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Pregnancy

NICE Guideline To Drive Down A Leading Cause Of Maternal Death - Hypertension In

Pregnancy (Medical News Today-27 August 2010)

A small amount of aspirin a day could help certain groups of pregnant women keep a potentially
serious and sometimes fatal condition at bay. The National Institute for Health and Clinical
Excellence (NICE) says this is just one of a number of ways to help prevent and treat
hypertension (high blood pressure) before, during and after pregnancy. The condition is a leading
cause of maternal death in the UK[1].

A new guideline published today (25 August), sets out a series of measures to help healthcare
professionals including GPs, midwives and obstetricians care for women with, or at risk of,
developing hypertension during their pregnancy. Hypertension in pregnancy includes the
condition pre-eclampsia and is more common in first-time pregnancies. It can also have serious
health implications - babies are more likely to be premature, stillborn or smaller than average and
mothers are at an increased risk of developing high blood pressure later in life. This guideline
aims to keep mums-to-be with, or at risk of developing, a form of hypertension safe and healthy.

Dr Fergus Macbeth, Director of the Centre for Clinical Practice at NICE, said: "Hypertension, or
high blood pressure, can be fairly common and can develop at any time during pregnancy. If not
properly managed, it can cause serious health problems. That's why it's important that women
who are pregnant or planning a pregnancy and who have either been diagnosed or identified as
being at risk of developing a form of hypertension, receive a consistent, high standard of
antenatal and postnatal care to prevent problems occurring.

"Until now there's been no national guidance available to help GPs, midwives and others care for
pregnant women with chronic hypertension or new mothers diagnosed with hypertension. This
NICE guideline will help health professionals offer a full package of care, from prevention
strategies to properly managing such conditions, ensuring optimum health for both the woman
and her unborn child."

Fiona Milne developed pre-eclampsia when she was 35 years old and pregnant with her first
child. Fiona, who is a trustee of the charity, Action on Pre-eclampsia, helped to develop this
guideline and said: "I was diagnosed with pre-eclampsia during my first pregnancy and sadly,
my baby was stillborn at 37 weeks. It was a traumatic time that deeply affected a lot of people;
family, friends, doctors and nurses.

"This guideline, which I played a part in developing, will mean pregnant women and those
planning a pregnancy who have or may develop a hypertensive disorder, will receive the best
possible care and attention to keep them and their unborn babies safe and healthy."
Susan Mitchinson, was diagnosed with gestational hypertension when she was 26 years old and
pregnant with twins. Susan, who is now 60, also helped to develop this guideline and said: "My
pregnancy ended on a dramatic note with a full blown hypertension crisis during the delivery of
my twins. This carries a high risk of stroke and cardiac arrest but thankfully it was resolved
satisfactorily, although doctors never investigated the cause. Gestational hypertension can also
increase a woman's risk of developing heart or kidney disease later in life, but this was not
widely known at the time and so my condition wasn't monitored. After experiencing more
hypertensive problems, it wasn't until my late forties that doctors diagnosed the cause of the
hypertension. I have spent the past three years gradually getting better thanks to treatments that
keep my condition under control.

"It's important to raise awareness of the significance of long-term monitoring in the management
of those with gestational hypertension and help empower women to take an active partnership in
managing their health. The new guideline will provide essential guidance for health professionals
to engage with women to minimise the short and long-term effects of gestational hypertension."

Key recommendations in the guideline for obstetricians, GPs, midwives and other healthcare
professionals include:

- Advising pregnant women with a moderate to high risk of developing pre-eclampsia to take a
low dose (75mg) of aspirin each day from the twelfth week of pregnancy until birth to reduce
their risk of developing the condition.

- Informing women with hypertension who are planning a pregnancy that angiotensin-converting
enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs), which can be used to
control hypertension in non-pregnant women, can increase the risk of congenital abnormalities if
taken during pregnancy and discuss more suitable forms of antihypertensive treatment.

- Offering women with hypertension or pre-eclampsia a package of care including admission to

hospital, treatment, measurement of blood pressure, testing for protein in their urine and blood
tests.

-Carrying out ultrasounds to assess fetal growth, amniotic fluid volume and Doppler ultrasound
to measure blood flow in the umbilical artery at different stages of pregnancy (as stated in the
guideline) and according to the seriousness of hypertension in the expectant mother.

- Offering birth to women with pre-eclampsia after 34 weeks, but only once their blood pressure
is under control, after discussions with specialists and, if needed, a course of antenatal steroids
has been given to the woman to help mature the baby's lungs before birth.

- Advising women who have had pre-eclampsia to keep or achieve a healthy BMI before their
next pregnancy.
The guideline also informs mothers-to-be that restricting their salt intake and taking dietary
supplements such as magnesium or antioxidants (vitamins C and E) will not help prevent
hypertension during pregnancy.

Stephen Walkinshaw, a consultant in maternal and fetal medicine at Liverpool Women's Hospital
who chaired the development group for this guideline, said: "Standards of practice for treating
and managing hypertension during pregnancy can vary from region to region. What this NICE
guideline does is set out a clear pathway of care to guarantee that women are looked after in the
best way possible no matter where they live. It will also ensure mums-to-be are given clear
information by their doctor or midwife about their risks of developing such a condition and what
is and is not effective in preventing these from occurring. It is important that both women and
NHS staff have the knowledge to make informed decisions about care and treatment to ensure
the best outcome for mother and child."

Lynda Mulhair, Consultant Midwife at Guy's and St Thomas' NHS Foundation Trust and
guideline developer, said: "Although GPs and midwives already test a woman's blood pressure
and urine for signs of hypertension and pre-eclampsia at each antenatal visit, there is a lack of
guidance on what to do if a condition like this is diagnosed. This guideline seeks to fill that gap
so that women who subsequently develop such a condition receive the best possible care from
the NHS."

Notes Dr Margaret Macdonald, Chief Executive of the charity Action on Pre-eclampsia, said:
"The NICE guideline on hypertension in pregnancy brings great authority and expert opinion to
what is a difficult and dangerous area of medical care. Pre-eclampsia is the most common of the
deadly pregnancy diseases and can only be combated with expert management. This guideline
will be especially useful for health professionals whose own experience in this field may not be
comprehensive. The difference between successful pregnancy and failure, and even life and
death, can be found in the pages of this expert guideline."

About hypertension

Hypertension includes the following conditions:

- Chronic hypertension. Hypertension that is present at the booking visit or before 20 weeks or if
the woman is already taking antihypertensive medication when referred to maternity services. It
can be primary or secondary in aetiology.

- Gestational hypertension. New hypertension presenting after 20 weeks without significant

proteinuria.

- Pre-eclampsia. New hypertension presenting after 20 weeks with significant proteinuria

- Severe pre-eclampsia. Pre-eclampsia with severe hypertension and/or with symptoms, and/or
biochemical and/or haematological impairment.

- Eclampsia. A convulsive condition associated with pre-eclampsia.

- HELLP syndrome. Haemolysis, elevated liver enzymes and low platelet count.

- Significant proteinuria. This is when the urinary protein:creatinine ratio is greater than 30
mg/mmol or a validated 24-hour urine collection result shows greater than 300 mg protein.

In addition, the guideline also defines mild, moderate and severe hypertension as:

- Mild hypertension - diastolic blood pressure 90-99 mmHg, systolic blood pressure 140-149
mmHg.

- Moderate hypertension - diastolic blood pressure 100-109 mmHg, systolic blood pressure 150-
159 mmHg.

- Severe hypertension - diastolic blood pressure 110 mmHg or greater, systolic blood pressure
160 mmHg or greater.

There are a number of factors which increase the risk of hypertension during pregnancy. These
are categorised into moderate and high risk factors. Moderate risk factors include:

- A first pregnancy

- Older mothers-to-be (aged over 40 years)

- A Body Mass Index (BMI) over 35 at first antenatal visit

- A family history of pre-eclampsia

- Multiple pregnancy

Women at high risk of developing hypertension may have been previously diagnosed with
hypertension during an earlier pregnancy or have a condition which may cause hypertension,
such as chronic renal disease or diabetes.

Celebrities who have experienced a form of hypertension while pregnant include Sophie Ellis-
Bextor, Melinda Messenger, Jane Seymour and Darcey Bussell CBE. They all developed pre-
eclampsia during at least one of their pregnancies.

About the guideline

The NICE guideline on hypertension in pregnancy, including a version for patients and carers
and corresponding implementation tools, are available from the NICE website NICE website.
(from Wednesday 25 August 2010)

This guideline has been jointly developed with the National Collaborating Centre for Women
and Children's Health
The guideline recommends aspirin as a method to prevent pre-eclampsia in women at moderate
or high risk of developing the condition. The recommended dosage of 75mg is a low dose of
aspirin. This recommendation was made following a thorough evaluation of the available
evidence. The committee considered there to be enough research to support the use of aspirin as
a preventative measure against pre-eclampsia, although only in women at high or moderate risk
of developing the condition.

The recommendation of birth after 34 weeks was made in the best interests of mother and baby
after looking at all available evidence. The guideline also makes recommendations for birth
before 34 weeks, but this is only for women with the most severe form of the condition and
where there is a real risk to the health of either the woman or her baby and very early birth might
be the safest thing to do. The guideline states that this decision should only be made by a
specialist and according to the patient's care plan. This guideline does not recommend early birth
for all women with a hypertensive disorder.

The charity, Action on Pre-eclampsia (APEC) is holding an educational study day for midwives
to help them learn how to put this new NICE guideline into practice. The study day,
Implementing the 2010 NICE Guideline 'Hypertensive Disorders in Pregnancy', is taking place
on Wednesday 1 December 2010 at Kings College, Stamford Street, London. Registration is via
the APEC website.