CARDIOVASCULAR JOURNAL OF AFRICA • Vol 22, No 6, November/December 2011
AFRICA
333
women requesting a diagnostic test for pregnancy. It is incum-
bent on these professionals to ensure that blood pressure meas-
urements are taken, so that careful counselling is given about
the options of antihypertensive agents in respect of their safety
in pregnancy. General practitioners also need to be aware of the
supine hypotensive syndrome associated with pregnancy and the
fact that Koratokoff 5 is used for measurement of diastolic blood
pressure in pregnancy.
23
Furthermore, general practitioners may be faced with a preg-
nant women presenting with severe hypertension during preg-
nancy, with or without symptoms and signs of a hypertensive
emergency. These situations must be recognised and antihyper-
tensive therapy initiated prior to referral to an appropriate health
facility or specialist.
Figs 3 and 4 summarise clinical management and may be
useful for general practitioners, obstetricians and physicians.
Ideally, such patients should be managed in referral centres,
staffed by experts in hypertensive disorders of pregnancy.
Conclusions
Hypertension in pregnancy is associated with significant mater-
nal and perinatal morbidity and mortality. Regular blood pres-
sure monitoring, detection of signs of pregnancy-associated
hypertensive conditions and management by health professionals
experienced in this field will minimise sequaelae associated with
hypertensive disorders in pregnancy, and may have a positive
impact on women’s cardiovascular events and outcomes years
after the affected pregnancies.
References
1.
Report on the National High Blood Pressure Education Program
Working Group on High Blood Pressure in Pregnancy.
Am J Obstet
Gynecol
2000;
183
: S1–S22.
2.
Panday M, Mantel GD, Moodley J. Audit of severe acute morbidity in
hypertensive pregnancies in a developing country.
J Obstet Gynaecol
2004;
24
(4): 387–391.
3.
Moodley J, Kalane G. A review of the management of eclampsia: prac-
tical issues.
J Hypertens Pregnancy
2006;
25
: 47–62.
4.
Harskaqmp RE, Zeeman GG. Pre-eclampsia: at risk for remote cardio-
vascular disease.
Am J Med Sci
2007;
334
: 291–295.
5.
Wilson BJ, Watson MS, Prescott GJ, Sunderland S, Campbell DM,
Hannaford P,
et al
. Hypertensive diseases of pregnancy and risk of
hypertension and stroke in later life: results from cohort study.
Br Med
J
2003;
326
: 845–851.
6.
Chobanian AV, Bakrsi GL, Black HR, Cushman WC, Green LA, Izzo
JL Jr,
et al
. and the National High Blood Pressure Education Program
Co-ordinating committee. The 7th Report of the Joint National
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High Blood Pressure : the JNC 7 Report.
J Am Med Assoc
2003;
289
:
2560–2572.
Fig. 3. Management of mild gestational hypertension or
pre-eclampsia.
Mild gestational hypertension or pre-eclampsia
(BP 140/90–160/110 mmHg and no symptoms)
Maternal and foetal evaluation
Maternal monitoring:
Expectant management:
– measure BP
≥
2/week
– lab result weekly (FBC, U & E)
– assess for proteinuria: screen
with dipstick or spot protein/
creatinine ratio and periodic
24-hr urine collections
≥
40 weeks of gestation
≥
37 weeks of gestation
Bishop score
≥
6
Noncompliant patient
≥
34 weeks of gestation
Labour or rupture of
membranes
Abnormal foetal testing results
Intra-uterine growth restriction?
<
37 weeks
of gestation
>
37–39 weeks
of gestation
Inpatient or outpatient
management
Maternal and foetal
evaluation
Delivery
Delivery
Yes
No
Worsening maternal or foetal condition
40 weeks of gestation
Ripe cervix (Bishop score
≥
6)
at
≥
37 weeks of gestation
Labour
Delivery
Fig. 4. Management of severe pre-eclampsia.
Admit to labour and delivery area
Maternal and foetal evaluation for 24 hours
Magnesium sulphate for 24 hours
Antihypertensives if systolic blood pressure
≥
160 mmHg
Diastolic blood pressure
≥
110 mmHg
or mean arterial pressure
>
125 mmHg
Severe pre-eclampsia
Maternal distress, *non-reassuring foetal status, labour
or rupture of membranes,
>
34 weeks of gestation?
Yes
No
Delivery Severe intra-uterine
growth restriction?
Delivery
< 23 weeks
of gestation
23–32 weeks
of gestation
33–34 weeks
of gestation
Steroids
Termination
of pregnancy
– Steroids 24–32
weeks of gestation
– Antihypertensives
– Daily evaluations
of maternal and
foetal conditions
– Delivery at 34
weeks of gestation
Magnesium
sulphate
Delivery
* Symptoms and signs of impending eclampsia rapid-acting antihypertensive
agents
Yes
Yes
No
