BP Thresholds for Medical Review

Transcription

1 BP Threshlds fr Medical Review Wmen presents t GP pstnatally with high bld pressure r referred t GP by midwife GP t review patient n the same day if BP>150/100. If BP (dne by midwife) persistently /90-99, GP t review patient within the week Patient attends GP surgery: Take BP with crrect sized cuff Review fr signs f pre-eclampsia (see belw) Check urine fr prteinuria If BP<140/90 BP / BP>150/100 and asymptmatic fr PET symptms* >150/100 and symptmatic fr PET* N further actin *PET symptms: Severe headache Prblems with visin, such as blurring r flashing befre the eyes Severe pain just belw the ribs r vmiting Papilledema Signs f clnus (>3 beats) Liver tenderness HELLP syndrme Platelet cunt falling t belw 100 x 10 per litre Abnrmal liver enzymes (ALT r AST rising t abve 70iu/litre) Cntinue t mnitr twice weekly If BP persistently between / at 6 week check, manage as essential hypertensin eg Referral fr ABPM Start antihypertensive treatment: Labetall 100 mg twice daily (increase by 100 mg increments up t 400 mg QDS) Nifedipine mg nce daily Captpril mg twice daily (increase t 75mg BD at intervals f 2 weeks) r Enalapril 5-10 mg d (maximum 40 mg OD) Check BP again daily (GP r midwife) until BP stabilised. Review treatment every 3-7 days unless BP increasing despite treatment Refer t n-call Obs SpR n bleep 003 Nte: If severe hypertensin >160/ 110, cnsider discussin with ncall Obs SpR Fr wmen wh develped hypertensin during pregnancy, medicatin can be tapered ff and stpped nce BP <130/80. Wmen with pre-existing hypertensin can be switched back t their pre-pregnancy antihypertensive nce the bld pressure is cntrlled in the pstnatal perid.

2 MANAGEMENT OF POSTNATAL HYPERTENSION FOR CMWs/GPs Intrductin Hypertensin is the leading cause f maternal pstnatal readmissin. It is well dcumented that admissin t hspital in the pstnatal perid causes a lt f disruptin and distress t family life at a challenging time, when they are adjusting t a new-brn. The demands f lking after a new-brn als makes cmpliance t medicatin difficult at this time. Our mst recent audit shws that abut 60% f the wmen readmitted stay in hspital fr 24 hurs r less, ften nly requiring initiatin r adjustment f antihypertensive medicatin. The majrity f these wmen were referred t hspital by their cmmunity midwives during their rutine pstnatal visits. If these wmen are referred initially t their n-call GP, their care culd have been prvided in the cmmunity reducing a significant prprtin f readmissins causing less disruptin f family life. Wmen wh had pre-existing/gestatinal hypertensin will have n their discharge letter details f bld pressure threshlds fr which they shuld be referred fr medical attentin. Pre-existing Hypertensin / Pregnancy induced hypertensin / Preeclampsia The fllwing definitins are taken frm the NICE Guidelines n Hypertensin in pregnancy (CG ). Mild hypertensin diastlic bld pressure mmhg, systlic bld pressure mmhg. Mderate hypertensin diastlic bld pressure mmhg, systlic bld pressure mmhg. Severe hypertensin diastlic bld pressure 110 mmhg r greater, systlic bld pressure 160 mmhg r greater. Severe pre-eclampsia is pre-eclampsia with severe hypertensin and/r with symptms, and/r bichemical and/r haematlgical impairment.

3 The fllwing symptms, signs and bld investigatins are als cnsidered significant in relatin t Preeclampsia. severe headache prblems with visin, such as blurring r flashing befre the eyes severe pain just belw the ribs r vmiting papilledema signs f clnus ( 3 beats) liver tenderness HELLP (Haemlysis, elevated liver enzymes, lw platelets) syndrme platelet cunt falling t belw 100 x 10 9 per litre abnrmal liver enzymes (ALT r AST rising t abve 70 iu/litre). BP threshlds Mild hypertensin Pstnatal wmen with BP /90-99 mmhg, withut symptms, shuld be advised t take their medicatin; if they are n medicatin and haven t taken it. They shuld be advised f symptms t lk ut fr and have their bld pressure repeated the next day. Wmen nt n medicatin shuld have their bld pressure repeated after 30 minutes, if it is still between /90-99 mmhg and less; they shuld be advised f symptms t lk ut fr and have their bld pressure repeated the next day. If it s abve 150/100mmHg, see belw. If the mild hypertensin persists next day, they shuld be referred t their wn GP fr further management. If their bld pressure is nrmal the next day (<140/90 mmhg), it shuld be checked again the fllwing week either by the cmmunity midwife r practice nurse. If they develp any symptms, they shuld g t A&E r call an ambulance, depending n the severity f their symptms.

4 Mderate Hypertensin Wmen with BP / mmhg, withut symptms, shuld be advised t take their medicatin; if they are n medicatin and haven t taken it. Their bld pressure shuld be re-checked an hur after medicatin. If it still abve 150/100mmHg and they remain symptm free, they shuld be referred t see the n-call GP same day. If their bld pressure settles an hur after taking their medicatin (< 150/100mmHg); they shuld be advised n cmpliance t medicatin. Their bld pressure shuld be checked again the next day and then twice weekly fr the next 2 weeks. Wmen nt n medicatin shuld have their bld pressure repeated after 30 minutes. If still abve 150/100mmHg, refer t the n-call GP fr their practice. If they have any significant symptms f Preeclampsia, they shuld be referred the n-call bstetric team (Bleep 003, SpR) and advised t attend A&E. Severe Hypertensin Wmen with a bld pressure >160/100 mmhg, withut symptms f Preeclampsia; shuld be referred urgently t their n-call GP. If they are n medicatin and have nt taken any fr the day, they shuld be advised t take the recmmended dse whist waiting t see the GP. If they have already taken the recmmended dse f medicatin fr the day, the GP can give verbal rders fr further dses prir t review depending n the BP reading. If they have any significant symptms f Preeclampsia, they shuld be referred the n-call bstetric team (Bleep 003, SpR) and advised t attend A&E r the labur ward as apprpriate. Cnsider ambulance transfer fr such patients. On-call GPs can cntact the Obstetric SpR/Cnsultant n-call via the hspital switchbard t discuss such cases and fr advice as necessary.

5 Recmmended anti-hypertensives in breastfeeding mthers Wmen with pre-existing hypertensin can be switched back t their prepregnancy antihypertensive nce the bld pressure is cntrlled in the pstnatal perid. The fllwing antihypertensives are deemed safe in breastfeeding mthers, as per NICE guidance. Labetall Nifedipine Enalapril Captpril Atenll Metprll There is insufficient evidence fr the use f Amldipine, ARBs and ACE inhibitrs ther than thse abve in breastfeeding wmen. It is als advised that Methyl Dpa is discntinued in the pstnatal perid due t its ptential t aggravate pstnatal depressin. Individual patients wh have been well cntrlled n it may be cntinued with the right safeguards in place. Diuretics are nt recmmended fr bld pressure cntrl during breastfeeding as they cause vlume depletin and interfere with breast milk prductin. GPs shuld cnsider starting treatment if bld pressure is persistently abve 150/100mmHg; with the aim f keeping the bld pressure less than 140/90mmHg. Medicatins can be tapered ff and stpped nce bld pressure is less than 130/80mmHg. Once medicatin is initiated/amended, bld pressure shuld be checked daily and medicatin reviewed after 3 days t 1 week unless bld pressure is rising despite treatment. Labetall is the first line antihypertensive fr gestatinal hypertensin, starting at 100mg BD, increasing by 100mg increments thrugh TDS t 400mg QDS. Maximum dse is 2.4g daily, patients requiring mre than 400mg QDS shuld ideally have a secnd agent r be referred t secndary care. Its multiple daily dsing may nt make it the mst apprpriate fr nn-cmpliant patients.

6 Atenll (25-100mg OD) shuld be cnsidered fr patients with cmpliance issues as it s taken nce daily. It shuld als be nted that patients f African descent tend t respnd better t calcium channel blckers; as such Nifedipine MR 10-40mg BD shuld be the preferred antihypertensive fr such patients if BP is nt well cntrlled n Labetall. Once bld pressure settled, this can be changed t Nifedipine 30-90mg OD fr patients requiring treatment lng term. Amldipine 5-10mg OD is a gd alternative in wmen wh are nt breastfeeding. Enalapril mg OD is als an alternative first/secnd line antihypertensive t use in breastfeeding wmen. References 1. Hypertensin in pregnancy: diagnsis and management; NICE Clinical Guidance CG107, Severe Pre-eclampsia and Eclampsia Guideline, Hmertn University Hspital NHS Fundatin Trust; Smith M, Waugh J, Nelsn-Piercy C. Management f pstpartum hypertensin. The Obstetrician Gynaeclgist 2013;15: Magee L, vn Dadelszen P. Preventin and treatment f pstpartum hypertensin. Cchrane Database Syst Rev Apr 30;4 Created by: Dr Kirsten Brwn, Dr Balvinder Duggal and Albert Opku (Obstetric cnsultant at Hmertn) 1/4/16