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CDHB

Gestational Proteinuric Hypertension (Pre-eclampsia)

Normally appears beyond 20 weeks gestation. Once present it will progress at a variable rate until the fetus is delivered. Resolution is not immediate after delivery, and severe hypertension or an eclamptic seizure post-partum may be the first presentation. The disorder is usually asymptomatic until at an advanced stage, at which time the patient may complain of headache, visual disturbance, or epigastric pain.

Clinical signs

• Hypertension.
• Proteinuria.
• Rapid development of oedema.
• Headache.
• Visual disturbance.
• Hyperreflexia/clonus.
• Epigastric pain and tenderness.
• Nausea and vomiting.
• Chest pain or dyspnoea.
• Altered level of consciousness; seizures.
• Placental abruption.

Investigations

• CBC + diff, Na, K, creatinine, urea, urate, alb, bili, ALP, AST, GGT, ALT, coagulation profile (if platelet count reduced), and urinary protein/ creatinine ratio.
• Pulse oximetry for oxygen saturation.
• Group and hold if delivery imminent.
• Ultrasound scan of fetus including doppler studies.
• Cardiotocograph (CTG) if >24 weeks gestation.

Management

• Call Obstetric Registrar.
• If BP ≥160 mm Hg systolic or ≥100 mm Hg diastolic, institute antihypertensive therapy:
  • Loading dose of methyldopa 1 g orally and then 250-500 mg 6 hourly.
• If urgent reduction in BP necessary (BP ≥170 mm Hg systolic or ≥110 mm Hg diastolic), the options, in addition to implementing the above, are:
  • Labetolol 20 mg IV bolus repeated as required or followed by a continuous infusion (avoid in patients with a history of asthma), or
  • Nifedipine immediate release 10 mg orally and repeated as required, or
  • Hydralazine 5 mg IV slowly repeated as required (beware of precipitating hypotension). Total dose 30 mg.

  Whichever option is used, the fetus needs to be monitored by CTG if the blood pressure is being acutely lowered.

• These drugs should be given until the BP falls below 160/110. Seek Specialist advice.
• If at high risk of eclampsia (indicators include severe hypertension, headache, epigastric pain, and hyperreflexia with 2 or more beats of clonus) start seizure prophylaxis with magnesium sulphate (protocol available on delivery suite - seek Specialist advice).

Reference: Society of Obstetric Medicine Australia and New Zealand '2008 Guidelines for the management of hypertensive disorders of pregnancy'; available as a PDF download at http://www.somanz.org.

Topic Code: 3359