Hypertensive disorders in pregnancy - Frimley Health and Care · Hypertensive disorders of pregnancy V1.2 May 2019 Page 3 of 26 1. Background Pre-eclampsia and eclampsia is the 4th

Hypertensive Disorders in Pregnancy

Version: 1.2

Derived from: Pre-eclampsia and eclampsia, Version 6 (2012) (FPH)

Hypertensive disorders of pregnancy, Version 8.2 (2014) (WPH)

Names of authors: Anne Deans (Consultant obstetrician FPH)

Olufemi Eniola (Consultant obstetrician WPH) Sumita Nayak (Locum consultant obstetrician WPH)

Ratified by (Committee): Obstetric and Gynaecology Clinical Governance

Date ratified: 27/09/2016

Date implemented: October 2016

Review date: August 2019

Pharmaceutical dosing advice and formulary compliance checked by:

Ruth Botting May 2019

Key words: Hypertension, hypertensive, pre-eclampsia, HELLP, eclampsia, anti-hypertensives, oedema proteinuria

This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of

the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date

Version Control

Version Date Authors Reason for review Comments 1.1 18th Oct 2018 Tillett, A

Karava-Sood Correction of appendices for clarity, approved at cross site OGCG June 2018 (chair’s action)

Appendices 4 and 5 amended: intervals of labetolol administration the same on both, preparation of labetolol infusion corrected to reflect the rate of administration

1.2 May 2019 Magnesium vials no longer available:

Instructions for preparation updated to reflect new presentation. Minor typos corrected

Hypertensive disorders of pregnancy V1.2 May 2019 Page 2 of 26

Contents 1. Background .................................................................................................................................. 3

2. Definitions (NICE Guidelines) ...................................................................................................... 3

3. Assessment of Gestational Hypertension/Pre-eclampsia ............................................................ 4

4 Management of Gestational Hypertension .................................................................................. 5

4.1 Management of mild to moderate gestational hypertension: ................................................ 5

4.2 Management of women with severe gestational hypertension (BP >160/110mmHg and without proteinuria): ......................................................................................................................... 6

4.3 Timing of birth in women with gestational hypertension ....................................................... 6

4.4 Postnatal care of women with gestational hypertension ....................................................... 6

5. Management of Mild Pre-eclampsia ............................................................................................ 7

6. Management of Moderate Pre-eclampsia .................................................................................... 8

7. Management of Severe Pre-eclampsia .................................................................................... 9

8. Eclampsia – the fitting patient .................................................................................................... 14

9. Post-delivery management in Eclampsia and Severe Pre-eclampsia ....................................... 14

10. Management after discharge of post-natal hypertensive patients .......................................... 16

11. Management of chronic hypertension .................................................................................... 16

12. Auditable standards ............................................................................................................... 18

13. Monitoring .............................................................................................................................. 18

14. Communication ...................................................................................................................... 18

15. Equality Impact Assessment .................................................................................................. 18

References ........................................................................................................................................ 19

Appendix 1a: Postnatal blood pressure management plan: Pre-eclampsia/Pregnancy induced hypertension ..................................................................................................................................... 20

Appendix 1b: Postnatal blood pressure management plan: Chronic Hypertension ......................... 21

Appendix 1c: Discharge advice for GPs of women taking antihypertensive following birth ............. 22

Appendix 2: Management of pregnancy with gestational hypertension.7 ......................................... 23

Appendix 3: Management of pregnancy with pre-eclampsia.7 ......................................................... 24

Appendix 4 Preparation and dosages of intravenous Hydralazine, Labetalol and MgSO4 .............. 25

Appendix 5: Flow chart of management of severe pre-eclampsia and Eclampsia ........................... 26


1. Background Pre-eclampsia and eclampsia is the 4th leading cause of all direct maternal deaths in UK.13

Gestational hypertension occurs in 6 to 17 per cent of healthy nulliparous women and 2 to 4 per cent of multiparous women. 15,16

Pre-eclampsia is a major cause of poor outcome in pregnancy. It is a multi-system disorder of pregnancy affecting 6.2% of all pregnancies in the UK of which most are primigravida. 1.

Serious morbidity associated with pre-eclampsia can occur from 20 weeks gestation to after delivery: placental abruption, haemolysis elevated liver enzymes, and low platelet count syndrome, fetal growth restriction and renal failure are more common before 32 weeks, whereas eclampsia is most common at term.2, 3 Onset before 32 weeks has the most serious outcome and the interval between diagnosis and delivery is on average 14 days (range 0-62 days), with a substantial number of women requiring delivery within 72 hours.4

An increase in lifetime cardiovascular risk has been seen with hypertensive disorders in pregnancy. 7

Eclampsia is not always associated with severe hypertension; in a UK population study, 34% of eclamptic women had a maximum diastolic blood pressure of ≤100 mm Hg.3

New proteinuria with new hypertension is strongly associated with poor fetal and maternal outcome.5, 6 Women may progress rapidly: 25-55% of women with hypertension of ≥ 160 mm Hg systolic or ≥ 110 mm Hg diastolic with new proteinuria (≥ +) require delivery within 48 hours of admission.4

2. Definitions (NICE Guidelines)7 Hypertension - Diastolic blood pressure ≥90 mm Hg /systolic blood pressure ≥ 140 mmHg

Mild hypertension diastolic blood pressure 90–99 mmHg, systolic blood pressure 140–149 mmHg.

Moderate hypertension diastolic blood pressure 100–109 mmHg, systolic blood pressure 150–159 mmHg.

Severe hypertension diastolic blood pressure 110 mmHg or greater, systolic blood pressure 160 mmHg or greater.

Significant proteinuria - presence of proteinuria as shown by ≥+ (0.3 g/l) on dipstick

testing, a protein to creatinine ratio (PCR) ≥ 30 mg/mmol on a random sample, or a urine protein excretion of ≥300 mg in 24 hours (on a validated 24 hour urinary collection).

Gestational hypertension - new hypertension presenting after 20 weeks of pregnancy

without significant proteinuria. Chronic hypertension - hypertension that is present at the booking visit or before 20 weeks

or if the woman is already taking antihypertensive medication when referred to maternity services. It can be primary or secondary in aetiology.

Pre-eclampsia - new hypertension presenting after 20 weeks with significant proteinuria. Severe pre-eclampsia - pre-eclampsia with severe hypertension and/or with symptoms,

and/or biochemical and/or haematological impairment. Superimposed pre-eclampsia - development of features of pre-eclampsia in the context of

pre-existing hypertension or pre-existing proteinuria, or both (as per section 7).


Eclampsia - a convulsive condition associated with pre-eclampsia.

HELLP syndrome (haemolysis, elevated liver enzymes and low platelet count) probably

represents a severe form of pre-eclampsia.

3. Assessment of gestational hypertension/pre-eclampsia

The main goals in the initial evaluation of pregnant women with newly developed

hypertension are to distinguish gestational hypertension from pre-eclampsia, which has a different course and prognosis, and to determine whether hypertension is severe, which affects management and outcome.

At initial presentation, women should be assessed by a midwife and obstetric registrar with

advice if necessary taken from senior obstetric staff. Women in the following groups are of particular risk for pre-eclampsia: nulliparity age 40 years or older pregnancy interval of more than 10 years family history of pre-eclampsia multiple pregnancy BMI of 35 kg/m2 or more late gestational age at presentation previous history of pre-eclampsia or gestational hypertension pre-existing hypertension pre-existing kidney disease

Although the classification of severity of pre-eclampsia is primarily based on the level of

blood pressure and the presence of proteinuria, clinicians should be aware of the potential involvement of other organs when assessing maternal risk, including placental disease with fetal manifestations. Particularly significant are:

symptoms of severe headache, visual disturbance (blurring or flashing before the eyes),

epigastric pain and/or vomiting clinical signs of liver tenderness, clonus, papilloedema platelet count falling to below 100 x 109/l abnormal liver enzymes (ALT or AST rising to above 70 iu/l) HELLP syndrome Evidence of fetal intrauterine growth restriction

When taking the blood pressure the woman must be rested and sitting at a 45 degree angle.

The blood pressure cuff should be of the appropriate size and placed at the level of the heart. Multiple readings should be used to confirm the diagnosis.

The screening test for proteinuria is dipstick assessment using the automated reagent-strip

reading device. Equivalence: + = 0.3 g/l ++ = 1g/l +++ = 3g/l

There is a high false positive rate so a PCR should be performed unless clinical urgency indicates delivery.


Oedema is a generalised accumulation of fluid. Eighty per cent of normal pregnancies have physiological oedema. Increasing oedema is not in itself a sign that should determine management. A sudden acceleration in weight gain noted by the woman may be a useful sign. In 15% of pre-eclampsia there is no oedema - a particularly dangerous variant.

4 Management of gestational hypertension

(New hypertension developing after 20 weeks without significant proteinuria)

4.1 Management of mild to moderate gestational hypertension:

Antenatal care of women with mild gestational hypertension (BP 140/90 -140/99

mmHg) and no proteinuria: Normally admission to hospital or treatment with antihypertensive is not necessary Measure BP weekly Test for proteinuria at each visit (see protocol as in section 3) Carry out routine antenatal blood tests If presenting <32 weeks or at high risk of pre-eclampsia (e.g. nulliparous, age≥ 40years,

BMI ≥ 35, multiple pregnancy, previous history pre-eclampsia) – measure BP and test for proteinuria twice weekly

Antenatal care of women with moderate gestational hypertension (BP 150/100 –

159/109 mmHg) and no proteinuria: Do not normally require admission to hospital; manage them in Day Assessment Unit

(FPH), Fetal Assessment Unit (WPH) Treat with 1st line labetalol to keep BP <150/80-100 mmHg or methyldopa if preferred or

if labetalol contraindicated (e.g. for asthmatics) Please see section 6 for the dosages of the antihypertensives

Measure BP and Urine dipstick only (PCR need not be repeated once > 30) Test for kidney function, electrolytes, full blood count, transaminases, bilirubin No further blood tests if no subsequent proteinuria and no other evidence of PIH/PET

Fetal surveillance in mild to moderate gestational hypertension (140/90 – 159/109

mmHg): If diagnosis is confirmed before 34 weeks, perform ultrasound for fetal growth, amniotic

fluid and umbilical artery doppler velocimetry If results are normal do not repeat after 34 weeks (unless indicated for other reasons) If fetal activity is abnormal carry out CTG

Intrapartum care of women with mild to moderate gestational hypertension (BP of

140/90 – 159/109 mmHg and without proteinuria): Measure BP hourly Continue antenatal hypertensive treatment if started or needed Carry out haematological and biochemical monitoring according to criteria from

antenatal period Do not routinely limit duration of second stage of labour if BP is stable

Timing of birth: Please see section 4.3


4.2 Management of women with severe gestational hypertension (BP >160/110mmHg and without proteinuria)

Antenatal care of severe gestational hypertension

Admit to hospital for observation and treatment until BP <159/109 mmHg or lower. Treat with 1st line labetalol to keep BP < 150/80-100 mmHg or methyldopa if preferred

or if labetalol is contraindicated (e.g. asthma) .Use second line drugs like oral nifedipine or oral hydralazine if BP is difficult to control. Please see section 6 for the dosages of the anti-hypertensives.

Measure BP at least 4 times a day. Test dipsticks or PCR daily. Test FBC, liver function test, urea and electrolytes and urates at presentation then at

least twice weekly until delivery. In women receiving outpatient care after severe hypertension has been effectively

controlled in hospital measure BP and test for proteinuria twice a week and carry blood tests weekly.

Fetal surveillance in severe gestational hypertension (BP ≥160/110 mmHg):

At diagnosis perform ultrasound for fetal growth and amniotic fluid index (AFI) and umbilical doppler velocimetry (if conservative management planned). Do not repeat more than every 2 weeks, unless concerns regarding growth or doppler when weekly or twice weekly doppler may be appropriate.

CTG is indicated if changes in fetal movement reported by woman, vaginal bleeding, abdominal pain or deterioration in maternal condition.

Any CTG abnormality inform senior obstetrician (Consultant/CCT holder). A care plan by the senior obstetrician should be made, which includes:

Timing and nature of future fetal monitoring, indication of delivery and timing of corticosteroids.

Fetal indications for birth, if and when corticosteroids should be given. When discussion with neonatal paediatricians and obstetric anaesthetists should

take place and what decisions should be made. Intrapartum care of severe gestational hypertension (BP ≥160/110 mmHg):

Measure BP every 15 minutes or more frequently as advised by senior obstetrician. Continue antenatal hypertensive treatment. If BP is controlled within target ranges, do not routinely limit duration of second stage of

labour. If BP does not respond to initial treatment, advise operative birth.

4.3 Timing of birth in women with gestational hypertension

If BP is controlled and fetal growth normal, delivery is timed after 37 weeks. For women with gestational hypertension whose blood pressure is lower than 160/110

mmHg after 37 weeks, with or without antihypertensive treatment, this timing of birth, and maternal and fetal indications for birth should be agreed between the woman and the senior obstetrician.

Offer birth to women with uncontrolled severe gestational hypertension earlier after a course of corticosteroids (if required) has been given.

4.4 Postnatal care of women with gestational hypertension

Measure BP 4hrly when inpatient except during night time to allow sleep. Woman will normally be discharged on day 2. Following discharge the management is as per section 10.


The BP measurements of community midwife will be as per Appendix-1a. Continue antenatal antihypertensive treatment, unless methyldopa in which case

change antihypertensive due to increased risk of postnatal depression. Reduce treatment if BP <130/80. Commence antihypertensive if BP >149/99. Use labetalol 100mg orally twice daily (not if asthmatic), increasing if necessary up to a

maximum dose of 400mg three times daily( May use higher doses if appropriate). Nifedipine MR (modified release) 10mg twice daily can be added increasing if necessary

to 30mg twice daily. Consider changing the antihypertensive treatment to enalapril 5mg daily on day 3

postnatal (or earlier) if BP control (BP is not <150/100) is not achieved by above treatment. One can increase the enalapril dose up to 40mg daily either as a single or as 2 divided doses (If the patient is on diuretics or has impaired renal function, discuss with senior physician on call before starting enalapril).

Community review of antihypertensive therapy at 2 weeks postnatal and at 6 weeks post natal.

Refer to Appendix 1c for communication to GP.

5. Management of mild pre-eclampsia

(Blood pressure <150/100 with proteinuria and asymptomatic) Before 37 weeks, management can be conservative with close maternal and fetal

surveillance to monitor for disease progression. This may mean admission to the antenatal ward initially, but thereafter outpatient management with regular review on Day Assessment Unit (FPH) or Fetal Assessment Unit (WPH).

If the blood pressure is below 150/100 mmHg, there is no need for antihypertensive therapy. An exception may be made such as heavy proteinuria (protein 2+ or more on dipstick) or disordered liver or haematological test results (also when there are other medical problems such as diabetes, chronic renal conditions or any long term medical problems). Since, in this situation, alarming rises in blood pressure may be anticipated, anti-hypertensive treatment at lower blood pressure levels may be justified.

Maternal surveillance (inpatient)

Four hourly BP (if BP <160/100, a single BP reading may be omitted overnight to allow a period of rest).

Daily urine testing by dipstick. Urine protein creatinine ratio (PCR) to be done once but do not repeat it if the patient

already has significant proteinuria. Serum uric acid, renal function tests, haemoglobin, platelets, clotting screen, liver

function tests twice a week.

Maternal surveillance: Outpatient in Day Assessment Unit (FPH) or Fetal Assessment Unit (WPH) Outpatient management of such cases should only be considered after discussion with

senior obstetrician (Consultant or CCT holder). Three BP recordings at least 10 minutes apart twice a week (depending on severity

could be once in some cases). Urinalysis (dipstick) at each visit. Serum uric acid, renal function tests, haemoglobin, platelets, liver function tests twice a

week. In pre-eclampsia, a rise in uric acid correlates with poorer outcome for both mother and

baby.8, 9 this rise corroborates the diagnosis of pre-eclampsia but the levels, in themselves, should not be used for clinical decision-making.


Fetal surveillance Daily CTG if admitted, or at each visit to DAU/triage (FPH) or FAU (WPH). Ultrasound scan every 2 weeks for growth and amniotic fluid volume. Weekly umbilical ± MCA Doppler (at least) if IUGR suspected on ultrasound scan.

Timing of birth in pre-eclampsia

Manage pregnancy in women with pre-eclampsia conservatively if possible until 34 weeks gestation.

Clear documentation by the patient’s consultant in the notes should be made regarding the maternal (biochemical, haematological and clinical) and fetal thresholds for elective birth.

Birth before 34 weeks is likely to be needed if severe hypertension develops refractory to treatment or maternal or fetal indications as specified above and offer birth after discussion with neonatal and anaesthetic teams and a course of corticosteroids has been completed (if appropriate).

Recommend birth for women who have pre-eclampsia with severe hypertension after 34 weeks when their blood pressure has been controlled and a course of corticosteroids has been completed (if appropriate).

Offer birth to women who have pre-eclampsia with moderate to severe hypertension at 34+0 to 36+6 weeks depending on maternal and fetal condition, risk factors and availability of neonatal intensive care.

Recommend birth within 24–48 hours for women who have pre-eclampsia with mild or moderate hypertension after 37+0 weeks.

6. Management of moderate pre-eclampsia

(Blood pressure 150/100 to 159/109 mmHg with significant proteinuria) The woman requires admission. The aim is to protect the mother from acute effect of high BP i.e. CVA and prolong the

pregnancy to allow improved fetal maturation. Delivery is the ultimate treatment for this condition. BP should not be lowered too much below 90mmHg diastolic as this can compromise

placental perfusion. The situation can change rapidly into severe pre-eclampsia. Inform Senior Obstetrician (Consultant/CCT Fellow) to plan management. Increased risk of abruption should be discussed.

Aim to control BP (diastolic blood pressure between 80–100 mmHg systolic blood

pressure less than 150 mmHg) The BP should be checked every 15 minutes until the woman is stabilised and then

every 30 minutes in the initial phase of assessment. The BP should be checked 4-hourly if a conservative management plan is in place and

the woman is stable and asymptomatic. Labetalol 100mg twice/day orally increasing to 400mg three times/day (Peak action

2hrs post dose). This is contraindicated in women with asthma. If preferred or labetalol is contraindicated start methyldopa as a loading dose 500 -750

mg orally. (Peak action 4 hours post dose). Thereafter prescribe methyldopa 250mg eight hourly, increasing to a maximum of 500mg six hourly.

If the above does not control the blood pressure alternatively start: Nifedipine modified release 20mg twice /day orally to maximum of 60mg daily.

OR Hydralazine 25mg six hourly orally rising to 75mg six hourly alone or given with

methyldopa or labetalol


Monitor uric acid, platelets, renal and liver function tests at least three times a week

A falling platelet count is associated with worsening disease and is itself a risk to the mother9.

If the count is less than 100 x 109/l, there may be an associated coagulation abnormality and a coagulation screen should be undertaken.

A platelet count of less than 100 x 109/l should be a consideration for delivery. An AST/ALT level of above 70iu/l is seen as significant and a level above 150iu/l is

associated with increased morbidity to the mother. Strict fluid input and output charts should be maintained. Fetal assessment

An initial assessment with CTG should be undertaken. This gives information about fetal wellbeing at that time but does not give any predictive information.

If conservative management is planned, then further assessment of the fetus with ultrasound measurements of fetal size, umbilical artery Doppler and liquor volume should be undertaken.

Serial assessment will allow timing of delivery to be optimised. IUGR occurs in around 30% of pre-eclamptic pregnancies.

Twice daily CTGs should be performed.

Timing of Birth - Refer to section 5, page 8 7. Management of severe pre-eclampsia

Definition Blood pressure ≥160 mmHg systolic or ≥110mmHg diastolic on two occasions (MAP

>125), significant proteinuria (as mentioned section 2.2). Moderate pre-eclampsia with one or more of the following

Oliguria Cerebral or visual disturbances such as blurring or flashing before the eyes Epigastric pain Pulmonary oedema or cyanosis Impaired liver function tests (ALT or AST rising to above 70 iu/l) Thrombocytopenia (platelets falling below 100 x 109/l HELLP syndrome Evidence of clonus >or= 3 beats

Possible presentations Severe pre-eclampsia developing in mother already controlled on oral anti-

hypertensives New presentation May present with placental abruption These patients need delivery as the mother is at risk of fitting, cerebral haemorrhage,

DIC and multi-organ failure.

Management of severe pre-eclampsia Ensure that the following senior people have been alerted:

The consultant obstetrician in charge of the woman/ Senior Obstetrician(consultant on call /CCT holder)

The SpR anaesthetist on call for the delivery suite and the consultant anaesthetist covering the labour ward.

The paediatric registrar on call.


Coordinator in charge of the labour ward. Special care baby unit (SCBU) if gestation is <37/40 or significant IUGR Transfer the patient to labour ward if not already there. A midwife should be designated whose sole duty is to look after this woman and to

make sure patient not left unattended. Monitoring – as per MEOWS chart

The BP should be measured every 15 minutes using automatic sphygmomanometer until stable then half-hourly.

Strict hourly fluid balance needs to be kept. All fluids given intravenous (IV) must go through a pump. Fluids should be restricted to 80ml/hour. Hourly oral fluid intake (if occurring) should be monitored so that can be subtracted from the IV input to maintain fluid restriction. Monitor urine output hourly with a urinary catheter with a calibrated meter on it.

Perform full blood count, clotting screen, urea and electrolytes, liver function tests every four to six hours.

Ensure two blood samples (One booking blood and one current) have been taken for group and save.

Listen to the chest to exclude pulmonary oedema if the respiratory rate rises above 20. Consider oxygen saturation monitor (pulse oximeter) – normal values ≥ 95% on air/97% on oxygen – if values fall below this contact anaesthetic and obstetric registrar.

Commence magnesium sulphate monitoring - record respiratory rate and patella reflexes hourly.

CTG monitoring to assess fetal condition/continuous Electronic Fetal Monitoring (EFM) if in labour.

All women should remain on this monitoring regime for a minimum of 24 hours post-delivery.

Anti-Hypertensive Management

Antihypertensive treatment should be started in women with a systolic blood pressure over 160 mmHg or diastolic blood pressure over 110 mmHg (MAP > 125).

In women with other markers of potentially severe disease, treatment can be considered at lower degrees of hypertension.

The aim is to gradually lower the BP to a diastolic BP of <100 (MAP <125) to reduce the risk of cerebral haemorrhage without compromising renal or placental perfusion

Oral therapy should be used initially unless the has features of impending eclampsia

Start with oral nifedipine MR 10mg-20mg Check BP every 15 minutes; if it is still high after 45 minutes, administer hydralazine as

below. In high BP (MAP>140,) check BP every 5 minutes, if it is still high after 15 minutes,

administer hydralazine as below.


Hydralazine Loading dose:

Dissolve the contents of one 20mg hydralazine ampoule with 1ml water for injection BP. Further dilute the contents of the ampoule with 19ml of 0.9% sodium chloride to give 20mg hydralazine in 20ml (1mg/ml solution). Administer 5ml (5mg) over a period of 5 minutes (1ml/min) Check BP every 15 minutes. Repeated 5mg doses of hydralazine can be given every 20 minutes up to maximum 20 mg aiming to get the BP around 160/100.

Maintenance dose:

Dissolve the contents of 3 ampoules (60 mg) with one ml of water for each ampoule. Further dilute with 57 ml of 0.9% sodium chloride to give 60mg hydralazine in 60ml (one mg/ml) solution. Start infusion at 10ml/hr doubling every 30 minutes to a maximum of 40mg/hr (40ml/hr).

Labetalol

Loading dose: If hydralazine fails to control BP give labetalol (contraindicated if asthmatic) Give initial dose of labetalol 20 mg IV stat. Repeat 20mg doses every 10 minutes until satisfactory control reached or up to a maximum of 200 mg.

Maintenance dose:

Maintain BP with an IV infusion of labetalol 200 mg in 50 ml of 0.9%sodium chloride at infusion rate 40 mg(10ml)/hour. Double the infusion rate every 30 minutes as required to a maximum of 160 mg (40ml)/hour titrated against BP.

Once blood pressure is controlled, it may be sustained with IV hydralazine maintenance

dose or with oral methydopa, nifedipine or hydralazine, as per section 6, depending on the woman’s clinical condition.

Anticonvulsants

Indication and duration Magnesium sulphate (MgSO4) should be prescribed to women with pre-eclampsia for

whom there is concern about the risk of eclampsia. The administration of magnesium sulphate to women with pre-eclampsia reduces the risk

of an eclamptic seizure11. It should be given to women with severe pre-eclampsia once a delivery decision has been

made and in the immediate postpartum period. In women with less severe disease the decision is less clear and will depend on individual case assessment, although should be administered for neuroprotection of fetus under 30 weeks.

When conservative management of a woman with severe hypertension and a premature fetus is made, it would be reasonable not to treat until the decision to deliver has been made.

When magnesium sulphate is given it should be continued for 24 hours following delivery, or 24 hours after the last seizure, whichever is the later, unless there is a clinical reason to continue.


MgSO4 Regime **Magnesium sulphate is provided as a ready to use 20% solution: no further dilution is necessary**

Loading Dose Start the anti-convulsant regime by giving 4 grams of MgSO4 IV over 10 minutes.

Prepare as follows: Using 20% MgSO4 (provided as 10mL ampoules) draw up 20mL and administer over 5 to 10 minutes via a syringe pump (equivalent to 120 – 240ml/hour).

If the woman experiences a hot flush slow the rate of administration.

Maintenance dose

Immediately after the loading dose start a maintenance infusion of MgSO4 at 1gram/hour for next 24 hours.

Prepare as follows: Draw up a suitable volume of 20% MgSO4 and administer via a syringe pump at 5ml/hour. The infusion needs to continue for 24 hours; prepare fresh syringes from further ampoules of 20% MgSO4 as necessary.

Monitoring for magnesium toxicity Magnesium toxicity is unlikely with the above regimen and levels do not need to be routinely measured. Magnesium sulphate is mostly excreted in the urine. Toxicity can be assessed clinically as it causes a loss of deep tendon reflexes and respiratory depression. Monitor urine output – ensure remains above 100ml over 4 hours Check patellar reflexes hourly (use arm reflexes if epidural in situ) Check respiratory rate hourly – should be greater than 10/min Pulse oximetry – aiming for ≥95% oxygen saturation in air

Stop the magnesium infusion if: Urine output becomes reduced below 100ml over 4 hours Tendon reflexes become absent Fall in respiratory rate or oxygen saturation below 95% Patient complains of flushing/double vision, weakness, slurred speech

Inform the obstetric registrar. Restart magnesium at half strength infusion if tendon reflexes and respiratory rate return to normal. If respiratory depression occurs: Give 10-15 l/min oxygen by mask with reservoir bag and place in the left lateral position. Stop magnesium therapy Fast bleep the obstetric and anaesthetic registrars Give 2mls of calcium gluconate 10% injection intravenously. Repeat 2mls every 2

minutes up to 10mls (1g) until resumption of normal spontaneous respiration (respiratory rate > 10/min)

If a respiratory arrest occurs: Obstetric crash call to go out (2222) Ventilate immediately and consider intubation (anaesthetic team) Stop magnesium therapy Give 2mls of calcium gluconate 10% injection intravenously. Repeat every 2 minutes up

to 10mls (1g) until resumption of normal spontaneous respiration


Fluid Protocol Fluid restriction is advisable to reduce the risk of fluid overload in the intrapartum and

postpartum periods. Strict input and output fluid balance chart should be maintained. In usual circumstances, total fluids should be limited to 80 ml/hour or 1 ml/kg/hour.

Pulmonary oedema leading to death can result from inappropriate fluid management. Remember these patients have contracted intravascular compartment so although they are

hypovolemic they can easily become overloaded. They have a low oncotic pressure due to low albumin and leaky capillaries.

There is no evidence of the benefit of fluid expansion12 and a fluid restriction regimen is associated with good maternal outcome.

The regime of fluid restriction should be maintained until there is a postpartum diuresis, as oliguria is common with severe pre-eclampsia.

If there is associated maternal haemorrhage, fluid balance is more difficult and fluid restriction may be inappropriate.

Usual regime is to administer plasmalyte infusion 80ml/hour (reduce if oral intake and/or other infusions) and monitor urine output with an indwelling catheter. Urine output should be > 100ml over four hours.

If urine output over 4 hours is below 100mls then consultant anaesthetist should be contacted as soon as possible to discuss further management and discuss transfer to HDU (in FPH site) /Transfer to ICU (In WPH site).

Particular attention is needed when patients are hypovolaemic due to haemorrhage, underestimated blood loss at APH, or LSCS, or DIC. Monitoring with CVP line and administration of blood and blood products will be required in those circumstances.

Planning delivery

The decision to deliver should be made once the woman is stable and with appropriate senior personnel present.

If the fetus is less than 34 weeks of gestation and delivery can be deferred, corticosteroids should be given, although after 24 hours the benefits of conservative management should be reassessed. Conservative management at very early gestations may improve the perinatal outcome but must be carefully balanced with maternal wellbeing.

The mode of delivery should be determined after considering the presentation of the fetus and the fetal condition, together with the likelihood of success of induction of labour after assessment of the cervix.

If gestation is below 34 weeks, Caesarean section is likely to be best as the success of induction of labour is reduced.

After 34 weeks with a cephalic presentation, vaginal delivery is feasible although consideration should be given to Caesarean section if the cervix is not favourable and a long labour is anticipated. Anti-hypertensive treatment should be continued throughout labour.

In general, these women are not suitable for in-utero transfer. The third stage should be managed with 5 international units of intravenous Syntocinon®

given slowly. Ergometrine® or Syntometrine® should not be given for prevention of haemorrhage, as this can further increase blood pressure.


8. Eclampsia – the fitting patient

Eclampsia occurs antenatal, intrapartum or in the postnatal mother. It can occur in a woman who is known to be pre-eclamptic and previously controlled as

above or occur for the first time in an untreated, undiagnosed patient as convulsions. Treatment of eclampsia

Do not leave the woman alone but call for help by setting off the obstetric crash bleep (2222). Get the resuscitation trolley moved into the room. Call for the eclampsia box.

The labour ward coordinator, senior resident obstetrician and senior resident anaesthetist must attend. Consultant help should be sought as soon as possible. The paediatrician should be informed if the woman is antenatal or intrapartum.

The principles of management should follow the basic principles of airway, breathing and circulation.

Aim to prevent maternal injury during the convulsion and maintain the airway. Place the woman in the left lateral position and administer oxygen via a mask with a reservoir bag at 10-15 l/min. Assess the airway and breathing and check pulse and blood pressure. Pulse oximetry is helpful.

Set up intravenous access if not present already using a 16g IV cannula. Magnesium sulphate is the therapy of choice to control seizures. A loading dose of 4 g

should be given over 5 to10 minutes, followed by a further infusion of 1 g/hour maintained for 24 hours after the last seizure. Please refer to section 7

Recurrent seizures should be treated with either a further bolus of 2g magnesium sulphate or an increase in the infusion rate to 1.5 g or 2.0 g/hour.

Once stabilised, plans should be made to deliver the woman but there is no particular hurry and a delay of several hours to make sure the correct care is in hand is acceptable, assuming that there is no acute fetal concern such as a fetal bradycardia. The woman’s condition will always take priority over the fetal condition.

Magnesium sulphate is the therapy of choice and diazepam should no longer be used as a first-line drug although if further seizures occur despite two bolus of MgSO4 being administered then diazepam 10mg IV bolus can be given followed by a infusion of 2.5mg/hr.

Persistent fitting will require transfer to ITU and paralysis and ventilation. Blood pressure and fluid balance management should be as for severe pre-eclampsia.

9. Post-delivery management in Eclampsia and Severe Pre-eclampsia

Clinicians should be aware of the risk of late seizures and ensure that women have a careful review before discharge from hospital. Up to 44% of eclampsia occurs postpartum, especially at term.

Women with persisting hypertension and proteinuria at 6 weeks may have renal disease and should be considered for further investigation by their GP.

Women who have had severe pre-eclampsia or eclampsia should be offered a formal postnatal review with their obstetric consultant to discuss the events of pregnancy and to discuss planning for future pregnancy.

The control of maternal hypertension post delivery in eclampsia and pre-eclampsia Anti-hypertensive medication should be continued after delivery as dictated by the blood

pressure. It may be necessary to maintain treatment for up to 3 months, although most women can have treatment stopped before this as the largest single cause of death among women with pre-eclampsia and eclampsia was intracranial haemorrhage – reflecting a failure of effective anti-hypertensive treatment.


In postpartum women with pre-eclampsia who did not take antihypertensive treatment prior to delivery: (Refer to Appendix 1a) Blood pressure monitoring: at least four times a day while the woman is an inpatient If mild pre-eclampsia discharge home from hospital on day 2 Community midwife to take BP and check for symptoms on day 3, 4, and 6 after birth.

No further action needed if symptom free and BP<150/100 Community Midwife will refer the patient to hospital if women has raised BP >150/90

and/or with symptoms Ask about severe headache and epigastric pain each time blood pressure is

measured. Start antihypertensive treatment if blood pressure is 150/100 mmHg or higher (may be

started on lower BP as earlier mentioned in Section 5). o Use labetalol 100mg orally twice daily as a starting dose, increasing if necessary

up to a maximum dose of 400mg three times daily (could go higher if indicated). o Nifedipine MR 10mg twice daily can be added increasing if necessary to 30mg

twice daily. o Consider changing the antihypertensive treatment to enalapril 5mg daily on day 3

postnatal if BP control (BP is not <150/100) is not achieved by above treatment. One can increase the enalapril dose up to 40mg daily either as a single or as 2 divided doses (If patient on diuretics or impaired renal function, discuss with senior physician on call before starting enalapril).

In postpartum women with pre-eclampsia who took antihypertensive treatment prior to delivery:

Women will normally be discharged to community midwife care when BP is <150/100 and she is asymptomatic and blood test results are stable or improving.

Blood pressure monitoring: at least four times a day while the woman is an inpatient every 1–2 days for up to 2 weeks after transfer to community care until the woman is off

treatment and has no hypertension. Continue antenatal antihypertensive treatment if taking nifedipine or labetalol. If on methyldopa before delivery, switch to nifedipine or enalapril If BP remains high despite antihypertensive, consider switching to enalapril as mentioned in

section 9 Aim to keep blood pressure between130/80-149/99. If BP is <130/80 dose should be gradually

reduced as per Appendix 1a For all women who have pre-eclampsia with moderate hypertension

Measure platelet count, liver function tests (AST and ALT) and serum creatinine 48–72 hours after birth

Do not repeat platelet count, liver function tests or serum creatinine measurements if results are normal at 48–72 hours (unless indicated or symptomatic/unwell).

Women will normally be discharged to community midwife care when BP is <150/100 and she is asymptomatic and blood test results are stable or improving

If biochemical and haematological indices are improving but stay within the abnormal range repeat platelet count, liver function tests and serum creatinine measurements as clinically indicated and at the postnatal review at 6–8 weeks with GP (request GP on the discharge letter as in Appendix 1c)


10. Management after discharge of post-natal hypertensive patients Women should be discharged home on 4 weeks supply of medication. All women will be given a postnatal blood pressure management plan (Appendix 1a/1b) with

her to carry and a copy will be sent to her GP and midwife. The discharge advice for GPs of women taking antihypertensive following birth (appendix 1c)

should be included in the discharge letter for GPs. Following discharge from the community midwife, the woman should be advised to see her

GP for a blood pressure check at least weekly or if she experiences hypotensive side effects (dizziness, fainting).

At this weekly review, the dose of medication should be gradually reduced, with the aim of maintaining the blood pressure <150/100mm Hg without hypotensive side effects. Medication is usually completely discontinued by six weeks post delivery.

For women with chronic hypertension, it is advisable to leave them on current medications, often ACE inhibitors initially, and then they can be switched back to their pre-pregnancy antihypertensive at six weeks post-partum.

11. Management of chronic hypertension

Pre-pregnancy advice: Tell women who are on ACE inhibitors, ARBs or chlorothiazide diuretics because of

increased risk of congenital abnormalities; discuss other antihypertensive treatments with the healthcare professional responsible for managing their hypertension, if they are planning a pregnancy.

Encourage women to lower dietary sodium or use sodium substitute. Antenatal care:

Antihypertensive treatment Stop ACE inhibitors, ARBs, within 2 days of notification of pregnancy and offer

alternatives Offer antihypertensive treatment based on pre-existing treatment, side effect profile and

teratogenicity. Aim for BP <150/100 mmHg If target organ damage, aim for BP <140/90 mmHg

Do not offer treatment to lower diastolic DBP <80 mmHg If secondary chronic hypertension, offer referral to specialist in hypertensive disorders Start aspirin 75mg from 12 weeks or earlier if not already started.

Fetal monitoring:

At 28 and 32 weeks carry out US fetal growth and amniotic fluid volume assessment and umbilical Doppler velocimetry.

If results are normal do not repeat after 32 weeks unless clinically indicated. If fetal activity abnormal carry out CTG.

Timing of birth:

If BP <160/110 with or without antihypertensive treatment do not offer birth before 37 weeks

After 37 weeks, timing of and maternal and fetal indications for birth should be agreed between woman and senior obstetrician.

If refractory severe chronic hypertension, offer birth after corticosteroids (if required) has been completed.


Intrapartum care: Mild or moderate hypertension (BP ≤ 150/109 mmHg):

Measure BP hourly If BP stable do not routinely limit duration of second stage. Carry out assessment of bloods according to criteria from antenatal period, even if

regional analgesia is being considered

Severe hypertension (≥ 160/110 mmHg): Continue antenatal antihypertensive treatment Measure BP continually every 15 minutes or more frequently depending on patient’s

individual plan If BP controlled within target ranges do not routinely limit duration of second stage If BP does not respond to initial treatment advise operative birth

Post natal care

Measure blood pressure: daily for the first 2 days after birth Community midwife will check her BP on day 4. every 2 days if antihypertensive treatment is changed after birth.

Aim to keep blood pressure lower than 140/90 mmHg. Continue antenatal antihypertensive treatment Review long-term antihypertensive treatment 2 weeks after delivery with GP If a woman has taken methyldopa to treat chronic hypertension during pregnancy, stop

within 2 days of birth and restart the antihypertensive treatment the woman was taking before she planned the pregnancy.

Women with chronic hypertension should be recommended to have a postnatal review (6–8 weeks after the birth) with their GP or specialist team they have been seeing pre-pregnancy

After discharge management of blood pressure as per Appendix 1a/1b All women will be given a postnatal blood pressure management plan (Appendix1a/1b)

with her to carry and a copy will be sent to her GP and midwife.


12. Auditable standards

Rate of documented involvement of consultant obstetrician and anaesthetist in acute management or severe pre-eclampsia and eclampsia

Proportion of women with the full complement of appropriate investigations Proportion of women whose blood pressure is controlled Proportion of women with pre-eclampsia who have an agreed consultant obstetrician-led

plan for the timing and mode of birth. Proportion of pregnant women with severe hypertension who are admitted for a full

assessment. Proportion of women in whom fluids has been restricted appropriately to 80 ml/hour Proportion of women receiving appropriate magnesium sulphate prophylaxis Proportion of women with eclampsia treated with magnesium sulphate Proportion of women attending for postnatal review and /or pre-conceptual counselling

13. Monitoring

All women with eclampsia should be reported to the risk management committee via Datix reporting and will be subject to multidisciplinary review in the maternity risk management group The management of eclampsia will be subject to continuous audit on a case by case basis and the findings will be presented quarterly to labour ward forum. Action plans will be monitored at labour ward forum. The management of severe pre-eclampsia will be subject to regular audit. The audit midwife is responsible for coordinating the audit. Results presented to the departmental clinical audit meeting/educational half day Action plans will be monitored at the quarterly departmental clinical governance meeting.

14. Communication

If there are communication issues (e.g. English as a second language, learning difficulties, blindness/partial sightedness, and deafness) staff will take appropriate measures to ensure the patient (and her partner, if appropriate) understand the actions and rationale behind them.

15. Equality Impact Assessment

This policy has been subject to an Equality Impact assessment.


References 1 Roberts JM, Redman CWG. Pre-eclampsia: more than pregnancy-induced hypertension.

Lancet 1993;341:1447-51.

2 Banias BB, Devoe LD, Nolan TE. Severe pre-eclampsia in preterm pregnancy between 26 and 32 weeks' gestation. Am J Perinatol 1992;9: 357-60.

3 Douglas KA, Redman CW. Eclampsia in the United Kingdom. BMJ 1994;309: 1395-1400.

4 Sibai BM, Mercer BM, Schiff E, Friedman SA. Aggressive versus expectant management of severe pre-eclampsia 28 to 32 weeks gestation: a randomised controlled trial. Am J Obstet Gynecol 1994;171: 818-22.[

5 Seshadri L, Venkataraman I. Hypertension in pregnancy. Outcomes, proteinuric vs. nonproteinuric. J Reprod Med 1997;42: 88-90.

6 Ferrazzani S, Caruso A, De Carolis S, Martino IV, Mancuso S. Proteinuria and outcome of 444 pregnancies complicated by hypertension. Am J Obstet Gynecol 1990;162: 366-71.

7 NICE clinical guideline 107 Developed by the National Collaborating Centre for Women’s and Children’s Health Hypertension in pregnancy The management of hypertensive disorders during pregnancy Aug 2010

8 Redman CW, Bonnar J, Beilin L. Early platelet consumption in pre-eclampsia. Br Med J 1978; i(6111):467–9.

9 Martin JN Jr,May WL, Magann EF,Terrone DA, Rinehart BK, Blake PG. Early risk assessment of severe pre-eclampsia: admission battery of symptoms and laboratory tests to predict likelihood of subsequent significant maternal morbidity. Am J Obstet Gynecol 1999;180:1407–14

10 Redman CW, Bonnar J. Plasma urate changes in pre-eclampsia.Br Med J 1978;i(6125):1484–5.

11 Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate? The Magpie Trial: a randomised placebo-controlled trial. 2002 ,Volume 359, Issue 9321, Pages 1877-1890

12 Duley L,Williams J, Henderson-Smart DJ. Plasma volume expansion for treatment of women with pre-eclampsia. Cochrane Database Syst Rev 2000(2):CD001805.

13 Npeu.ox.ac.uk, (2015). MBRRACE-UK | NPEU. [online] Available at: https://www.npeu.ox.ac.uk/mbrrace-uk [Accessed 9 Nov. 2015].

14 Christopher W.G. Redman. ‘Hypertension’ in Medical Disorders in Obstetric Practice, edited by Michael De Swiet. 2002.

15 Hauth JC, Ewell MG, Levine RJ, et al. Pregnancy outcomes in healthy nulliparas who developed hypertension. Calcium for Pre-eclampsia Prevention Study Group. Obstet Gynecol 2000; 95:24.

16 Yoder SR, Thornburg LL, Bisognano JD. Hypertension in pregnancy and women of childbearing age. Am J Med 2009; 122:890.


Appendix 1a: Postnatal blood pressure management plan: Pre-eclampsia/Pregnancy induced hypertension

Name: Date of birth: Hospital number: NHS number: Date of discharge from the hospital Antihypertensive medication on the day of discharge Women with mild pre-eclampsia or pregnancy induced hypertension (not on medication) will normally be discharged home from hospital on day 2 if BP is <150/100 and asymptomatic. The community midwife should measure BP and check for symptoms on day 3, 4 and 6 .

If the woman is symptom free and the BP is <150/100 mm Hg no further action is required. If the woman has symptoms and has raised BP, arrangements must be made for her to be

reviewed at the hospital, usually at the maternity triage.

Women with pre-eclampsia on antihypertensive medication normally will normally be discharged to community midwife care when BP is <150/100 and she is asymptomatic and blood test results are stable or improving.

If she is on antihypertensive medication she is likely to be taking labetalol and /or nifedipine MR or sometimes enalapril

Community midwife will check the BP 2 days after discharge from hospital and then on alternate days adjusting the dose of antihypertensive (as per the regimen below) until the women is off medications

If the woman is still on medication 12 days after delivery, she must be told to arrange an appointment with GP on day 13/14 or hospital appointment if still unwell or need debriefing).

If at any check the woman has raised BP >149/99 mm Hg or symptoms, arrangements must be made for her to be reviewed at the hospital or by GP on the same day.

If the woman’s BP is 130/80 -149/99mm Hg the midwife will advise the woman to continue on her current regimen.

If her BP is <130/80 mm Hg, the midwife should advise the women to decrease the antihypertensive medications following the plan below and review the BP again 2 days later.

If the midwife stops the medication as instructed on the plan below she should then check the BP again 2 days later.

If the woman is on more than one antihypertensive, the midwife should follow the reducing regimen for one drug until it has been stopped before decreasing the other one. Clinically it doesn’t matter which drug is reduced first. Labetalol reducing regime Nifedipine MR reducing regime Enalapril reducing regime Current Dose Reduced to Current Dose Reduced to Current Dose Reduced to 400mg tds 300mg tds 200mg tds 100mg tds 100mg bd

300mg tds 200mg tds 100mg tds 100mg bd stop

30mg bd 20mg bd 10mg bd

20mg bd 10mg bd stop

20mg OD 15mg OD 10mg OD 5mg OD

15mg OD 10mg OD 5mg OD stop

If the woman is still on antihypertensive medication on day 12 the community midwife must ensure the woman’s current antihypertensive regime is clearly documented in hand held care plan and she should be reminded to take the care plan with her at 2 weeks BP review with GP. The community midwife will need to collect the care plan from the woman after her GP review.


Appendix 1b: Postnatal blood pressure management plan: Chronic Hypertension

Name: Date of birth Hospital number: NHS number: Date of discharge from the hospital: Antihypertensive medication on the day of discharge: It is likely that this woman will stay on the same antihypertensive regime until she sees her GP two weeks post-delivery. The GP will then change the medication to either her pre pregnancy regime or a regime that is compatible with breast feeding. The community midwife will check her blood pressure (BP) on day 4

If her BP is 140/90 mm Hg and the woman doesn’t complain of dizziness or fainting, the midwife will not arrange any further BP check.

If the woman complains of dizziness or fainting the community midwife should phone the midwife in-charge of the Maternity Triage for advice.

If the BP is 141/91-150/100, the midwife will check her BP every 2 days until it is less than 140/90.

If BP is >150/100 the community midwife should phone the midwife in charge of the maternity triage while she is with the woman for advice. Women with chronic hypertension do not need to be readmitted to hospital unless there are other concerns. If the dose of the antihypertensive is increased, midwife will check the BP again on the following day.

It is the midwife’s responsibility to clearly document changes in medication in the woman’s hand held care plan. All women taking antihypertensive medication should arrange a GP check-up at 2 weeks and the woman should take her care plan with her to the GP appointment. The community midwife will need to collect the care plan from the woman after her GP review.


Appendix 1c: Discharge advice for GPs of women taking antihypertensive following birth

Following birth blood pressure usually returns to normal over a period of six weeks. Community midwife would assess the BP of women every 1-2 days up to 2 weeks after transfer to community care as per the post-natal blood pressure management plan provided to woman at the time of discharge from hospital. The antihypertensive dose needs reducing if BP falls to < 130/80 mmHg. We recommend that antihypertensive treatment be reduced stepwise according to blood pressure. Women are advised following discharge from the community midwife (usually at 2weeks following hospital discharge) to make an appointment to have their blood pressure checked weekly or if they have hypotensive side effects. . Woman will bring her hand held care plan with her which will have clear documentation of her current dose of antihypertensive by her community midwife. After six weeks, raised blood pressure or proteinuria can no longer be attributed to pregnancy and should be investigated as normal. Women with hypertension prior to pregnancy should restart their pre-pregnancy antihypertensive at six weeks. Please discuss the following with the patient at 6-8 weeks postnatal medical review.

Long-term health risks 7

Future risk Hypertensive disorder

Gestational hypertension

Pre-eclampsia Severe pre- eclampsia, HELLP syndrome or eclampsia

Gestational hypertension in future pregnancy

Risk ranges from about 1 in 6 (16%) to about 1 in 2 (47%).

Risk ranges from about 1 in 8 (13%) to about 1 in 2 (53%).

Pre-eclampsia in future pregnancy

Risk ranges from 1 in 50 (2%) to about 1 in 14 (7%).

Risk up to about 1 in 6 (16%).

No additional risk if interval before next pregnancy < 10 years.

If birth was needed before 34 weeks risk is about 1 in 4 (25%).

If birth was needed before 28 weeks risk is about 1 in 2 (55%).

Cardiovascular disease

Increased risk of hypertension and its complications

Increased risk of hypertension and its complications.

Increased risk of hypertension and its complications.

End-stage kidney disease

If no proteinuria and no hypertension at 6–8 week postnatal review, relative risk increased but absolute risk low. No follow-up needed.


Appendix 2: Management of pregnancy with gestational hypertension.7

Degree of hypertension

Mild hypertension (140/90 to 149/99 mmHg)

Moderate hypertension (150/100 to 159/109 mmHg)

Severe hypertension (160/110 mmHg or higher)

Admit to hospital No No Yes (until blood pressure is 159/109 mmHg or lower)

Treat No With oral labetalol as first-line treatment to keep: • diastolic blood pressure between 80–100 mmHg • systolic blood pressure less than 150 mmHg

With oral labetalol as first-line treatment to keep: • diastolic blood pressure between 80– 100 mmHg • systolic blood pressure less than 150 mmHg

Measure blood pressure

Not more than once a week

At least twice a week At least four times a day

Test for proteinuria At each visit using automated reagent stripreading device or urinary protein: creatinine ratio

At each visit using automated reagent-strip reading device or urinary protein : creatinine ratio

Daily using automated reagent-strip reading device or urinary protein : creatinine ratio

Blood tests Only those for routine antenatal care

Test kidney function, electrolytes, full blood count, transaminases, bilirubin Do not carry out further blood tests if no proteinuria at subsequent visits

Test at presentation and then monitor weekly: • kidney function, electrolytes, full blood count, transaminases, bilirubin


Appendix 3: Management of pregnancy with pre-eclampsia.7

Degree of hypertension

Mild hypertension (140/90 to 149/99 mmHg

Moderate hypertension (150/100 to 159/109 mmHg

Severe hypertension (160/110 mmHg or higher)

Admit to hospital Yes Yes Yes Treat No With oral labetalol as

first-line treatment to keep: • diastolic blood pressure between 80– 100 mmHg • systolic blood pressure less than 150 mmHg

With oral labetalol as first-line treatment to keep: • diastolic blood pressure between 80– 100 mmHg • systolic blood pressure less than 150 mmHg

Measure blood pressure

At least four times a day

At least four times a day

More than four times a day, depending on clinical circumstances

Test for proteinuria

Do not repeat quantification of proteinuria



Blood tests Monitor using the following tests twice a week: kidney function, electrolytes, full blood count, transaminases, bilirubin

Monitor using the following tests three times a week: kidney function, electrolytes, full blood count, transaminases, bilirubin

Monitor using the following tests three times a week: kidney function, electrolytes, full blood count, transaminases, bilirubin


Appendix 4: Preparation and dosages of intravenous Hydralazine, Labetalol and MgSO4

Hydralazine Labetalol MgSO4 Loading dose preparation

Dissolve the contents of one 20mg hydralazine ampoule with 1ml water for injection BP. Further dilute the contents of the ampoule with 19ml of 0.9% sodium chloride to give 20mg hydralazine in 20ml (1mg/ml solution)

No loading dose necessary

Draw 20ml of 20%MgSO4 (4g) from two ampoules

Loading dose administration

Administer 5ml (5mg) over a period of 5 minutes (1ml/min) Check BP every 15 minutes. Repeated 5mg doses of hydralazine can be given every 20 minutes up to maximum 20mg aiming to get the BP around 160/100

Administer initial dose of labetalol 20 mg IV stat. Repeat 20mg doses every 10 minutes until satisfactory control reached or up to a maximum of 200 mg

Administer the 20ml of 20% solution via a syringe pump at the rate between 120ml/hour to 240ml/hour (20ml/4gms in 5 to 10 minutes)

Maintenance dose preparation

Dissolve the contents of 3 ampoules (60mg) with 1ml of water for each ampoule. Further dilute with 57ml of 0.9% sodium chloride to give 60mg hydralazine in 60ml (1mg/ml) solution

Prepare IV infusion of labetalol 200 mg made up to 50ml total with 0.9% sodium chloride

Draw up 50ml (10g) of the ready-made 20% solution of MgSO4 from 5 ampoules

Maintenance dose administration

Start infusion at 10mg/hr (10ml/hr) doubling every 30 minutes to a maximum of 40mg/hr (40ml/hr)

Maintain BP with rate of 40 mg (10ml)/hour. Double the infusion rate every 30 minutes as required to a maximum of 160 mg (40ml)/hour titrated against BP

Administer the 50ml of 20% solution via a syringe pump at 5ml/hour (1g per hour) for 24 hours. Prepare fresh syringes every 10 hours as required


Appendix 5: Flow chart of management of severe pre-eclampsia and Eclampsia

Do not leave patient alone

Airway

Breathing

Place in semi-prone position Call for HELP - Obstetric Team, Senior Midwife and Anaesthetist Inform Consultants

Assess Maintain patency Apply oxygen

Assess Protect airway Ventilate

Circulation

Control seizures

Control hypertension

If not postpartum…

deliver

Evaluate pulse and BP If absent, initiate CPR and call the arrest

team Secure IV access as soon as safely

possible

Loading Dose MgSO4: Give 20ml (4g) of 20% solution via syringe pump at 120 to 240ml/hour (equivalent to 20ml (4g) in 5 to 10 minutes.).

Maintenance Dose of MgSO4: Give 50ml of 20% solution via syringe pump at 5ml/hour (equivalent to1g per hour) for 24 hours.

If seizures continue or recur: 10ml (2g) of 20% MgSO4 can be given as a slow IV, or the rate of the existing infusion increased to 10ml/hr (equivalent to 2g per hour). Alternatively 10mg diazepam can be given IV (with caution)

Monitor: hourly urine output, respiratory rate, oxygen saturations & patellar reflexes. Stop infusion: If serum magnesium toxicity is suspected on clinical grounds:

a. Reflexes are absent b. Respirations <10/minute c. If oxygen saturation <95% d. Hourly urine output (if less than 10-20ml/hr inform the Registrar)

Always get suppression of reflexes before respiratory depression Antidote: • Give 2ml of calcium gluconate 10% injection intravenously. Repeat 2ml every 2 minutes up to 10 mL

Treat hypertension if systolic BP >160mmHg or diastolic BP >110mmHg or MAP >125mmHg. Aim to reduce BP to 130-140/90-100mmHg. Beware of maternal hypotension and FHR abnormalities - monitor FHR with continuous CTG

Rapid Control 1. Oral nifedipine MR 10-20mg. 2. Hydralazine 5mg IV slowly repeated every 20 minutes up to 20 mg or labatalol 20mg IV repeat every 20min up to 200mg

Sustained control Oral methyldopa (250mg QDS to 500 QDS max) or oral nifedipine MR (10-20mg BD) or hydralazine 10mg-40mg/hr prepared as per Appendix 4

The continuation of pregnancy is not an option if eclampsia occurs STABILISE THE MOTHER BEFORE DELIVERY Delivery is a team effort involving obstetricians, midwives, anaesthetist and the neonatal team. Ergometrine should not be used in severe pre-eclampsia and eclampsia Consider prophylaxis against thromboembolism. Maintain vigilance as the majority of eclamptic seizures occur after delivery.

INVESTIGATIONS Blood - FBC & platelets, U&E’s , urate, LFT’s, coagulation screen and group & save Urine - MSU and PCR

OBSERVATIONS Respiration rate, pulse, temperature, O2 saturations, BP, ECG, CEFM, fluid balance, and CVP reading

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Hypertensive disorders in pregnancy - Frimley Health and Care · Hypertensive disorders of pregnancy V1.2 May 2019 Page 3 of 26 1. Background Pre-eclampsia and eclampsia is the 4th