Hypertension in pregnancy

1. Hypertension in pregnancy Implementing NICE guidance 2010 NICE clinical guideline 107

2. What this presentation covers • Background • Definitions • Scope • Key priorities for implementation • Savings • Discussion • Find out more

3. Background • Hypertension can develop during pregnancy or can be pre-existing. • Hypertensive disorders during pregnancy carry risks for the woman and her baby. • The number of women with hypertensive disorders during pregnancy is increasing.

4. Scope • This guideline covers the care and management of women with hypertensive disorders in pregnancy. • The scope covers chronic and gestational hypertension, as well as pre-eclampsia. • The scope also covers women at risk of developing hypertensive disorders, and care of the fetus until birth.

5. Definitions aSignificant proteinuria is > 300 mg protein in a 24-hour urine collection OR >30mg/ml in a spot urinary protein:creatinine sample

6. Key priorities for implementation • Reducing risk of hypertensive disorders in pregnancy • Management of pregnancy with chronic hypertension • Assessment of proteinuria • Management of pregnancy with gestational hypertension • Management of pregnancy with pre-eclampsia • Advice and follow-up care at transfer to community care

7. Reducing risk Advise women at high risk of pre-eclampsia to take 75 mg of aspirin daily from 12 weeks until the birth of the baby

8. Management of pregnancy with chronic hypertension • Tell women who take angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) - there is an increased risk of congenital abnormalities if these drugs are used in pregnancy - to discuss alternative antihypertensive treatment with their healthcare professional • Aim to keep blood pressure lower than 150/100 mmHg in women with uncomplicated chronic hypertension

9. Assessment of proteinuria Use an automated reagent-strip reading device or a spot urinary protein:creatinine ratio for estimating proteinuria in a secondary care setting.

10. Management of pregnancy with gestational hypertension • Offer women with gestational hypertension an integrated package of care • This should cover admission to hospital, treatment, measurement of blood pressure, testing for proteinuria and blood tests • ‘Do not’ recommendations are included within the algorithm

11. Management of pregnancy with pre-eclampsia • Offer women with pre-eclampsia an integrated package of care covering admission to hospital, treatment, measurement of blood pressure, testing for proteinuria and blood tests • A consultant obstetrician should document the maternal and fetal thresholds for elective birth prior to 34 weeks in the woman’s notes • Offer medical review at the postnatal review • ‘Do not’ recommendations are also included within the algorithm

12. Advice and follow-up care at transfer to community care • Tell women who had pre-eclampsia about their risk of developing gestational hypertension or pre-eclampsia in future pregnancies • The chance of developing pre-eclampsia in a future pregnancy is greater if their pre-eclampsia was severe, or complicated by HELLP syndrome or eclampsia, and if it led to birth before 34 weeks

13. Costs and savingsper 100,000 population

14. Discussion • What pathways are in place for managing hypertensive disorders in pregnant women, and how can they be updated? • How is advice and follow-up care provided to women locally? • How does our current prescribing of antihypertensives compare with the guideline recommendations?

15. Find out more • Visit www.nice.org.uk/guidance/CG107 for: • the guideline • the quick reference guide • ‘Understanding NICE guidance’ • costing report and template • audit support