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Hypertension in pregnancy

About

What is covered

This interactive flowchart covers the care of pregnant women with:
  • chronic hypertension
  • gestational hypertension
  • a moderate or high risk of pre-eclampsia
  • pre-eclampsia
  • severe hypertension
  • severe pre-eclampsia
  • eclampsia.
It also offers guidance on reducing the risk of hypertensive disorders during pregnancy and advice for women, their community midwives and primary care physicians.
Women with chronic hypertension who are pregnant or planning pregnancy should be given advice and treatment in line with the advice on management of hypertension in adults in NICE's recommendations on hypertension unless it specifically differs from the advice in this flowchart.
Women with hypertensive disorders during pregnancy should be given advice and treatment in line with NICE's recommendations on intrapartum care, unless it specifically differs from recommendations in this flowchart.

Updates

Updates to this interactive flowchart

30 September 2016 Restructured and summarised recommendations replaced by full recommendations.
10 May 2016 PlGF-based testing to help diagnose suspected pre-eclampsia (NICE diagnostic guidance 23) added to helping to diagnose pre-eclampsia.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on diagnosing and managing hypertension in pregnancy in an interactive flowchart

What is covered

This interactive flowchart covers the care of pregnant women with:
  • chronic hypertension
  • gestational hypertension
  • a moderate or high risk of pre-eclampsia
  • pre-eclampsia
  • severe hypertension
  • severe pre-eclampsia
  • eclampsia.
It also offers guidance on reducing the risk of hypertensive disorders during pregnancy and advice for women, their community midwives and primary care physicians.
Women with chronic hypertension who are pregnant or planning pregnancy should be given advice and treatment in line with the advice on management of hypertension in adults in NICE's recommendations on hypertension unless it specifically differs from the advice in this flowchart.
Women with hypertensive disorders during pregnancy should be given advice and treatment in line with NICE's recommendations on intrapartum care, unless it specifically differs from recommendations in this flowchart.

Updates

Updates to this interactive flowchart

30 September 2016 Restructured and summarised recommendations replaced by full recommendations.
10 May 2016 PlGF-based testing to help diagnose suspected pre-eclampsia (NICE diagnostic guidance 23) added to helping to diagnose pre-eclampsia.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Hypertension in pregnancy: diagnosis and management (2010 updated 2011) NICE guideline CG107
Hypertension in pregnancy (2013) NICE quality standard 35

Quality standards

Quality statements

Pre-pregnancy advice for women with treated hypertension

This quality statement is taken from the hypertension in pregnancy quality standard. The quality standard defines clinical best practice for hypertension in pregnancy and should be read in full.

Quality statement

Women of childbearing potential with treated hypertension are given information annually about safe antihypertensive treatment during pregnancy.

Rationale

Information can be provided to women who may become pregnant about safe antihypertensive treatment during pregnancy as part of an annual review of hypertension care. Women should be informed about potential risks, including the risk of congenital abnormalities, linked to particular antihypertensive drugs. This should enable women to arrange a discussion with the healthcare professional responsible for managing their hypertension about alternative antihypertensive treatments if they are planning pregnancy or become pregnant.

Quality measures

Structure
Evidence of local arrangements to ensure that women of childbearing potential with treated hypertension are given information annually about safe antihypertensive treatment during pregnancy.
Data source: Local data collection.
Process
Proportion of women who have had treated hypertension for 12 months or longer who received information about safe antihypertensive treatment during pregnancy in the past 12 months.
Numerator: the number of women in the denominator who received information about safe antihypertensive treatment during pregnancy in the past 12 months.
Denominator: the number of women of childbearing potential who have had treated hypertension for 12 months or longer.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that systems are in place to give women of childbearing potential with treated hypertension information annually about safe antihypertensive treatment in pregnancy.
Healthcare professionals give information annually to women of childbearing potential with treated hypertension about safe antihypertensive treatment in pregnancy.
Commissioners ensure they commission services that give information annually to women of childbearing potential with treated hypertension about safe antihypertensive treatment in pregnancy.

What the quality statement means for patients, service users and carers

Women who are having treatment for hypertension (high blood pressure) and who may become pregnant are given information annually about safe treatment for high blood pressure during pregnancy.

Source guidance

Definitions of terms used in this quality statement

Safe antihypertensive treatment
  • Women taking angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) should be provided with information to advise that there is an increased risk of congenital abnormalities if these drugs are taken during pregnancy, and discuss other antihypertensive treatment with the healthcare professional responsible for managing their hypertension, if they are planning pregnancy.
  • Women taking chlorothiazide should be provided with information to advise that: there may be an increased risk of congenital abnormality and neonatal complications if these drugs are taken during pregnancy, and to discuss other antihypertensive treatment with the healthcare professional responsible for managing their hypertension, if they are planning pregnancy.
  • Women who take antihypertensive treatments other than ACE inhibitors, ARBs or chlorothiazide should be provided with information to advise that the limited evidence available has not shown an increased risk of congenital malformation with such treatments.
Treated hypertension is hypertension that is treated with 1 or more antihypertensive drug.

Equality and diversity considerations

'Childbearing potential' should be determined for women on an individual basis. Access to information about safe antihypertensive treatment during pregnancy should not be determined solely by age, because childbearing potential is also dependent on factors other than age.
Where information is provided, there must be equal access to information for all women, including those with additional needs, such as physical or learning disabilities, and those who do not speak or read English. Women receiving information should have access to an interpreter or advocate if needed.

Antenatal assessment of pre-eclampsia risk

This quality statement is taken from the hypertension in pregnancy quality standard. The quality standard defines clinical best practice for hypertension in pregnancy and should be read in full.
This quality statement updates and replaces Quality statement 7: Risk assessment - pre-eclampsia in Antenatal care (NICE quality standard 22).

Quality statement

Pregnant women at increased risk of pre-eclampsia at the booking appointment are offered a prescription of 75 mg of aspirin to take daily from 12 weeks until birth.

Rationale

Aspirin prophylaxis, unless contraindicated, reduces the occurrence of pre-eclampsia, preterm birth and fetal and neonatal mortality in women at increased risk of developing the condition (if they have 1 high risk factor or more than 1 moderate risk factor for pre-eclampsia).

Quality measures

Structure
a) Evidence of local arrangements to ensure that pregnant women have their risk factors for pre-eclampsia identified and recorded at the booking appointment.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that pregnant women at increased risk of pre-eclampsia at the booking appointment are offered a prescription of 75 mg of aspirin (unless contraindicated) to take daily from 12 weeks until birth.
Data source: Local data collection.
Process
a) Proportion of pregnant women who have their risk factors for pre-eclampsia identified and recorded at the booking appointment.
Numerator: the number of women in the denominator whose risk factors for pre-eclampsia are identified and recorded.
Denominator: the number of pregnant women attending a booking appointment.
Data source: The Maternity Services Secondary Uses Dataset collects data on the following risk factors at booking: hypertension, renal disease, diabetes, autoimmune disease (global number 17200350) and obstetric diagnoses from previous pregnancies including 'severe pre-eclampsia requiring preterm birth', 'eclampsia' and 'gestational hypertension' (global number 17200720).
b) Proportion of pregnant women at increased risk of pre-eclampsia at the booking appointment who are offered a prescription of 75 mg of aspirin (unless contraindicated) to take daily from 12 weeks until birth.
Numerator: the number of women in the denominator offered a prescription of 75 mg of aspirin to take daily from 12 weeks until birth.
Denominator: the number of pregnant women at increased risk of pre-eclampsia and without contraindications to aspirin at the booking appointment.
Data source: Local data collection.
Outcome
Incidence of pre-eclampsia in women at increased risk of developing pre-eclampsia.
Data source: The Maternity Services Secondary Uses Dataset collects data on obstetric conditions diagnosed in the current pregnancy, including severe pre-eclampsia, severe pre-eclampsia requiring preterm birth and eclampsia (global number 17203940).

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that systems are in place to offer pregnant women at increased risk of pre-eclampsia at the booking appointment a prescription of 75mg of aspirin (unless contraindicated) to take daily from 12 weeks until birth.
Healthcare professionals offer pregnant women at increased risk of pre-eclampsia at the booking appointment a prescription of 75 mg of aspirin (unless contraindicated) to take daily from 12 weeks until birth.
Commissioners ensure they commission services that offer pregnant women at increased risk of pre-eclampsia at the booking appointment a prescription of 75 mg of aspirin (unless contraindicated) to take daily from 12 weeks until birth.

What the quality statement means for patients, service users and carers

Pregnant women who have a higher risk of developing pre-eclampsia (a pregnancy-related rise in blood pressure with protein in the urine that happens in some pregnancies) are offered a prescription of aspirin (unless this is unsuitable) to take every day from 12 weeks of pregnancy until their baby is born.

Source guidance

Definitions of terms used in this quality statement

The booking appointment is the appointment where the woman enters the maternity care pathway. See Antenatal appointments (schedule and content) in NICE clinical guideline 62.
Contraindications to taking aspirin include, but are not limited to: aspirin allergy; medical conditions precluding the use of aspirin; present use of another drug with the potential to interact with aspirin.
Note: aspirin did not have UK marketing authorisation for the indication in question at the time of publication of NICE clinical guideline 107 (August 2010). Informed consent should be obtained and documented.
Increased risk of pre-eclampsia Women are at an increased risk of pre-eclampsia if they have 1 high risk factor or more than 1 moderate risk factor for pre-eclampsia.
High risk factors include:
  • hypertensive disease in a previous pregnancy
  • chronic kidney disease
  • autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome
  • type 1 or type 2 diabetes
  • chronic hypertension.
Moderate risk factors include:
  • first pregnancy
  • age 40 years or older
  • pregnancy interval of more than 10 years
  • body mass index (BMI) of 35 kg/m2 or more at first visit
  • family history of pre-eclampsia
  • multiple pregnancy.
Pre-eclampsia New hypertension presenting after 20 weeks of pregnancy with significant proteinuria (urinary protein:creatinine ratio greater than 30 mg/mmol or a validated 24-hour urine collection result greater than 300 mg protein).

Antenatal blood pressure targets

This quality statement is taken from the hypertension in pregnancy quality standard. The quality standard defines clinical best practice for hypertension in pregnancy and should be read in full.

Quality statement

Women with hypertension in pregnancy have a blood pressure target set below 150/100 mmHg or, if they also have target organ damage, below 140/90 mmHg.

Rationale

Antihypertensive treatment should aim to lower blood pressure from the moderate or severe range, while avoiding excessive reductions that may affect fetal growth. It is recommended that women with evidence of target organ damage from hypertension will need a lower target blood pressure.

Quality measures

Structure
a) Evidence of local arrangements to ensure that pregnant women who have hypertension without target organ damage have a blood pressure target of below 150/100 mmHg.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that pregnant women who have hypertension and target organ damage have a blood pressure target of below 140/90 mmHg.
Data source: Local data collection.
Outcome
Rate of pregnant women with hypertension who maintain their target blood pressure throughout their pregnancy.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that there are local arrangements to set target blood pressures for pregnant women who have hypertension of below 150/100 mmHg, or below 140/90 mmHg if they have target organ damage, and to maintain blood pressures to these targets throughout pregnancy.
Healthcare professionals set target blood pressures for pregnant women who have hypertension of below 150/100 mmHg, or below 140/90 mmHg if they have target organ damage, and ensure that these blood pressures are maintained throughout pregnancy.
Commissioners ensure they commission services that set target blood pressures for pregnant women who have hypertension of below 150/100 mmHg, or below 140/90 mmHg for women with target organ damage, and ensure that these blood pressures are maintained throughout pregnancy.

What the quality statement means for patients, service users and carers

Pregnant women with hypertension (high blood pressure) receive treatment aimed at keeping their blood pressure below 150/100 mmHg, or below 140/90 mmHg if their high blood pressure has led to problems with their eyes, heart or kidneys.

Source guidance

Definitions of terms used in this quality statement

Hypertension in pregnancy This definition includes chronic hypertension (present at the booking visit or before 20 weeks of pregnancy; this could include pre-existing hypertension), gestational hypertension (new hypertension presenting after 20 weeks without proteinuria) and pre-eclampsia (new hypertension presenting after 20 weeks with significant proteinuria [urinary protein:creatinine ratio greater than 30 mg/mmol or a validated 24 hour urine collection result greater than 300 mg protein]).
Target organ damage Left ventricular hypertrophy, chronic kidney disease and hypertensive retinopathy are examples of target organ damage. See NICE clinical guideline 127 recommendation 1.2.6.

Assessing women with severe hypertension in pregnancy

This quality statement is taken from the hypertension in pregnancy quality standard. The quality standard defines clinical best practice for hypertension in pregnancy and should be read in full.

Quality statement

Pregnant women with severe hypertension are admitted for a full assessment, carried out by a healthcare professional trained in managing hypertension in pregnancy.

Rationale

Effective and safe control of severe hypertension is the most important aspect of critical care management, because the main causes of maternal death and severe maternal morbidity (including stroke) are the consequence of poorly controlled hypertension. Women with severe hypertension in pregnancy should be referred from primary care or emergency departments as soon as possible to receive assessment from healthcare professionals with expertise in managing hypertensive disorders. This is essential to ensure early identification of pre-eclampsia and the provision of critical care where it is needed.

Quality measures

Structure
Evidence of local arrangements for pregnant women with severe hypertension to be admitted for a full assessment, carried out by a healthcare professional trained in managing hypertensive disorders in pregnancy.
Data source: Local data collection.
Process
Proportion of women with severe hypertension who are admitted for a full assessment, carried out by a healthcare professional trained in managing hypertensive disorders in pregnancy.
Numerator: the number of women in the denominator who are admitted for a full assessment, carried out by a healthcare professional trained in managing hypertensive disorders in pregnancy.
Denominator: the number of pregnant women with severe hypertension.
Data source: Local data collection.
Outcome
Number of women with severe hypertension in pregnancy who have a stroke.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that there are local arrangements for pregnant women with severe hypertension to be admitted for a full assessment, carried out by a healthcare professional trained in managing hypertensive disorders in pregnancy.
Healthcare professionals admit pregnant women with severe hypertension for a full assessment, carried out by a healthcare professional trained in managing hypertensive disorders in pregnancy.
Commissioners ensure they commission services that admit pregnant women with severe hypertension for a full assessment, carried out by a a healthcare professional trained in managing hypertensive disorders in pregnancy.

What the quality statement means for patients, service users and carers

Pregnant women with severe hypertension (high blood pressure) are admitted to hospital for a full assessment, carried out by a healthcare professional trained in managing high blood pressure and related conditions in pregnancy.

Source guidance

Definitions of terms used in this quality statement

Full assessment should include blood pressure measurements, proteinuria testing and blood tests in accordance with those set out for severe gestational hypertension and pre-eclampsia with severe hypertension in tables 1 and 2 of recommendations 1.4.1.3 and 1.5.1.2 respectively.
Hypertension in pregnancy This definition includes chronic hypertension (present at the booking visit or before 20 weeks of pregnancy; this could include pre-existing hypertension), gestational hypertension (new hypertension presenting after 20 weeks without proteinuria) and pre-eclampsia (new hypertension presenting after 20 weeks with significant proteinuria [urinary protein:creatinine ratio greater than 30 mg/mmol or a validated 24 hour urine collection result greater than 300 mg protein]).
Severe hypertension Systolic blood pressure is 160 mmHg or greater or diastolic blood pressure is 110 mmHg or greater.

Admission to hospital for women with pre-eclampsia

This quality statement is taken from the hypertension in pregnancy quality standard. The quality standard defines clinical best practice for hypertension in pregnancy and should be read in full.

Quality statement

Women with a diagnosis of pre-eclampsia are admitted to hospital and monitored daily.

Rationale

Women with pre-eclampsia should be admitted to hospital to enable their condition to be fully assessed and its progress monitored. High-quality care should include an integrated package of care for women with pre-eclampsia that includes admission and daily monitoring. Some women may need to stay in hospital until after the birth of their baby. For other women, daily monitoring may be possible if pre-eclampsia is stable and if the woman has easy access to monitoring services, and can be readmitted to hospital if her clinical condition deteriorates.

Quality measures

Structure
a) Evidence of local arrangements to ensure that women with a diagnosis of pre-eclampsia are admitted to hospital.
Data source: Local data collection.
b) Evidence of local arrangements for women with pre-eclampsia to receive an integrated package of care that includes daily monitoring of their condition.
Data source: Local data collection.
Process
a) The proportion of women with a diagnosis of pre-eclampsia who are admitted to hospital.
Numerator: the number of women in the denominator who are admitted to hospital when pre-eclampsia is diagnosed.
Denominator: the number of women with pre-eclampsia.
Data source: Local data collection.
b) The proportion of women with pre-eclampsia who are monitored daily.
Numerator: the number of women in the denominator who are monitored daily.
Denominator: the number of women who have pre-eclampsia.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that local arrangements are in place for women with a diagnosis of pre-eclampsia to be admitted to hospital and for their condition to be monitored daily.
Healthcare professionals admit women with a diagnosis of pre-eclampsia to hospital and monitor their condition daily.
Commissioners ensure they commission services that admit women with a diagnosis of pre-eclampsia to hospital and monitor their condition daily.

What the quality statement means for patients, service users and carers

Women with pre-eclampsia (a pregnancy-related rise in blood pressure with protein in the urine that happens in some pregnancies) are admitted to hospital and have their condition monitored every day (while in hospital and at home if they go home before their baby is born).

Source guidance

  • Hypertension in pregnancy (NICE clinical guideline 107) recommendation 1.5.1.2 (key priority for implementation).

Definitions of terms used in this quality statement

Integrated package of care NICE clinical guideline 107 recommends admission to hospital for women with pre-eclampsia as part of an integrated package of care. This covers admission to hospital, treatment, measurement of blood pressure, testing for proteinuria and blood tests.
Pre-eclampsia New hypertension presenting after 20 weeks of pregnancy with significant proteinuria (urinary protein:creatinine ratio greater than 30 mg/mmol or a validated 24 hour urine collection result greater than 300 mg protein).

Planning mode and timing of birth for women with pre-eclampsia

This quality statement is taken from the hypertension in pregnancy quality standard. The quality standard defines clinical best practice for hypertension in pregnancy and should be read in full.

Quality statement

Women with pre-eclampsia have an agreed consultant obstetrician-led plan for the timing and mode of birth.

Rationale

Some women who have pre-eclampsia with mild or moderate hypertension will progress to severe pre-eclampsia, which is associated with serious adverse outcomes. Because the progress of the condition differs between women, a consultant-led plan should be developed for each woman with pre-eclampsia including acceptable thresholds for intervention of all monitored thresholds (maternal and fetal) for early birth. This will be agreed with the pregnant woman, updated as needed, and will supersede any original birth plan.

Quality measures

Structure
Evidence of local arrangements to ensure that women with pre-eclampsia have an agreed consultant obstetrician-led plan for the timing and mode of birth.
Data source: Local data collection.
Process
Women with pre-eclampsia have an agreed consultant obstetrician-led plan for the timing and mode of birth documented in their notes.
Numerator – the number of women in the denominator who have an agreed consultant obstetrician-led plan for the timing and mode of birth documented in their notes.
Denominator – the number of women who have given birth who had pre-eclampsia.
Data source: The Maternity Services Secondary Uses Dataset collects data on the date a care plan has been created or changed. This covers antenatal, birth and postnatal care plans (global number 17201890). Data are also collected on the stage to which the plan applies (global number 17201900) and the professional category of the clinician with overall responsibility for care during the pregnancy (global number 17201920).
Outcome
a) Feedback from women who have had pre-eclampsia that they felt sufficiently involved in planning the timing and mode of the birth of their baby.
Data source: Local data collection.
b) Number of maternal deaths of women with pre-eclampsia.
Data source: Local data collection.
c) Number of fetal deaths for women with pre-eclampsia.
Data source: Local data collection.
d) Number of admissions of women with pre-eclampsia to intensive care units (ICU).
Data source: Local data collection.
e) Number of admissions of babies born to women with pre-eclampsia to neonatal intensive care units (NICU).
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that there are local arrangements in place for women with pre-eclampsia to have an agreed consultant obstetrician-led plan for the timing and mode of birth.
Healthcare professionals ensure that women with pre-eclampsia have an agreed consultant obstetrician-led plan for the timing and mode of birth.
Commissioners ensure they commission services that develop an agreed consultant obstetrician-led plan for the timing and mode of birth for women with pre-eclampsia.

What the quality statement means for patients, service users and carers

Women with pre-eclampsia (a pregnancy-related rise in blood pressure with protein in the urine that happens in some pregnancies) and their consultant obstetrician agree a plan for when and how they will give birth and that the plan is followed.

Source guidance

Definitions of terms used in this quality statement

The consultant obstetrician-led plan should be agreed with both the pregnant woman and the multidisciplinary team providing the woman's care, including other specialists, in particular anaesthetists. This should be done as soon after admission as possible. The birth should be according to the most up-to-date version of the plan.
Pre-eclampsia New hypertension presenting after 20 weeks of pregnancy with significant proteinuria (urinary protein:creatinine ratio greater than 30 mg/mmol or a validated 24 hour urine collection result greater than 300 mg protein).
Timing and mode of birth For indications for timing and mode of birth, see NICE clinical guideline 107 recommendations 1.5.2.1-1.5.2.7

Transfer of information about ongoing management

This quality statement is taken from the hypertension in pregnancy quality standard. The quality standard defines clinical best practice for hypertension in pregnancy and should be read in full.

Quality statement

Women who have had hypertension in pregnancy have a plan for ongoing antihypertensive management included in their postnatal care plan, which is communicated to their GP when they are transferred to community care after the birth.

Rationale

There are particular risks to women who have had hypertension in pregnancy (such as the risk of stroke) in the immediate postnatal period. The development of an individualised care plan for women who have had hypertension in pregnancy before they are transferred to community care should support ongoing antihypertensive management and enable risks to be monitored and addressed, including variations in blood pressure.

Quality measures

Structure
Evidence of local arrangements to communicate a plan for ongoing antihypertensive management for women who had hypertension in pregnancy to their GP when they are transferred to community care after the birth.
Data source: Local data collection.
Process
The proportion of women with hypertension in pregnancy for whom a plan for ongoing antihypertensive management is communicated to their GP when they are transferred to community care after the birth.
Numerator: the number of women in the denominator for whom a plan for ongoing antihypertensive management is communicated to their GP when they are transferred to community care after the birth.
Denominator: the number of women who have given birth who had hypertension in pregnancy.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that local arrangements are in place to communicate a plan for ongoing antihypertensive management to GPs of women who had hypertension in pregnancy when they are transferred to community care after the birth.
Healthcare professionals communicate a plan for ongoing antihypertensive management to GPs of women who had hypertension in pregnancy when they are transferred to community care after the birth.
Commissioners ensure they commission services that communicate a plan for ongoing antihypertensive management to GPs of women who had hypertension in pregnancy when they are transferred to community care after the birth.

What the quality statement means for patients, service users and carers

Women who had hypertension (high blood pressure) in pregnancy have a plan for continuing management of their blood pressure, which is communicated to their GP when they go home after their baby is born.

Source guidance

Definitions of terms used in this quality statement

A plan for ongoing antihypertensive management should include information about postpartum management, including a plan for ongoing management. NICE clinical guideline 107 recommends that a care plan should be written for women with gestational hypertension or pre-eclampsia who have given birth and are being transferred to community care that includes all of the following:
  • who will provide follow-up care, including medical review if needed
  • frequency of blood pressure monitoring needed
  • thresholds for reducing or stopping treatment
  • indications for referral to primary care for blood pressure review.
The plan for women with pre-eclampsia should also include self-monitoring for symptoms.
Community care Transfer to the care of a community midwife or health visitor.
Hypertension in pregnancy This definition includes chronic hypertension (present at the booking visit or before 20 weeks of pregnancy; this could include pre-existing hypertension), gestational hypertension (new hypertension presenting after 20 weeks without proteinuria) and pre-eclampsia (new hypertension presenting after 20 weeks with significant proteinuria [urinary protein:creatinine ratio greater than 30 mg/mmol or a validated 24 hour urine collection result greater than 300 mg protein]).

Communicating information about future risks

This quality statement is taken from the hypertension in pregnancy quality standard. The quality standard defines clinical best practice for hypertension in pregnancy and should be read in full.

Quality statement

Women who have had gestational hypertension or pre-eclampsia discuss future pregnancy and lifetime cardiovascular risks during a medical review at their 6–8 week postnatal medical check.

Rationale

The long-term risks for women who have had hypertension in pregnancy include developing high blood pressure and an increased lifetime cardiovascular risk. Increased awareness and surveillance may lead to earlier intervention, such as antihypertensive treatment, with likely benefits for the woman. Women should be made aware of risks in future pregnancies resulting from hypertension in a previous pregnancy.

Quality measures

Structure
Evidence of local arrangements for women who have had gestational hypertension or pre-eclampsia to have a discussion about future related risks during the medical review at their 6–8 week postnatal medical check.
Data source: Local data collection.
Process
The proportion of women who have had gestational hypertension or pre-eclampsia who have a discussion about future related risks during the medical review at their 6–8 week postnatal medical check.
Numerator: the number of women in the denominator who have a discussion about future related risks.
Denominator: the number of women who have had gestational hypertension or pre-eclampsia who have a medical review at their 6–8 week postnatal check.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that local arrangements are in place for women who have had gestational hypertension or pre-eclampsia to have a discussion about future related risks during the medical review at their 6–8 week postnatal medical check.
Healthcare professionals discuss future related risks with women who have had gestational hypertension or pre-eclampsia during the medical review at their 6–8 week postnatal medical check.
Commissioners ensure that they commission services that discuss future related risks with women who have had gestational hypertension or pre-eclampsia during the medical review at their 6–8 week postnatal medical check.

What the quality statement means for patients, service users and carers

Women who have had gestational hypertension (new high blood pressure starting after 20 weeks of pregnancy) or pre-eclampsia (a pregnancy-related rise in blood pressure with protein in the urine that happens in some pregnancies) have an appointment with their doctor or midwife 6 to 8 weeks after they have had their baby, at which they discuss their risk of having problems with their blood pressure or pregnancies in the future.

Source guidance

Definitions of terms used in this quality statement

Future pregnancy and lifetime cardiovascular risk
NICE clinical guideline 107 recommends that women who have had gestational hypertension or pre-eclampsia should be told that these conditions are associated with an increased risk of developing high blood pressure and its complications in later life.
NICE clinical guideline 107 recommends that women who have had gestational hypertension should be told that their risk of developing:
  • gestational hypertension in a future pregnancy ranges from about 1 in 6 (16%) pregnancies to about 1 in 2 (47%) pregnancies
  • pre-eclampsia in a future pregnancy ranges from 1 in 50 (2%) to about 1 in 14 (7%) pregnancies.
Women who have had pre-eclampsia should be told that their risk of developing:
  • gestational hypertension in a future pregnancy ranges from about 1 in 8 (13%) pregnancies to about 1 in 2 (53%) pregnancies
  • pre-eclampsia in a future pregnancy is up to about 1 in 6 (16%) pregnancies
  • pre-eclampsia in a future pregnancy is about 1 in 4 (25%) pregnancies if their pre-eclampsia was complicated by severe pre-eclampsia, HELLP syndrome or eclampsia and led to birth before 34 weeks, and about 1 in 2 (55%) pregnancies if it led to birth before 28 weeks.
Gestational hypertension New hypertension presenting after 20 weeks of pregnancy without significant proteinuria.
Medical review
NICE clinical guideline 107 recommends that women who have had gestational hypertension or pre-eclampsia should be offered a medical review at their postnatal check, which takes place 6–8 weeks after birth. (Topic expert group consensus was that this would be carried out by a GP or an appropriately trained midwife.)
Pre-eclampsia New hypertension presenting after 20 weeks of pregnancy with significant proteinuria (urinary protein:creatinine ratio greater than 30 mg/mmol or a validated 24-hour urine collection result greater than 300 mg protein).

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Drug information

It is assumed that prescribers will use a drug's SPC to inform decisions made with individual patients. Drugs for which particular attention should be paid to the contraindications and special warnings during pregnancy and lactation are listed below.
Atenolol is licensed for the treatment of hypertension and is already used widely in UK postnatal obstetric practice, but the SPC (August 2010) advises that anticipated benefit be weighed against the possible risks of its use in the first and second trimesters of pregnancy, and in women who may become pregnant or who are breastfeeding. Informed consent on the use of atenolol in these situations should be obtained and documented.
Captopril is licensed for the treatment of hypertension and is already used in UK postnatal obstetric practice, but the SPC (August 2010) advises that it is contraindicated in the second and third trimesters of pregnancy and in lactation, and that it is not recommended during the first trimester of pregnancy. Informed consent on the use of captopril in these situations should be obtained and documented.
Enalapril is licensed for the treatment of hypertension and is already used widely in UK postnatal obstetric practice, but the SPC (August 2010) advises that it is contraindicated in the second and third trimesters of pregnancy and that it is not recommended during the first trimester of pregnancy or in breastfeeding for preterm infants and for the first few weeks after delivery. Informed consent on the use of enalapril in these situations should be obtained and documented.
Labetalol is licensed for the treatment of hypertension, including during pregnancy and is already used widely in UK obstetric practice, but the SPC (August 2010) advises that it should only be used during the first trimester of pregnancy if the potential benefit outweighs the potential risk, and that breastfeeding is not recommended. Informed consent on the use of labetalol in these situations should be obtained and documented.
Methyldopa is licensed for the treatment of hypertension and is already used widely in UK obstetric practice, but the SPC (August 2010) advises that its use in women who are, or may become, pregnant or who are breastfeeding their newborn infant requires that anticipated benefits be weighed against possible risks. Informed consent on the use of methyldopa in these situations should be obtained and documented.
Metoprolol is licensed for the treatment of hypertension and is already used widely in UK postnatal obstetric practice, but the SPC (August 2010) advises that anticipated benefit be weighed against the possible risks of its use in women who are pregnant or breastfeeding. Informed consent on the use of metoprolol in these situations should be obtained and documented.
Nifedipine is licensed for the treatment of hypertension and is already used widely in UK obstetric practice, but the SPC (August 2010) advises that it is contraindicated in pregnancy before week 20, and that it should not be administered during the entire pregnancy or in women who may become pregnant. It also advises that nifedipine should not be used during breastfeeding. Informed consent on the use of nifedipine in these situations should be obtained and documented.
Degree of hypertension
Mild hypertension (140/90 to 149/99 mmHg)
Moderate hypertension (150/100 to 159/109 mmHg)
Severe hypertension (160/110 mmHg or higher)
Admit to hospital
No
No
Yes (until blood pressure is 159/109 mmHg or lower)
Treat
No
With oral labetalol* as first-line treatment to keep:
- diastolic blood pressure between 80-100 mmHg
- systolic blood pressure less than 150 mmHg
With oral labetalol* as first-line treatment to keep:
- diastolic blood pressure between 80-100 mmHg
- systolic blood pressure less than 150 mmHg
Measure blood pressure
Not more than once a week
At least twice a week
At least four times a day
Test for proteinuria
At each visit using automated reagent-strip reading device or urinary protein:creatinine ratio
At each visit using automated reagent-strip reading device or urinary protein:creatinine ratio
Daily using automated reagent-strip reading device or urinary protein:creatinine ratio
Blood tests
Only those for routine antenatal care
Test kidney function, electrolytes, full blood count, transaminases, bilirubin. Do not carry out further blood tests if no proteinuria at subsequent visits
Test at presentation and then monitor weekly: kidney function, electrolytes, full blood count, transaminases, bilirubin
* For further details see drug information.
Degree of hypertension
Mild hypertension (140/90 to 149/99 mmHg)
Moderate hypertension (150/100 to 159/109 mmHg)
Severe hypertension (160/110 mmHg or higher)
Admit to hospital
Yes
Yes
Yes
Treat
No
With oral labetalol* as first-line treatment to keep:
- diastolic blood pressure between 80-100 mmHg
- systolic blood pressure less than 150 mmHg
With oral labetalol* as first-line treatment to keep:
- diastolic blood pressure between 80-100 mmHg
- systolic blood pressure less than 150 mmHg
Measure blood pressure
At least four times a day
At least four times a day
More than four times a day, depending on clinical circumstances
Test for proteinuria
Do not repeat quantification of proteinuria
Do not repeat quantification of proteinuria
Do not repeat quantification of proteinuria
Blood tests
Monitor using the following tests twice a week: kidney function, electrolytes, full blood count, transaminases, bilirubin
Monitor using the following tests three times a week: kidney function, electrolytes, full blood count, transaminases, bilirubin
Monitor using the following tests three times a week: kidney function, electrolytes, full blood count, transaminases, bilirubin
* For further details see drug information.
Women with hypertensive disorders during pregnancy should be given advice and treatment in line with NICE's recommendations on intrapartum care, unless it specifically differs from recommendations in this interactive flowchart.

Blood pressure

During labour, measure blood pressure:
  • hourly in women with mild or moderate hypertension
  • continually in women with severe hypertension.
Continue use of antenatal antihypertensive treatment during labour.

Haematological and biochemical monitoring

Determine the need for haematological and biochemical tests during labour in women with mild or moderate hypertension using the same criteria as in the antenatal period even if regional analgesia is being considered.

Care during epidural analgesia

Do not preload women who have severe pre-eclampsia with intravenous fluids before establishing low-dose epidural analgesia and combined spinal epidural analgesia.

Management of the second stage of labour

Do not routinely limit the duration of the second stage of labour:
  • in women with stable mild or moderate hypertension or
  • if blood pressure is controlled within target ranges in women with severe hypertension.
Recommend operative birth in the second stage of labour for women with severe hypertension whose hypertension has not responded to initial treatment.
Use an automated reagent-strip reading device or a spot urinary protein:creatinine ratio for estimating proteinuria in a secondary care setting.
If an automated reagent-strip reading device is used to detect proteinuria and a result of 1+ or more is obtained, use a spot urinary protein:creatinine ratio or 24-hour urine collection to quantify proteinuria.
Diagnose significant proteinuria if the urinary protein:creatinine ratio is greater than 30 mg/mmol or a validated 24-hour urine collection result shows greater than 300 mg protein.
Where 24-hour urine collection is used to quantify proteinuria, there should be a recognised method of evaluating completeness of the sample.
Carry out cardiotocography at diagnosis of severe gestational hypertension or pre-eclampsia.
If conservative management of severe gestational hypertension or pre-eclampsia is planned, carry out all the following tests at diagnosis:
  • ultrasound fetal growth and amniotic fluid volume assessment
  • umbilical artery doppler velocimetry.
If the results of all fetal monitoring are normal in women with severe gestational hypertension or pre-eclampsia, do not routinely repeat cardiotocography more than weekly.
In women with severe gestational hypertension or pre-eclampsia, repeat cardiotocography if any of the following occur:
  • the woman reports a change in fetal movement
  • vaginal bleeding
  • abdominal pain
  • deterioration in maternal condition.
In women with severe gestational hypertension or pre-eclampsia, do not routinely repeat ultrasound fetal growth and amniotic fluid volume assessment or umbilical artery doppler velocimetry more than every 2 weeks.
If the results of any fetal monitoring in women with severe gestational hypertension or pre-eclampsia are abnormal, tell a consultant obstetrician.
For women with severe gestational hypertension or pre-eclampsia, write a care plan that includes all of the following:
  • the timing and nature of future fetal monitoring
  • fetal indications for birth and if and when corticosteroids should be given
  • when discussion with neonatal paediatricians and obstetric anaesthetists should take place and what decisions should be made.
Encourage women with chronic hypertension to keep their dietary sodium intake low, either by reducing or substituting sodium salt, because this can reduce blood pressure.

Glossary

angiotensin-converting enzyme inhibitors
alanine aminotransferase
angiotensin II receptor blockers
aspartate aminotransferase
body mass index
hypertension that is present at the booking visit or before 20 weeks or if the woman is already taking antihypertensive medication when referred to maternity services; it can be primary or secondary in aetiology
a convulsive condition associated with pre-eclampsia
haemolysis, elevated liver enzymes and low platelet count
new hypertension presenting after 20 weeks without significant proteinuria
diastolic blood pressure 90–99 mmHg, systolic blood pressure 140–149 mmHg
diastolic blood pressure 100–109 mmHg, systolic blood pressure 150–159 mmHg
diastolic blood pressure 110 mmHg or greater, systolic blood pressure 160 mmHg or greater
offer elective early birth through induction of labour or by elective caesarean section if indicated
new hypertension presenting after 20 weeks with significant proteinuria
pre-eclampsia with severe hypertension and/or with symptoms, and/or biochemical and/or haematological impairment
summary of product characteristics

Paths in this pathway

Pathway created: August 2013 Last updated: June 2017

© NICE 2017. All rights reserved. Subject to Notice of rights.

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