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Referral and warning signs
When to refer
Refer ALL women with chronic hypertension to hospital (HC4/H) for co-management. Urgent referral if BP >=160/110 or signs of superimposed pre-eclampsia.
Red flags
- BP >= 160/110 mmHg.
- New or worsening proteinuria.
- Symptoms of severe pre-eclampsia.
- Signs of fetal compromise.
Signs and symptoms
- Elevated BP (>=140/90 mmHg) before 20 weeks.
- Usually asymptomatic unless severe.
- May have signs of underlying cause or end-organ damage.
Risk factors
- Pre-existing hypertension.
- Older maternal age.
- Obesity.
- Diabetes.
- Kidney disease.
- Family history.
Diagnosis
Clinical assessment
BP >=140/90 mmHg on >=2 occasions before 20 weeks, or history of hypertension pre-pregnancy. Increased risk for superimposed pre-eclampsia.
Investigations
- Baseline renal function tests (Urea, Creatinine, eGFR).
- Urinalysis (baseline proteinuria).
- Baseline LFTs.
- ECG (if long-standing/severe).
- Regular BP monitoring.
- Ultrasound for fetal growth.
Diagnostic criteria
BP >=140/90 mmHg before 20 weeks gestation.
Management
Non-pharmacological management
- Lifestyle modifications (low salt diet, exercise if appropriate, no alcohol/smoking).
- Close monitoring (BP, fetal growth, signs of superimposed pre-eclampsia).
- Fetal movement counting.
Pharmacological treatment
- Goal: BP <140/90 mmHg.
- Medication Review: STOP ACE inhibitors, ARBs, potentially diuretics.
- Antihypertensive Choice: Methyldopa (start 250mg TID), Nifedipine SR (start 20-40mg BID), Labetalol. AVOID Atenolol.
- Low-dose Aspirin (75-150mg daily) from 12 weeks if high risk for pre-eclampsia.
Monitoring
Frequent BP checks. Regular urine protein checks. Monthly fetal growth scans from 28 weeks. Monitor for symptoms of superimposed pre-eclampsia.
Complications
- Superimposed Pre-eclampsia.
- Fetal Growth Restriction (IUGR).
- Placental abruption.
- Preterm birth.
- Caesarean delivery.
- Perinatal mortality.
Prevention
- Pre-conception counseling and BP control.
- Weight management.
- Low-dose aspirin in high-risk.
Patient education
- Importance of monitoring/ANC.
- Safe/unsafe medications.
- Symptoms of superimposed pre-eclampsia.
- Fetal movement monitoring.
- Lifestyle modifications.
- Delivery planning.
Uganda-specific notes
Methyldopa and Nifedipine common options. Close monitoring crucial. Limited access to frequent growth scans.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 16, Section 16.2.3