Hypertension in Pregnancy 2013-G Lipkin
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Transcript of 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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