Management of Hypertension in Pregnancy

Communication Skills

Author – Kalyani Shinkar  Editor – Kalyani Shinkar

Last updated 29/07/24

Table of Contents

Introduction

Managing hypertension in pregnancy is vital to ensure the health and safety of both the mother and the foetus. In an OSCE scenario for managing hypertension in pregnancy, it is important to demonstrate thorough understanding of the condition and exhibit strong communication skills.

This article provides a structured approach to explaining the management of hypertension in pregnancy and compares the management strategies for the different hypertensive disorders of pregnancy: chronic hypertension, gestational hypertension, and pre-eclampsia.  

Example OSCE Candidate Instructions

Mrs Fiona Radcliffe is a 30-year-old woman who is 24 weeks pregnant. She saw her GP a couple of days ago and was found to have a blood pressure of 150/100 mmHg and proteinuria. Please discuss her management plan and answer any questions she may have regarding her new diagnosis. 

Introduction and History

  1. Introduce yourself, confirm patient details, and gain consent to speak to the patient.
  2. Explain the purpose of the consultation
  3. “I understand that you have had high blood pressure readings recently and would like to discuss how we can manage your blood pressure.”
  4. Read the exam instructions carefully before entering the station. If the station requires you to take a history, important questions you can ask the patient include:
    1. Onset and duration: “When was your high blood pressure first noticed?”
    2. Symptoms: “Have you experienced any symptoms, such as a headache, blurry vision, tummy pain, or swelling in your face, hands, or feet?”
    3. Previous Pregnancies: “Have you been pregnant before and had this condition in your previous pregnancies?”
    4. Past Medical History: “Do you have a history of other medical conditions, such as high blood pressure before pregnancy, diabetes, chronic kidney disease, or autoimmune conditions?”
    5. Drug History – “Are you on any medications?”
    6. Family History – “Does high blood pressure run in the family?”
  5. Check the patient’s baseline understanding of hypertension in pregnancy – “What do you know about having high blood pressure in pregnancy?”
  6. ICE the patient:
    1. Ideas – “Do you have any ideas about this condition?”
    2. Concerns – “Are you worried/concerned about anything in particular?”
    3. Expectations – “What were you hoping to get out of today’s consultation other than discussing how we can manage your blood pressure?”

Explaining the Diagnosis

  • “Based on your blood pressure readings and the results of your urine test (which shows protein in the urine), you have a condition called pre-eclampsia”.
  • “Pre-eclampsia is a condition that can happen during pregnancy, usually after the 20th week. It means that your blood pressure is higher than normal.”
  • “We don’t fully understand what causes pre-eclampsia, but it’s thought to be related to how the placenta develops. Certain things like being pregnant for the first time, carrying more than one pregnancy, or having a history of high blood pressure can make it more likely.”
  • “It’s important we keep a close eye on both you and your baby’s health. This is because pre-eclampsia can affect your organs, like your liver and kidneys, and can affect your baby’s growth and wellbeing if it’s not managed properly.”

Discuss the Management

  • Monitoring:
    • Maternal Monitoring – “We will need to monitor your blood pressure regularly, which may include more frequent clinic visits or home blood pressure monitoring. We will also need to perform regular blood and urine tests to check how your organs are functioning.”
    • Foetal Monitoring – “Regular ultrasounds will be necessary to monitor the growth of the baby and check the baby’s health.” 
  • Lifestyle modifications:
    • “There are certain things that you can try yourself to reduce high blood pressure. These include following a healthy diet that is low in salt and engaging in moderate physical activity.”
    • “It’s also important to get adequate rest and avoid stressful situations as much as possible.”
  • Medications:
    • “We may need to start you on medications that help to reduce high blood pressure and are safe in pregnancy.”
  • Hospitalisation:
    • “If your blood pressure becomes difficult to control or if there are any signs of severe pre-eclampsia, we may need to admit you to the hospital for closer monitoring.”
  • Delivery
    • “The only cure for pre-eclampsia is delivering the baby. Depending on how far along you are and how severe the pre-eclampsia is, we might recommend delivering the baby early. This could mean inducing labour or having a C-section.”
  • Postpartum Care
    • “We will also continue to monitor you closely after your baby is born, as pre-eclampsia can sometimes continue after delivery.”

Closing the Consultation

  • If there is time left at the end, you can summarise what you have discussed and ask if the patient has any questions. “To summarise, we have discussed your management plan, which involves monitoring your blood pressure regularly, possibly starting medication, and performing regular checks on you and your baby to ensure everything is progressing well. Does that all make sense? Do you have any questions for me?”
  • Safety Netting – “I will see you at your follow-up appointment, but in the meantime, if you experience any concerning symptoms like severe headaches, changes to your vision, tummy pain, or reduced foetal movements, please seek immediate medical attention.”
  • Provide them with a leaflet or signpost them to useful resources (e.g. NHS website)

General Tips and Advice

  • During your explanation, remember to ‘chunk and check’ to facilitate patient understanding
  • Provide support and reassurance throughout the discussion and encourage the patient to ask questions if they have any. They may feel anxious and concerned about their baby’s wellbeing following this diagnosis. It’s therefore important to offer reassurance and support throughout the consultation.
    • “I understand you may be feeling worried, but we will monitor you closely and take the necessary steps to ensure the best outcome for you and your baby”

Viva Questions

There are 5 main types of hypertension in pregnancy:

  1. Chronic Hypertension: Hypertension that predates pregnancy and is diagnosed before 20 weeks of gestation. It is not caused by dysfunction in the placenta.
  2. Gestational Hypertension: Pregnancy-induced hypertension that develops after 20 weeks of gestation without proteinuria.
  3. Pre-eclampsia: Pregnancy-induced hypertension that develops after 20 weeks of gestation with signs of end-organ damage, notably proteinuria.
  4. Eclampsia: Pre-eclampsia plus seizures.
  5. Chronic Hypertension with Superimposed Pre-eclampsia/Eclampsia: Chronic hypertension as defined above that worsens and develops signs and symptoms of pre-eclampsia/eclampsia after 20 weeks of gestation.
 

Chronic Hypertension

Gestational Hypertension

Pre-eclampsia

Goals of Management

  • Monitor for the development of superimposed pre-eclampsia
  • Ensure maternal and foetal wellbeing
  • Monitor and manage blood pressure to prevent progression to pre-eclampsia
  • Ensure maternal and foetal wellbeing
  • Prevent progression to severe pre-eclampsia or eclampsia
  • Ensure maternal and foetal wellbeing
  • Plan delivery timing to optimise outcomes for both mother and baby

Monitoring

  • Regular blood pressure monitoring
  • Regular urinalysis to check for proteinuria
  • Serial ultrasounds for foetal growth assessment
  • Regular blood pressure monitoring
  • Repeat urinalysis if clinically indicated e.g. if new signs and symptoms develop or there is diagnostic uncertainty
  • Measure FBC, LFTs, and renal function regularly
  • Serial ultrasounds for foetal growth assessment

Lifestyle Modifications

All women with hypertension in pregnancy should be offered lifestyle advice, including eating a low-salt diet, engaging in regular moderate exercise, and avoiding smoking and alcohol.

Medications

  • Women with chronic hypertension should be prescribed aspirin 75-150mg from 12 weeks gestation through to 36 weeks to reduce the risk of pre-eclampsia
  • Offer antihypertensive to women with chronic hypertension who are not already on treatment if BP≥140/90 mmHg
  • Offer antihypertensive treatment if BP remains ≥140/90
  • Non-Severe Hypertension (BP 140/90 – 159/109 mmHg)
    • Measure BP weekly
  • Severe Hypertension (BP ≥160/110 mmHg)
    • Admit to hospital until BP ≤159/109 mmHg)
    • Measure BP at least 4 times a day
  • Offer antihypertensive treatment if BP remains ≥140/90
  • Non-Severe Hypertension (BP 140/90 – 159/109 mmHg)
    • Measure BP at least every 48 hours
  • Severe Hypertension (BP ≥160/110 mmHg)
    • Admit to hospital until BP ≤159/109 mmHg)
    • Measure BP every 15-30 minutes until BP ≤159/109 mmHg, then at least 4 times daily while the woman is an inpatient

Delivery Planning

  • Aim for delivery at 38-39 weeks if blood pressure is well-controlled and no complications arise
  • In cases of poorly controlled hypertension or superimposed pre-eclampsia, earlier delivery may be necessary, a decision that should be made by a consultant obstetrician
  • If early delivery is required, offer a course of antenatal corticosteroids and magnesium sulphate
  • Aim for delivery at 37-38 weeks if blood pressure is well-controlled and no complications arise
  • In cases of severe hypertension or the development of pre-eclampsia, earlier delivery may be necessary, a decision that should be made by a consultant obstetrician
  • If early delivery is required, offer a course of antenatal corticosteroids and magnesium sulphate
  • The definitive management of pre-eclampsia is delivery of the foetus
  • Mild pre-eclampsia:
    • Plan delivery >34 weeks gestation
    • After 37 weeks gestation, initiate birth within 24-48 hours
  • Severe pre-eclampsia
    • Plan delivery <34 weeks gestation
  • If early delivery is required, offer a course of antenatal corticosteroids and magnesium sulphate

Postpartum Management

  • Continued BP monitoring as some women may develop postpartum pre-eclampsia
  • Consider continuing or adjusting antihypertensive medication if BP is above target of 140/90 mmHg in the post-natal period. Breast-feeding safe medications should be chosen. 
  • Arrange regular follow-ups with their GP or specialist to monitor BP and manage chronic hypertension if present

 

The NICE guidelines (2019) recommend the use of placental growth factor (PlGF) testing to help rule out the possibility of pre-eclampsia.

  • PlGF is a hormone that is released by the placenta and stimulates angiogenesis (formation of new blood vessels)
  • The levels of PlGF will be low in pre-eclampsia
  • The test should be offered between 20 weeks and 36 weeks and 6 days of pregnancy
  •  
  • A common 1st line agent in hypertension in pregnancy is labetalol
  • If labetalol is not suitable, consider the use of nifedipine
  • If both labetalol and nifedipine are not suitable, consider the use of methyldopa
  • Hydralazine is sometimes used to treat hypertension in pregnancy, but often only after all other options have been explored

ACE inhibitors, angiotensin II receptor blockers (ARBs), and thiazide diuretics are avoided in pregnancy owing to the increased risk of congenital malformation.

135/85 mmHg

  1. https://www.nice.org.uk/guidance/ng133/chapter/Recommendations
  2. https://www.nhs.uk/conditions/pre-eclampsia/
  3. https://mlamedics.com/pre-eclampsia-station/

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