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Executive Summary
This is a brief summary of the recommendations of a multidisciplinary working party convened by the Society of Obstetric
Medicine of Australia and New Zealand (SOMANZ). They reflect current medical literature and the clinical experience of
members of the working party.
The full guideline, development process, methodology and references are available at: http://www.somanz.org/.
© 2014 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists 11
The Australian and
New Zealand Journal
of Obstetrics and
Gynaecology
Executive Summary
12 © 2014 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
Executive Summary
those centres with appropriate experience, expertise and compromise. However, fetal distress as a result of such
neonatal unit. Clear ‘endpoints’ for delivery should be treatment is rare.
defined for each patient so that the decision to deliver is Persistent or refractory severe hypertension may require
based on agreed criteria. repeated intravenous boluses or even an intravenous
In cases of preterm preeclampsia before 34 weeks, infusion of labetalol or hydralazine. Such infusions are
delivery should be delayed for at least 24–48 h, if maternal used to stabilise the woman to effect safe delivery and/or
and fetal status permit, to allow fetal benefit from short-term postpartum blood pressure control: they are
antenatal corticosteroids administered for lung maturation. less effective for prolonged use. Sustained blood pressure
Additionally, antenatal administration of magnesium lowering is usually best achieved by concurrent oral and
sulphate may provide neonatal neuroprotection. intravenous treatment.
Continuation of pregnancy carries fetal risk, and some It is recommended that protocols for the management of
stillbirths will occur despite careful monitoring. severe hypertension should be readily accessible in all obstetric
In the presence of HELLP syndrome, expectant units.
management is harmful, with a 6.3% incidence of maternal
death and an increased risk of placental abruption. In such
Mild-moderate hypertension
cases, delivery should be planned as soon as feasible.
Preeclampsia presenting in the late preterm period (34– This guideline recommends antihypertensive treatment for
366 weeks’ gestation) is associated with increasing risk of all pregnant women with blood pressure ≥160 mmHg
SGA neonates with a higher risk of delivery via caesarean systolic or ≥110 mmHg diastolic. In the absence of
section, respiratory distress syndrome and longer compelling evidence, treatment of mild to moderate
admissions in the neonatal intensive care unit. Antenatal hypertension in the range 140–160/90–100 mmHg should
steroid prophylaxis may be beneficial in this group. be considered an option and will reflect local practice.
At a mature gestation, severe preeclampsia should not A number of drugs have been proven to be safe and
delay delivery. Even so, it is important to control severe efficacious. These include oral labetalol, oxprenolol,
hypertension and other maternal derangements before methyl-dopa, clonidine, nifedipine, hydralazine and
subjecting the woman to the stresses of delivery. prazosin.
In women with gestational hypertension at low risk of Angiotensin converting enzyme (ACE) inhibitors and
adverse outcomes, an expectant management approach angiotensin receptor blockers remain contraindicated in
beyond 37 weeks with close maternal and fetal monitoring pregnancy, particularly the third trimester but are suitable
should be considered. alternatives for management of hypertension in the
A team approach, involving obstetrician, midwife, postpartum period.
neonatologist, anaesthetist and physician, provides the best
chance of achieving a successful outcome for mother and
Other aspects of management:
baby. Regular assessment of both mother and fetus is
required. Careful clinical assessment daily should be Thromboprophylaxis: Preeclampsia is an independent risk
complemented by regular blood and urine tests. factor for venous thromboembolism (VTE) occurring in
pregnancy or the puerperium. Pharmacological
prophylaxis is indicated in a woman who has 2 major, or
Treatment of hypertension in pregnancy 1 major and 2 minor risk factors, unless there are surgical
contraindications.
Severe hypertension in pregnancy
Fluid management: Although maternal plasma volume is
Severe hypertension requiring urgent treatment is defined often reduced in women with preeclampsia, there is no
as a systolic blood pressure greater than or equal to evidence to support maternal or fetal benefit from
170 mmHg or diastolic blood pressure greater than or maintenance fluid therapy. The administration of fluid at a
equal to 110 mmHg. Severe hypertension should be rate greater than normal requirements should only be
treated promptly aiming for a gradual and sustained considered, with care, prior to parenteral hydralazine,
lowering of blood pressure to avoid maternal complication regional anaesthesia or for initial management in women
and fetal compromise from too rapid adjustment. with oliguria. The choice between colloid and crystalloid
Commonly used agents include intravenous labetalol or fluid remains controversial.
hydralazine, or oral nifedipine. There is concern that a Haematological and hepatic manifestations:
precipitous fall in blood pressure after antihypertensive Thrombocytopenia, a progressive decline in platelet count,
treatment, particularly intravenous hydralazine, may or evidence of disseminated intravascular coagulation is an
impair placental perfusion resulting in fetal distress. This indication for delivery. The risk of peripartum bleeding
can be prevented by co-administration of a small bolus of complications is not significantly increased until the
fluid, for example normal saline 250 ml, at the time of platelet count falls below 50 9 109/L. Platelet transfusion
administration of antihypertensive therapy. Continuous is the only rapidly effective treatment for severe
CTG monitoring should be considered in these situations, thrombocytopenia, and this may be necessary at the time
particularly when there is evidence of existing fetal of caesarean section or in the case of postpartum
© 2014 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists 13
Executive Summary
haemorrhage or other bleeding. Fresh-frozen plasma and/ particularly important in early onset disease. The
or cryoprecipitate may be required for management of frequency, intensity and type of fetal evaluation will
coagulopathy. depend on characteristics specific to the pregnancy.
Epigastric, right upper quadrant pain or even chest pain Individual obstetric units should devise their own
in a woman with preeclampsia often represents hepatic protocols for monitoring the fetus and/or fetal medicine
involvement. The pain responds poorly to analgesia, but referral in pregnancies complicated by hypertension.
both the pain and associated increases in liver enzymes
(AST, ALT) may subside (temporarily) after blood
pressure lowering, particularly with vasodilators. Imaging Antenatal corticosteroid administration
of the liver and gallbladder is only indicated if other Prior to 34 weeks’, administration of corticosteroids for
pathologies (e.g cholelithiasis) require exclusion. fetal lung maturation is desirable if maternal and fetal
The combination of haemolysis, elevated liver enzymes conditions allow. The use of antenatal steroids beyond
and low platelets has been coined ‘HELLP syndrome’ and 34 weeks’ will depend on individual patient circumstances,
should be managed as severe preeclampsia. Steroid but urgent delivery should not be delayed purely for the
therapy (other than for fetal lung maturation) does not benefits of corticosteroid therapy.
reduce maternal morbidity or mortality in women with
preeclampsia, even with HELLP syndrome.
Antenatal magnesium sulphate administration
for fetal neuroprotection
6. Eclampsia
Where delivery is indicated prior to 30 weeks’, magnesium
There are no reliable clinical markers that predict eclampsia,
sulphate should be administered for fetal neuroprotection,
and conversely, the presence of neurological symptoms and/
even in the setting of milder degrees of hypertensive
or signs is rarely associated with seizures. Seizures may
disease.
occur antenatally, intrapartum or postnatally.
Comprehensive protocols for the prevention and management
of eclampsia should be available in all appropriate areas. 8. Resolution of preeclampsia and
Following resuscitation, treatment should be
gestational hypertension
commenced with magnesium sulphate (4 g over 15–
20 minutes) followed by an infusion (1–2 g/hr). In the After delivery, all clinical and laboratory derangements of
event of a further seizure, a further 2–4 g of magnesium preeclampsia recover, but there is often a delay of several
sulphate is given IV over 10 minutes. Monitoring should days, and sometimes longer, in return to normality. On
include blood pressure, respiratory rate, urine output, the first day or two after delivery, liver enzyme elevations
oxygen saturation and deep tendon reflexes. Serum and thrombocytopenia may worsen before they improve.
magnesium levels do not need to be measured routinely Hypertension can persist for days, weeks or even up to
unless renal function is compromised, Magnesium three months and will require monitoring and slow
sulphate by infusion should continue for 24 h after the last withdrawal of antihypertensive therapy. The woman and
fit. her family are often overwhelmed and distressed from
Concurrent control of severe hypertension to levels their experience, and appropriate counselling postpartum
below 160/100 mmHg is essential as the threshold for should include psychological and family support.
further seizures is lowered after eclampsia. Engaged patient advocacy organisations include
Arrangements for delivery should be decided once the the Australian Action on Pre-eclampsia (AAPEC) and
woman’s condition is stable. In the meantime, close fetal New Zealand Action on Pre-eclampsia (NZ APEC)
monitoring should be maintained. groups.
The drug of choice for the prevention of eclampsia is All women who develop preeclampsia and gestational
magnesium sulphate, given as described above. The case hypertension are at risk of these disorders in future
for its routine administration in women with preeclampsia pregnancies and should receive appropriate counselling
in countries with low maternal and perinatal mortality before conception and certainly before embarking upon
rates is debatable although there is increasing evidence that another pregnancy.
it should be considered for fetal neuroprotection at
preterm gestations (see below). It is appropriate for
9. Chronic hypertension in pregnancy
individual units to determine their own protocols and
monitor outcomes Women with chronic hypertension are at high risk of
developing preeclampsia and should be observed jointly
during the pregnancy by an obstetrician and a physician
7. Fetal surveillance and management familiar with the management of hypertension in
All hypertensive women have a higher rate of adverse pregnancy. The pharmacological management of ongoing
perinatal outcome. Balancing the fetal risks of chronic hypertension should follow the principles outlined
preeclampsia with the neonatal risks of prematurity is for gestational hypertension and preeclampsia.
14 © 2014 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
Executive Summary
© 2014 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists 15
Executive Summary
16 © 2014 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists