Hypertension in Pregnancy Diagnosis and Management PDF 66141717671365 PDF

Hypertension in pregnancy:
diagnosis and management
NICE guideline
Published: 25 June 2019
www.nice.org.uk/guidance/ng133
© NICE 2020. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-conditions#notice-of-

rights).
Hypertension in pregnancy: diagnosis and management (NG133)
Your responsibility
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.
© NICE 2020. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and- Page 2 of
conditions#notice-of-rights). 55
Contents
Overview ................................................................................................................................................................................ 5
Who is it for? ...................................................................................................................................................................................... 5
Recommendations .............................................................................................................................................................. 6
1.1 Reducing the risk of hypertensive disorders in pregnancy ..................................................................................... 6
1.2 Assessment of proteinuria in hypertensive disorders of pregnancy ................................................................... 8
1.3 Management of chronic hypertension in pregnancy .................................................................................................. 9
1.4 Management of gestational hypertension ..................................................................................................................... 13
1.5 Management of pre-eclampsia ........................................................................................................................................... 17
1.6 Fetal monitoring ........................................................................................................................................................................ 24
1.7 Intrapartum care ....................................................................................................................................................................... 26
1.8 Medical management of severe hypertension, severe pre-eclampsia or eclampsia in a critical care
setting ................................................................................................................................................................................................... 28
1.9 Antihypertensive treatment during the postnatal period, including during breastfeeding ....................... 31
1.10 Advice and follow-up at transfer to community care .............................................................................................. 32
Terms used in this guideline ........................................................................................................................................................ 36
Recommendations for research ....................................................................................................................................39
Key recommendations for research ......................................................................................................................................... 39
Other recommendations for research (from 2010 guideline) ....................................................................................... 40
Rationale and impact .........................................................................................................................................................41
Assessment of proteinuria ........................................................................................................................................................... 41
Treatment of chronic hypertension ......................................................................................................................................... 43
Monitoring and treatment of gestational hypertension .................................................................................................. 45
Assessment of women with pre-eclampsia ........................................................................................................................... 45
Monitoring and treatment of pre-eclampsia and timing of birth .................................................................................. 46
Antihypertensive treatment during the postnatal period, including during breastfeeding .............................. 48
Risk of recurrence of hypertensive disorders of pregnancy and long-term cardiovascular disease.............. 49
Context ....................................................................................................................................................................................51
Finding more information and resources ..................................................................................................................53
Update information ............................................................................................................................................................54
This guideline replaces CG107.
This guideline is the basis of QS35.
Overview
This guideline covers diagnosing and managing hypertension (high blood pressure), including pre-
eclampsia, during pregnancy, labour and birth. It also includes advice for women with hypertension
who wish to conceive and women who have had a pregnancy complicated by hypertension. It aims
to improve care during pregnancy, labour and birth for women and their babies.
Who is it for?
• Healthcare professionals
• Women who develop hypertension during pregnancy, who have hypertension and wish to
conceive, and who have had a pregnancy complicated by hypertension, and their relatives and
carers
Recommendations
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.
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
[1]
aspirin 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[ ] daily from 12 weeks until the birth of
1
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]
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]
To find out why the committee made the 2019 recommendations on the assessment of
proteinuria and how they might affect practice, see rationale and impact.
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[ ] (ARBs):
2
• 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[ ] for women in whom labetalol is not suitable, or methyldopa if both
3
labetalol and nifedipine[ ] are not suitable. Base the choice on any pre-existing
3
treatment, side-effect profiles, risks (including fetal effects) and the woman's
preference. [2019]
1.3.11 Offer pregnant women with chronic hypertension aspirin[ ] 75–150 mg once
1
daily from 12 weeks. [2019]
1.3.12 Offer placental growth factor (PlGF)-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 PlGF-based testing to help diagnose suspected pre-
eclampsia). [2019]
To find out why the committee made the 2019 recommendations on the treatment of
chronic hypertension and how they might affect practice, see rationale and impact.
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]
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: Severe hypertension:

blood pressure of 140/90–159/ blood pressure of 160/110 mmHg or
109 mmHg more
Admission to Do not routinely admit to hospital Admit, but if BP falls below 160/
hospital 110 mmHg then manage as for
hypertension
Antihypertensive Offer pharmacological treatment if Offer pharmacological treatment to

pharmacological BP remains above 140/90 mmHg all women
treatment
Target blood Aim for BP of 135/85 mmHg or less Aim for BP of 135/85 mmHg or less
pressure once on
antihypertensive
treatment
Blood pressure Once or twice a week (depending on Every 15–30 minutes until BP is less
measurement BP) until BP is 135/85 mmHg or less than 160/110 mmHg
Dipstick Once or twice a week (with BP Daily while admitted

proteinuria measurement)
testinga
Blood tests Measure full blood count, liver Measure full blood count, liver
function and renal function at function and renal function at
presentation and then weekly presentation and then weekly
PlGF-based Carry out PlGF-based testing on Carry out PlGF-based testing on

testing 1 occasion (in accordance with NICE 1 occasion (in accordance with NICE
guidance, see recommendation 1.4.4) guidance, see recommendation 1.4.4)
if there is suspicion of pre-eclampsia if there is suspicion of pre-eclampsia
Fetal assessment Offer fetal heart auscultation at Offer fetal heart auscultation at
every antenatal appointment every antenatal appointment
Carry out ultrasound assessment of Carry out ultrasound assessment of
the fetus at diagnosis and, if normal, the fetus at diagnosis and, if normal,
repeat every 2 to 4 weeks, if clinically repeat every 2 weeks, if severe
indicated hypertension persists
Carry out a CTG only if clinically Carry out a CTG at diagnosis and
indicated then only if clinically indicated
(See section 1.6 for advice on fetal (See section 1.6 for advice on fetal
monitoring) 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; PlGF, placental growth factor.
1.4.4 Offer placental growth factor (PlGF)-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 PlGF-based testing to help
diagnose suspected pre-eclampsia.) [2019]
1.4.5 Consider labetalol to treat gestational hypertension. Consider nifedipine[ ]for 3
women in whom labetalol is not suitable, and methyldopa if labetalol or

nifedipine[ ] are not suitable. Base the choice on side-effect profiles, risk
3
(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]
To find out why the committee made the 2019 recommendations on the monitoring and
treatment of gestational hypertension and how they might affect practice, see rationale
and impact.
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
• 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]
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]
To find out why the committee made the 2019 recommendations on assessment of
women with pre-eclampsia and how they might affect practice see rationale and impact.
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: Severe hypertension:

blood pressure of 140/90–159/ blood pressure of 160/
109 mmHg 110 mmHg or more
Admission to Admit if any clinical concerns for the Admit, but if BP falls below 160/
hospital wellbeing of the woman or baby (see 110 mmHg then manage as for
recommendation 1.5.2) or if high risk of hypertension
adverse events suggested by the
fullPIERS or PREP-S risk prediction
models
Antihypertensive Offer pharmacological treatment if BP Offer pharmacological treatment

pharmacological remains above 140/90 mmHg to all women
treatment
Target blood Aim for BP of 135/85 mmHg or less Aim for BP of 135/85 mmHg or
pressure once on less
antihypertensive
treatment
Blood pressure At least every 48 hours, and more Every 15–30 minutes until BP is
measurement frequently if the woman is admitted to less than 160/110 mmHg, then at
hospital least 4 times daily while the
woman is an inpatient, depending
on clinical circumstances
Dipstick Only repeat if clinically indicated, for Only repeat if clinically indicated,
proteinuria example, if new symptoms and signs for example, if new symptoms
testinga develop or if there is uncertainty over and signs develop or if there is
diagnosis uncertainty over diagnosis
Blood tests Measure full blood count, liver function Measure full blood count, liver
and renal function twice a week function and renal function
3 times a week
Fetal assessment Offer fetal heart auscultation at every Offer fetal heart auscultation at
antenatal appointment every antenatal appointment
Carry out ultrasound assessment of the Carry out ultrasound assessment
fetus at diagnosis and, if normal, repeat of the fetus at diagnosis and, if
every 2 weeks normal, repeat every 2 weeks
Carry out a CTG at diagnosis and then Carry out a CTG at diagnosis and
only if clinically indicated then only if clinically indicated
(See section 1.6 for advice on fetal (See section 1.6 for advice on
monitoring) 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[ ] for women in whom labetalol is not suitable, and methyldopa
3
if labetalol or nifedipine[ ] are not suitable. Base the choice on any pre-existing
3
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 women with pre-eclampsia

Weeks of Timing of birth
pregnancy
Before Continue surveillance unless there are indications (see recommendation 1.5.7) for
34 weeks 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 Continue surveillance unless there are indications (see recommendation 1.5.7) for
to 36+6 planned early birth.
weeks When considering the option of planned early birth, take into account the woman's
and baby's condition, risk factors (such as maternal comorbidities, multi-fetal
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 Initiate birth within 24–48 hours.

onwards
To find out why the committee made the 2019 recommendations on the monitoring and
treatment of pre-eclampsia and timing of birth and how they might affect practice, see rationale
and impact.
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
• 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]
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 10th 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]
1.7 Intrapartum care

1.7.1 Give advice and treatment to women with hypertensive disorders of pregnancy
in line with the NICE guideline on intrapartum care, unless there are
recommendations in this guideline on the same topic. Offer care in accordance
with the NICE guideline on intrapartum care for women with hypertension
whether treated or untreated, and not just on the basis of blood pressure in
labour. [2010, amended 2019]
1.7.2 Give women with chronic hypertension advice and care in line with the NICE
guideline on intrapartum care for women with existing medical conditions or
obstetric complications and their babies. [2019]
Blood pressure
1.7.3 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. [2010, amended 2019]
1.7.4 Continue use of antenatal antihypertensive treatment during labour. [2010]
Haematological and biochemical monitoring

1.7.5 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. [2010]
Care during epidural analgesia

1.7.6 Do not preload women who have severe pre-eclampsia with intravenous fluids
before establishing low-dose epidural analgesia or combined spinal epidural
analgesia. [2010, amended 2019]
Management of second stage of labour

1.7.7 Do not routinely limit the duration of the second stage of labour in women with
controlled hypertension. [2010, amended 2019]
1.7.8 Consider operative or assisted birth in the second stage of labour for women
with severe hypertension whose hypertension has not responded to initial
treatment. [2010, amended 2019]
1.8 Medical management of severe hypertension,

severe pre-eclampsia or eclampsia in a critical care
setting
Anticonvulsants
1.8.1 If a woman in a critical care setting who has severe hypertension or severe pre-
eclampsia has or previously had an eclamptic fit, give intravenous magnesium
sulfate. [2010]
1.8.2 Consider giving intravenous magnesium sulfate to women with severe pre-
eclampsia who are in a critical care setting if birth is planned within 24 hours.
[2010]
1.8.3 Consider the need for magnesium sulfate treatment, if 1 or more of the
following features of severe pre-eclampsia is present:
• ongoing or recurring severe headaches
• visual scotomata
• nausea or vomiting
• epigastric pain
• oliguria and severe hypertension
• progressive deterioration in laboratory blood tests (such as rising creatinine or liver

transaminases, or falling platelet count). [2010, amended 2019]
1.8.4 Use the Collaborative Eclampsia Trial regimen for administration of magnesium
sulfate[ ]:
4
• A loading dose of 4 g should be given intravenously over 5 to 15 minutes, followed by

an infusion of 1 g/hour maintained for 24 hours. If the woman has had an eclamptic fit,
the infusion should be continued for 24 hours after the last fit.
• Recurrent fits should be treated with a further dose of 2–4 g given intravenously over
5 to 15 minutes. [2010, amended 2019]
1.8.5 Do not use diazepam, phenytoin or other anticonvulsants as an alternative to

magnesium sulfate in women with eclampsia. [2010, amended 2019]
Antihypertensives
1.8.6 Treat women with severe hypertension who are in critical care during
pregnancy or after birth immediately with 1 of the following:
• labetalol (oral or intravenous)
• oral nifedipine[ ] 3
• intravenous hydralazine. [2010, amended 2019]
1.8.7 In women with severe hypertension who are in critical care, monitor their
response to treatment:
• to ensure that their blood pressure falls
• to identify adverse effects for both the woman and the baby
• to modify treatment according to response. [2010]
1.8.8 Consider using up to 500 ml crystalloid fluid before or at the same time as the
first dose of intravenous hydralazine in the antenatal period. [2010]
Corticosteroids for fetal lung maturation

1.8.9 If early birth is considered likely within 7 days in women with pre-eclampsia,
offer a course of antenatal corticosteroids in line with the NICE guideline on
preterm labour and birth. [2010, amended 2019]
Corticosteroids to manage HELLP syndrome

1.8.10 Do not use dexamethasone or betamethasone for the treatment of HELLP
syndrome. [2010]
Fluid balance and volume expansion

1.8.11 Do not use volume expansion in women with severe pre-eclampsia unless
hydralazine is the antenatal antihypertensive. [2010]
1.8.12 In women with severe pre-eclampsia, limit maintenance fluids to 80 ml/hour

unless there are other ongoing fluid losses (for example, haemorrhage). [2010]
Caesarean section versus induction of labour

1.8.13 Choose mode of birth for women with severe hypertension, severe pre-
eclampsia or eclampsia according to the clinical circumstances and the woman's
preference. [2010]
Referral to critical care

1.8.14 Refer women with severe hypertension or severe pre-eclampsia to the
appropriate critical care setting using the criteria in table 4. [2010]
Table 4 Clinical criteria for choice of critical care level

Level 3 Severe pre-eclampsia and needing ventilation
care
Level 2 Step-down from level 3 or severe pre-eclampsia with any of the following
care complications:
• eclampsia
• HELLP syndrome
• haemorrhage
• hyperkalaemia
• severe oliguria
• coagulation support
• intravenous antihypertensive treatment
• initial stabilisation of severe hypertension
• evidence of cardiac failure
• abnormal neurology
Level 1 Pre-eclampsia with hypertension

care Ongoing conservative antenatal management of severe preterm hypertension
Step-down treatment after the birth
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[ ]to treat hypertension in women during the postnatal period,
5
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[ ] or
3
• 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[ ] (or 3
amlodipine) and enalapril[ ]. If this combination is not tolerated or is ineffective,

5
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[ ] to treat 5
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]
To find out why the committee made the 2019 recommendations on antihypertensive
treatment during breastfeeding and how they might affect practice, see rationale and
impact.
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 5). [2019]
Table 5 Likelihood of recurrence of hypertensive disorders of
pregnancy
Type of hypertension in previous or current pregnancy
Prevalence of hypertensive Any Pre-eclampsia Gestational

disorder in a future pregnancy hypertension in hypertension
pregnancy
Any hypertension Approximately Approximately 20% Approximately

21% (1 in 5 women) 22%
(1 in 5 women) (1 in 5 women)
Pre-eclampsia Approximately Up to approximately 16% Approximately 7%

14% (1 in 6 women) (1 in 14 women)
(1 in 7 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)
Gestational hypertension Approximately Between approximately Between

9% 6 and 12% approximately 11
(1 in 11 women) (up to 1 in 8 women) and 15%
(up to 1 in 7
women)
Chronic hypertension Not applicable Approximately 2% Approximately 3%

(up to 1 in 50 women) (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 6). [2019]
Table 6 Cardiovascular risk in women who have had a

hypertensive disorder of pregnancy
Type of hypertension in current or previous pregnancy
Risk of future Any hypertension Pre-eclampsia Gestational Chronic

cardiovascular in pregnancy hypertension hypertension
diseasea, b
Major adverse Risk increased Risk increased Risk increased Risk increased
cardiovascular event (up to (approximately (approximately (approximately
approximately 2 1.5–3 times) 1.5–3 times) 1.7 times)
times)
Cardiovascular Risk increased Risk increased (no data) (no data)

mortality (up to (approximately
approximately 2 2 times)
times)
Stroke Risk increased Risk increased Risk may be Risk increased

(up to (approximately increased (approximately
approximately 1.5 2–3 times) 1.8 times)
times)
Hypertension Risk increased Risk increased Risk increased (not

(approximately (approximately (approximately applicable)
2–4 times) 2–5 times) 2–4 times)
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]
To find out why the committee made the 2019 recommendations on risk of recurrence
of hypertensive disorders of pregnancy and long-term cardiovascular disease, and how
they might affect practice, see rationale and impact.
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.
[1]
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.
[2]
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'.
[3]
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.
[4]
The MHRA has issued a warning about the risk of skeletal adverse effects in the neonate
following prolonged or repeated use of magnesium sulfate in pregnancy. Maternal administration
of magnesium sulfate for longer than 5–7 days in pregnancy has been associated with skeletal
adverse effects and hypocalcaemia and hypermagnesemia in neonates. If use of magnesium sulfate
in pregnancy is prolonged or repeated, consider monitoring of neonates for abnormal calcium and
magnesium levels and skeletal adverse effects.
[5]
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'.
Recommendations for research

As part of the 2019 update, the guideline committee made 6 research recommendations on the
management of pregnancy with chronic hypertension, pre-eclampsia, fetal monitoring, the use of
antihypertensives in breastfeeding and advice and follow-up. A research recommendation from the
2010 guideline which was superseded by these new research recommendations was deleted, and
3 research recommendations where research was now underway or had been completed were also
deleted.
Key recommendations for research

1 Management of chronic hypertension in pregnancy
In women who need treatment for chronic hypertension in pregnancy, what is the effectiveness and
safety of antihypertensive agents (compared in head-to-head trials) in improving maternal and
perinatal outcomes? [2019]
To find out why the committee made the research recommendation on pre-eclampsia, see rationale
and impact.
2 Management of hypertension in pregnancy

In women who need treatment for hypertension in pregnancy, what are the adverse neonatal
outcomes associated with maternal use of beta blockers (or mixed alpha-beta blockers)? [2019]
To find out why the committee made these research recommendations on chronic hypertension,
see rationale and impact.
3 Management of pre-eclampsia
In which women with pre-eclampsia is inpatient management associated with better outcomes for
women and babies? [2019]
To find out why the committee made the research recommendation on pre-eclampsia, see rationale
and impact.
4 Antihypertensive treatment during the postnatal period

In women who need treatment for high blood pressure after birth, what is the effectiveness and
safety (including in breastfeeding women) of antihypertensive agents in achieving adequate blood
pressure control? [2019]
To find out why the committee made the research recommendation on antihypertensive treatment
during breastfeeding, see rationale and impact.
5 Fetal monitoring
In women with hypertensive disorders of pregnancy, what is the optimal fetal monitoring strategy
to detect small for gestational age infants? [2019]
To find out why the committee made the research recommendation on fetal monitoring, see
rationale and impact.
6 Advice and follow-up at transfer to community care

In women who have had hypertension during pregnancy, what interventions reduce the risk of a)
recurrent hypertensive disorders of pregnancy, and b) subsequent cardiovascular disease? [2019]
To find out why the committee made the research recommendation on follow-up after
hypertensive disorders of pregnancy, see rationale and impact.
Other recommendations for research (from 2010

guideline)
Haematological and biochemical monitoring in women with
gestational hypertension
What is the role of assessing haematological or biochemical parameters at diagnosis of gestational
hypertension and during surveillance of gestational hypertension? [2010]
Rationale and impact

These sections briefly explain why the committee made the recommendations and how they might
affect practice. They link to details of the evidence and a full description of the committee's
discussion.
Assessment of proteinuria
Recommendations 1.2.1 to 1.2.7
Why the committee made the recommendations

The committee were aware that there is often over-reliance on a proteinuria result in the diagnosis
of pre-eclampsia, and agreed that healthcare professionals should use the results of a full clinical
review, including severity of hypertension and other signs and symptoms, before making a
diagnosis of pre-eclampsia.
The committee amended the recommendation on automated dipstick tests from the 2010
guideline to emphasise that this should be used as a screening tool for proteinuria. The committee
highlighted the importance of using automated dipstick analysis in secondary care rather than
visual analysis, which they were aware from their experience has a higher error rate.
Protein:creatinine ratio (PCR) and albumin:creatinine ratio (ACR) were both shown to have high
specificity and high sensitivity at the chosen thresholds (30 mg/mmol and 8 mg/mmol respectively),
and therefore either could be used depending on local availability. The committee agreed that using
both tests together did not have any additional diagnostic benefit.
There was some evidence that using the first morning urine void in assessment of proteinuria can
lead to lower diagnostic accuracy, and so the committee recommended against using this.
As PCR and ACR show very high diagnostic accuracy, they should be used in place of 24-hour urine
collection, which is awkward for women and could delay identification of proteinuria. However,
there are rare occasions when it might be more appropriate to use 24-hour collection (for example,
women with renal complications), and so the committee agreed it should not be ruled out entirely.
There was good evidence that a PCR of 30 mg/mmol had good diagnostic accuracy, showing high
sensitivity and specificity and should be used as the threshold for significant proteinuria. However,
the committee recommended retesting for results above 30 mg/mmol if there is still diagnostic
uncertainty (for example, the woman has no other clinical signs or symptoms of pre-eclampsia)
because there is large variation in protein excretion during the day and from day to day. The
committee agreed that this would prevent women being diagnosed with pre-eclampsia on the basis
of a single raised PCR result.
Evidence from a single study showed high sensitivity and specificity for an ACR result of 8 mg/
mmol to diagnose proteinuria. However, the committee were also aware of further results from a
large, UK-based study, which provided further evidence for the efficacy of a threshold of 8 mg/
mmol in the diagnosis of severe pre-eclampsia. The committee were aware that this threshold is
different to that used for detection of microalbuminuria in the non-pregnant population. However,
they agreed that, on the basis of the evidence reviewed, it was appropriate to use a threshold of
8 mg/mmol for pregnant women.
As with PCR, the committee were aware that women are sometimes diagnosed with pre-eclampsia
on the basis of a single raised ACR, and that this may lead to over-diagnosis. Therefore they made a
recommendation to consider repeating the ACR measurement if there was ongoing clinical
uncertainty about the diagnosis.
No evidence was reviewed that examined the timing of repeat testing for either ACR or PCR, and
so no recommendations could be made regarding this.
How the recommendations might affect practice

The recommendation to take account of other clinical features when assessing women for
suspected pre-eclampsia might lead to an increased need for follow-up and surveillance. However,
this will also reduce the chance that a diagnosis of pre-eclampsia is missed by raising awareness of
the multi-system nature of the disease, and so could reduce the number of women who go on to
develop complications from undiagnosed pre-eclampsia.
Not all secondary care units currently use automated dipstick analysis to screen for proteinuria, so
the recommendations might increase the need for automated reagent-strip reading devices.
However, the accuracy and reliability of screening will be improved, reducing the need for further
investigations for some women and correctly identifying more women who need further testing or
investigations.
Moving from 24-hour urine collection to spot urine ACR or PCR will save time, with potential for
faster diagnosis, and a reduction in inaccuracies because of incomplete samples. It is also likely to
improve quality of life, as the process of completing a 24-hour urine collection is time-consuming
and awkward.
A PCR of 30 mg/mmol is already used routinely as a diagnostic threshold and therefore should not
change practice. Currently units may use different ACR levels for diagnosis and so the
recommendation to use 8 mg/mmol will standardise practice.
Recommendations have been made for the use of either ACR or PCR allowing local decisions to use
whichever test is available, so this should not affect practice.
Repeating the PCR or ACR test may incur a small additional cost. However, this should reduce the
false positive rate, and mean some women will avoid unnecessary follow-up or intensive monitoring
(such as hospital admission) if their proteinuria resolves and is shown to be transient.
Full details of the evidence and the committee's discussion are in evidence review G: assessment of
proteinuria.
Return to recommendations
Treatment of chronic hypertension


The committee agreed that pregnant woman with chronic hypertension should be offered lifestyle
advice similar to other adults with hypertension, and in line with the NICE guideline on
hypertension in adults.
There was very little evidence available on treatment initiation thresholds for chronic hypertension
in pregnancy, so the committee based their recommendations on the values specified in the recent
Control of Hypertension in Pregnancy Study (CHIPS) and the NICE guideline on hypertension in
adults. There was evidence for target blood pressure levels from the large CHIPS trial, so the
committee made recommendations based on this.
There was some very limited evidence of both benefits and harms for different antihypertensive
medicines. However, there was not enough evidence to recommend one treatment over another.
As labetalol, nifedipine and methyldopa had been recommended in the previous guideline (for
gestational hypertension and pre-eclampsia), and these medicines had been used for many years in
pregnancy, the committee agreed they should be preferred treatment options for chronic
hypertension in pregnancy. Labetalol is specifically licensed for use in pregnancy and so is
suggested as the first-line option, with nifedipine as the next alternative, and methyldopa as the
third option (as it may lead to more side effects and be the least effective option of the 3).
There was some very limited evidence for the benefits of aspirin in reducing preterm births and
neonatal unit admissions, so the committee retained the recommendation on aspirin from the
previous guideline, but incorporated it into the section on the treatment of chronic hypertension in
pregnancy. The committee noted that the studies used different doses of aspirin (ranging from
50–150 mg daily), and that common practice in the UK was to offer 75–150 mg, therefore this dose
range was recommended.
The committee were aware of the link between chronic hypertension and both pre-existing and
gestational diabetes, therefore they made an overarching recommendation at the beginning of the
guideline to cross-refer to the existing NICE guideline on diabetes in pregnancy.
The committee made a new recommendation referring to the NICE diagnostics guidance on
placental growth factor (PlGF) testing as this may be applicable to women with chronic
hypertension.
As there is currently a lack of evidence on the difference in outcomes between different

antihypertensive medications, and concerns about possible adverse neonatal events from beta
blockers, the committee made research recommendations on these topics.

Based on these recommendations, a clear blood pressure target should now be set for women with
chronic hypertension in pregnancy who need antihypertensive treatment to improve consistency
of treatment targets.
Starting treatment for hypertension and offering aspirin to women with chronic hypertension who
are pregnant are standard care, so these recommendations are not expected to change practice
significantly.
Full details of the evidence and the committee's discussion are in evidence review A: interventions
for chronic hypertension.
Monitoring and treatment of gestational hypertension

Recommendations 1.4.3 and 1.4.4

The committee updated the table from the previous guideline on the management of pregnancy
with gestational hypertension. There was very little evidence available on treatment initiation
thresholds for gestational hypertension in pregnancy, so the committee made recommendations
using the values specified in the recent Control of Hypertension in Pregnancy Study (CHIPS). There
was evidence for target blood pressure levels from the large CHIPS trial, so the committee made
recommendations based on this. The committee made a new recommendation referring to the
NICE diagnostics guidance on placental growth factor (PlGF) testing as this is applicable to women
with gestational hypertension.
The committee were aware of the link between gestational hypertension and both pre-existing and
gestational diabetes, therefore they made an overarching recommendation at the beginning of the
guideline to cross-refer to the existing NICE guideline on diabetes in pregnancy.
There was no evidence on fetal monitoring in gestational hypertension, so the committee made a
research recommendation.

The recommendations reflect current clinical practice in many units, but may help standardise
practice across the NHS for units that currently use other blood pressure targets.
Full details of the evidence and the committee's discussion are in evidence review B: monitoring
gestational hypertension.
Assessment of women with pre-eclampsia


The committee agreed, based on their clinical expertise, that women with pre-eclampsia should
have a full clinical assessment at every antenatal appointment and should be admitted to hospital if
there are any concerns about the wellbeing of the woman or her baby. The committee agreed that
this would include (but was not limited to) reasons such as severe hypertension or other features of
pre-eclampsia indicating increased risk of adverse outcomes.
There was some evidence that the fullPIERS and PREP-S models can help identify women at
different risks of adverse outcomes because of pre-eclampsia. There was more extensive validation
of the fullPIERS model, and the validation studies were conducted in populations from a range of
healthcare settings. The PREP-S model had been developed using a UK population, and validated
using data from similar multinational settings. It was noted that further validation of PREP-S was
unlikely to be conducted, because of the cost of conducting these studies. The committee therefore
agreed that both models could be considered as options, in addition to a full clinical assessment, to
help guide decisions relating to interventions and place of care.
The tools predict adverse outcomes in women, but are not designed to predict outcomes for babies.
The committee agreed it was important to highlight this.

The use of a full clinical assessment and validated models to predict risk may improve consistency
in current practice with regard to admission to hospital for women with pre-eclampsia. Some
centres offer admission to all women with pre-eclampsia, whereas others only offer it to a small
proportion of women. The guidance might increase the number of women who are admitted to
hospital in some centres if admission is not currently routine, but might decrease admission in
other centres, thus standardising practice.
Full details of the evidence and the committee's discussion are in evidence review C: prediction of
complications in pre-eclampsia.
Monitoring and treatment of pre-eclampsia and timing

of birth
Recommendations 1.5.5, 1.5.7 and 1.5.12

The committee updated the table from the previous guideline on the management of pregnancy
with pre-eclampsia. There was limited evidence on the best place of treatment for women with pre-
eclampsia. Because of this, the committee made recommendations based on other evidence they
reviewed (see evidence review C), which showed that women should be admitted if there were
concerns for the wellbeing of the woman or her baby, or a high risk of complications of pre-
eclampsia predicted using the fullPIERS or PREP-S model. (See the section of the guideline on
assessing pre-eclampsia and evidence review C for more details on the use of the fullPIERS and
PREP-S models.)
There was no evidence on treatment initiation thresholds or target blood pressure levels for pre-
eclampsia, so the committee based their recommendations on the NICE guideline on hypertension
in adults and the values specified in the Control of Hypertension In Pregnancy Study (CHIPS; see
evidence review A), which included women with chronic or gestational hypertension.
There was some very limited evidence of both benefits and harms for different pharmacological
interventions. However, as there was not enough evidence to recommend one treatment over
another, the committee adopted the choices from the previous guideline and recommended
choosing a treatment based on previous treatments, side-effect profiles and the woman's
preferences. Labetalol is specifically licensed for use in pregnancy and so is suggested as the first-
line option, with nifedipine as the next alternative, and methyldopa as the third option (as it may
lead to more side effects and be the least effective option of the 3).
There was limited evidence on the benefits and harms of planned early birth compared with
expectant management of pregnancy in women with pre-eclampsia, so the committee
recommended that decisions about timing of birth should be based on whether the woman and
baby are at risk of adverse outcomes if pregnancy is prolonged. These recommendations were
based on those from the previous guideline, and expanded based on international guidelines, which
were used by the committee in their clinical practice. Based on the data from HYPITAT-II study, the
committee also agreed that pregnancies in women with pre-eclampsia could be managed with
continued surveillance to 37 weeks, unless there were specific concerns or indications to offer a
planned early birth before then.
There was limited evidence to guide the best place of care for women with pre-eclampsia and their
babies, so the committee made a research recommendation.

The recommendations are in line with current best clinical practice, so are unlikely to cause a
significant change in practice.
Currently, some units admit all women with pre-eclampsia routinely, some only admit women who
they believe to be at a high risk of complications, and some admit very few. Standardising practice
could therefore increase or reduce the number of women who will be admitted, depending on a
unit's current practice, but is likely to reduce unwanted variance between units.
Full details of the evidence and the committee's discussion are in evidence review D: interventions
for pre-eclampsia.
Antihypertensive treatment during the postnatal period,

including during breastfeeding
Recommendations 1.9.1 to 1.9.7 and 1.9.9

There was very little evidence on the efficacy and safety of antihypertensive agents in postnatal
women, so the committee made recommendations based on the NICE guideline on hypertension in
adults, with adaptations based on the potential effects of medicines on the baby. The committee
therefore recommended the use of an angiotensin converting enzyme (ACE) inhibitor as first-line
treatment, except in women of African or Caribbean family origin, in whom a calcium-channel
blocker would be used first line. The choice of second-line medicine was modified from the NICE
guideline on hypertension in adults as angiotensin receptor blockers, thiazide and thiazide-like
diuretics are not recommended during breastfeeding. Therefore the committee agreed that beta-
blockers should be used as the second-line antihypertensive agent. The committee also agreed that
the medicines with once-daily administration should be used wherever possible and for this reason
the committee recommended enalapril in preference to captopril (which is taken 3 times daily) and
atenolol as an alternative to labetalol (which is taken 2 to 4 times daily).
Based on their experience, the committee made recommendations on advice for women who wish
to breastfeed while taking antihypertensives, and on the monitoring of babies whose mothers are
taking antihypertensives.
As there was very little evidence on the effectiveness and safety of antihypertensives for postnatal
use, the committee revised the research recommendation made in the 2010 guideline.

There is currently wide variation in practice over use of antihypertensive treatment in the
postnatal period, and these recommendations may reduce variation in practice. The
recommendations could lead to an increase in the use of atenolol instead of labetalol in the
postnatal period.
Full details of the evidence and the committee's discussion are in evidence review E: postnatal
management of hypertension.
Risk of recurrence of hypertensive disorders of

pregnancy and long-term cardiovascular disease

Long-term follow-up studies of women who have experienced hypertensive disorders during
pregnancy showed an increased risk of long-term cardiovascular disease and a higher prevalence of
hypertensive disorders in subsequent pregnancies compared with women unaffected by
hypertensive disorders.
There was no evidence on which interventions could reduce the risk of recurrence of hypertensive
disorders of pregnancy or future cardiovascular disease, so the committee made a research
recommendation.

Providing guidance and advice to women on future risks and signposting appropriate care and
lifestyle advice may be an additional activity for some healthcare professionals, compared with
current practice.
Full details of the evidence and the committee's discussion are in evidence review F: advice at
discharge.
Context
Hypertensive disorders during pregnancy affect around 8% to 10% of all pregnant women and can
be associated with substantial complications for the woman and the baby. Women can have
hypertension before pregnancy or it can be diagnosed in the first 20 weeks (known as chronic
hypertension), new onset of hypertension occurring in the second half of pregnancy (gestational
hypertension) or new hypertension with features of multi-organ involvement (pre-eclampsia).
Although the proportion of women with pregnancy hypertensive disorders overall appears to have
stayed reasonably stable, maternal mortality from hypertensive causes has fallen dramatically: less
than 1 woman in every million who gives birth now dies from pre-eclampsia. There is consensus
that introduction of the 2010 NICE evidence-based guidelines, together with the findings from the
confidential enquiry into maternal deaths, has made a pivotal contribution to this fall in maternal
mortality. However, hypertension in pregnancy continues to cause substantial maternal morbidity,
stillbirths and neonatal deaths, and perinatal morbidity. Women with hypertension in pregnancy
are also at increased risk of cardiovascular disease later in life.
Variations in care contribute to inequity in adverse outcomes. Adoption and implementation of

evidence-based national guidelines have a central role in reducing this variance and improving care
and outcomes across the maternity service. Research that has been done since publication of the
previous guideline has addressed areas of uncertainty and highlighted where the recommendations
can be updated. A surveillance report from 2017 identified new studies in the following areas:
• management of pregnancy with chronic hypertension
• management of pregnancy with gestational hypertension
• management of pregnancy with pre-eclampsia
• breastfeeding
• advice and follow-up care at transfer to community care.
The scope of this update was limited to these sections; it did not include other areas being looked at
by other groups (for example, screening strategies for pre-eclampsia, which is being evaluated by
the UK National Screening Committee), and did not look into alternative approaches to
categorisation of hypertension in pregnancy (for example, looking at treatment for all types of
pregnancy hypertension together, rather than within the subdivisions of chronic hypertension,
gestational hypertension and pre-eclampsia). This update has also clarified the basis for the current
definition of pre-eclampsia, in order to better align with the stated aims of the 2010 guideline to be
consistent with those agreed by the International Society for the Study of Hypertension in
Pregnancy (ISSHP).
The aim of the 2019 guideline is to present updated evidence-based recommendations, relevant to
practising clinicians, while identifying outstanding areas of uncertainty that need further research.
There is a strong argument for uptake of these new guidelines into clinical practice, in order to
minimise unnecessary variance and provide optimal care for women and their babies. In doing this,
low rates of maternal mortality should be maintained, and progress on reduction of maternal
morbidity and perinatal morbidity and mortality can be pursued.
Finding more information and resources

You can see everything NICE says on hypertension in pregnancy in our interactive flowchart on
hypertension in pregnancy.
To find out what NICE has said on topics related to this guideline, see our web page on
hypertension.
For full details of the evidence and the guideline committee's discussions, see the evidence reviews.
You can also find information about how the guideline was developed, including details of the
committee.
NICE has produced tools and resources to help you put this guideline into practice. For general help
and advice on putting NICE guidelines into practice, see resources to help you put guidance into
practice.
Update information
June 2019: We have reviewed the evidence on the assessment of proteinuria and the treatment of
women with chronic and gestational hypertension and pre-eclampsia, breastfeeding and advice on
discharge. These recommendations are marked [2019]
[2019].
We have also made some changes without an evidence review:
• Combined, updated and clarified advice throughout to make it simpler to follow.
• Updated advice on pre-eclampsia in line with the NICE guidelines on antenatal care and pre-
term labour and birth.
• Amended dose information for aspirin use in pre-eclampsia in line with current national
guidance.
• Updated advice on rest, exercise and work for women with pre-eclampsia in line with the NICE
guideline on antenatal care.
• Expanded the advice on the risks of angiotensin-converting enzyme (ACE) inhibitors to treat
hypertension in pregnancy.
• Expanded and amended the advice on chlorothiazide to thiazide and thiazide-like diuretics,
because chlorothiazide is no longer widely used.
• Updated terminology used for various aspects of treatment in line with current practice.
• Updated the advice on when to offer planned early birth and action to take beforehand.
• Updated the advice on continuing antihypertensive treatment after birth, including treatment
with methyldopa.
• Added cross references where suitable to NICE guidance on breastfeeding.
• Updated guidance if necessary to be more specific on which healthcare professionals are

responsible for undertaking reviews and checks.
• Updated scan and test times for women with chronic hypertension in pregnancy, and why
scans and tests may be needed.
• Updated advice about creating care plans and who should be involved.
• Updated advice on anti-convulsants.
• Updated advice on angiotensin-receptor blockers during breastfeeding.
• Updated definitions and terms used to reflect current clinical practice.
These recommendations are marked [2010, amended 2019]

2019].
Recommendations marked [2010] last had an evidence review in 2010. In some cases, minor
changes have been made to the wording to bring the language and style up to date, without
changing the meaning.
ISBN: 978-1-4731-3434-8
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Hypertension in pregnancy:

diagnosis and management

© NICE 2020. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-conditions#notice-of-

Commissioners and providers have a responsibility to promote an environmentally sustainable

Who is it for? ...................................................................................................................................................................................... 5

1.1 Reducing the risk of hypertensive disorders in pregnancy ..................................................................................... 6

1.2 Assessment of proteinuria in hypertensive disorders of pregnancy ................................................................... 8

1.3 Management of chronic hypertension in pregnancy .................................................................................................. 9

1.4 Management of gestational hypertension ..................................................................................................................... 13

1.5 Management of pre-eclampsia ........................................................................................................................................... 17

1.6 Fetal monitoring ........................................................................................................................................................................ 24

1.7 Intrapartum care ....................................................................................................................................................................... 26

1.10 Advice and follow-up at transfer to community care .............................................................................................. 32

Terms used in this guideline ........................................................................................................................................................ 36

Recommendations for research ....................................................................................................................................39

Key recommendations for research ......................................................................................................................................... 39

Other recommendations for research (from 2010 guideline) ....................................................................................... 40

Rationale and impact .........................................................................................................................................................41

Assessment of proteinuria ........................................................................................................................................................... 41

Treatment of chronic hypertension ......................................................................................................................................... 43

Monitoring and treatment of gestational hypertension .................................................................................................. 45

Assessment of women with pre-eclampsia ........................................................................................................................... 45

Monitoring and treatment of pre-eclampsia and timing of birth .................................................................................. 46

Risk of recurrence of hypertensive disorders of pregnancy and long-term cardiovascular disease.............. 49

Finding more information and resources ..................................................................................................................53

Update information ............................................................................................................................................................54

This guideline replaces CG107.

This guideline is the basis of QS35.

1.1 Reducing the risk of hypertensive disorders in

• problems with vision, such as blurring or flashing before the eyes

• severe pain just below the ribs

• sudden swelling of the face, hands or feet.

• hypertensive disease during a previous pregnancy

• chronic kidney disease

• autoimmune disease such as systemic lupus erythematosus or antiphospholipid

• type 1 or type 2 diabetes

• chronic hypertension. [2010, amended 2019]

the baby. Factors indicating moderate risk are:

• 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

• nitric oxide donors

• low molecular weight heparin. [2010]

• antioxidants (vitamins C and E)

• fish oils or algal oils

1.2 Assessment of proteinuria in hypertensive

1.2.3 If dipstick screening is positive (1+ or more), use albumin:creatinine ratio or

1.2.5 Do not routinely use 24-hour urine collection to quantify proteinuria in

1.2.6 If using protein:creatinine ratio to quantify proteinuria in pregnant women:

• use 30 mg/mmol as a threshold for significant proteinuria

1.2.7 If using albumin:creatinine ratio as an alternative to protein:creatinine ratio to

• use 8 mg/mmol as a diagnostic threshold

1.3 Management of chronic hypertension in pregnancy

1.3.2 Advise women who take angiotensin-converting enzyme (ACE) inhibitors or

• to discuss alternative antihypertensive treatment with the healthcare professional

• to discuss alternative treatment with the healthcare professional responsible for