Hypertension in pregnancy: diagnosis and management

1.1 Reducing the risk of hypertensive disorders in pregnancy

Symptoms of pre-eclampsia

1.1.1 Advise pregnant women to see a healthcare professional immediately if they experience symptoms of pre-eclampsia. Symptoms include:

• severe headache
• problems with vision, such as blurring or flashing before the eyes
• severe pain just below the ribs
• vomiting
• sudden swelling of the face, hands or feet.

See the NICE guideline on antenatal care for advice on risk factors and symptoms of pre-eclampsia. [2010, amended 2019]

Antiplatelet agents

1.1.2 Advise pregnant women at high risk of pre-eclampsia to take 75–150 mg of aspirin^[A] daily from 12 weeks until the birth of the baby. Women at high risk are those with any of the following:

• hypertensive disease during a previous pregnancy
• chronic kidney disease
• autoimmune disease such as systemic lupus erythematosus or antiphospholipid syndrome
• type 1 or type 2 diabetes
• chronic hypertension. [2010, amended 2019]

1.1.3 Advise pregnant women with more than 1 moderate risk factor for pre-eclampsia to take 75–⁠150 mg of aspirin^[A] daily from 12 weeks until the birth of the baby. Factors indicating moderate risk are:

• 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. [2010, amended 2019]

Other pharmaceutical agents

1.1.4 Do not use the following to prevent hypertensive disorders during pregnancy:

• nitric oxide donors
• progesterone
• diuretics
• low molecular weight heparin. [2010]

Nutritional supplements

1.1.5 Do not recommend the following supplements solely with the aim of preventing hypertensive disorders during pregnancy:

• magnesium
• folic acid
• antioxidants (vitamins C and E)
• fish oils or algal oils
• garlic. [2010]

Diet

1.1.6 Do not recommend salt restriction during pregnancy solely to prevent gestational hypertension or pre-eclampsia. [2010]

Lifestyle

1.1.7 Give the same advice on rest, exercise and work to women with chronic hypertension or at risk of hypertensive disorders during pregnancy as healthy pregnant women. See the NICE guideline on antenatal care. [2010, amended 2019]

Diabetes

1.1.8 For women with pre-existing diabetes or gestational diabetes, see the NICE guideline on diabetes in pregnancy. [2019]

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1.2 Assessment of proteinuria in hypertensive disorders of pregnancy

1.2.1 Interpret proteinuria measurements for pregnant women in the context of a full clinical review of symptoms, signs and other investigations for pre-eclampsia. [2019]

1.2.2 Use an automated reagent-strip reading device for dipstick screening for proteinuria in pregnant women in secondary care settings. [2019]

1.2.3 If dipstick screening is positive (1+ or more), use albumin:creatinine ratio or protein:creatinine ratio to quantify proteinuria in pregnant women. [2019]

1.2.4 Do not use first morning urine void to quantify proteinuria in pregnant women. [2019]

1.2.5 Do not routinely use 24-hour urine collection to quantify proteinuria in pregnant women. [2019]

1.2.6 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. [2019]

1.2.7 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. [2019]

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1.3 Management of chronic hypertension in pregnancy

Pre-pregnancy advice

1.3.1 Offer women with chronic hypertension referral to a specialist in hypertensive disorders of pregnancy to discuss the risks and benefits of treatment. [2010, amended 2019]

1.3.2 Advise women who take angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers^[B] (ARBs):

• that there is an increased risk of congenital abnormalities if these drugs are taken during pregnancy
• to discuss alternative antihypertensive treatment with the healthcare professional responsible for managing their hypertension, if they are planning pregnancy
• to discuss alternative treatment with the healthcare professional responsible for managing their condition, if ACE inhibitors or ARBs are being taken for other conditions such as renal disease. [2010, amended 2019]

1.3.3 Stop antihypertensive treatment in women taking ACE inhibitors or ARBs if they become pregnant (preferably within 2 working days of notification of pregnancy) and offer alternatives. [2010]

1.3.4 Advise women who take thiazide or thiazide-like diuretics: 

• that there may be an increased risk of congenital abnormalities and neonatal complications if these drugs are taken during pregnancy
• to discuss alternative antihypertensive treatment with the healthcare professional responsible for managing their hypertension, if they are planning pregnancy. [2010, amended 2019]

1.3.5 Advise women who take antihypertensive treatments other than ACE inhibitors, ARBs, thiazide or thiazide-like diuretics that the limited evidence available has not shown an increased risk of congenital malformation with such treatments. [2010, amended 2019]

Treatment of chronic hypertension

1.3.6 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 the NICE guideline on hypertension in adults: diagnosis and treatment.[2019]

1.3.7 Continue with existing antihypertensive treatment if safe in pregnancy, or switch to an alternative treatment, unless:

• sustained systolic blood pressure is less than 110 mmHg or
• sustained diastolic blood pressure is less than 70 mmHg or
• the woman has symptomatic hypotension. [2019]

1.3.8 Offer antihypertensive treatment to pregnant women who have chronic hypertension and who are not already on treatment if they have:

• sustained systolic blood pressure of 140 mmHg or higher or
• sustained diastolic blood pressure of 90 mmHg or higher. [2019]

1.3.9 When using medicines to treat hypertension in pregnancy, aim for a target blood pressure of 135/85 mmHg. [2019]

1.3.10 Consider labetalol to treat chronic hypertension in pregnant women. Consider nifedipine^[C] for women in whom labetalol is not suitable, or methyldopa if both labetalol and nifedipine^[C] are not suitable. Base the choice on any pre-existing treatment, side-effect profiles, risks (including fetal effects) and the woman’s preference. [2019]

1.3.11 Offer pregnant women with chronic hypertension aspirin^[A] 75–150 mg once daily from 12 weeks. [2019]

1.3.12 Offer placental growth factor (PIGF)-based testing to help rule out pre-eclampsia between 20 weeks and up to 35 weeks of pregnancy, if women with chronic hypertension are suspected of developing pre-eclampsia. (See the NICE diagnostics guidance on PIGF-based testing to help diagnose suspected pre-eclampsia). [2019]

Antenatal appointments

1.3.13 In women with chronic hypertension, schedule additional antenatal appointments based on the individual needs of the woman and her baby. This may include:

• weekly appointments if hypertension is poorly controlled
• appointments every 2 to 4 weeks if hypertension is well-controlled. [2010, amended 2019]

Timing of birth

1.3.14 Do not offer planned early birth before 37 weeks to women with chronic hypertension whose blood pressure is lower than 160/110 mmHg, with or without antihypertensive treatment, unless there are other medical indications. [2010, amended 2019]

1.3.15 For women with chronic hypertension whose blood pressure is lower than 160/110 mmHg after 37 weeks, with or without antihypertensive treatment, timing of birth and maternal and fetal indications for birth should be agreed between the woman and the senior obstetrician. [2010]

1.3.16 If planned early birth is necessary (see recommendation 1.5.7), offer a course of antenatal corticosteroids and magnesium sulfate if indicated, in line with the NICE guideline on preterm labour and birth.[2010, amended 2019]

Postnatal investigation, monitoring and treatment

1.3.17 In women with chronic hypertension who have given birth, measure blood pressure:

• daily for the first 2 days after birth
• at least once between day 3 and day 5 after birth
• as clinically indicated if antihypertensive treatment is changed after birth. [2010]

1.3.18 In women with chronic hypertension who have given birth:

• aim to keep blood pressure lower than 140/90 mmHg
• continue antihypertensive treatment, if required (see section 1.9 for choice of antihypertensive during the postnatal period)
• offer a review of antihypertensive treatment 2 weeks after the birth, with their GP or specialist. [2010, amended 2019]

1.3.19 If a woman has taken methyldopa to treat chronic hypertension during pregnancy, stop within 2 days after the birth and change to an alternative antihypertensive treatment (see section 1.9 for choice of antihypertensive during the postnatal period). [2010, amended 2019]

1.3.20 Offer women with chronic hypertension a medical review 6–8 weeks after the birth with their GP or specialist as appropriate. [2010, amended 2019]

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1.4 Management of gestational hypertension

Assessment and treatment of gestational hypertension

1.4.1 In women with gestational hypertension, a full assessment should be carried out in a secondary care setting by a healthcare professional who is trained in the management of hypertensive disorders of pregnancy. [2010, amended 2019]

1.4.2 In women with gestational hypertension, take account of the following risk factors that require additional assessment and follow-up:

• nulliparity
• age 40 years or older
• pregnancy interval of more than 10 years
• family history of pre-eclampsia
• multi-fetal pregnancy
• BMI of 35 kg/m² or more
• gestational age at presentation
• previous history of pre-eclampsia or gestational hypertension
• pre-existing vascular disease
• pre-existing kidney disease. [2010]

1.4.3 Offer women with gestational hypertension the tests and treatment listed in table 1. [2019]

Table 1: 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 testing[A]	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 PIGF-based testing on 1 occasion (in accordance with NICE guidance, see recommendation 1.4.4) if there is suspicion of pre‑eclampsia	Carry out PIGF-based testing on 1 occasion (in accordance with NICE guidance, see recommendation 1.4.4) 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 (See section 1.6 for advice on fetal monitoring)	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 (See section 1.6 for advice on fetal monitoring)
[A] Use an automated reagent-strip reading device for dipstick screening for proteinuria in a secondary care setting. Abbreviations: BP=blood pressure; CTG=cardiotocography; PIGF=placental growth factor.

1.4.4 Offer placental growth factor (PIGF)-based testing to help rule out pre-eclampsia in women presenting with suspected pre-eclampsia (for example, with gestational hypertension) between 20 weeks and up to 35 weeks of pregnancy. (See the NICE diagnostics guidance on PIGF-based testing to help diagnose suspected pre-eclampsia.) [2019]

1.4.5 Consider labetalol to treat gestational hypertension. Consider nifedipine^[C] for women in whom labetalol is not suitable, and methyldopa if labetalol or nifedipine^[C] are not suitable. Base the choice on side-effect profiles, risk (including fetal effects) and the woman’s preferences. [2010, amended 2019]

1.4.6 Do not offer bed rest in hospital as a treatment for gestational hypertension. [2010]

Timing of birth

1.4.7 Do not offer planned early birth before 37 weeks to women with gestational hypertension whose blood pressure is lower than 160/110 mmHg, unless there are other medical indications. [2010, amended 2019]

1.4.8 For women with gestational hypertension whose blood pressure is lower than 160/110 mmHg after 37 weeks, timing of birth, and maternal and fetal indications for birth should be agreed between the woman and the senior obstetrician. [2010, amended 2019]

1.4.9 If planned early birth is necessary (see recommendation 1.5.7), offer a course of antenatal corticosteroids and magnesium sulfate if indicated, in line with the NICE guideline on preterm labour and birth. [2010, amended 2019]

Postnatal investigation, monitoring and treatment

1.4.10 In women with gestational hypertension who have given birth, measure blood pressure:

• daily for the first 2 days after birth
• at least once between day 3 and day 5 after birth
• as clinically indicated if antihypertensive treatment is changed after birth. [2010]

1.4.11 In women with gestational hypertension who have given birth: 

• continue antihypertensive treatment if required (see section 1.9 for choice of antihypertensive during the postnatal period)
• advise women that the duration of their postnatal antihypertensive treatment will usually be similar to the duration of their antenatal treatment (but may be longer)
• reduce antihypertensive treatment if their blood pressure falls below 130/80 mmHg. [2010, amended 2019]

1.4.12 If a woman has taken methyldopa to treat gestational hypertension, stop within 2 days after the birth and change to an alternative treatment if necessary (see section 1.9 for choice of antihypertensive during the postnatal period). [2010, amended 2019]

1.4.13 For women with gestational hypertension who did not take antihypertensive treatment and have given birth, start antihypertensive treatment if their blood pressure is 150/100 mmHg or higher. [2010, amended 2019]

1.4.14 Write a care plan for women with gestational hypertension 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. [2010]

1.4.15 Offer women who have had gestational hypertension and who remain on antihypertensive treatment, a medical review with their GP or specialist 2 weeks after transfer to community care. [2010, amended 2019]

1.4.16 Offer all women who have had gestational hypertension a medical review with their GP or specialist 6–8 weeks after the birth. [2010, amended 2019]

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1.5 Management of pre-eclampsia

Assessing pre-eclampsia

1.5.1 Assessment of women with pre-eclampsia should be performed by a healthcare professional trained in the management of hypertensive disorders of pregnancy. [2010, amended 2019]

1.5.2 Carry out a full clinical assessment at each antenatal appointment for women with pre‑eclampsia, and offer admission to hospital for surveillance and any interventions needed if there are concerns for the wellbeing of the woman or baby. Concerns 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. [2019]

1.5.3 Consider using either the fullPIERS or PREP-S validated risk prediction models to help guide decisions about the most appropriate place of care (such as the need for in utero transfer) and thresholds for intervention. [2019]

1.5.4 When using a risk prediction model, take into account that:

• fullPIERS is intended for use at any time during pregnancy
• PREP-S is intended for use only up to 34 weeks of pregnancy
• fullPIERS and PREP-S models do not predict outcomes for babies. [2019]

Treatment of pre-eclampsia

1.5.5 Offer women with pre-eclampsia the tests and treatments listed in table 2. [2019]

Table 2: 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 (see recommendation 1.5.2) 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 testing[a]	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 (See section 1.6 for advice on fetal monitoring)	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 (See section 1.6 for advice on fetal monitoring)
[a] Use an automated reagent-strip reading device for dipstick screening for proteinuria in a secondary care setting. Abbreviations: BP=blood pressure; CTG=cardiotocography.

1.5.6 Offer labetalol to treat hypertension in pregnant women with pre-eclampsia. Offer nifedipine^[C] for women in whom labetalol is not suitable, and methyldopa if labetalol or nifedipine^[C] are not suitable. Base the choice on any pre-existing treatment, side-effect profiles, risks (including fetal effects) and the woman’s preference. [2010, amended 2019]

Timing of birth

1.5.7 Record maternal and fetal thresholds for planned early birth before 37 weeks in women with pre-eclampsia. Thresholds for considering planned early birth could include (but are not limited to) any of the following known features of severe pre-eclampsia:

• inability to control maternal blood pressure despite using 3 or more classes of antihypertensives in appropriate doses
• maternal pulse oximetry less than 90%
• progressive deterioration in liver function, renal function, haemolysis, or platelet count
• ongoing neurological features, such as severe intractable headache, repeated visual scotomata, or eclampsia
• placental abruption
• reversed end-diastolic flow in the umbilical artery doppler velocimetry, a non-reassuring cardiotocograph, or stillbirth.

Other features not listed above may also be considered in the decision to plan early birth. [2019]

1.5.8 Involve a senior obstetrician in any decisions on timing of birth for women with pre-eclampsia. [2010, amended 2019]

1.5.9 Discuss with the anaesthetic team if birth is planned in a woman with pre-eclampsia. [2010, amended 2019]

1.5.10 Discuss with the neonatal team if birth is planned in a woman with pre-eclampsia, and neonatal complications are anticipated. [2010, amended 2019]

1.5.11 Offer intravenous magnesium sulfate and a course of antenatal corticosteroids if indicated, if early birth is planned for women with preterm pre-eclampsia, in line with the NICE guideline on preterm labour and birth. [2010, amended 2019]

1.5.12 Decide on timing of birth in women with pre-eclampsia as recommended in table 3. [2019]

Table 3: Timing of birth in woman with pre-eclampsia

Weeks of pregnancy	Timing of birth
Before 34 weeks	Continue surveillance unless there are indications (see recommendation 1.5.7) for planned early birth. Offer intravenous magnesium sulfate and a course of antenatal corticosteroids in line with the NICE guideline on preterm labour and birth.
From 34 to 36+6 weeks	Continue surveillance unless there are indications (see recommendation 1.5.7) for planned early birth. When considering the option of planned early birth, take into account the woman’s and baby’s condition, risk factors (such as maternal comorbidities, multifetal pregnancy) and availability of neonatal unit beds. Consider a course of antenatal corticosteroids in line with the NICE guideline on preterm labour and birth.
37 weeks onwards	Initiate birth within 24–48 hours.

Postnatal investigation, monitoring and treatment (including after discharge from critical care)

Blood pressure

1.5.13 In women with pre-eclampsia who did not take antihypertensive treatment and have given birth, measure blood pressure:

• at least 4 times a day while the woman is an inpatient
• at least once between day 3 and day 5 after birth
• on alternate days until normal, if blood pressure was abnormal on days 3–5. [2010]

1.5.14 In women with pre-eclampsia who did not take antihypertensive treatment and have given birth, start antihypertensive treatment if blood pressure is 150/100 mmHg or higher. [2010]

1.5.15 Ask women with pre-eclampsia who have given birth about severe headache and epigastric pain each time blood pressure is measured. [2010]

1.5.16 In women with pre-eclampsia who took antihypertensive treatment and have given birth, measure blood pressure:

• at least 4 times a day while the woman is an inpatient
• every 1–2 days for up to 2 weeks after transfer to community care until the woman is off treatment and has no hypertension. [2010]

1.5.17 For women with pre-eclampsia who have taken antihypertensive treatment and have given birth:

• continue antihypertensive treatment (see section 1.9 for choice of antihypertensive during the postnatal period)
• consider reducing antihypertensive treatment if their blood pressure falls below 140/90 mmHg
• reduce antihypertensive treatment if their blood pressure falls below 130/80 mmHg. [2010, amended 2019]

1.5.18 If a woman has taken methyldopa to treat pre-eclampsia, stop within 2 days after the birth and change to an alternative treatment if necessary (see section 1.9 for choice of antihypertensive during the postnatal period). [2010, amended 2019]

1.5.19 Offer women with pre-eclampsia who have given birth transfer to community care if all of the following criteria have been met:

• there are no symptoms of pre-eclampsia
• blood pressure, with or without treatment, is 150/100 mmHg or less
• blood test results are stable or improving. [2010, amended 2019]

1.5.20 Write a care plan for women with 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
• thresholds for reducing or stopping treatment
• indications for referral to primary care for blood pressure review
• self-monitoring for symptoms. [2010]

1.5.21 Offer women who have had pre-eclampsia and who remain on antihypertensive treatment, a medical review with their GP or specialist 2 weeks after transfer to community care. [2010, amended 2019]

1.5.22 Offer all women who have had pre-eclampsia a medical review with their GP or specialist 6–8 weeks after the birth. [2010, amended 2019]

Haematological and biochemical monitoring

1.5.23 In women who have pre-eclampsia with mild or moderate hypertension, or after step‑down from critical care:

• measure platelet count, transaminases and serum creatinine 48–72 hours after birth or step-down
• do not repeat platelet count, transaminases or serum creatinine measurements if results are normal at 48–72 hours. [2010]

1.5.24 If biochemical and haematological indices are outside the reference range in women with pre-eclampsia who have given birth, repeat platelet count, transaminases and serum creatinine measurements as clinically indicated until results return to normal. [2010, amended 2019]

1.5.25 In women with pre-eclampsia who have given birth, carry out a urinary reagent-strip test 6–8 weeks after the birth. [2010]

1.5.26 Offer women who had pre-eclampsia and still have proteinuria (1+ or more) at 6–8 weeks after the birth, a further review with their GP or specialist at 3 months after the birth to assess kidney function. [2010, amended 2019]

1.5.27 Consider referring women with an abnormal kidney function assessment at 3 months for a specialist kidney assessment in line with the NICE guideline on chronic kidney disease in adults. [2010, amended 2019]

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1.6 Fetal monitoring

Fetal monitoring in chronic hypertension

1.6.1 In women with chronic hypertension, carry out an ultrasound for fetal growth and amniotic fluid volume assessment, and umbilical artery doppler velocimetry at 28 weeks, 32 weeks and 36 weeks. [2010, amended 2019]

1.6.2 In women with chronic hypertension, only carry out cardiotocography if clinically indicated. [2010, amended 2019]

Fetal monitoring in gestational hypertension

1.6.3 In women with gestational hypertension, carry out an ultrasound for fetal growth and amniotic fluid volume assessment and umbilical artery doppler velocimetry at diagnosis and if normal repeat every 2 to 4 weeks, if clinically indicated. [2010, amended 2019]

1.6.4 In women with gestational hypertension, only carry out cardiotocography if clinically indicated. [2010, amended 2019]

Fetal monitoring in pre-eclampsia or severe gestational hypertension

1.6.5 Carry out cardiotocography at diagnosis of pre-eclampsia or severe gestational hypertension. [2010]

1.6.6 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. [2010]

1.6.7 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. [2010, amended 2019]

1.6.8 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. [2010]

1.6.9 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. [2010, amended 2019]

1.6.10 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. [2010, amended 2019]

Women who need additional fetal monitoring

1.6.11 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 10^th centile
• intrauterine death
• placental abruption. [2010]

1.6.12 In women who need additional fetal monitoring (see recommendation 1.6.11), carry out cardiotocography only if clinically indicated. [2010, amended 2019]

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1.9 Antihypertensive treatment during the postnatal period, including during breastfeeding

1.9.1 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. [2019]

1.9.2 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. [2019]

1.9.3 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. [2019]

1.9.4 Offer enalapril^[D] to treat hypertension in women during the postnatal period, with appropriate monitoring of maternal renal function and maternal serum potassium. [2019]

1.9.5 For women of black African or Caribbean family origin with hypertension during the postnatal period, consider antihypertensive treatment with:

• nifedipine^[C] or
• amlodipine if the woman has previously used this to successfully control her blood pressure. [2019]

1.9.6 For women with hypertension in the postnatal period, if blood pressure is not controlled with a single medicine, consider a combination of nifedipine^[C] (or amlodipine) and enalapril^[D]. 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. [2019]

1.9.7 When treating women with antihypertensive medication during the postnatal period, use medicines that are taken once daily when possible. [2019]

1.9.8 Where possible, avoid using diuretics or angiotensin receptor blockers^[D] to treat hypertension in women in the postnatal period who are breastfeeding or expressing milk. [2010, amended 2019]

1.9.9 Treat women with hypertension in the postnatal period who are not breastfeeding and who are not planning to breastfeed in line with the NICE guideline on hypertension in adults. [2019]

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1.10 Advice and follow-up at transfer to community care

Risk of recurrence of hypertensive disorders of pregnancy

1.10.1 Advise women with hypertensive disorders of pregnancy that the overall risk of recurrence in future pregnancies is approximately 1 in 5 (see Table 4). [2019]

Table 4: 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 weeks[a]: 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 and 12% (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.

Long-term risk of cardiovascular disease

1.10.2 Advise women who have had a hypertensive disorder of pregnancy that this is associated with an increased risk of hypertension and cardiovascular disease in later life (see Table 5). [2019]

Table 5: Cardiovascular risk in women who have had a hypertensive disorder of pregnancy

	Type of hypertension in current or previous pregnancy
Risk of future cardiovascular disease[a,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).

1.10.3 Advise women who have had a hypertensive disorder of pregnancy to discuss how to reduce their risk of cardiovascular disease, including hypertensive disorders, with their GP or specialist. This may include:

• avoiding smoking, as recommended in the NICE guideline on stop smoking interventions and services
• maintaining a healthy lifestyle, as recommended in the NICE guideline on cardiovascular disease
• maintaining a healthy weight, as recommended in the NICE guideline on obesity [2019]

1.10.4 In women who have had pre-eclampsia or hypertension with early birth before 34 weeks, consider pre-pregnancy counselling to discuss possible risks of recurrent hypertensive disorders of pregnancy, and how to lower them for any future pregnancies. [2019]

Body mass index and recurrence of hypertensive disorders of pregnancy

1.10.5 Advise women who have had pre-eclampsia to achieve and keep a BMI within the healthy range before their next pregnancy (18.5–24.9 kg/m²). See also the NICE guideline on obesity: identification, assessment and management. [2010, amended 2019]

Inter-pregnancy interval and recurrence of hypertensive disorders of pregnancy

1.10.6 Advise women who have had pre-eclampsia that the likelihood of recurrence increases with an inter-pregnancy interval greater than 10 years. [2010, amended 2019]

Long-term risk of end-stage kidney disease

1.10.7 Tell women with a history of pre-eclampsia who have no proteinuria and no hypertension at the postnatal review (6–8 weeks after the birth) that although the relative risk of end-stage kidney disease is increased, the absolute risk is low and no further follow-up is necessary. [2010]

Thrombophilia and the risk of pre-eclampsia

1.10.8 Do not routinely perform screening for thrombophilia in women who have had pre-eclampsia. [2010]

Terms used in this guideline

Chronic hypertension

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

Eclampsia

A convulsive condition associated with pre-eclampsia.

Gestational hypertension

New hypertension presenting after 20 weeks of pregnancy without significant proteinuria.

HELLP syndrome

Haemolysis, elevated liver enzymes and low platelet count.

Hypertension

Blood pressure of 140 mmHg systolic or higher, or 90 mmHg diastolic or higher. [2019]

Multi-fetal pregnancy

A pregnancy with more than 1 baby (such as twins, triplets).

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 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/100 ml 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.

Severe hypertension

Blood pressure over 160 mmHg systolic or over 110 mmHg diastolic.

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.

Footnotes

[A]  Although this use is common in UK clinical practice, at the time of publication (June 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.

[B] In 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’.

[C] At the time of publication (June 2019), some brands of nifedipine were specifically contraindicated during pregnancy by the manufacturer in its summary of product characteristics. Refer to the individual summaries of product characteristics for each preparation of nifedipine for further details.

[D] In 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’.