) endocrine disease (phaeochromocytoma, primary aldosteronism)] coarctation of the aorta, renal artery stenosis, essential hypertension.
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Early onset (≤32 weeks) severe PE, particularly if associated with IUGR, requires further investigation (inherited or acquired thrombophilia, antiphospholipid syndrome, autoantibody screen, renal disease).
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Royal Women's Hospital Clinical Practice Guidelines (CPGs) are intended to provide guidance to health care professionals, based on a thorough evaluation of research evidence, on the practical assessment and management of specific clinical issues or situations. The guidelines allow some flexibility on the part of the health care professional based on the needs of the specific patient for whom they are caring.
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