Hypertension in Pregnancy 2013-G Lipkin

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    Hypertension in Pregnancy

    Graham Lipkin

    Consultant Nephrologist

    University Hospital Birmingham

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    Hypertension in Pregnancy

    http://www.nice.org.uk/guidance/CG107

    http://www.nice.org.uk/guidance/CG107http://www.nice.org.uk/guidance/CG107
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    Definitions of Hypertension in

    Pregnancy

    PresentationSignificant

    Proteinuria*

    Chronic

    Hypertension

    20 weeks No

    Pre-Eclampsia (PET) >20 weeks Yes

    PET Superimposedon Chronic

    Hypertension

    >20 weeks Yes

    *Significant proteinuria is > 300 mg protein in a 24-hour urine collection OR

    >30mg/ml in a spot urinary protein:creatinine sample

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    Severity Of Hypertension

    Systolic BP* Diastolic BP*

    Mild 140-149 90-99

    Moderate 150-159 100-109

    Severe >160 >110

    NICE clinical guideline 107: 2011

    * Measurement of BP in Pregnancy

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    Proteinuria

    Assessment

    Automated reagent strip reading device

    If > +1 (without UTI) further assess with

    Protein/creatinine ratio (PCR): 24h urine protein (validated):

    Abnormal PCR > 30 mg/mmol

    Abnormal 24h >300mg*

    * Lab must use method to assess completeness ofcollection

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    Physiological Adaptation to Normal

    Pregnancy

    Major Challenge for those with CKD

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    Physiology of Normal Pregnancy

    0

    20

    40

    60

    80

    100

    120

    140

    160

    0 12 28 40

    GFR

    Sturgiss et al. 1994

    Weeks

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    Physiological changes to the kidney during healthy pregnancy.

    Williams D , Davison J BMJ 2008;336:211-215

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    Aspirin in Prevention of PET in High Risk

    Pregnancies

    Coomarasamy et al. Obstet Gynaecol 2003;101:1319

    OR

    PET 0.79

    Perinatal

    death

    0.79

    Birth Wt 215gAbruption 0.98

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    Risks of Pre-eclampsia: Aspirin 75mg

    Moderate risk

    First pregnancy

    Age>40

    Pregnancy interval >10y

    BMI > 35

    FH of PET

    Twins

    High Risk

    Hypertension in

    previous pregnancy

    CKD

    SLE/APS

    Type 1 or 2 DM

    Chronic Hypertension

    If 2 moderate of 1 Severe risk factors advise

    Aspirin 75mg from 12 weeks

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    Renal disease vs Pre-eclampsia;

    (systemic disease)

    Golden RulesProteinuria >20 weeks = PET

    BP control in PET does not stop

    illness

    Rx of severe PET = delivery

    Most conditions improve with

    delivery

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    What BP Treatment Target?

    Von Dadelzson. The Lancet 2000; 355:87-92, BHS IV 2004

    Chronic hypertension

    BP

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    Maternal-Fetal Interface

    Drug Transfer

    IVCFetal

    liver Placenta Uterus

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    Management of Chronic HypertensionPreconception Counselling

    Is BP Essential or secondary?

    Avoid conception on ACEi, ARB, Chlorthiazide

    Conversion and control to pregnancy safe drugs

    Labetolol

    Nifedipine LA

    Methyl Dopa

    Discuss risks of worsening hypertension/PET

    Smoking/weight/Folic acid

    Aspirin from 12 weeks

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    ACE inhibitor: Safety in Early Pregnancy0.5 million pregnancies

    De-Kun Li, BMJ 2011:

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    Risk of Major Congenital Malformations;ACE during the First Trimester

    ACEi exposure in early pregnancy increasing

    Cardiac and CNS malformations in first trimester useDiscontinue ACE/ARB pre-pregnancy and stabilise on alternative

    Treatment(Pre-conception counselling/contraception)

    Cooper et al, NEJM 2006;8354:2443

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    Chronic Hypertension

    Antenatal care

    Target BP < 150/100 or

    If end organ damage target 160/110)

    hypertension plan birth (after steroids)

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    Chronic Hypertension

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    Maternal Chronic Kidney Disease

    and Pregnancy

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    Causes of CKD in Pregnancy

    Hypertension/Sickle

    Reflux nephropathy

    Primary GN Lupus Nephritis

    Diabetic Nephropathy

    Polycystic kidney

    disease

    Pregnancy-Screening Opportunity for CKD

    Pregnancy identifies unrecognised Renal Disease

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    Pregnancy and Kidney Disease

    Pregnancy frequently unmasks previously

    unrecognised renal disease

    Proteinuria

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    Pregnancy in Renal Disease

    Frequency increasing

    Often complicatedCare optimal in Obstetric Renal Clinic

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    Proteinuria in Pregnancy

    121514 121514N =

    Categorised by proteinuria before 20 weeks (g/24 hours)

    >31-30.3-1

    12

    11

    10

    9

    8

    7

    6

    5

    4

    3

    2

    10

    Proteinuria

    before 20 weeks

    32 or 36 weeks

    UK CORD 2006

    Heavy Proteinuria is common in women withCKD in Pregnancy in 3rdTrimester

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    Effects of Pre-pregnancy Creatinine on

    Pregnancy Outcome

    Pre-

    Pregnancy

    Creatinine

    Pre-term

    delivery (%)

    Fetal growth

    restriction (%)

    Pre-eclamsia

    (%)

    Peri-natal

    death (%)

    180 >90 65 60 10

    On Dialysis >90 >90 75 50 (25)

    Williams, Davison BMJ 2008;336:211-5

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    Effect of Pregnancy on Maternal Renal function:

    Loss of >25% renal function

    Pre-

    Pregnancy

    Creatinine(umol/l)

    During

    pregnancy

    Persists

    postpartum

    ESRF at 1

    Year

    180 70 50 35

    Williams, Davison BMJ 2008;336:211-5

    Based on literature review 1985-2007

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    Gestational Hypertension

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    Pre-eclampsia

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    Bp Drug Choice and Breast Feeding

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    Long Term Health Risks

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    Reducing Risk of Hypertensive

    Disorders in Pregnancy

    Preconception Counselling

    Avoid ACEi/ARB and stabilise on preg-friendly

    Aspirin 75mg for pregnancy at high risk PET

    Target BP +1-use Protein/creatinine ratio (>30)

    Proteinuria

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    Risks in Future Pregnancy after PET

    Gestational Hypertension-around 1:4

    Pre-eclampsia

    RiskGestational Hypertension 1 in 8 to 1 in 2

    Pre-eclampsia 1 in 6

    Pre-eclampsia (if severePET/HELLP delivery

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    Hypertension in Pregnancy

    http://www.nice.org.uk/guidance/CG107

    http://www.nice.org.uk/guidance/CG107http://www.nice.org.uk/guidance/CG107
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