1 Guidance

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.

Definitions

For the purposes of this guideline, the following definitions apply:

  • Chronic hypertension is 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 is a convulsive condition associated with pre-eclampsia.

  • HELLP syndrome is haemolysis, elevated liver enzymes and low platelet count.

  • Gestational hypertension is new hypertension presenting after 20 weeks without significant proteinuria.

  • Pre-eclampsia is new hypertension presenting after 20 weeks with significant proteinuria.

  • Severe pre-eclampsia is pre-eclampsia with severe hypertension and/or with symptoms, and/or biochemical and/or haematological impairment.

  • Significant proteinuria is defined in recommendation 1.3.1.3

In addition, the Guideline Development Group (GDG) has defined mild, moderate and severe hypertension to help with implementation of this guidance as follows:

  • Mild hypertension diastolic blood pressure 90–99 mmHg, systolic blood pressure 140–149 mmHg.

  • Moderate hypertension diastolic blood pressure 100–109 mmHg, systolic blood pressure 150–159 mmHg.

  • Severe hypertension diastolic blood pressure 110 mmHg or greater, systolic blood pressure 160 mmHg or greater.

    Techniques for the measurement of blood pressure in pregnancy are described in 'Antenatal care' (NICE clinical guideline 62).

In this guideline, offer birth means to offer elective early birth through induction of labour or by elective caesarean section if indicated.

1.1 Reducing the risk of hypertensive disorders in pregnancy

1.1.1 Symptoms of pre-eclampsia

1.1.1.1 Pregnant women should be made aware of the need to seek immediate advice from a healthcare professional 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.

    [This recommendation is adapted from 'Antenatal care' (NICE clinical guideline 62)].

1.1.2 Antiplatelet agents

1.1.2.1 Advise women at high risk of pre-eclampsia to take 75 mg of 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 erythematosis or antiphospholipid syndrome

  • type 1 or type 2 diabetes

  • chronic hypertension.

1.1.2.2 Advise women with more than one moderate risk factor for pre-eclampsia to take 75 mg of aspirin* 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

  • multiple pregnancy.

1.1.3 Other pharmaceutical agents

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

  • nitric oxide donors

  • progesterone

  • diuretics

  • low molecular weight heparin.

1.1.4 Nutritional supplements

1.1.4.1 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.

1.1.5 Diet

1.1.5.1 Do not recommend salt restriction during pregnancy solely to prevent gestational hypertension or pre-eclampsia.

1.1.6 Lifestyle

1.1.6.1 Advice on rest, exercise and work for women at risk of hypertensive disorders during pregnancy should be the same as for healthy pregnant women (see 'Antenatal care', NICE clinical guideline 62).

1.2 Management of pregnancy with chronic hypertension

Women with chronic hypertension should be given advice and treatment in line with 'Hypertension: the management of hypertension in adults in primary care' (NICE clinical guideline 34) (replaced by 'Hypertension: clinical management of primary hypertension in adults' [NICE clinical guideline 127]), unless it specifically differs from recommendations in this guideline.

1.2.1 Pre-pregnancy advice

1.2.1.1 Tell women who take angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs):

  • that there is an increased risk of congenital abnormalities if these drugs are taken during pregnancy

  • to discuss other antihypertensive treatment with the healthcare professional responsible for managing their hypertension, if they are planning pregnancy.

1.2.1.2 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.

1.2.1.3 Tell women who take chlorothiazide:

  • that there may be an increased risk of congenital abnormality and neonatal complications if these drugs are taken during pregnancy

  • to discuss other antihypertensive treatment with the healthcare professional responsible for managing their hypertension, if they are planning pregnancy.

1.2.1.4 Tell women who take antihypertensive treatments other than ACE inhibitors, ARBs or chlorothiazide that the limited evidence available has not shown an increased risk of congenital malformation with such treatments.

1.2.2 Diet

1.2.2.1 Encourage women with chronic hypertension to keep their dietary sodium intake low, either by reducing or substituting sodium salt, because this can reduce blood pressure. (This recommendation is adapted from 'Hypertension: management of hypertension in adults in primary care' [NICE clinical guideline 34] [replaced by 'Hypertension: clinical management of primary hypertension in adults {NICE clinical guideline 127}].)

1.2.3 Treatment of hypertension

1.2.3.1 In pregnant women with uncomplicated chronic hypertension aim to keep blood pressure lower than 150/100 mmHg.

1.2.3.2 Do not offer pregnant women with uncomplicated chronic hypertension treatment to lower diastolic blood pressure below 80 mmHg.

1.2.3.3 Offer pregnant women with target-organ damage secondary to chronic hypertension (for example, kidney disease) treatment with the aim of keeping blood pressure lower than 140/90 mmHg.

1.2.3.4 Offer pregnant women with secondary chronic hypertension referral to a specialist in hypertensive disorders.

1.2.3.5 Offer women with chronic hypertension antihypertensive treatment dependent on pre-existing treatment, side-effect profiles and teratogenicity.

1.2.4 Antenatal consultations

1.2.4.1 In women with chronic hypertension, schedule additional antenatal consultations based on the individual needs of the woman and her baby.

1.2.5 Timing of birth

1.2.5.1 Do not offer birth to women with chronic hypertension whose blood pressure is lower than 160/110 mmHg, with or without antihypertensive treatment, before 37 weeks.

1.2.5.2 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.

1.2.5.3 Offer birth to women with refractory severe chronic hypertension, after a course of corticosteroids (if required) has been completed.

1.2.6 Postnatal investigation, monitoring and treatment

1.2.6.1 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.

1.2.6.2 In women with chronic hypertension who have given birth, aim to keep blood pressure lower than 140/90 mmHg.

1.2.6.3 In women with chronic hypertension who have given birth:

  • continue antenatal antihypertensive treatment.

  • review long-term antihypertensive treatment 2 weeks after
    the birth.

1.2.6.4 If a woman has taken methyldopa to treat chronic hypertension during pregnancy, stop within 2 days of birth and restart the antihypertensive treatment the woman was taking before she planned the pregnancy.

1.2.6.5 Offer women with chronic hypertension a medical review at the postnatal review (6–8 weeks after the birth) with the pre-pregnancy care team.

1.3 Assessment of proteinuria in hypertensive disorders of pregnancy

1.3.1.1 Use an automated reagent-strip reading device or a spot urinary protein:creatinine ratio for estimating proteinuria in a secondary care setting.

1.3.1.2 If an automated reagent-strip reading device is used to detect proteinuria and a result of 1+ or more is obtained, use a spot urinary protein:creatinine ratio or 24-hour urine collection to quantify proteinuria.

1.3.1.3 Diagnose significant proteinuria if the urinary protein:creatinine ratio is greater than 30 mg/mmol or a validated 24-hour urine collection result shows greater than 300 mg protein.

1.3.1.4 Where 24-hour urine collection is used to quantify proteinuria, there should be a recognised method of evaluating completeness of the sample.

1.4 Management of pregnancy with gestational hypertension

1.4.1 Treatment of hypertension

1.4.1.1 In women with gestational hypertension full assessment should be carried out in a secondary care setting by a healthcare professional who is trained in the management of hypertensive disorders.

1.4.1.2 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

  • multiple 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.

1.4.1.3 Offer women with gestational hypertension an integrated package of care covering admission to hospital, treatment, measurement of blood pressure, testing for proteinuria and blood tests as indicated in Table 1.

Table 1 Management of pregnancy with gestational hypertension

Degree of hypertension

Mild hypertension

(140/90 to 149/99 mmHg)

Moderate hypertension

(150/100 to 159/109 mmHg)

Severe hypertension

(160/110 mmHg or higher)

Admit to hospital

No

No

Yes (until blood pressure is 159/109 mmHg or lower)

Treat

No

With oral labetalol as first-line treatment to keep:

  • diastolic blood pressure between 80–100 mmHg

  • systolic blood pressure less than 150 mmHg

With oral labetalol as first-line treatment to keep:

  • diastolic blood pressure between 80–100 mmHg

  • systolic blood pressure less than 150 mmHg

Measure blood pressure

Not more than once a week

At least twice a week

At least four times a day

Test for proteinuria

At each visit using automated reagent-strip reading device or urinary protein:creatinine ratio

At each visit using automated reagent-strip reading device or urinary protein:creatinine ratio

Daily using automated reagent-strip reading device or urinary protein:creatinine ratio

Blood tests

Only those for routine antenatal care

Test kidney function, electrolytes, full blood count, transaminases, bilirubin

Do not carry out further blood tests if no proteinuria at subsequent visits

Test at presentation and then monitor weekly:

  • kidney function, electrolytes, full blood count, transaminases, bilirubin

1.4.1.4 Only offer women with gestational hypertension antihypertensive treatment other than labetalol after considering side-effect profiles for the woman, fetus and newborn baby. Alternatives include methyldopa and nifedipine.

1.4.1.5 In women receiving outpatient care for severe gestational hypertension, after it has been effectively controlled in hospital, measure blood pressure and test urine twice weekly and carry out weekly blood tests.

1.4.1.6 In women with mild hypertension presenting before 32 weeks, or at high risk of pre-eclampsia (see 1.1.1.1), measure blood pressure and test urine twice weekly.

1.4.1.7 Do not offer bed rest in hospital as a treatment for gestational hypertension.

1.4.2 Timing of birth

1.4.2.1 Do not offer birth before 37 weeks to women with gestational hypertension whose blood pressure is lower than 160/110 mmHg, with or without antihypertensive treatment.

1.4.2.2 For women with gestational 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.

1.4.2.3 Offer birth to women with refractory severe gestational hypertension after a course of corticosteroids (if required) has been completed.

1.4.3 Postnatal investigation, monitoring and treatment

1.4.3.1 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.

1.4.3.2 In women with gestational hypertension who have given birth:

  • continue use of antenatal antihypertensive treatment

  • 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.

1.4.3.3 If a woman has taken methyldopa to treat gestational hypertension, stop within 2 days of birth.

1.4.3.4 For women with gestational hypertension who did not take antihypertensive treatment and have given birth, start antihypertensive treatment if their blood pressure is higher than 149/99 mmHg.

1.4.3.5 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.

1.4.3.6 Offer women who have had gestational hypertension and remain on antihypertensive treatment 2 weeks after transfer to community care, a medical review.

1.4.3.7 Offer women who have had gestational hypertension a medical review at the postnatal review (6–8 weeks after the birth).

1.4.3.8 Offer women who have had gestational hypertension and who still need antihypertensive treatment at the postnatal review
(6–8 weeks after the birth) a specialist assessment of their hypertension.

1.5 Management of pregnancy with pre-eclampsia

1.5.1 Treatment of hypertension

1.5.1.1 Assess women with pre-eclampsia at each consultation. Assessment should be performed by a healthcare professional trained in the management of hypertensive disorders of pregnancy.

1.5.1.2 Offer women with pre-eclampsia an integrated package of care covering admission to hospital, treatment, measurement of blood pressure, testing for proteinuria and blood tests as indicated in Table 2.

Table 2 Management of pregnancy with pre-eclampsia

Degree of hypertension

Mild hypertension

(140/90 to 149/99 mmHg)

Moderate hypertension

(150/100 to 159/109 mmHg)

Severe hypertension

(160/110 mmHg or higher)

Admit to hospital

Yes

Yes

Yes

Treat

No

With oral labetalol as first-line treatment to keep:

  • diastolic blood pressure between 80–100 mmHg

  • systolic blood pressure less than 150 mmHg

With oral labetalol as first-line treatment to keep:

  • diastolic blood pressure between 80–100 mmHg

  • systolic blood pressure less than 150 mmHg

Measure blood pressure

At least four times a day

At least four times a day

More than four times a day, depending on clinical circumstances

Test for proteinuria

Do not repeat quantification of proteinuria

Do not repeat quantification of proteinuria

Do not repeat quantification of proteinuria

Blood tests

Monitor using the following tests twice a week: kidney function, electrolytes, full blood count, transaminases, bilirubin

Monitor using the following tests three times a week: kidney function, electrolytes, full blood count, transaminases, bilirubin

Monitor using the following tests three times a week: kidney function, electrolytes, full blood count, transaminases, bilirubin

1.5.1.3 Only offer women with pre-eclampsia antihypertensive treatment other than labetalol after considering side-effect profiles for the woman, fetus and newborn baby. Alternatives include methyldopa and nifedipine.

1.5.2 Timing of birth

1.5.2.1 Manage pregnancy in women with pre-eclampsia conservatively (that is, do not plan same-day delivery of the baby) until 34 weeks.

1.5.2.2 Consultant obstetric staff should document in the woman's notes the maternal (biochemical, haematological and clinical) and fetal thresholds for elective birth before 34 weeks in women with pre-eclampsia.

1.5.2.3 Consultant obstetric staff should write a plan for antenatal fetal monitoring during birth.

1.5.2.4 Offer birth to women with pre-eclampsia before 34 weeks, after discussion with neonatal and anaesthetic teams and a course of corticosteroids has been given if:

  • severe hypertension develops refractory to treatment

  • maternal or fetal indications develop as specified in the consultant plan (see 1.5.22).

1.5.2.5 Recommend birth for women who have pre-eclampsia with severe hypertension after 34 weeks when their blood pressure has been controlled and a course of corticosteroids has been completed (if appropriate).

1.5.2.6 Offer birth to women who have pre-eclampsia with mild or moderate hypertension at 34+0 to 36+6 weeks depending on maternal and fetal condition, risk factors and availability of neonatal intensive care.

1.5.2.7 Recommend birth within 24–48 hours for women who have pre-eclampsia with mild or moderate hypertension after 37+0 weeks.

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

Blood pressure

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

  • at least four 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.

1.5.3.2 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.

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

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

  • at least four 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.

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

  • continue antenatal antihypertensive treatment

  • 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.

1.5.3.6 If a woman has taken methyldopa to treat pre-eclampsia, stop within 2 days of birth.

1.5.3.7 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 149/99 mmHg or lower

  • blood test results are stable or improving.

1.5.3.8 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.

1.5.3.9 Offer women who have pre-eclampsia and are still on antihypertensive treatment 2 weeks after transfer to community care a medical review.

1.5.3.10 Offer all women who have had pre-eclampsia a medical review at the postnatal review (6–8 weeks after the birth).

1.5.3.11 Offer women who have had pre-eclampsia and who still need antihypertensive treatment at the postnatal review (6–8 weeks after the birth) a specialist assessment of their hypertension.

Haematological and biochemical monitoring

1.5.3.12 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.

1.5.3.13 If biochemical and haematological indices are improving but stay within the abnormal range in women with pre-eclampsia who have given birth, repeat platelet count, transaminases and serum creatinine measurements as clinically indicated and at the postnatal review (6–8 weeks after the birth).

1.5.3.14 If biochemical and haematological indices are not improving relative to pregnancy ranges in women with pre-eclampsia who have given birth, repeat platelet count, transaminases and serum creatinine measurements as clinically indicated.

1.5.3.15 In women with pre-eclampsia who have given birth, carry out a urinary reagent-strip test at the postnatal review (6–8 weeks after the birth).

1.5.3.16 In women with pre-eclampsia who have given birth and have stepped down from critical care level 2, do not measure fluid balance if creatinine is within the normal range.

1.5.3.17 Offer women who had pre-eclampsia and still have proteinuria (1+ or more) at the postnatal review (6–8 weeks after the birth) a further review at 3 months after the birth to assess kidney function and consider offering them a referral for specialist kidney assessment.

1.6 Fetal monitoring

1.6.1 Chronic hypertension

1.6.1.1 In women with chronic hypertension, carry out ultrasound fetal growth and amniotic fluid volume assessment and umbilical artery doppler velocimetry between 28 and 30 weeks and between 32 and 34 weeks. If results are normal, do not repeat at more than 34 weeks, unless otherwise clinically indicated.

1.6.1.2 In women with chronic hypertension, only carry out cardiotocography if fetal activity is abnormal.

1.6.2 Mild or moderate gestational hypertension

1.6.2.1 In women with mild or moderate gestational hypertension, carry out ultrasound fetal growth and amniotic fluid volume assessment and umbilical artery doppler velocimetry if diagnosis is confirmed at less than 34 weeks. If results are normal, do not repeat at more than 34 weeks, unless otherwise clinically indicated.

1.6.2.2 In women with mild or moderate gestational hypertension, do not carry out ultrasound fetal growth and amniotic fluid volume assessment and umbilical artery doppler velocimetry if diagnosis is confirmed after 34 weeks, unless otherwise clinically indicated.

1.6.2.3 In women with mild or moderate gestational hypertension, only carry out cardiotocography if fetal activity is abnormal.

1.6.3 Severe gestational hypertension or pre-eclampsia

1.6.3.1 Carry out cardiotocography at diagnosis of severe gestational hypertension or pre-eclampsia.

1.6.3.2 If conservative management of severe gestational hypertension or pre-eclampsia is planned, carry out all the following tests at diagnosis:

  • ultrasound fetal growth and amniotic fluid volume assessment

  • umbilical artery doppler velocimetry.

1.6.3.3 If the results of all fetal monitoring are normal in women with severe gestational hypertension or pre-eclampsia, do not routinely repeat cardiotocography more than weekly.

1.6.3.4 In women with severe gestational hypertension or pre-eclampsia, repeat cardiotocography if any of the following occur:

  • the woman reports a change in fetal movement

  • vaginal bleeding

  • abdominal pain

  • deterioration in maternal condition.

1.6.3.5 In women with severe gestational hypertension or pre-eclampsia, do not routinely repeat ultrasound fetal growth and amniotic fluid volume assessment or umbilical artery doppler velocimetry more than every 2 weeks.

1.6.3.6 If the results of any fetal monitoring in women with severe gestational hypertension or pre-eclampsia are abnormal, tell a consultant obstetrician.

1.6.3.7 For women with severe gestational hypertension or pre-eclampsia, write a care plan that includes all of the following:

  • the timing and nature of future fetal monitoring

  • fetal indications for birth and if and when corticosteroids should be given

  • when discussion with neonatal paediatricians and obstetric anaesthetists should take place and what decisions should be made.

1.6.4 Women at high risk of pre-eclampsia

1.6.4.1 Carry out ultrasound 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 needed birth before 34 weeks

  • pre-eclampsia with a baby whose birth weight was less than the 10th centile

  • intrauterine death

  • placental abruption.

1.6.4.2 In women who are at high risk of pre-eclampsia (see 1.1.2.2), only carry out cardiotocography if fetal activity is abnormal.

1.7 Intrapartum care

Women with hypertensive disorders during pregnancy should be given advice and treatment in line with 'Intrapartum care: management and delivery of care to women in labour' (NICE clinical guideline 55), unless it specifically differs from recommendations in this guideline.

1.7.1 Blood pressure

1.7.1.1 During labour, measure blood pressure:

  • hourly in women with mild or moderate hypertension

  • continually in women with severe hypertension.

1.7.1.2 Continue use of antenatal antihypertensive treatment during labour.

1.7.2 Haematological and biochemical monitoring

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

1.7.3 Care during epidural analgesia

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

1.7.4 Management of the second stage of labour

1.7.4.1 Do not routinely limit the duration of the second stage of labour:

  • in women with stable mild or moderate hypertension or

  • if blood pressure is controlled within target ranges in women with severe hypertension.

1.7.4.2 Recommend operative birth in the second stage of labour for women with severe hypertension whose hypertension has not responded to initial treatment.

1.8 Medical management of severe hypertension or severe pre-eclampsia in a critical care setting

1.8.1 Anticonvulsants

1.8.1.1 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 sulphate*.

1.8.1.2 Consider giving intravenous magnesium sulphate* to women with severe pre-eclampsia who are in a critical care setting if birth is planned within 24 hours.

1.8.1.3 If considering magnesium sulphate* treatment, use the following as features of severe pre-eclampsia:

  • severe hypertension and proteinuria or

  • mild or moderate hypertension and proteinuria with one or more of the following:

    • symptoms of severe headache

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

    • severe pain just below the ribs or vomiting

    • papilloedema

    • signs of clonus (≥3 beats)

    • liver tenderness

    • HELLP syndrome

    • platelet count falling to below 100 x 109 per litre

    • abnormal liver enzymes (ALT or AST rising to above 70 iu/litre).

1.8.1.4 Use the Collaborative Eclampsia Trial[2] regimen for administration of magnesium sulphate*:

  • loading dose of 4 g should be given intravenously over 5 minutes, followed by an infusion of 1 g/hour maintained for 24 hours

  • recurrent seizures should be treated with a further dose of 2–4 g given over 5 minutes.

1.8.1.5 Do not use diazepam, phenytoin or lytic cocktail as an alternative to magnesium sulphate* in women with eclampsia.

1.8.2 Antihypertensives

1.8.2.1 Treat women with severe hypertension who are in critical care during pregnancy or after birth immediately with one of the following:

  • labetalol (oral or intravenous)

  • hydralazine (intravenous)

  • nifedipine (oral).

1.8.2.2 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 fetus

  • to modify treatment according to response.

1.8.2.3 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.

1.8.2.4 In women with severe hypertension who are in critical care, aim to keep systolic blood pressure below 150 mmHg and diastolic blood pressure between 80 and 100 mmHg.

1.8.3 Corticosteroids for fetal lung maturation

1.8.3.1 If birth is considered likely within 7 days in women with pre-eclampsia:

  • give two doses of betamethasone* 12 mg intramuscularly 24 hours apart in women between 24 and 34 weeks

  • consider giving two doses of betamethasone* 12 mg intramuscularly 24 hours apart in women between 35 and 36 weeks.

1.8.4 Corticosteroids to manage HELLP syndrome

1.8.4.1 Do not use dexamethasone or betamethasone for the treatment of HELLP syndrome.

1.8.5 Fluid balance and volume expansion

1.8.5.1 Do not use volume expansion in women with severe pre-eclampsia unless hydralazine is the antenatal antihypertensive.

1.8.5.2 In women with severe pre-eclampsia, limit maintenance fluids to 80 ml/hour unless there are other ongoing fluid losses (for example, haemorrhage).

1.8.6 Caesarean section versus induction of labour

1.8.6.1 Choose mode of birth for women with severe hypertension, severe pre-eclampsia or eclampsia according to the clinical circumstances and the woman's preference.

1.8.7 Indications for referral to critical care levels

1.8.7.1 Offer women with severe hypertension or severe pre-eclampsia referral to the appropriate critical care setting using the following criteria[3]:

Level 3 care

Severe pre-eclampsia and needing ventilation

Level 2 care

Step-down from level 3 or severe pre-eclampsia with any of the following 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 care

– Pre-eclampsia with mild or moderate hypertension

– Ongoing conservative antenatal management of severe preterm hypertension

– Step-down treatment after the birth

1.9 Breastfeeding

1.9.1.1 In women who still need antihypertensive treatment in the postnatal period, avoid diuretic treatment for hypertension if the woman is breastfeeding or expressing milk.

1.9.1.2 Tell women who still need antihypertensive treatment in the postnatal period that the following antihypertensive drugs have no known adverse effects on babies receiving breast milk:

  • labetalol

  • nifedipine

  • enalapril

  • captopril

  • atenolol

  • metoprolol.

1.9.1.3 Tell women who still need antihypertensive treatment in the postnatal period that there is insufficient evidence on the safety in babies receiving breast milk of the following antihypertensive drugs:

  • ARBs

  • amlodipine

  • ACE inhibitors other than enalapril and captopril.

1.9.1.4 Assess the clinical wellbeing of the baby, especially adequacy of feeding, at least daily for the first 2 days after the birth.

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

1.10.1 Long-term risk of cardiovascular disease

1.10.1.1 Tell women who have had gestational hypertension or pre-eclampsia, and their primary care clinicians, that these conditions are associated with an increased risk of developing high blood pressure and its complications in later life.

1.10.2 Long-term risk of end-stage kidney disease

1.10.2.1 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.

1.10.3 Thrombophilia and the risk of pre-eclampsia

1.10.3.1 Do not routinely perform screening for thrombophilia in women who have had pre-eclampsia.

1.10.4 Risk of recurrence of hypertensive disorders of pregnancy

1.10.4.1 Tell women who had gestational hypertension that their risk of developing:

  • gestational hypertension in a future pregnancy ranges from about 1 in 6 (16%) pregnancies to about 1 in 2 (47%) pregnancies

  • pre-eclampsia in a future pregnancy ranges from 1 in 50 (2%) to about 1 in 14 (7%) pregnancies.

1.10.4.2 Tell women who had pre-eclampsia that their risk of developing:

  • gestational hypertension in a future pregnancy ranges from about 1 in 8 (13%) pregnancies to about 1 in 2 (53%) pregnancies

  • pre-eclampsia in a future pregnancy is up to about 1 in 6 (16%) pregnancies

  • pre-eclampsia in a future pregnancy is about 1 in 4 (25%) pregnancies if their pre-eclampsia was complicated by severe pre-eclampsia, HELLP syndrome or eclampsia and led to birth before 34 weeks, and about 1 in 2 (55%) pregnancies if it led to birth before 28 weeks.

1.10.5 Inter-pregnancy interval and recurrence of hypertensive disorders of pregnancy

1.10.5.1 Tell women who have had pre-eclampsia that there is no additional risk of recurrence with inter-pregnancy interval up to 10 years.

1.10.6 Body mass index and recurrence of hypertensive disorders of pregnancy

1.10.6.1 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, 'Obesity', NICE clinical guideline 43).



[2] The Eclampsia Trial Collaborative Group (1995) Which anticonvulsant for women with eclampsia? Evidence from the Collaborative Eclampsia Trial. Lancet 345:1455–63

[3] Table adapted by the Guideline Development Group from Intensive Care Society, Standards and Guidelines 2002.

  • National Institute for Health and Care Excellence (NICE)