Ask the expert: Diagnosis and management of complications in pregnancy in primary care

• Published in: BMJ (Online) 2023-07, Vol.382, p.p1345-1345
• Main Authors: Munro, Kerry, Griffin, Laoise, Banerjee, Anita
• Format: Article
• Language: English
• Subjects: Amniotic fluid; Anemia; Angiotensin; Antihypertensives; Aorta; Aspirin; Blood pressure; Body weight; Breast feeding; Breastfeeding & lactation; Contraindications; Creatinine; Diabetes; Diuretics; Drug dosages; Echocardiography; Edema; EKG; Fetuses; Heart; Hemoglobin; Hypertension; Hypertrophy; Iron; Medical diagnosis; Methyldopa; Nifedipine; Obstetrics; Polycystic kidney; Practice; Pre-eclampsia; Preeclampsia; Pregnancy; Pregnancy complications; Primary care; Renal function; Ultrasonic imaging; Ultrasound; Urinalysis; Women
• ISSN: 1756-1833; 1756-1833
• DOI: 10.1136/bmj.p1345

Advice on weight management, exercise, healthy eating, and reducing salt intake10 75 mg to 150 mg oral aspirin daily (at night) from 12 weeks until the birth of the baby (in the absence of contraindications) to reduce the risk of superimposed pre-eclampsia10 Ultrasound for fetal growth and amniotic fluid volume assessment, and umbilical artery Doppler velocimetry at 28, 32, and 36 weeks to identify signs of early fetal compromise.10 Blood pressure targets are slightly lower in pregnancy, the aim being for a systolic pressure of 135 mm Hg and a diastolic pressure of 85 mm Hg.10 Women are seen regularly in specialist antenatal clinics, the frequency of which will depend on blood pressure control and other arising obstetric complications. If blood pressure is inadequately controlled and changes in antihypertensive treatment are required, weekly review will be necessary, but this can be extended to two to four weekly once blood pressure is well controlled.101415 Any evidence of superimposed pre-eclampsia is an indication for admission to hospital. Examination for exclusion of conditions such as coarctation of the aorta (cardiac murmur, radio femoral delay) or polycystic kidney (rare but can occur as a spontaneous genetic abnormality that might not previously have been detected) Electrocardiogram (to screen for left ventricular hypertrophy), renal profile, and urinalysis for blood, protein, and protein-creatinine ratio (to screen for underlying renal disease and end organ damage) Other investigations such as a renal ultrasound scan and/or echocardiogram may be considered in some women dependent on history, examination, and initial investigations After delivery, women with chronic hypertension have their blood pressure checked daily for the first two days and at least once between day three and five either in hospital or by their midwife. If starting treatment for hypertension in a woman who is breastfeeding, NICE recommends enalapril as first line (with renal function and serum potassium monitoring) or, if patients are of Black African or Caribbean ethnicity, a calcium channel blocker (nifedipine or amlodipine).10 These drugs can be used in combination should this be necessary for blood pressure control.10 Avoid methyldopa in all women in the postnatal period, and diuretics and angiotensin receptor blockers should be avoided in women who are breastfeeding.