Hypertension in PregnancyHypertension in Pregnancyfor Postgraduatesfor Postgraduates

Max Brinsmead MB BS PhD Max Brinsmead MB BS PhD

January 2015January 2015

This talkThis talk How to measure BPHow to measure BP When is a pregnant woman hypertensiveWhen is a pregnant woman hypertensive What is the Differential DiagnosisWhat is the Differential Diagnosis What tests are required and how do you What tests are required and how do you

interpret theminterpret them Tests for proteinuriaTests for proteinuria Risk factors for pre-eclampsiaRisk factors for pre-eclampsia Pathophysiology of pre eclampsiaPathophysiology of pre eclampsia How to manage the hypertensive gravidaHow to manage the hypertensive gravida Which is the best drug to lower BPWhich is the best drug to lower BP

This talk(2)This talk(2) Who should be delivered? How & WhereWho should be delivered? How & Where Best practice intrapartum careBest practice intrapartum care Who requires an anticonvulsant?Who requires an anticonvulsant? What is the best drug for Eclampsia?What is the best drug for Eclampsia? Best practice postpartum careBest practice postpartum care Best practice anaesthetic careBest practice anaesthetic care Prognosis after pre-eclampsiaPrognosis after pre-eclampsia Can pre-eclampsia be predicted?Can pre-eclampsia be predicted? Can pre-eclampsia be prevented?Can pre-eclampsia be prevented?

How to Measure BP in a Pregnant WomanHow to Measure BP in a Pregnant Woman

o Automated machines not recommendedAutomated machines not recommendedo Unless calibrated against a mercury sphygmomanometer in Unless calibrated against a mercury sphygmomanometer in

the individual patientthe individual patient

Appropriate sized cuffAppropriate sized cuff Seated for 2 - 3 minutes with feet supportedSeated for 2 - 3 minutes with feet supported Both arms first visitBoth arms first visit Palpate systolic and go 20 mm higherPalpate systolic and go 20 mm higher Deflate slowly 2 mm every secDeflate slowly 2 mm every sec Use Korotkoff 5 (or 4 if 5 absent) for diastolicUse Korotkoff 5 (or 4 if 5 absent) for diastolic Repeated measures may be requiredRepeated measures may be required Ambulatory monitoring useful for White Coat Ambulatory monitoring useful for White Coat

HypertensionHypertension

When is a Pregnant Woman When is a Pregnant Woman Hypertensive?Hypertensive?

>140/90 on >one occasion>140/90 on >one occasion (Rise of >30 systolic or >15 diastolic)(Rise of >30 systolic or >15 diastolic)

Knowledge of prior BP very importantKnowledge of prior BP very important Not in itself diagnostic – look for other problemsNot in itself diagnostic – look for other problems

Severe hypertension is >169 systolic Severe hypertension is >169 systolic and and oror diastolic >109 diastolic >109

Requires admission and urgent RxRequires admission and urgent Rx

However, the diagnosis is more important However, the diagnosis is more important than the actual level of BP.than the actual level of BP.

Differential Diagnosis of Hypertension Differential Diagnosis of Hypertension in Pregnancyin Pregnancy

Gestational HypertensionGestational Hypertension Sustained hypertension after 20w of pregnancy without any Sustained hypertension after 20w of pregnancy without any

other organ involvement. Returns to normal in 3mother organ involvement. Returns to normal in 3m

PreeclampsiaPreeclampsia Sustained hypertension after 20w of pregnancy with Sustained hypertension after 20w of pregnancy with

evidence of other organ involvement. Returns to normal in evidence of other organ involvement. Returns to normal in 3m3m

Chronic HypertensionChronic Hypertension Hypertensive before 20w. 95% is Essential Hypertension Hypertensive before 20w. 95% is Essential Hypertension

Includes “White Coat Hypertension”Includes “White Coat Hypertension”

Systems involved in PreeclampsiaSystems involved in Preeclampsia RenalRenal

Significant proteinuria (>300 mg in 24 hours or P:C > 0.30)Significant proteinuria (>300 mg in 24 hours or P:C > 0.30) S Creat >90 S Creat >90 OliguriaOliguria

HepaticHepatic Elevated transaminases (AST or ALT >70)Elevated transaminases (AST or ALT >70) Epigastric or RUQ painEpigastric or RUQ pain

HaematologicalHaematological Thrombocytopenia (<100)Thrombocytopenia (<100) HaemolysisHaemolysis DICDIC

CNSCNS Eclampsia or strokeEclampsia or stroke Hyperreflexia with sustained clonusHyperreflexia with sustained clonus Severe headache or visual disturbanceSevere headache or visual disturbance

CardiovascularCardiovascular Pulmonary oedemaPulmonary oedema

PlacentalPlacental IUGRIUGR AbruptionAbruption

Please notePlease note

I have not used the words “Pregnancy induced I have not used the words “Pregnancy induced Hypertension” or PIHHypertension” or PIH

No mention is made of oedemaNo mention is made of oedema

Proteinuria is the most common manifestation of Proteinuria is the most common manifestation of “other system involvement” and some method of “other system involvement” and some method of assessment is critical to good obstetric careassessment is critical to good obstetric care

Evidence for other organ involvement in Pre Evidence for other organ involvement in Pre eclampsia is a mix of symptoms, signs and testseclampsia is a mix of symptoms, signs and tests

Tests of ProteinuriaTests of Proteinuria The screening test is by dipstickThe screening test is by dipstick

Have a sensitivity >90% using ≥ 1+Have a sensitivity >90% using ≥ 1+But correlate poorly with high protein lossBut correlate poorly with high protein lossAnd false negative rates up to 20%And false negative rates up to 20%Will miss >300 mg/24 hours in up to 1:8 patientsWill miss >300 mg/24 hours in up to 1:8 patientsAnd the test strips spoil quickly in humidityAnd the test strips spoil quickly in humidity

Boiling urine is sensitive and quantifiableBoiling urine is sensitive and quantifiableBut messy and disliked by midwivesBut messy and disliked by midwives

24 hour collection and quantification by lab24 hour collection and quantification by lab Is the gold standardIs the gold standardBut labour intensive and slowBut labour intensive and slow

The protein:creatinine ratio on a spot sample is a The protein:creatinine ratio on a spot sample is a good compromisegood compromise

Proteinuria in PracticeProteinuria in Practice

Significant proteinuria occurs when...Significant proteinuria occurs when...There is ≥ 2+ on dipstickThere is ≥ 2+ on dipstickTrace or 1+ should be regarded as equivocalTrace or 1+ should be regarded as equivocal

The 24 hour urine collection is > 300 mgThe 24 hour urine collection is > 300 mgThe spot urine protein:creatinine ratio is ≥ The spot urine protein:creatinine ratio is ≥

30 mg/mmol30 mg/mmolThere is > “cloud” on boiled urineThere is > “cloud” on boiled urineWhen significant proteinuria has been When significant proteinuria has been

detected there is little point in repeating detected there is little point in repeating the measurethe measure

Some rare causes of preeclampsia Some rare causes of preeclampsia before 20w before 20w

Hydatidiform moleHydatidiform mole

Fetal triploidy (with or without partial mole)Fetal triploidy (with or without partial mole)

Severe renal diseaseSevere renal disease

Lupus obstetric syndromeLupus obstetric syndrome

Renal Disease in PregnancyRenal Disease in Pregnancy

Responsible for about 5% of chronic hypertensionResponsible for about 5% of chronic hypertension Causes include:Causes include:

chronic or recurrent infectionchronic or recurrent infection glomerulonephritisglomerulonephritis renal artery stenosisrenal artery stenosis

Must be assessed by creatinine clearance (CC) Must be assessed by creatinine clearance (CC) which doubles in normal pregnancywhich doubles in normal pregnancy

When CC falls below 50% the prognosis is very When CC falls below 50% the prognosis is very badbad

Monitoring for superimposed pre eclampsia can Monitoring for superimposed pre eclampsia can be difficult if there is chronic proteinuriabe difficult if there is chronic proteinuria

Donors of a kidney have 2.4-fold increased risk Donors of a kidney have 2.4-fold increased risk of PE but usually not severeof PE but usually not severe

Some rare causes of hypertensionSome rare causes of hypertension

Coarctation of the aortaCoarctation of the aortaSometimes the clue is to measure BP in both armsSometimes the clue is to measure BP in both armsThere is a systolic murmur that can be heard in the There is a systolic murmur that can be heard in the

backback

PhaeochromocytomaPhaeochromocytomaParoxysms of symptomatic hypertensionParoxysms of symptomatic hypertensionThe clue to diagnosis is to think of itThe clue to diagnosis is to think of itAssociated with high levels of catecholaminesAssociated with high levels of catecholamines

HyperaldosteronismHyperaldosteronismAlso known as Conn’s diseaseAlso known as Conn’s disease

Placental tissuePlacental tissueIn healthy pregnancies cytotrophoblast In healthy pregnancies cytotrophoblast

infiltrates the decidual portion of the uterine infiltrates the decidual portion of the uterine spiral arteriesspiral arteries

In order to increase maternal blood flow to the In order to increase maternal blood flow to the placentaplacenta

In patients destined to develop pre eclampsia In patients destined to develop pre eclampsia this fails to occurthis fails to occur

This results in placental hypoperfusionThis results in placental hypoperfusionThese changes occur at <16 weeks gestation These changes occur at <16 weeks gestation

but the pre eclampsia may not be manifest until but the pre eclampsia may not be manifest until much later in the pregnancymuch later in the pregnancy

Pathophysiology of Pre eclampsiaPathophysiology of Pre eclampsia

HypoperfusionHypoperfusion of the Placenta of the Placenta Becomes worse as pregnancy progresses Becomes worse as pregnancy progresses The abnormal uterine vasculature is unable to The abnormal uterine vasculature is unable to

accommodate the normal rise in blood flow to accommodate the normal rise in blood flow to the fetus/placenta that occurs with increasing the fetus/placenta that occurs with increasing gestational age. gestational age.

Late placental changes consistent with Late placental changes consistent with ischemia include atherosis (lipid-laden cells in ischemia include atherosis (lipid-laden cells in the wall arterioles), fibrinoid necrosis, the wall arterioles), fibrinoid necrosis, thrombosis, sclerotic narrowing of arterioles, thrombosis, sclerotic narrowing of arterioles, and placental infarction and placental infarction

Pathophysiology of Pre eclampsiaPathophysiology of Pre eclampsia

An ‘immunolgical’ response to pregnancyAn ‘immunolgical’ response to pregnancy ---in ‘at risk’ or predisposed women---in ‘at risk’ or predisposed women

A response to a conceptus whose genetic A response to a conceptus whose genetic material is 50% foreign (from the father)material is 50% foreign (from the father)

A failure of ‘Blocking Antibody’A failure of ‘Blocking Antibody’

This disease is still a mysteryThis disease is still a mystery

Pathophysiology WHY?Pathophysiology WHY?

Contracted intravascular volume of motherContracted intravascular volume of motherIn reality a failure to increase plasma volumeIn reality a failure to increase plasma volume

↑↑Sensitivity to pressure agentsSensitivity to pressure agentsLeaky CapillariesLeaky CapillariesReduced oncotic pressureReduced oncotic pressure

In part due to low serum albumenIn part due to low serum albumen

Poor placental reservePoor placental reserveA fetus at risk of hypoxia and deathA fetus at risk of hypoxia and death

Pathophysiology WHAT?Pathophysiology WHAT?

Hypertension/ Proteinuria/ oedemaHypertension/ Proteinuria/ oedema

Low plateletsLow platelets ConsumptionConsumption Raised urateRaised urate Cell (DNA) deathCell (DNA) death Raised HaematocritRaised Haematocrit Reduced plasma volumeReduced plasma volume Haemolysis Haemolysis Abnormal LFT’sAbnormal LFT’s Abnormal clotting Widespread DICAbnormal clotting Widespread DIC

Pathophysiology WHAT?Pathophysiology WHAT?

Tests for the Hypertensive GravidaTests for the Hypertensive Gravida Blood testsBlood tests

FBC - look at HB, Haematocrit and PlateletsFBC - look at HB, Haematocrit and Platelets UEC - look at Creatinine Should be < 0.07 (or 70)UEC - look at Creatinine Should be < 0.07 (or 70) URATE - equivalent to weeks gestationURATE - equivalent to weeks gestation Liver enzymes – AST & ALT should be <70. Ignore ALPLiver enzymes – AST & ALT should be <70. Ignore ALP

UUrine Tests rine Tests UMCS - exclude UTI and look for castsUMCS - exclude UTI and look for casts Protein:Creatinine ratio from spot test >30 significantProtein:Creatinine ratio from spot test >30 significant 24 hr protein excretion >300 mg/day significant24 hr protein excretion >300 mg/day significant

Assess fetal welfare by CTG & Scan for AFI Assess fetal welfare by CTG & Scan for AFI and UA Dopplersand UA Dopplers

Frequency of TestingFrequency of Testing

Management of Hypertensive Management of Hypertensive GravidaGravida

Hospitalise if pre-eclampticHospitalise if pre-eclamptic Discharge if “just BP”Discharge if “just BP” Bed rest only when there is proteinuriaBed rest only when there is proteinuria Control BP to protect mother from severe Control BP to protect mother from severe

hypertensionhypertension Role of antihypertensive agents for mild & Role of antihypertensive agents for mild &

moderate chronic hypertension is moderate chronic hypertension is controversialcontroversial

Delivery will cure pre eclampsia & gestational Delivery will cure pre eclampsia & gestational hypertensionhypertension

Remember thromboprophylaxisRemember thromboprophylaxis

Tests of Fetal WelfareTests of Fetal Welfare

Which Drug is Best for Which Drug is Best for Hypertension in Pregnancy?Hypertension in Pregnancy?

The drug that you know bestThe drug that you know best AldometAldomet

Up to 2250 mg per dayUp to 2250 mg per day

LabetalolLabetalol Up to 1200 mg/dayUp to 1200 mg/day

OxyprenalolOxyprenalolUp to 480 mg/dayUp to 480 mg/day

NifedipineNifedipineUp to 120 mg/dayUp to 120 mg/day

PrazosinPrazosin Up to 15 mg/day Up to 15 mg/day

Drugs for Hypertension in Drugs for Hypertension in Pregnancy?Pregnancy?

Combination therapy of drugs from Combination therapy of drugs from different classes is possible e.g.different classes is possible e.g.Aldomet + Beta blocker + PrazosinAldomet + Beta blocker + Prazosin

Do not use…Do not use…Thiazide diuretics – reduce plasma volumeThiazide diuretics – reduce plasma volumeHighly selective beta blokers – cause IUGRHighly selective beta blokers – cause IUGRACE inhibitors – may cause IUFDACE inhibitors – may cause IUFD

Aim for BP 130 -150 systolic and 80 – Aim for BP 130 -150 systolic and 80 – 100 diastolic100 diastolic

Which Drug is Best for Acute Which Drug is Best for Acute Hypertension?Hypertension?

The drug that you know bestThe drug that you know best

IV IV HydralazineHydralazine 5 – 10 mg every 20-30 min 5 – 10 mg every 20-30 min or by infusionor by infusion

IV IV LabetalolLabetalol 20 – 50 mg over 2 min. 20 – 50 mg over 2 min. Repeat after 15 – 30 minRepeat after 15 – 30 min

NifedipineNifedipine crushed oral 10 mg crushed oral 10 mg Repeat after 30 minRepeat after 30 min

IV IV DiazoxideDiazoxide 15 – 45 mg bolus 15 – 45 mg bolus Repeat after 5 min to a maximum of 300 mgRepeat after 5 min to a maximum of 300 mg

Which Drug is Best for Eclampsia?Which Drug is Best for Eclampsia?

First aid is more important than drugsFirst aid is more important than drugs Protect from injuryProtect from injury Secure an airwaySecure an airway Administer oxygenAdminister oxygen Then secure IV accessThen secure IV access

IV MgSOIV MgSO4 4G over 10 – 15 min Then 1 -2 G/hour by infusion If seizure recurs then give another 2 – 4 G

bolus IV Diazepam only for status eclampticus Monitor urine output, respirations, O2

saturation and DTJ’s

Who Needs Fluid Expansion?Who Needs Fluid Expansion?

If there is severe proteinuria and oliguriaIf there is severe proteinuria and oliguria Then give 500 – 1000 ml cautiouslyThen give 500 – 1000 ml cautiously

Injudicious use carries a risk of pulmonary oedema and Injudicious use carries a risk of pulmonary oedema and adult RDSadult RDS

Pre load prior to epidural or spinalPre load prior to epidural or spinalConsult with anaesthetistConsult with anaesthetistUse colloids rather than crystalloidsUse colloids rather than crystalloids

Sometimes required if BP drops suddenlySometimes required if BP drops suddenly Sometimes occurs with Diazoxide/HydralazineSometimes occurs with Diazoxide/Hydralazine CTG monitoring desirableCTG monitoring desirable

Abruption requires prompt resuscitationAbruption requires prompt resuscitation Often requires bloodOften requires blood

Watch urine output and/or JVPWatch urine output and/or JVP

Who Requires Delivery?Who Requires Delivery?

Pre eclampsia >36 completed weeksPre eclampsia >36 completed weeks Uncontrollable hypertensionUncontrollable hypertension Deteriorating renal, hepatic or haematologic Deteriorating renal, hepatic or haematologic

statestate For GA >32w and good neonatal facilities For GA >32w and good neonatal facilities

delay only long enough to give steroidsdelay only long enough to give steroids Eclampsia or imminently eclampticEclampsia or imminently eclamptic Fetus is compromisedFetus is compromised APH - abruptionAPH - abruption

Induction of Labour vs Expectant Management for Induction of Labour vs Expectant Management for

Gestational Hypertension Gestational Hypertension Koopmans et al Lancet 2009 Koopmans et al Lancet 2009

The HYPITAT studyThe HYPITAT study A multicentre RCT of 756 women in NetherlandsA multicentre RCT of 756 women in Netherlands Were 36 – 41 weeks with a diagnosis of mild pre Were 36 – 41 weeks with a diagnosis of mild pre

eclampsia or gestational hypertensioneclampsia or gestational hypertension Of the women randomised to induction of labour Of the women randomised to induction of labour

31% had a poor outcome vs 44% for observation 31% had a poor outcome vs 44% for observation (RR=0.71, CI 0.59-0.86, p<0.001)(RR=0.71, CI 0.59-0.86, p<0.001)

Poor outcomes included eclampsia, HELLP, severe Poor outcomes included eclampsia, HELLP, severe pre eclampsia and PPHpre eclampsia and PPH

No greater risk of Caesarean or neonatal morbidityNo greater risk of Caesarean or neonatal morbidity Active management is also more cost effectiveActive management is also more cost effective

How to DeliverHow to Deliver

Deliver vaginally if >37w and Cx is favourable Deliver vaginally if >37w and Cx is favourable or can be ripenedor can be ripened

Caesarean only if the above not metCaesarean only if the above not met Elective CS usually at gestations <35wElective CS usually at gestations <35w Inappropriate attempts at delivery when it is Inappropriate attempts at delivery when it is

not indicated is an invitation to CS (and more not indicated is an invitation to CS (and more CS) CS)

Deliver in an environment that can cope with Deliver in an environment that can cope with a severe multisystem diseasea severe multisystem disease

Don’t overlook patient’s and family’s psychological needsDon’t overlook patient’s and family’s psychological needs

Intrapartum CareIntrapartum Care

Assess convulsive risk and consider Assess convulsive risk and consider prophylactic MgSOprophylactic MgSO4

Control BP with an epidural or IV HydralazineControl BP with an epidural or IV Hydralazine Careful fluid balanceCareful fluid balance Monitor the fetusMonitor the fetus Avoid ergometrineAvoid ergometrine SVD is not a sin!SVD is not a sin!

Anaesthetic ImplicationsAnaesthetic Implications Epidural good for both vaginal & abdominal Epidural good for both vaginal & abdominal

deliverydelivery Spinal + Vasopressin also okaySpinal + Vasopressin also okay Spinal plus epidural for a few casesSpinal plus epidural for a few cases Low dose aspirin okay for epiduralLow dose aspirin okay for epidural GA for acute fetal compromise or low GA for acute fetal compromise or low

plateletsplatelets <50, and 50 – 75 is a grey zone<50, and 50 – 75 is a grey zone

Watch for hypertension during GA intubationWatch for hypertension during GA intubation Use antacid and lateral tiltUse antacid and lateral tilt Cautious use of oxytocin bolusesCautious use of oxytocin boluses

Postpartum CarePostpartum Care Things may get worse before they get Things may get worse before they get

betterbetter Oliguria for 24 hours is commonOliguria for 24 hours is common

Seizure risk is greatest for 48 hrsSeizure risk is greatest for 48 hrs Continue MgSOContinue MgSO4 infusion for 24 hrs infusion for 24 hrs

Avoid NSAIDsAvoid NSAIDs Treat any BP >150/100Treat any BP >150/100

Use Nifedipine PRNUse Nifedipine PRN

OK to discharge 3d after BP controlOK to discharge 3d after BP control Follow up weekly to 6w then 3mFollow up weekly to 6w then 3m

The Prognosis after Pre eclampsiaThe Prognosis after Pre eclampsia

Mild pre eclampsia near term has a low Mild pre eclampsia near term has a low recurrence riskrecurrence risk

Unless there is a new partner or a long gap to the next Unless there is a new partner or a long gap to the next pregnancypregnancy

Severe pre eclampsia prior to 34w has a 50- Severe pre eclampsia prior to 34w has a 50- 66% recurrence risk66% recurrence risk

Most recover by 12w but these patients are at Most recover by 12w but these patients are at increased lifetime risk of hypertension and increased lifetime risk of hypertension and related diseaserelated disease

Can Preeclampsia be predicted Can Preeclampsia be predicted and prevented?and prevented?

Identifying the patient at riskIdentifying the patient at risk

Early pregnancy testingEarly pregnancy testing

Prevention strategiesPrevention strategiesEspecially the role of low dose aspirinEspecially the role of low dose aspirin

Risk factors for severe pre eclampsiaRisk factors for severe pre eclampsia

Previous pre eclampsia at <35wPrevious pre eclampsia at <35w Renal diseaseRenal disease ThombophiliasThombophilias Autoimmune disease e.g. SLEAutoimmune disease e.g. SLE DiabetesDiabetes Multiple pregnancyMultiple pregnancy Severe alloimmunisationSevere alloimmunisation Family history of pre eclampsiaFamily history of pre eclampsia ObesityObesity Increasing maternal ageIncreasing maternal age

Patients at riskPatients at risk

Prediction of Pre eclampsiaPrediction of Pre eclampsia

Risk factors alone are insensitive and non Risk factors alone are insensitive and non specificspecific

Response to an infusion of angiotensinResponse to an infusion of angiotensin Suitable only in a research settingSuitable only in a research setting

Measure vasoactive proteins in serumMeasure vasoactive proteins in serum PAPP-A, Placental growth factor (PlGF)PAPP-A, Placental growth factor (PlGF)

Doppler studies at 12 – 14wDoppler studies at 12 – 14w Placental resistance & Uterine artery pulsatilityPlacental resistance & Uterine artery pulsatility

Together these last two can identify 90% of Together these last two can identify 90% of women who will get PE before 34wwomen who will get PE before 34w

With false positive rate of 10%With false positive rate of 10%

The prevention of pre eclampsiaThe prevention of pre eclampsiawith low dose Aspirin – WHO?with low dose Aspirin – WHO?

History of fetal death or severe IUGRHistory of fetal death or severe IUGRPatients who previously required delivery Patients who previously required delivery

for pre eclampsia prior to 34wfor pre eclampsia prior to 34wConditions with high risk of pre eclampsia Conditions with high risk of pre eclampsia

eg Lupus or homozygous for thrombophiliaeg Lupus or homozygous for thrombophiliaThese patients also require heparinThese patients also require heparin

Patients identified by Screening at 12 – Patients identified by Screening at 12 – 14w (London FMF program)14w (London FMF program)

Also use Ca supplements of 1.5G dailyAlso use Ca supplements of 1.5G daily

The prevention of pre eclampsiaThe prevention of pre eclampsiawith low dose Aspirin - Resultswith low dose Aspirin - Results

Meta analysis suggests that 100 – 150 mg Meta analysis suggests that 100 – 150 mg daily started BEFORE 16 wdaily started BEFORE 16 w

Reduces risk of early onset pre-eclampsia by 50 – Reduces risk of early onset pre-eclampsia by 50 – 90%90%

Less valuable if started after 16wLess valuable if started after 16w You need to treat 4-5 women to prevent one FDIU You need to treat 4-5 women to prevent one FDIU

or severe IUGRor severe IUGR

RISKSRISKSDoes Does notnot increase the risk of APH, PPH or fetal increase the risk of APH, PPH or fetal

intracranial haemoorhageintracranial haemoorhageIt is also not teratogenicIt is also not teratogenic

Measures to prevent preeclampsia Measures to prevent preeclampsia that are not effectivethat are not effective

Anti oxidant supplements (Vitamins C, E)Anti oxidant supplements (Vitamins C, E) Increase the risk of stillbirth and IUGRIncrease the risk of stillbirth and IUGR

Folic acid and multivitaminsFolic acid and multivitamins Requires RCTsRequires RCTs

Abdominal decompressionAbdominal decompression UnprovenUnproven

For the NICE Guideline go For the NICE Guideline go toto

http://pathways.nice.org.uk/pathways/http://pathways.nice.org.uk/pathways/hypertension-in-pregnancyhypertension-in-pregnancy

Any Questions or Any Questions or Comments?Comments?

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