Surveillance decision

Surveillance decision

We will plan an update of the following sections of the guideline:

We will amend the following recommendations:

  • Obesity CG43 (recommendation 1.10.6.1)

    • This guideline has been updated and replaced by: obesity: identification, assessment and management (November 2014) CG189

  • Intrapartum care CG55 (section 1.7, Intrapartum care)

    • This guideline has been updated and replaced by: intrapartum care for healthy women and babies (December 2014) CG190.

Other amendments:

  • Footnotes: the full guideline will be updated to repeat footnotes relating to license status or SPC information (* and †) on each page where they are applicable to drugs, to clarify the meaning of the symbols for readers.

  • Collaborative Eclampsia Trial – the wording of recommendation 1.8.1.4 will be clarified to include the wording 'after last fit' based on the license for magnesium sulphate which states to continue for 24 hours (or at least 24 hours) after last fit.

  • Licensing information: some brands of magnesium sulphate injection are licensed to prevent further seizures associated with eclampsia, although not all are licensed for this and one preparation is licensed for prevention of recurrent seizures in eclampsia. The indication for magnesium sulphate in recommendation 1.8.1.1 is now a licensed indication, and the asterisk indicating that it is unlicensed should be removed. This will also be considered for recommendations 1.8.1.2, 1.8.1.3, 1.8.1.4, 1.8.1.5. Additionally, the spelling of 'magnesium sulphate', listed as 'magnesium sulfate' in the BNF, will be amended in the guideline.

  • Hydralazine: a footnote for hydralazine will be added in recommendation 1.8.2.1. IV hydralazine is licensed for this indication but the Summary of product characteristics (Dec 2013) also states: Use of hydralazine in pregnancy, before the third trimester should be avoided but the drug maybe employed in later pregnancy if there is no safer alternative or when the disease itself carries serious risks for the mother or child for example, pre-eclampsia and /or eclampsia. The required footnote would be the same as that of labetalol and nifedipine in recommendation 1.8.2.1, to state:

    • This guideline assumes that prescribers will use a drug's summary of product characteristics (SPC) to inform decisions made with individual patients. Drugs for which particular attention should be paid to the contraindications and special warnings during pregnancy and lactation are marked with † and detailed in section 1.6 of the full guideline.

  • Appendix D: Drug information: this will be updated with hydralazine added and updated licensing information.

Reason for the decision

We found 140 studies through surveillance of this guideline.

New evidence that could affect recommendations was identified. Topic experts, including those who helped to develop the guideline, advised us about whether the following sections of the guideline should be updated:

Management of pregnancy with chronic hypertension

  • What interventions for chronic hypertension are effective at improving outcomes for women and infants?

Topic experts advised that the question should be updated to replace the Control of Hypertension In Pregnancy Study (CHIPS) pilot study results with the full CHIPS study results. Topic expert advice further indicated that the full results elucidated the protection from severe hypertension if blood pressure is lowered to a diastolic level of 85mmHg, which has a potential impact on recommendation 1.2.3.1.

Decision: This question should be updated.

Assessment of proteinuria in hypertensive disorders of pregnancy

  • Measurement of proteinuria (no review questions for this section of the guideline).

Topic expert feedback indicated that the new published evidence is unlikely to impact on recommendations because the 12 hour urine collection is not used in clinical practice. However, further topic expert advice advised that the results of the Diagnostic Accuracy in Pregnancy using Proteinuria Assessment (DAPPA) trial could have a potential impact on the recommendations and should be awaited before updating the guideline.

Decision: The review question should be considered for a future update, following publication of the DAPPA study. The study is likely to be published in 2017 and will be tracked by the Surveillance team.

Management of pregnancy with gestational hypertension

  • What investigations, monitoring and advice should take place when gestational hypertension is diagnosed?

Topic experts advised that Saving Mothers' Lives: Reviewing maternal deaths to make motherhood safer: 2006–08. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom is unlikely to impact on the guideline recommendations. This is because the evidence was based on observational data and expert advice, rather than on clinical trials.

However, topic experts advised that the question should be updated to incorporate the CHIPS study results. Topic expert advice further indicated that the full results elucidated the protection from severe hypertension if blood pressure is lowered to a diastolic level of 85 mmHg, which has a potential impact on Table 1 Management of pregnancy with gestational hypertension.

Decision: This question should be updated.

Management of pregnancy with pre-eclampsia

  • What advice, investigations and monitoring should take place when pre-eclampsia is diagnosed?

  • What interventions are effective in improving outcomes for women and infants in women with pre-eclampsia?

Topic experts advised that Saving Mothers' Lives: Reviewing maternal deaths to make motherhood safer: 2006–08. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom is unlikely to impact on Table 2 Management of pregnancy with pre-eclampsia, particularly as Table 2 already states that treatment should be carried out if blood pressure rises above 150 mmHg. Additionally, the report was based on observational data and expert advice, rather than on clinical trials.

Topic expert feedback indicated that nicardipine is now licensed for the indication of severe pre-eclampsia, when other intravenous antihypertensive agents are not recommended or are contra-indicated. There is a potential impact on Table 2 and recommendation 1.5.1.3, to consider nicardipine as an additional alternative licensed drug for the first line treatment of severe or moderate pre-eclampsia.

Decision: These questions should be updated.

Breastfeeding

  • How should women, who were hypertensive in pregnancy, especially for those who wish to breastfeed, be managed in the postnatal period?

No new evidence was identified that would affect recommendations.

However, topic expert feedback indicated that the wording of recommendations 1.9.1.2 and 1.9.1.4 requires review due to discrepancies between the NICE guideline and the full guideline. The wording of these recommendations may therefore require review.

Decision: This question should be updated.

Advice and follow-up care at transfer to community care

  • What advice should be given to women who have had hypertension in pregnancy at discharge from maternity care?

Topic expert feedback indicated that the new individual patient data (IPD) meta-analysis evidence indicating a relatively low recurrence rate of hypertension in pregnancy in a next pregnancy has a potential impact on recommendations 1.10.4.1 and 1.10.4.2, relating to the advice given to women about risk of recurrence.

Decision: This question should be updated.

Other clinical areas

We did not find any new evidence in areas not covered by the original guideline.

For new evidence relating to PlGF-based testing to help diagnose suspected pre-eclampsia (2016) NICE diagnostics guidance 23, the guideline surveillance review deferred to the diagnostic guidance.

Equalities

No equalities issues were identified during the surveillance process.

Overall decision

After considering all the new evidence and views of topic experts, we decided that a partial update is necessary for this guideline.

See how we made the decision for further information.


This page was last updated: 09 January 2017