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Cardiovascular care (hypertensive disorders of pregnancy)

Hypertension:

NICE Guidelines 2019: https://www.nice.org.uk/guidance/ng133/resources/hypertension-in-pregnancy-diagnosis-and-management-pdf-66141717671365

Diagnosis and management of hypertension in pregnancy: summary of updated NICE guidance https://www.bmj.com/content/366/bmj.l5119

CMQCC: Hypertensive disorders of pregnancy toolkit https://www.cmqcc.org/resources-tool-kits/toolkits/HDP

ACOG: https://journals.lww.com/greenjournal/fulltext/2013/11000/hypertension_in_pregnancy___executive_summary.36.aspx

Hypertensive disorders of pregnancy

• Chronic hypertension—Hypertension that is present at the booking visit or before 20 weeks’ gestation, or if the woman is already taking antihypertensive medication when starting maternity care. It can be primary or secondary in aetiology

• Gestational hypertension—New hypertension presenting after 20 weeks of pregnancy without significant proteinuria

• Pre-eclampsia—New onset hypertension (>140 mm Hg systolic or >90 mm Hg diastolic) after 20 weeks of pregnancy and the coexistence of one or both of the following new-onset conditions:

  • Proteinuria (urine protein:creatinine ratio ≥30 mg/mmol, or albumin:creatinine ratio ≥8 mg/mmol, or ≥1 g/L [2+] on dipstick testing)

  • Other maternal organ dysfunction, including features such as renal or liver involvement, neurological or haematological complications, or uteroplacental dysfunction (such as fetal growth restriction, abnormal umbilical artery Doppler waveform analysis, or stillbirth)

Postpartum HTN Management: (NICE 1.9):

• 1.9.3 As antihypertensive agents have the potential to transfer into breast milk: • consider monitoring the blood pressure of babies, especially those born preterm, who have symptoms of low blood pressure for the first few weeks • when discharged home, advise women to monitor their babies for drowsiness, lethargy, pallor, cold peripheries or poor feeding. [2019]

• 1.9.4 Offer enalapril[5] to treat hypertension in women during the postnatal period, with appropriate monitoring of maternal renal function and maternal serum potassium. [2019]

• 1.9.5 For women of black African or Caribbean family origin with hypertension during the postnatal period, consider antihypertensive treatment with: • nifedipine[3] or • amlodipine if the woman has previously used this to successfully control her blood pressure. [2019]

• 1.9.6 For women with hypertension in the postnatal period, if blood pressure is not controlled with a single medicine, consider a combination of nifedipine[3] (or amlodipine) and enalapril[5] . If this combination is not tolerated or is ineffective, consider either: • adding atenolol or labetalol to the combination treatment or • swapping 1 of the medicines already being used for atenolol or labetalol. [2019]

• 1.9.7 When treating women with antihypertensive medication during the postnatal period, use medicines that are taken once daily when possible. [2019]

• 1.9.8 Where possible, avoid using diuretics or angiotensin receptor blockers[5] to treat hypertension in women in the postnatal period who are breastfeeding or expressing milk. [2010, amended 2019]

• 1.9.9 Treat women with hypertension in the postnatal period who are not breastfeeding and who are not planning to breastfeed in line with the NICE guideline on hypertension in adults. [2019]

Cardiovascular Disease in Pregnancy/Postpartum:

ACOG 2019: https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2019/05/pregnancy-and-heart-disease

ESC 2018: https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Cardiovascular-Diseases-during-Pregnancy-Management-of

Substance use disorder screening, referral, and treatment:

WHO Guidelines: https://www.who.int/publications/i/item/9789241548731

• Evidence Profile 1: Screening and brief interventions

• Evidence Profile 2: Psychosocial interventions for harmful use and dependence on alcohol and other substances in pregnancy

• Evidence Profile 3: Detoxification or quitting programmes for alcohol and other substance dependence in pregnancy

• Evidence Profile 4: Pharmacological treatment (maintenance and relapse prevention) for alcohol and other substance dependence in pregnancy

• Evidence Profile 5: Breastfeeding

• Evidence Profile 6: Management of infants exposed to alcohol and other psychoactive substances .

Other supporting evidence-based recommendations for postpartum care services:

Breastfeeding Support:

CDC Guide to Strategies Supporting Breastfeeding: https://www.cdc.gov/breastfeeding/pdf/bf-guide-508.pdf

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