NICE 133: Hypertension in Pregnancy— Part 2

Post # 2

This blogpost is Part #2 of summary of latest NICE guideline “NG 133: Hypertension in pregnancy: diagnosis and management released in June 2019. As this is a long guideline, so I planned to cover the topic in 2 posts. 

You can access the Part #1 here: NICE: 133 Hypertension in Pregnancy— Part 1

This Post covers Fetal Monitoring, Intrapartum Care, Management in Critical Care, Post delivery, Drugs, Follow up and Next Pregnancy advice. This guideline has significant changes in recommendations. I have tried my best to extract all the important points.

You must go through the original guideline, which can be downloaded here: NG133

Let me know in comments if there are more points to be added. 

Thanks

Hypertension in pregnancy: diagnosis and management

Fetal Monitoring

Chronic HTN

• Carry out USG for fetal growth & amniotic fluid volume assessment plus umbilical artery doppler at 28, 32 and 36 wks
• CTG → only if clinically indicated

Gestational HTN

• Carry out USG for fetal growth & amniotic fluid assessment plus umbilical artery doppler at diagnosis
• If normal → repeat if clinically indicated
• CTG → only of clinically indicated

Pre-eclampsia or severe gestational HTN

• CTG→ at diagnosis
• If conservative management, do ALL at diagnosis

• USG for fetal growth/amniotic fluid assessment
• Umbilical artery doppler
• If normal results→ do not routinely repeat CTG unless clinically indicated
• Repeat CTG → women reports change in fetal movements ; vaginal bleeding; abdominal pain; deterioration in maternal condition

• Repeat USG for fetal growth/amniotic fluid assessment or umblical artery Doppler velocimetry every 2 weeks (subsequent monitoring depend on these scans)
• Write a care plan including ALL
• Timing & nature of future fetal monitoring
• Fetal indications for birth / when to give corticosteroids 
• Plans for discussions with neonatal pediatricians & obstetric anaesthetist

NICE 133: Hypertension in Pregnancy— Part 1

Post # 1

This blogpost is Part #1 of summary of latest NICE guideline “NG 133: Hypertension in pregnancy: diagnosis and management released in June 2019. As this is a long guideline, so I will be covering the topic in 2 posts.

This post covers diagnosis / management of hypertension, gestational hypertension, pre-eclampsia (PET) during pregnancy. This guideline has significant changes in recommendations. I have tried my best to extract all the important points.

You must go through the original guideline, which can be downloaded here: NG133

Let me know in comments if I need to add more to the post. 

Thanks

You can access the Part #2 here: NICE: 133 Hypertension in Pregnancy— Part 2

Hypertension in pregnancy: diagnosis and management

Some important numbers (from old guideline)

• Eclampsia rate→ fallen in UK 
• HTN → remains one of leading cause of Maternal Death
• Severe maternal morbidity → 1/3 due to HTN
• ICU admitted with PET/eclampsia: 1 in 20 (5%)
• Stillbirth without anomaly (with PET): 1 in 20 (5%)
• 8-10%→ ALL preterm births due to HTN disorders
• Primigravida→ 1 in 250 (0.4%)→ will deliver before 34wks
• In PET→ Less than 10th centile of birth weight for gestation
•     20-25% preterm births
•     14-19% term birth

Reducing the risk of hypertensive disorders in pregnancy

Symptoms of Pre-eclampsia

• Seek immediate advice if:
• Severe headache
• Vision problem (blurring/flashing)
• Severe pain below ribs
• Vomiting
• Sudden swelling of face, hands or feet

Antiplatelet agents

• Advised to take 75-150 mg aspirin daily from 12 wks until birth of baby

Obesity in Pregnancy —(GTG # 72)

This blog post is a summary of GTG guideline # 72 published in November 2018.

Obesity in pregnancy is associated with risks to both mother and fetus. The points in this post are exclusively summarized from latest guideline and some additional points from various sources. GTGs are a must for the exam. It is strongly recommended to go through the original document which is available free on the RCOG website.

GTG # 72 Care of Women with Obesity in Pregnancy

Introduction 

• Obesity is increasing in UK population 9-10% in 1990s : 16-19% in 2000s
• One of the most commonly occurring risk factor in obstetrics 
• Pregnancy:
• Normal BMI 47%
• Obese 21%

Classification of adults according to BMI (Source GTG)
Classification	BMI (kg/m2)
Underweight	< 18.50
Normal range	18.50–24.99
Overweight	≥ 25.00
Preobese	25.00–29.99
Obese class I	30.00–34.99
Obese class II	35.00–39.99
Obese class III	≥ 40.00

Risks of Obesity
Mother	Fetus
Miscarriage Gestational Diabetes (GDM) Hypertensive Disorders (PIH/PET) Venous Thromboembolism (VTE/PE) Induced Labour (IOL) Dysfunctional or Prolonged Labour Cesarean Section Anaeesthetic Complications PPH Fetal monitoring challenging  Difficulty in breastfeeding (both initiation & maintenance)	Congenital anomalies Prematurity Still Birth Macrosomia Neonatal Deaths Increased Obesity/ Metabolic disorders in childhood

• High pre-pregnancy BMI associated with small but statistically significant increase in severe maternal morbidity and mortality
• MBRRACE-UK 2015

• 30% of women who died were obese
• 22% women were overweight

• CEMACH 2003-5 recommended: women with BMI ≥30 kg/m2 should have prepregnancy counseling

Pre-pregnancy care

Primary care settings

• Should ensure to optimize weight before pregnancy in women of childbearing age
• Advice on weight and lifestyle during preconception counseling or contraceptive consultation 
• Measure weight and BMI
• Weight loss in between pregnancies reduces stillbirth, hypertensive disorders / macrosomia and improves chances of VBAC
• BMI ≥30 kg/m2 
• advised to take folic acid (5mg), starting at least one month before conception and continue till 1st trimester because of ↑ risk of NTD
• BMI ≥27 kg/m2 
• less likely to use nutritional supplement/folate in diet 
• folate levels are low even after controlling folate intake
• Vitamin D
• Prepregnancy BMI is inversely associated with serum Vit-D in pregnant women
• BMI ≥30 kg/m2
• ↑d risk of Vit-D deficiency
• cord serum Vit-D levels→ lower
• In UK women at risk of Vit-D deficiency 

• 1/4 aged 19-24 yrs 1/6 aged 25-34 yrs

• Vit-D supplements in single continued dose ↑ serum 25-hydroxyvitamin D at term and may reduce risk of low birthweight, preterm birth & pre-eclampsia
• If calcium and Vit-D combined → risk of preterm birth increased 
• Cholecalciferol 1000 iu/day is sufficient & a safe dose

Antenatal Care

• BMI ≥30: Must have multidisciplinary care, documented antenatal consultation about intrapartum risks
• BMI ≥35 : Deliver in consultant-led unit (CLD)
• At Booking Visit: Weight, height and BMI should be calculated for ALL women & recorded in handheld notes + electronic systems
• Consider re-weighing in 3rd trimester for women with obesity
• Measured weight is preferable but self-reporting is cost-effective/practical
• Optimal gestational weight gain → No consensus. Focus on healthy diet 
• Counseling regarding
• risks should be given wherever possible
• diet and exercise advice by appropriately trained professionals
• Anti-obesity or weight loss drugs are not recommended for use in pregnancy.

• Orlistat: no increase in major malformation risk
• Topiramate: linked to oral clefts (OR 6.26)
• Topriamate and Phentermine: excreted in breast milk and not recommended during lactation
• Lorcaserin: contraindicated in pregnancy

Risk assessment

Anaesthesia Risks 

• BMI ≥40 kg/m2:
• Refer to obstetric anaesthetist for antenatal assessment
• Obesity → significant risk factor for anaesthesia-related maternal mortality
• Difficulties in airway management, bag mask ventilation/ failed intubation, higher risk of desaturation/ postoperative atelactesis; significantly higher gastric volumes in laboring women

GTG # 73 PPROM from 24+0 weeks

This blogpost is a quick overview of the latest Green Top Guideline No. 73 Care of Women Presenting with Suspected Preterm Prelabour Rupture of Membranes (PPROM) from 24+0 weeks of Gestation released in June 2019

Previously this topic was covered in NICE guideline “Preterm Labour and Birth (NG25)”. Please keep in mind that the latest GTG does not replace NG25 rather it supplements it. So, both guidelines should be followed.

For summary of NG 25 please visit this page : NICE NG25 Summary

GTG # 73 Care of Women Presenting with Suspected Preterm Prelabour Rupture of Membranes from 24+0 weeks of Gestation

Introduction

• PPROM complicate 3% of pregnancies
• Associated with 40% of preterm births
• Can result in significant neonatal morbidity and mortality
• Median delivery latency after PPROM 7 days

Diagnosis

• Maternal history followed by sterile speculum examination
• Liquor found: 
• Diagnosis confirmed; No further testing needed
• Liquor not found: 
• Consider IGFBP-1 or PAMG-1 test (if available)
• should not be used alone to decide about the management
• must keep whole clinical picture in mind e.g medical and pregnancy history, gestational age
• PPROM not confirmed: return the women to her routine antenatal care

Assessment

• It is important because PPROM is associated with risk of ascending infection which can lead to chorioamniotis and later on fetal/neonatal infections
• No parameter to be used in isloation. 
• Combination of clinical assessment, maternal blood test (CRP, WBC) and FHR should be used to diagnose chorioamniotis 
• If results not consistent with each other keep women under observation and consider repeating the tests
• Observe the women for symptoms of clinical chorioamniotis (lower abdominal pain, abnormal vaginal discharge, fever, malaise and reduced fetal movements)
• WBC
• rises 24 hours after giving corticosteroids
• should return to baseline 3 days after the administration.
• Raised CRP
• most informative
• sensitivity 68.7% and specificity 77.1% for diagnosing histological chorioamniotis 
• If admitted 
• Use Obstetrics Early Warning Chart for monitoring
• If outpatient
• women should be advised of symptoms of chorioamniotis
• reviewed regularly (CRP & WBCs), clinical recordings and FHR monitoring once or twice per week. 
• must attend hospital immediately if any concerns
• As PPROM is associated with increased perinatal morbidity/mortality and preterm birth; once the diagnosis is confirmed and delivery is anticipated, neonatologist should be informed and women should be given an opportunity to discuss the baby’s care

Management

Antibiotics 

• Using antibiotics is associated with statistically significant reduction in 
• Chorioamniotis 
• Number of babies born within 48 hours and 7 days
• Also reduces neonatal infection, use of surfactant, oxygen therapy, abnormal cerebral USG prior to discharge from hospital
• No significant reduction in perinatal mortality and health of child at 7 years of age
• Give Erythromycin (250 mg QID) for 10 days or until the woman is in established labour
• Avoid Co-Amoxiclave 
• Give antibiotics only if PPROM diagnosis is confirmed

Steroids

• Corticosteroids in women with PPROM reduces
• RDS and intraventricular hemorrhage
• No difference in necrotisisng enterocolitis, neonatal sepsis and Apgar score of <7 at 5 min
• Similar perinatal mortality
• No increase risk of chorioamniotis and neonatal sepsis
• OFFER between 24+0 and 25+6 wks (this is a different point than NG25)
• OFFER between 26+0 and 33+6 wks
• CONSIDER between 34+0 and 35+6 wks

MgSO4

• PPROM women plus in established labour or having a planned preterm birth within 24 hours 
• OFFER MgSO4 between 24+0 and 29+6 wks
• CONSIDER between 30+0 and 33+6 wks (NG25)
• It reduces cerebral palsy and motor dysfunction

Tocolysis

• Not recommended in PPROM (not eonough evidence)
• Use of tocolysis is associated with average 73 hours longer latency of delivery, fewer births within 48 hours, increased risk of 5-min Apgar score of <7 and increased need for ventilation support, increased risk of chorioamniotis before 34+0 wks
• Tocolysis does not have an improved neonatal outcomes 

Home Monitoring

• This decision to be individualized considering past obstetrics history, home support and distance from hospital
• Median delivery latency
• 8-10 days from 24+0 to 28+0 wks 
• 5 days from 31+0 wks
• PPROM plus reduced liquor on USG → more likely to give birth within 7 days of rupture membrane
• If 26+0 wks , non-cephalic and oligohydramnios → hospital based care should be recommended
• There is no optimal method of monitoring to predict adverse fetal outcomes after PPROM
• If delivery is imminent → inpatient care is indicated

Amnioinfusion

• It is not recommended as part of routine clinical practice (not enough evidence)
• It might improve neonatal outcomes by preventing cord compression, postural deformities, pulmonary hypoplasia, intrauterine infection, improved umblical artery pH at delivery, reduced variable decelerations in labour, neonatal death, neonatal sepsis and perpetrated sepsis

Emotional support

• Women with PPROM and their partners should be offered additional emotional support during pregnancy and postnatally
• PTSD is more common in women whose pregnancies are complicated by PPROM 
• Antenatally: 14% versus 2%
• Postnatal at 6wks: 17% vs 3%

Birth

• Timing of delivery should be discussed with each woman on an individual basis 
• Must give careful consideration to patient preference and ongoing clinical assessment
• PPROM 24+0 wks plus no contraindications to continuing pregnancy —> offer expectant management until 37+0 wks
• Expectant management is associated with better outcomes for mother and baby
• Expectant management vs early delivery
• No difference in neonatal sepsis or infection, overall perinatal mortality or IUD
• Early delivery increase RDS, CS rates, neonatal deaths rates and need for ventilation

Subsequent pregnancy

• There is increased chance of recurrence of PPROM
• OR 8.7 in White
• OR 7.2 in African American 
• Short pregnancy interval increases the risk
• Care in subsequent pregnancy to be provided the an obstetrician with an interest in preterm birth; ideally in dedicated preterm labour clinics 
• Address modifiable risk factors like smoking and respiratory disease
• Limited evidence for offering genital tract screening for infection & TVS for cervical length 

Some facts from archived gtg 

• PPROM at term 10%
• Neonatal mortality due to sepsis 4 times increased
• Fetal tachycardia → late sign of infection (20-40% predictive)
• PPROM with positive amniotic culture → 36% intrauterine infection

Associated links

PDF version of guideline

Infographic

Audio version of guideline 

Patient information leaflet
NICE Preterm Labour and Birth (NG25)