A-Z
Topics

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.

Updates

Updates to this interactive flowchart

23 July 2019 Hypertension in pregnancy (NICE quality standard 35) updated.
24 June 2019 Restructured, and updated recommendations on management of hypertension in pregnancy, postnatal treatment of hypertension, and advice and follow-up at discharge.
30 September 2016 Restructured and summarised recommendations replaced by full recommendations.
10 May 2016 PlGF-based testing to help diagnose suspected pre-eclampsia (NICE diagnostics 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.

Updates

Updates to this interactive flowchart

23 July 2019 Hypertension in pregnancy (NICE quality standard 35) updated.
24 June 2019 Restructured, and updated recommendations on management of hypertension in pregnancy, postnatal treatment of hypertension, and advice and follow-up at discharge.
30 September 2016 Restructured and summarised recommendations replaced by full recommendations.
10 May 2016 PlGF-based testing to help diagnose suspected pre-eclampsia (NICE diagnostics guidance 23) added to helping to diagnose pre-eclampsia.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Hypertension in pregnancy (2013 updated 2019) 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 different audiences

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 practitioners 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.
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

Hypertension in pregnancy: diagnosis and management (2019) NICE guideline NG133, recommendations 1.3.2, 1.3.4 and 1.3.5

Definitions of terms used in this quality statement

Safe antihypertensive treatment
Women taking angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockersIn 2014, the Medicines and Healthcare products Regulatory Agency (MHRA) issued a drug safety update on ACE inhibitors and angiotensin II receptor antagonists: not for use in pregnancy, which states 'Use in women who are planning pregnancy should be avoided unless absolutely necessary, in which case the potential risks and benefits should be discussed'. (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 alternative antihypertensive treatment with the healthcare professional responsible for managing their hypertension, if they are planning pregnancy. If ACE inhibitors or ARBs are being taken for other conditions such as renal disease, alternative treatment should be discussed with the healthcare professional responsible for managing their condition.
Women taking thiazide or thiazide-like diuretics 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 alternative 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 thiazide or thiazide-like diuretics should be provided with information to advise that the limited evidence available has not shown an increased risk of congenital malformation with such treatments.
[NICE’s guideline on hypertension in pregnancy, recommendations 1.3.2 to 1.3.5]
Treated hypertension
Hypertension that is treated with 1 or more antihypertensive drug.
[Adapted from NICE’s full guideline on hypertension in pregnancy]
Annual review
Women with childbearing potential are given information annually about safe antihypertensive treatment during pregnancy.
[Timeframe from expert consensus]

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 NICE’s quality standard on antenatal care.

Quality statement

Pregnant women at increased risk of pre-eclampsia at the booking appointment are offered a prescription of 75–150 mg of aspirinAlthough this use is common in UK clinical practice, at the time of publication (July 2019), aspirin did not have a UK marketing authorisation for this indication. Community pharmacies cannot legally sell aspirin as a pharmacy medicine for prevention of pre-eclampsia in pregnancy in England. Aspirin for this indication must be prescribed. The prescriber should see the summary of product characteristics for the manufacturer’s advice on use in pregnancy. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Prescribing guidance: prescribing unlicensed medicines for further information. 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 75–150 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 Data Set collects data on the following risk factors at booking: hypertension, renal disease, diabetes, autoimmune disease and obstetric diagnoses from previous pregnancies including ‘severe pre-eclampsia requiring preterm birth', 'eclampsia' and ‘gestational hypertension'.
b) Proportion of pregnant women at increased risk of pre-eclampsia at the booking appointment who are offered a prescription of 75–150 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 75–150 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 Data Set collects data on obstetric conditions diagnosed in the current pregnancy, including severe pre-eclampsia, severe pre-eclampsia requiring preterm birth and eclampsia.

What the quality statement means for different audiences

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 75–150 mg of aspirin (unless contraindicated) to take daily from 12 weeks until birth.
Healthcare practitioners offer pregnant women at increased risk of pre-eclampsia at the booking appointment a prescription of 75–150 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 75–150 mg of aspirin (unless contraindicated) to take daily from 12 weeks until birth.
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

Booking appointment
The appointment where the woman enters the maternity care pathway.
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
  • multi-fetal pregnancy.
[NICE’s full guideline on hypertension in pregnancy]
Pre-eclampsia
New hypertension (over 140 mmHg systolic or over 90 mmHg diastolic) presenting after 20 weeks of pregnancy and the coexistence of 1 or more of the following new-onset conditions:
  • proteinuria (urine protein:creatinine ratio 30 mg/mmol or more, or albumin:creatinine ratio of 8 mg/mmol or more, or at least 1 g/litre [2+] on dipstick testing) or
  • other maternal organ dysfunction:
    • renal insufficiency (creatinine 90 micromol/litre or more, 1.02 mg/100ml or more)
    • liver involvement (elevated transaminases [alanine aminotransferase or aspartate aminotransferase over 40 IU/litre] with or without right upper quadrant or epigastric abdominal pain)
    • neurological complications such as eclampsia, altered mental status, blindness, stroke, clonus, severe headaches or persistent visual scotomata
    • haematological complications such as thrombocytopenia (platelet count below 150,000/microlitre), disseminated intravascular coagulation or haemolysis
  • uteroplacental dysfunction such as fetal growth restriction, abnormal umbilical artery Doppler waveform analysis, or stillbirth.
[NICE’s guideline on hypertension in pregnancy, terms used in this guideline]

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

Pregnant women taking antihypertensive medication have a blood pressure target of 135/85 mmHg or less.

Rationale

Antihypertensive treatment should aim to lower blood pressure from the moderate or severe range, while avoiding excessive reductions that may affect fetal growth.

Quality measures

Structure
Evidence of local arrangements to ensure that pregnant women taking antihypertensive medication have a blood pressure target of 135/85 mmHg or less.
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 different audiences

Service providers ensure that there are local arrangements to set target blood pressure for pregnant women taking antihypertensive medication to 135/85 mmHg or less, and to maintain this blood pressure throughout their pregnancy.
Healthcare practitioners set target blood pressure for pregnant women taking antihypertensive medication to 135/85 mmHg or less, and ensure that this blood pressure is maintained throughout pregnancy.
Commissioners ensure they commission services that set target blood pressure for pregnant women taking antihypertensive medication to 135/85 mmHg or less, and ensure that this blood pressure is maintained throughout pregnancy.
Pregnant women taking medication for hypertension (high blood pressure) have a blood pressure target of135/85 mmHg or less.

Source guidance

Hypertension in pregnancy: diagnosis and management (2019) NICE guideline NG133, recommendations 1.3.7–1.3.9, 1.4.3 and 1.5.5

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 different audiences

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 practitioners 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.
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

Hypertension in pregnancy: diagnosis and management (2019) NICE guideline NG133, recommendations 1.4.1 and 1.4.3

Definitions of terms used in this quality statement

Full assessment
This 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 the NICE guideline on hypertension in pregnancy.
[NICE’s guideline on hypertension in pregnancy, recommendation 1.4.3, table 1]
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 of pregnancy and the coexistence of 1 or more of the following new-onset conditions:
  • proteinuria (urine protein:creatinine ratio 30 mg/mmol or more, or albumin:creatinine ratio of 8 mg/mmol or more, or at least 1 g/litre [2+] on dipstick testing) or
  • other maternal organ dysfunction:
    • renal insufficiency (creatinine 90 micromol/litre or more, 1.02 mg/100ml or more)
    • liver involvement (elevated transaminases [alanine aminotransferase or aspartate aminotransferase over 40 IU/litre] with or without right upper quadrant or epigastric abdominal pain)
    • neurological complications such as eclampsia, altered mental status, blindness, stroke, clonus, severe headaches or persistent visual scotomata
    • haematological complications such as thrombocytopenia (platelet count below 150,000/microlitre), disseminated intravascular coagulation or haemolysis
  • uteroplacental dysfunction such as fetal growth restriction, abnormal umbilical artery Doppler waveform analysis, or stillbirth.
[NICE’s guideline on hypertension in pregnancy, terms used in this guideline]
Severe hypertension
Blood pressure over 160 mmHg systolic, or over 110 mmHg diastolic.
[NICE’s guideline on hypertension in pregnancy, terms used in this guideline]

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 pre-eclampsia who have severe hypertension or are at a high risk of adverse events, or if there are any clinical concerns, are admitted to hospital and monitored.

Rationale

Women with pre-eclampsia who have severe hypertension or are at a high risk of adverse events, or if there are any clinical concerns for the wellbeing of the woman or baby, 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 these women that includes admission and monitoring. Some women may need to stay in hospital until after the birth of their baby. For other women, monitoring may be possible if pre-eclampsia is stable and if the woman has 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 pre-eclampsia who have severe hypertension or are at a high risk of adverse events, or if there are any clinical concerns, are admitted to hospital.
Data source: Local data collection.
b) Evidence of local arrangements for women with pre-eclampsia who have severe hypertension or are at a high risk of adverse events or if there are any clinical concerns, to receive an integrated package of care that includes monitoring of their condition.
Data source: Local data collection.
Process
The proportion of women with pre-eclampsia who have severe hypertension or are at a high risk of adverse events, or if there are any clinical concerns, who are admitted to hospital and monitored.
Numerator – the number of women in the denominator who are admitted to hospital and monitored.
Denominator – the number of women with pre-eclampsia who have severe hypertension or are at a high risk of adverse events, or if there are any clinical concerns.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers ensure that local arrangements are in place for women with pre-eclampsia who have severe hypertension or are at a high risk of adverse events, or if there are any clinical concerns for the wellbeing of the woman or baby, to be admitted to hospital and for their condition to be monitored.
Healthcare practitioners admit women with pre-eclampsia who have severe hypertension or are at a high risk of adverse events, or if they have any clinical concerns for the wellbeing of the woman or baby, to hospital and monitor their condition.
Commissioners ensure they commission services that admit women with pre-eclampsia who have severe hypertension or are at a high risk of adverse events, or if there are any clinical concerns for the wellbeing of the woman or baby, to hospital and monitor their condition.
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 if they have very high blood pressure or a high risk of complications, or if their healthcare professional has concerns about the wellbeing of the mother or baby. The women have their condition monitored while in hospital and in the community if they go home before their baby is born.

Source guidance

Hypertension in pregnancy: diagnosis and management (2019) NICE guideline NG133, recommendations 1.5.2 and 1.5.5

Definitions of terms used in this quality statement

Pre-eclampsia
New hypertension (over 140 mmHg systolic or over 90 mmHg diastolic) presenting after 20 weeks of pregnancy and the coexistence of 1 or more of the following new-onset conditions:
  • Proteinuria (urine protein:creatinine ratio of 30 mg/mmol or more, or albumin:creatinine ratio of 8 mg/mmol or more, or at least 1 g/litre [2+] on dipstick testing) or
  • other maternal organ dysfunction:
    • renal insufficiency (creatinine 90 micromol/litre or more, 1.02 mg/100ml or more)
    • liver involvement (elevated transaminases [alanine aminotransferase or aspartate aminotransferase over 40 IU/litre] with or without right upper quadrant or epigastric abdominal pain)
    • neurological complications such as eclampsia, altered mental status, blindness, stroke, clonus, severe headaches or persistent visual scotomata
    • haematological complications such as thrombocytopenia (platelet count below 150,000/microlitre), disseminated intravascular coagulation or haemolysis
  • uteroplacental dysfunction such as fetal growth restriction, abnormal umbilical artery Doppler waveform analysis, or stillbirth.
[NICE’s guideline on hypertension in pregnancy, terms used in this guideline]
Severe hypertension
Blood pressure over 160 mmHg systolic or over 110 mmHg diastolic,
[NICE’s guideline on hypertension in pregnancy, terms used in this guideline]
High risk of adverse events
High risk of adverse events suggested by the fullPIERS or PREP-S risk prediction models.
[NICE’s guideline on hypertension in pregnancy, recommendation 1.5.5, table 2]
Clinical concerns
Concerns for the wellbeing of the woman or baby that could include any of the following:
  • sustained systolic blood pressure of 160 mmHg or higher
  • any maternal biochemical or haematological investigations that cause concern, for example, a new and persistent:
    • rise in creatinine (90 micromol/litre or more, 1 mg/100 ml or more) or
    • rise in alanine transaminase (over 70 IU/litre, or twice upper limit of normal range) or
    • fall in platelet count (under 150,000/microlitre)
  • signs of impending eclampsia
  • signs of impending pulmonary oedema
  • other signs of severe pre-eclampsia
  • suspected fetal compromise
  • any other clinical signs that cause concern.
[NICE’s guideline on hypertension in pregnancy, recommendation 1.5.2]
Admitted to hospital and monitored
Monitoring should include blood pressure measurements, proteinuria testing, blood tests and fetal assessments in accordance with those set out in the NICE guideline on hypertension in pregnancy.
[NICE’s guideline on hypertension in pregnancy, recommendation 1.5.5, table 2]

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 a senior obstetrician involved in any decisions about the timing 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 senior obstetrician should be involved in any decisions about the timing of birth.

Quality measures

Structure
Evidence of local arrangements to ensure that women with pre-eclampsia have a senior obstetrician involved in decisions about the timing of birth.
Data source: Local data collection.
Process
Proportion of women with pre-eclampsia who have given birth who had a senior obstetrician involved in decisions about the timing of birth.
Numerator – the number of women in the denominator who had a senior obstetrician involved in decisions about the timing of birth.
Denominator – the number of women who have given birth who had pre-eclampsia.
Data source: Local data collection, for example, an audit of patient maternity notes.
Outcome
a) Number of maternal deaths of women with pre-eclampsia.
Data source: Local data collection.
b) Number of fetal deaths for women with pre-eclampsia.
Data source: Local data collection.
c) Number of admissions of women with pre-eclampsia to intensive care units (ICU).
Data source: Local data collection.
d) 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 different audiences

Service providers ensure that there are local arrangements in place for women with pre-eclampsia to have a senior obstetrician involved in decisions about the timing of birth.
Healthcare practitioners ensure that women with pre-eclampsia have a senior obstetrician involved in decisions about the timing of birth.
Commissioners ensure they commission services that assign a senior obstetrician to women with pre-eclampsia.
Women with pre-eclampsia (a pregnancy-related rise in blood pressure with protein in the urine that happens in some pregnancies) have a senior specialist (called an obstetrician) involved in decisions about the timing of birth.

Source guidance

Hypertension in pregnancy: diagnosis and management (2019) NICE guideline NG133, recommendation 1.5.8

Definitions of terms used in this quality statement

Pre-eclampsia
New hypertension (over 140 mmHg systolic or over 90 mmHg diastolic) presenting after 20 weeks of pregnancy and the coexistence of 1 or more of the following new-onset conditions:
  • Proteinuria (urine protein:creatinine ratio of 30 mg/mmol or more, or albumin:creatinine ratio of 8 mg/mmol or more, or at least 1 g/litre [2+] on dipstick testing) or
  • other maternal organ dysfunction:
    • renal insufficiency (creatinine 90 micromol/litre or more, 1.02 mg/100ml or more)
    • liver involvement (elevated transaminases [alanine aminotransferase or aspartate aminotransferase over 40 IU/litre] with or without right upper quadrant or epigastric abdominal pain)
    • neurological complications such as eclampsia, altered mental status, blindness, stroke, clonus, severe headaches or persistent visual scotomata
    • haematological complications such as thrombocytopenia (platelet count below 150,000/microlitre), disseminated intravascular coagulation or haemolysis
  • uteroplacental dysfunction such as fetal growth restriction, abnormal umbilical artery Doppler waveform analysis, or stillbirth.
[NICE’s guideline on hypertension in pregnancy, terms used in this guideline]
Timing of birth
For indications for timing of birth, see NICE’s guideline on hypertension in pregnancy, recommendations 1.5.7 to 1.5.12.
Severe pre-eclampsia
Pre-eclampsia with severe hypertension that does not respond to treatment or is associated with ongoing or recurrent severe headaches, visual scotomata, nausea or vomiting, epigastric pain, oliguria and severe hypertension, as well as progressive deterioration in laboratory blood tests such as rising creatinine or liver transaminases or falling platelet count, or failure of fetal growth or abnormal Doppler findings.
[NICE’s guideline on hypertension in pregnancy, terms used in this guideline]

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 different audiences

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 practitioners 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.
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

Hypertension in pregnancy: diagnosis and management (2019) NICE guideline NG133, recommendations 1.3.20, 1.4.14, 1.5.20 and 1.10.2

Definitions of terms used in this quality statement

A plan for ongoing antihypertensive management
This should include information about postpartum management, including a plan for ongoing management. 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
  • self-monitoring for symptoms.
[NICE’s guideline on hypertension in pregnancy, recommendation 1.5.20]
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 of pregnancy and the coexistence of 1 or more of the following new-onset conditions:
  • proteinuria (urine protein:creatinine ratio of 30 mg/mmol or more, or albumin:creatinine ratio of 8 mg/mmol or more, or at least 1 g/litre [2+] on dipstick testing) or
  • other maternal organ dysfunction:
    • renal insufficiency (creatinine 90 micromol/litre or more, 1.02 mg/100ml or more)
    • liver involvement (elevated transaminases [alanine aminotransferase or aspartate aminotransferase over 40 IU/litre] with or without right upper quadrant or epigastric abdominal pain)
    • neurological complications such as eclampsia, altered mental status, blindness, stroke, clonus, severe headaches or persistent visual scotomata
    • haematological complications such as thrombocytopenia (platelet count below 150,000/microlitre), disseminated intravascular coagulation or haemolysis
  • Uteroplacental dysfunction such as fetal growth restriction, abnormal umbilical artery Doppler waveform analysis, or stillbirth.
[NICE’s guideline on hypertension in pregnancy, terms used in this guideline]

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 all 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 different audiences

Service providers ensure that local arrangements are in place for all 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 practitioners discuss future related risks with all 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 all women who have had gestational hypertension or pre-eclampsia during the medical review at their 6–8 week postnatal medical check.
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 GP or specialist 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

Hypertension in pregnancy: diagnosis and management (2019) NICE guideline NG133, recommendations 1.4.16, 1.5.22, 1.10.1 and 1.10.2

Definitions of terms used in this quality statement

Future pregnancy and lifetime cardiovascular risk
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.
Women who have had gestational hypertension should be told that the risk of developing:
  • gestational hypertension in a future pregnancy is approximately 1 in 7 (between 11% and 15%)
  • pre-eclampsia in a future pregnancy is approximately 1 in 14 (7%).
Women who have had pre-eclampsia should be told that the risk of developing:
  • gestational hypertension in a future pregnancy is up to 1 in 8 (between 6% and 12%)
  • pre-eclampsia in a future pregnancy is up to about 1 in 6 (16%)
  • pre-eclampsia in a future pregnancy is about 1 in 3 (33%) if their pre-eclampsia led to birth between 28 and 34 weeks.
[NICE’s guideline on hypertension in pregnancy, recommendation 1.10.1 (table 5)]
Gestational hypertension
New hypertension presenting after 20 weeks of pregnancy without significant proteinuria.
[NICE’s guideline on hypertension in pregnancy, terms used in this guideline]
Medical review
Women who have had gestational hypertension or pre-eclampsia should be offered a medical review by a GP or specialist at their postnatal check, which takes place 6–8 weeks after birth.
[NICE’s guideline on hypertension in pregnancy, recommendation 1.5.22]
Pre-eclampsia
New hypertension (over 140 mmHg systolic or over 90 mmHg diastolic) presenting after 20 weeks of pregnancy and the coexistence of 1 or more of the following new-onset conditions:
  • proteinuria (urine protein:creatinine ratio of 30 mg/mmol or more, or albumin:creatinine ratio of 8 mg/mmol or more, or at least 1 g/litre [2+] on dipstick testing) or
  • other maternal organ dysfunction:
    • renal insufficiency (creatinine 90 micromol/litre or more, 1.02 mg/100ml or more)
    • liver involvement (elevated transaminases [alanine aminotransferase or aspartate aminotransferase over 40 IU/litre] with or without right upper quadrant or epigastric abdominal pain)
    • neurological complications such as eclampsia, altered mental status, blindness, stroke, clonus, severe headaches or persistent visual scotomata
    • haematological complications such as thrombocytopenia (platelet count below 150,000/microlitre), disseminated intravascular coagulation or haemolysis
  • uteroplacental dysfunction such as fetal growth restriction, abnormal umbilical artery Doppler waveform analysis, or stillbirth.
[NICE’s guideline on hypertension in pregnancy, terms used in this guideline]

Equality and diversity considerations

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.

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

Management of pregnancy with gestational hypertension

Degree of hypertension
Hypertension: blood pressure of 140/90–159/109 mmHg
Severe hypertension: blood pressure of 160/110 mmHg or more
Admission to hospital
Do not routinely admit to hospital
Admit, but if BP falls below 160/110 mmHg then manage as for hypertension
Antihypertensive pharmacological treatment
Offer pharmacological treatment if BP remains above 140/90 mmHg
Offer pharmacological treatment to all women
Target blood pressure once on antihypertensive treatment
Aim for BP of 135/85 mmHg or less
Aim for BP of 135/85 mmHg or less
Blood pressure measurement
Once or twice a week (depending on BP) until BP is 135/85 mmHg or less
Every 15–30 minutes until BP is less than 160/110 mmHg
Dipstick proteinuria testinga
Once or twice a week (with BP measurement)
Daily while admitted
Blood tests
Measure full blood count, liver function and renal function at presentation and then weekly
Measure full blood count, liver function and renal function at presentation and then weekly
PIGF-based testing
Carry out PlGF-based testing on 1 occasion (in accordance with NICE's recommendations, see recommendation on PIGF-based testing after this table) if there is suspicion of pre-eclampsia
Carry out PlGF-based testing on 1 occasion (in accordance with NICE's recommendations on PIGF-based testing) if there is suspicion of pre-eclampsia
Fetal assessment
Offer fetal heart auscultation at every antenatal appointment
Carry out ultrasound assessment of the fetus at diagnosis and, if normal, repeat every 2 to 4 weeks, if clinically indicated
Carry out a CTG only if clinically indicated
Offer fetal heart auscultation at every antenatal appointment
Carry out ultrasound assessment of the fetus at diagnosis and, if normal, repeat every 2 weeks, if severe hypertension persists
Carry out a CTG at diagnosis and then only if clinically indicated.
a Use an automated reagent-strip reading device for dipstick screening for proteinuria in a secondary care setting.

Management of pregnancy with pre-eclampsia

Degree of hypertension
Hypertension: blood pressure of 140/90–159/109 mmHg
Severe hypertension: blood pressure of 160/110 mmHg or more
Admission to hospital
Admit if any clinical concerns for the wellbeing of the woman or baby or if high risk of adverse events suggested by the fullPIERS or PREP-S risk prediction models
Admit, but if BP falls below 160/110 mmHg then manage as for hypertension
Antihypertensive pharmacological treatment
Offer pharmacological treatment if BP remains above 140/90 mmHg
Offer pharmacological treatment to all women
Target blood pressure once on antihypertensive treatment
Aim for BP of 135/85 mmHg or less
Aim for BP of 135/85 mmHg or less
Blood pressure measurement
At least every 48 hours, and more frequently if the woman is admitted to hospital
Every 15-30 minutes until BP is less than 160/110 mmHg, then at least 4 times daily while the woman is an inpatient, depending on clinical circumstances
Dipstick proteinuria testinga
Only repeat if clinically indicated, for example if new symptoms and signs develop or if there is uncertainty over diagnosis
Only repeat if clinically indicated, for example if new symptoms and signs develop or if there is uncertainty over diagnosis
Blood tests
Measure full blood count, liver function and renal function twice a week
Measure full blood count, liver function and renal function 3 times a week
Fetal assessment
Offer fetal heart auscultation at every antenatal appointment
Carry out ultrasound assessment of the fetus at diagnosis and, if normal, repeat every 2 weeks
Carry out a CTG at diagnosis and then only if clinically indicated
Offer fetal heart auscultation at every antenatal appointment
Carry out ultrasound assessment of the fetus at diagnosis and, if normal, repeat every 2 weeks
Carry out a CTG at diagnosis and then only if clinically indicated
a Use an automated reagent-strip reading device for dipstick screening for proteinuria in a secondary care setting.
Give advice and treatment to women with hypertensive disorders of pregnancy in line with NICE's recommendations on intrapartum care, unless there are recommendations in this interactive flowchart on the same topic. Offer care in accordance with NICE's recommendations on intrapartum care for women with hypertension whether treated or untreated, and not just on the basis of blood pressure in labour.

Blood pressure

During labour, measure blood pressure:
  • hourly, in women with hypertension
  • every 15-30 minutes until blood pressure is less than 160/110 mmHg 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 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 or 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 controlled hypertension.
Consider operative or assisted birth in the second stage of labour for women with severe hypertension whose hypertension has not responded to initial treatment.
Interpret proteinuria measurements for pregnant women in the context of a full clinical review of symptoms, signs and other investigations for pre-eclampsia.
Use an automated reagent-strip reading device for dipstick screening for proteinuria in pregnant women in secondary care settings.
If dipstick screening is positive (1+ or more) use albumin:creatinine ratio or protein:creatinine ratio to quantify proteinuria in pregnant women.
Do not use first morning urine void to quantify proteinuria in pregnant women.
Do not routinely use 24-hour urine collection to quantify proteinuria in pregnant women.
If using protein:creatinine ratio to quantify proteinuria in pregnant women:
  • use 30 mg/mmol as a threshold for significant proteinuria
  • if the result is 30 mg/mmol or above and there is still uncertainty about the diagnosis of pre-eclampsia, consider re-testing on a new sample, alongside clinical review.
If using albumin:creatinine ratio as an alternative to protein:creatinine ratio to diagnose pre-eclampsia in pregnant women with hypertension:
  • use 8 mg/mmol as a diagnostic threshold
  • if the result is 8 mg/mmol or above and there is still uncertainty about the diagnosis of pre-eclampsia, consider re-testing on a new sample, alongside clinical review.
Carry out cardiotocography at diagnosis of pre-eclampsia or severe gestational hypertension.
If conservative management of pre-eclampsia or severe gestational hypertension is planned, carry out all the following tests at diagnosis:
  • ultrasound for fetal growth and amniotic fluid volume assessment
  • umbilical artery doppler velocimetry.
If the results of all fetal monitoring are normal in women with pre-eclampsia or severe gestational hypertension, do not routinely repeat cardiotocography unless clinically indicated.
In women with pre-eclampsia or severe gestational hypertension, 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 pre-eclampsia or severe gestational hypertension, repeat ultrasound for fetal growth and amniotic fluid volume assessment or umbilical artery doppler velocimetry every 2 weeks, with subsequent surveillance and monitoring determined by the findings of these scans.
For women with pre-eclampsia or severe gestational hypertension, 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 antenatal corticosteroids should be given
  • plans for discussion with neonatal paediatricians and obstetric anaesthetists.
Offer pregnant women with chronic hypertension advice on:
  • weight management
  • exercise
  • healthy eating
  • lowering the amount of salt in their diet
Provide this advice in line with NICE's recommendations on hypertension in adults: diagnosis and treatment.

Pre-eclampsia

New onset of hypertension (over 140 mmHg systolic or over 90 mmHg diastolic) after 20 weeks of pregnancy and the coexistence of 1 or more of the following new-onset conditions:
  • proteinuria (urine protein:creatinine ratio over 30 mg/mmol or more, or albumin:creatinine ratio of 8 mg/mmol or more, or at least 1 g/litre [2+] on dipstick testing) or
  • other maternal organ dysfunction:
    • renal insufficiency (creatinine 90 micromol/litre or more, 1.02 mg/100 ml or more)
    • liver involvement (elevated transaminases [ALT or AST over 40 IU/litre] with or without right upper quadrant or epigastric abdominal pain)
    • neurological complications such as eclampsia, altered mental status, blindness, stroke, clonus, severe headaches or persistent visual scotomata
    • haematological complications such as thrombocytopenia (platelet count below 150,000/microlitre), disseminated intravascular coagulation or haemolysis
  • uteroplacental dysfunction such as fetal growth restriction, abnormal umbilical artery doppler waveform analysis, or stillbirth.

Severe pre-eclampsia

Pre-eclampsia with severe hypertension that does not respond to treatment or is associated with ongoing or recurring severe headaches, visual scotomata, nausea or vomiting, epigastric pain, oliguria and severe hypertension as well as progressive deterioration in laboratory blood tests such as rising creatinine or liver transaminases or falling platelet count, or failure of fetal growth or abnormal doppler findings.
Carry out an ultrasound for fetal growth and amniotic fluid volume assessment and umbilical artery doppler velocimetry starting at between 28 and 30 weeks (or at least 2 weeks before previous gestational age of onset if earlier than 28 weeks) and repeating 4 weeks later in women with previous:
  • severe pre-eclampsia
  • pre-eclampsia that resulted in birth before 34 weeks
  • pre-eclampsia with a baby whose birth weight was less than the 10th centile
  • intrauterine death
  • placental abruption.
In women who need additional fetal monitoring, carry out cardiotocography only if clinically indicated.
Advise women with hypertension who wish to breastfeed that their treatment can be adapted to accommodate breastfeeding, and that the need to take antihypertensive medication does not prevent them from breastfeeding.
Explain to women with hypertension who wish to breastfeed that:
  • antihypertensive medicines can pass into breast milk
  • most antihypertensive medicines taken while breastfeeding only lead to very low levels in breast milk, so the amounts taken in by babies are very small and would be unlikely to have any clinical effect
  • most medicines are not tested in pregnant or breastfeeding women, so disclaimers in the manufacturer's information are not because of any specific safety concerns or evidence of harm.
Make decisions on treatment together with the woman, based on her preferences.
As antihypertensive agents have the potential to transfer into breast milk:
  • consider monitoring the blood pressure of babies, especially those born preterm, who have symptoms of low blood pressure for the first few weeks
  • when discharged home, advise women to monitor their babies for drowsiness, lethargy, pallor, cold peripheries or poor feeding.
Offer enalaprilIn 2009, the MHRA issued a drug safety update on ACE inhibitors and angiotensin II receptor antagonists: recommendations on how to use during breastfeeding, and a subsequent clarification was issued in 2014. This clarification states: 'although ACE inhibitors and angiotensin II receptor antagonists are generally not recommended for use by breastfeeding mothers, they are not absolutely contraindicated. Healthcare professionals may prescribe these medicines during breastfeeding if they consider that this treatment is essential for the lactating mother. In mothers who are breastfeeding older infants, the use of captopril, enalapril, or quinapril may be considered if an ACE inhibitor is necessary for the mother. Careful follow-up of the infant for possible signs of hypotension is recommended'. to treat hypertension in women during the postnatal period, with appropriate monitoring of maternal renal function and maternal serum potassium.
For women of black African or Caribbean family origin with hypertension during the postnatal period, consider antihypertensive treatment with:
  • nifedipineAt the time of publication (June 2019), some brands of nifedipine were specifically contraindicated during breastfeeding by the manufacturers in their summary of product characteristics. Refer to the individual summaries of product characteristics for each preparation of nifedipine for further details. or
  • amlodipine if the woman has previously used this to successfully control her blood pressure.
For women with hypertension in the postnatal period, if blood pressure is not controlled with a single medicine consider a combination of nifedipine (or amlodipine) and enalapril. If this combination is not tolerated or is ineffective, consider either:
  • adding atenolol or labetalol to the combination treatment or
  • swapping 1 of the medicines already being used for atenolol or labetalol.
When treating women with antihypertensive medication during the postnatal period, use medicines that are taken once daily when possible.
Where possible, avoid using diuretics or angiotensin receptor blockers to treat hypertension in women in the postnatal period who are breastfeeding or expressing milk.
Treat women with hypertension in the postnatal period who are not breastfeeding and who are not planning to breastfeed in line with NICE's recommendations on hypertension in adults.

Cardiovascular risk in women who have had a hypertensive disorder of pregnancy

Type of hypertension in current or previous pregnancy
Risk of future cardiovascular diseasea,b
Any hypertension in pregnancy
Pre-eclampsia
Gestational hypertension
Chronic hypertension
Major adverse cardiovascular event
Risk increased
(up to approximately 2 times)
Risk increased
(approximately 1.5–3 times)
Risk increased
(approximately 1.5–3 times)
Risk increased
(approximately 1.7 times)
Cardiovascular mortality
Risk increased
(up to approximately 2 times)
Risk increased
(approximately 2 times)
(no data)
(no data)
Stroke
Risk increased
(up to approximately 1.5 times)
Risk increased
(approximately 2–3 times)
Risk may be increased
Risk increased
(approximately 1.8 times)
Hypertension
Risk increased
(approximately 2–4 times)
Risk increased
(approximately 2–5 times)
Risk increased
(approximately 2–4 times)
(not applicable)
a Risks described are overall estimates, summarised from risk ratios, odds ratios and hazard ratios.
b Increased risk is compared to the background risk in women who did not have hypertensive disorders during pregnancy. Absolute risks are not reported, because these will vary considerably, depending on the follow-up time (range from 1 to 40 years postpartum).

Likelihood of recurrence of hypertensive disorders of pregnancy

Type of hypertension in previous or current pregnancy
Prevalence of hypertensive disorder in a future pregnancy
Any hypertension in pregnancy
Pre-eclampsia
Gestational hypertension
Any hypertension
Approximately 21%
(1 in 5 women)
Approximately 20%
(1 in 5 women)
Approximately 22%
(1 in 5 women)
Pre-eclampsia
Approximately 14%
(1 in 7 women)
Up to approximately 16%
(1 in 6 women)
If birth was at 28–34 weeksa: approximately 33%
(1 in 3 women)
If birth was at 34–37 weeks: approximately 23%
(1 in 4 women)
Approximately 7%
(1 in 14 women)
Gestational hypertension
Approximately 9%
(1 in 11 women)
Between approximately 6 and12%
(up to 1 in 8 women)
Between approximately 11 and 15%
(up to 1 in 7 women)
Chronic hypertension
Not applicable
Approximately 2%
(up to 1 in 50 women)
Approximately 3%
(up to 1 in 34 women)
a No evidence was identified for women who gave birth at less than 28 weeks, but the committee agreed that the risk was likely to be at least as high, if not higher, than that for women who gave birth between 28 and 34 weeks.

Glossary

angiotensin-converting enzyme inhibitors
alanine aminotransferase
angiotensin II receptor blockers
aspartate aminotransferase
blood pressure
(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)
cardiotocography
(a convulsive condition associated with pre-eclampsia)
(new hypertension presenting after 20 weeks of pregnancy without significant proteinuria)
(haemolysis, elevated liver enzymes and low platelet count)
(blood pressure of 140 mmHg systolic or higher, or 90 mmHg diastolic or higher)
(a pregnancy with more than 1 baby, such as twins, triplets)
placental growth factor
(blood pressure over 160 mmHg systolic or over 110 mmHg diastolic)

Paths in this pathway

Pathway created: August 2013 Last updated: July 2019

© NICE 2019. All rights reserved. Subject to Notice of rights.

Recently viewed