Management of pregnancies complicated by hypertensive disorders of pregnancy: Could we do better?

Background: Hypertensive disorders are among the most common medical problems in pregnancy. Compliance with clinical practice guidelines has potential to translate to significant maternal and perinatal health benefits. Aims: To evaluate compliance with Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) clinical guidelines for management of hypertension during pregnancy. Methods: Inclusion criteria: women with hypertension in pregnancy who gave birth at a tertiary obstetric centre in 2010. Compliance with SOMANZ guidelines was assessed, as well as uptake of findings from the 'Induction of labour versus expectant monitoring for mild gestational hypertension/pre-eclampsia after 36 weeks' gestation' (HYPITAT) trial. Results: Of 5624 women, 516 (9.2%) were identified with hypertension (49 chronic hypertension (CH); 457 gestational hypertension (GH) or pre-eclampsia (PE)). Thresholds to diagnose hypertension and initiate anti-hypertensive treatment were consistent with SOMANZ recommendations. Among women with CH, only 12.2% were prescribed aspirin prior to 16 weeks as PE prophylaxis. Of women with PE, 37 (18.6%) had known risk factors for development of PE at the initial visit yet only nine (24.3%) received aspirin. Of the 244 women who met HYPITAT inclusion criteria at 36 weeks, 174 (77.7%) were managed expectantly; nine (5.2%) developed severe adverse outcomes. Conclusion: Current management guidelines for hypertension treatment were generally followed, although aspirin prophylaxis was frequently overlooked, resulting in up to 19 excess PE cases. Uptake of recommendations from the HYPITAT trial was low; however, severe complications were fewer than expected. Overall, this suggests that clinicians appropriately weigh up the likely maternal risk compared to infant benefits of deferred delivery in each case, a key recommendation of HYPITAT-II.