1. Lowe SA, Bowyer L, Lust K, McMahon LP, Morton MR, North RA, Paech M, Said JM.
THE SOMANZ GUIDELINE FOR THE MANAGEMENT OF HYPERTENSIVE DISORDERS OF PREGNANCY 2014

2. Why write any guideline?
“guidelines are statements systematically developed from efficacy and effectiveness research and clinical consensus for practitioners and patients to use in making decisions about appropriate care under different clinical circumstances”
Health Policy. 1998 Oct;46(1):1-19

3. Why did SOMANZ write this guideline?
To positively impact on the diagnosis, management and outcomes of women with hypertensive disorders of pregnancy.
To provide an evidence based resource for all health care workers involved in the management of these women
To update the 2008 guideline that was well established as an Australian and New Zealand standard of care.
To provide a local point of view that reflects other National and International Guidelines

4. Previous guideline 2008 Widely adopted locally and overseas
Within hospitals
Within State Health departments and districts
Led the way for a more inclusive definition of preeclampsia in other countries
Led to consultation between countries and the International Society of Hypertension in Pregnancy (ISSHP) regarding similar guidelines

5. Classification of hypertension:
Preeclampsia – eclampsia
Gestational hypertension
Chronic hypertension
essential
secondary
white coat
Preeclampsia superimposed on chronic hypertension

6. Recognises the systemic nature of pre-eclampsia
HT and any additional organ involvement can be diagnostic of preeclampsia
need to exclude alternative diagnoses

7. Hematological involvement
Renal involvement:
Significant proteinuria – a spot urine protein/creatinine ratio ≥ 30 mg/mmol
Serum or plasma creatinine > 90 μmol/L
Oliguria: < 80 mL/4 hr
Hematological involvement
Thrombocytopenia < 100,000 /µl
Hemolysis: schistocytes or red cell fragments on blood film, raised bilirubin, raised Lactate Dehydrogenase > 600mIU/l, decreased haptoglobin
Disseminated intravascular coagulation
Liver involvement
Raised serum transaminases
Severe epigastric and/or right upper quadrant pain.
Neurological involvement
Convulsions (eclampsia)
Hypereflexia with sustained clonus
Persistent, new headache
Persistent visual disturbances (photopsia, scotomata, cortical blindness, posterior reversible encephalopathy syndrome, retinal vasospasm)
Stroke
Pulmonary oedema
Fetal growth restriction

8. Urate is not a diagnostic feature
Recommend spot urine protein:creatinine ratio >30 mg/mmol for confirmation of proteinuria
Urate is not a diagnostic feature
Add Posterior Reversible Encephalopathy Syndrome (PRES) to neurological criteria
Do not include measurement of angiogenic factors as a diagnostic criteria (yet)
A number of conditions need to be met before screening programs are introduced into clinical practice, particularly in low risk settings with heterogeneous patient groups. These include determination of local normal ranges for parameters such as placental growth factor and standardisation of mean arterial pressure (MAP). (3). Any proposed screening test for preeclampsia needs to be validated in well- designed studies of large populations comprised of pregnant women with similar characteristics to those of the population to which the test will be applied in future clinical practice. The benefits and potential harm should then be assessed in a randomised trial of the screening test, before introduction into clinical practice.
Valid screening techniques are valuable and keenly sought (e.g., Table 2, reference 1), but their accuracy and benefits must first be unequivocally established before they are accepted into mainstream practice.

9. Classification of severe preeclampsia
would ideally allow the identification of those women and babies at increased risk of adverse maternal/fetal outcomes and/or requiring more intensive monitoring and/or treatment.
BUT: indicators of severe disease are neither sensitive nor specific in identifying women and/or babies at particular risk
General consensus that factors determining severity include:
difficulty in controlling blood pressure
deteriorating clinical condition including HELLP syndrome
impending eclampsia,
worsening thrombocytopenia
worsening fetal growth restriction
there is less concern regarding increasing proteinuria
“A number of features of preeclampsia are recognised to significantly increase the risk of adverse maternal and fetal outcomes and are sometimes used to classify severe preeclampsia. The natural history of preeclampsia is to progress at an unpredictable rate, at least until delivery, and therefore all women with preeclampsia should be closely monitored. “
WE recognised that DRG funding is affected by the diagnosis of “severe” preeclampsia –at the discretion of clinician

10. Preeclampsia superimposed on chronic hypertension
Can be difficult to diagnose
Worsening or accelerated hypertension should increase surveillance for preeclampsia but is not diagnostic
SGA occurs more frequently in women with chronic hypertension (27%) and evidence of fetal effect other than SGA eg oligohydramnios or abnormal umbilical artery Doppler flows increases the likelihood of superimposed preeclampsia.
In women with pre-existing proteinuria, substantial increases in proteinuria and hypertension should raise suspicion of preeclampsia but the diagnosis is not secure without the development of other maternal systemic features or fetal effects

11. Investigation of new onset hypertension
Role of day assessment unit
ABPM-white coat hypertension
Specific indicators for admission:
severe hypertension
headache, epigastric pain
oliguria
nausea and vomiting
any concern about fetal wellbeing.
Do not include measurement of angiogenic factors as an investigation (yet)

12. Management of preeclampsia and gestational hypertension
Recognise progressive, unpredictable nature of preeclampsia
Therapy doesn’t alter placental pathology or pathophysiology
BUT
Aim to optimise neonatal and maternal outcomes through appropriate monitoring and therapy
DELIVERY IS THE DEFINITIVE MANAGEMENT

13. Issues Admission v outpatient monitoring
Frequency of bloods, CTG, ultrasound,
Timely transfer to a suitable facility
Timing of delivery
Planned endpoints
Steroids
Magnesium sulphate for neuroprotection
Impact of HYPITAT
Team approach

14. Treatment for mild-moderate hypertension
Antihypertensive treatment should be commenced in all women with a systolic BP ≥160mm Hg or a diastolic BP ≥110 mm Hg because of the risk of intracerebral haemorrhage and eclampsia
Controversy regarding the need to treat mild to moderate hypertension
should be considered an option and will reflect local practice

15. Antihypertensive treatment
Recommend a number of agents for both acute blood pressure lowering and ongoing treatment
Severe hypertension in pregnancy, intrapartum or in the postnatal period requires urgent treatment:
aim for a gradual and sustained lowering of blood pressure
The most important consideration in choice of antihypertensive agent is that the unit has experience and familiarity with that agent.
Intravenous magnesium sulphate is not primarily an antihypertensive agent although there may be a transient decrease in blood pressure after commencement
“It is recommended that protocols for the management of severe hypertension should be readily accessible in all obstetric units. “

16. Other aspects of management
Thromboprophylaxis-YES
Fluid management –CAREFULLY
Haematological – APPROPRIATE AND TIMELY REPLACEMENT FOR PATIENT NOT THE NUMBERS
Hepatic-LOWER BP

17. Eclampsia
no reliable clinical markers that predict eclampsia and conversely, the presence of neurological symptoms and/or signs is rarely associated with seizures
may occur antenatally, intra-partum or postnatally, usually within 24 hours of delivery but occasionally later.
hypertension and proteinuria may be absent prior to the seizure
further from delivery that the seizure occurs, the more carefully should other diagnoses be considered
Magnesium sulphate is the drug of choice for treatment and prevention
the case for its routine administration in women with preeclampsia in countries with low maternal and perinatal mortality rates is less than compelling
It is appropriate for individual units to determine their own protocols and monitor outcomes.

18. Management of eclampsia
“Comprehensive protocols for the management of eclampsia (and severe hypertension) should be available in all appropriate areas”
4 aspects to management
Resuscitation
Prevention of further seizures
Control of hypertension
Delivery

19. Fetal surveillance
Adverse perinatal outcome is increased in women with all subcategories of hypertensive disease in pregnancy as compared to normotensive women
increase in adverse outcomes is greatest in those with early gestation at onset of disease, severe hypertension and/or chronic hypertension with superimposed preeclampsia and is predominantly related to an increase in the rate of FGR
no established consensus on how and when fetal surveillance should be performed
frequency, intensity, and modality of fetal evaluation will depend on individual pregnancy (maternal and fetal) characteristics

20. Resolution of preeclampsia
Resolution is the norm
Significant psychological impact
Recognition of recurrence risk, underlying conditions
Preconception counselling
Role of prophylaxis
Who, what, when

21. Anaesthetic considerations
Whenever possible an anaesthetist should be informed about a woman with severe preeclampsia, preferably well prior to labour or operative delivery, because appropriate anaesthetic management is associated with reduction in both fetal and maternal morbidity
Relevant issues include anaesthetic risk assessment, blood pressure control, fluid management, eclampsia prophylaxis and planning of analgesia or anaesthesia
Admission to ITU/HDU
Role of invasive monitoring

22. Prevention of preeclampsia
WHO?
low dose aspirin is indicated for women with at least moderate to high risk of preeclampsia ie secondary prevention of preeclampsia in women at increased risk and in women with significantly increased risk in their first pregnancy
In most cases, aspirin may be ceased at 37 weeks gestation although continuation beyond this period is not unsafe
WHEN?
commenced before 20 weeks
WHAT?
LDA 75mg-150 mg/day
Calcium 1500mg/d -high risk women and those with low dietary calcium intake
NOT HEPARIN/LMWH:
Despite the comparative safety of LMWHs during pregnancy, the current data do not support widespread use of these agents during pregnancy for the purposes of prevention of adverse pregnancy outcomes
EXCEPTION: antiphospholipid antibody syndrome

23. Long term consequences
increased risk of subsequent hypertension and cardiovascular disease
has also been linked with increased risks of developing deep vein thrombosis, end stage renal disease, type II diabetes and hypothyroidism
Cognitive functioning also appears to be affected after severe preeclampsia and eclampsia.
impaired memory which is unrelated to scores of depression, anxiety or attention
Children born to a pregnancy complicated by preeclampsia have increased cardiovascular risk factors from an early age

24. Auditing outcomes
It is appropriate for all hospitals managing such patients to monitor and review their outcome data
Suggested criteria:
Maternal mortality: death during pregnancy or within 42 days of delivery.
Composite severe adverse maternal outcome: one or more of the following morbidities
Cardiovascular: positive inotrope support or myocardial infarction
Hepatic: failure or haematoma/rupture
Renal: Dialysis or transplantation
Neurological: Glascow coma score <13 or stroke or cortical blindness or 2 or more seizures
Respiratory: requirement of ≥50% FI02 for >1 hr or intubation or pulmonary edema
Haematological: transfusion of ≥10 units blood products
Death
Perinatal mortality: death during the perinatal period ie 20 completed weeks of gestation to 28 days after birth.
Rate of admission of term babies to neonatal intensive care units

25. RANZCOG- “ no involvement in the development or recent review of the guidelines, it is not possible to formally endorse the document” ”commended”
RACP: “does not currently have a governance structure capable of approving this document for endorsement” , “strongly values the work “
RACGP-” charges an application fee for its review and approval of resources and this fee depends on the size and complexity of the resource.  The review process we undertake does require a minimum of 6-8 weeks to complete.”
ACM-Endorsed
ANZSN: “very valuable and useful addition”
KHA: “we are not in a position to formally endorse “, “excellent contribution “

26. Conclusion
To positively impact on the diagnosis, management and outcomes of women with hypertensive disorders of pregnancy.
To provide an evidence based resource for all health care workers involved in the management of these women
To update the 2008 guideline that was well established as an Australian and New Zealand standard of care.
To provide a local point of view that reflects other National and International Guidelines

27. Thank you