This podcast makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this video I will go through a real-life case of a young woman with hypertension. It will focus on the NICE guidance on Hypertension in pregnancy: diagnosis and management addressing issues relevant to Primary Care only.

I am not giving medical advice; this video is intended for health care professionals; it is only my interpretation of the guidelines and you must use your clinical judgement.  

There is a YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The link to the PDF version of this episode can be downloaded here:

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mEqfJs8aMAUqULYy?e=wDydMJ

The visual summary- pre-pregnancy advice can be downloaded here:

·      https://1drv.ms/b/s!AiVFJ_Uoigq0mEsJdGIU4F7fR9MF?e=7nTS0f

The Full NICE guideline Hypertension in pregnancy: diagnosis and management [NG133] can be found at:

·      https://www.nice.org.uk/guidance/ng133/chapter/Recommendations 

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Transcript

Hello and welcome, I am Fernando, a GP in the UK. Today, we will go through a real-life case of a young woman with hypertension. We will focus on the NICE guidance addressing issues relevant to Primary Care only. 

So let’s jump into it.

Maria is a 31-year-old woman of mixed Afro-Caribbean family origin. She has hypertension and, because of her young age, she has been fully investigated for secondary causes and her diagnosis is essential hypertension.

Her medication is amlodipine 10 mg daily and she is otherwise fit and healthy.

Her blood pressure is 155/92 mmHg.

What should we do?

She is on step 1 treatment with 1 drug, in this case the maximum dose of amlodipine, a calcium channel blocker, which is the preferred choice for people who do not have diabetes and who are of Afro-Caribbean background.

NICE says that if the BP is not controlled with a CCB alone, we have to start step 2 treatment with two drugs adding either:

·      an ACE inhibitor or an ARB, and if the person is of Afro-Caribbean background an ARB should be used in preference to an ACE inhibitor

·      or alternatively we can prescribe a thiazide-like diuretic

So, our instinct will probably tell us to start an ARB, something like, for example, losartan 25 mg daily and titrate it up according to response. This seems to be fairly straightforward so far.

But then she tells you: doctor, I am actively trying to get pregnant. Is that going to be OK?

And obviously, it will not be OK. In fact, we should have thought about it even before she mentioned it because, being a woman of childbearing age, it is a possibility that we must always bear in mind.

And this is where we need to look at the NICE guideline: Hypertension in pregnancy: diagnosis and management which was last updated in April 2023 and which not only covers hypertension during pregnancy, but also includes advice for women with hypertension who wish to conceive.

We know that ACE inhibitors and ARBs have an increased risk of congenital abnormalities if taken during pregnancy and NICE recommends an alternative if the woman is planning to get pregnant.

There is also an MHRA drug safety advice, which states that the use of ACEIs or ARBs in women who are planning pregnancy should be avoided unless absolutely necessary, in which case the potential risks and benefits should be discussed.

So, if a woman taking an ACEI or ARB becomes pregnant, it should be stopped preferably within 2 working days and we should offer an alternative.

Equally, we should advise women taking thiazide or thiazide-like diuretics that there may be an increased risk of congenital abnormalities and we should also offer an alternative.

We should explain to the patient that antihypertensive treatments other than ACE inhibitors, ARBs, thiazide or thiazide-like diuretics have not shown an increased risk of congenital malformation, although the evidence is limited.

So how should we treat her?

NICE recommends offering referral to a specialist in hypertensive disorders of pregnancy to discuss the risks and benefits of treatment. And perhaps we should do just that.

Should we be doing something else in the meantime?

Well, we could if we are worried. But this is where, apart from the usual lifestyle advice, NICE does not give specific drug advice for this group of patients.

It does say, though, that for women who are pregnant  and who have chronic hypertension we should consider:

·      Labetalol first

·      Then we will consider nifedipine if labetalol is not suitable, but we will bear in mind that some brands of nifedipine were specifically contraindicated in pregnancy by the manufacturer, so we will check the specific product characteristics for each preparation of nifedipine

·      And lastly, methyldopa if both labetalol and nifedipine are not suitable.

This patient is already taking amlodipine as a calcium channel blocker, so we would not be considering nifedipine. If I wanted to add a second agent, I would recommend starting labetalol, for example 100mg BD while waiting to see the specialist.

In summary, we will:

·      Refer her to secondary care for expert advice

·      And we may consider adding labetalol in the meantime if we are worried.

Please note that this is the advice for chronic hypertension in pregnancy, that is, women with hypertension who become pregnant. It is different from gestational hypertension, that is, hypertension that develops during pregnancy, which has different recommendations. Gestational hypertension, including pre-eclampsia, should be assessed, and managed in secondary care.

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.