Recommendations | Hypertension in pregnancy: diagnosis and management | Guidance

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

For the indication in recommendations 1.1.2 and 1.1.3, although its use is common in UK clinical practice, at the time of publication (June 2019), aspirin did not have a UK marketing authorisation. 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. See NICE's information on prescribing medicines.

1.1.2 Advise pregnant women at high risk of pre-eclampsia to take 75 mg to 150 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 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 mg to 150 mg of aspirin daily from 12 weeks until the birth of the baby. Factors indicating moderate risk are:

nulliparity
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]

For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see the rationale and impact section on assessment of proteinuria.

Full details of the evidence and the committee's discussion are in evidence review G: assessment of proteinuria.

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):

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]

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'.

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. [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 labetalol and nifedipine are not suitable. Base the choice on any pre-existing treatment, side-effect profiles, risks (including fetal effects) and the woman's preference. [2019]

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. See NICE's information on prescribing medicines.

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

Although its 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. See NICE's information on prescribing medicines.

1.3.12 Offer placental growth factor (PLGF)-based testing to help rule out pre-eclampsia between 20 weeks and 36 weeks and 6 days 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 preterm pre-eclampsia). [2019, amended 2023]

For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see the rationale and impact section on treatment of chronic hypertension.

Full details of the evidence and the committee's discussion are in evidence review A: interventions for chronic hypertension.

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 in the section on timing of birth), 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 (for choice of antihypertensive during the postnatal period, see the section on antihypertensive treatment during the postnatal period, including during breastfeeding)
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 (for choice of antihypertensive during the postnatal period, see the section on antihypertensive treatment during the postnatal period, including during breastfeeding). [2010, amended 2019]

1.3.20 Offer women with chronic hypertension a medical review 6 to 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**
Management	Hypertension: blood pressure (BP) of 140/90 to 159/109 mmHg	Severe hypertension: blood pressure of 160/110 mmHg or more
Admission to hospital	Do not routinely admit to hospital	Admit, but if BP falls below 160/110 mmHg, then manage as for hypertension
Antihypertensive pharmacological treatment	Offer pharmacological treatment if BP remains above 140/90 mmHg	Offer pharmacological treatment to all women
Target blood pressure once on antihypertensive treatment	Aim for BP of 135/85 mmHg or less	Aim for BP of 135/85 mmHg or less
Blood pressure measurement	Once or twice a week (depending on BP) until BP is 135/85 mmHg or less	Every 15 to 30 minutes until BP is less than 160/110 mmHg
Dipstick proteinuria testing (Use an automated reagent-strip reading device for dipstick screening for proteinuria in a secondary care setting)	Once or twice a week (with BP measurement)	Daily while admitted
Blood tests	Measure full blood count, liver function and renal function at presentation and then weekly	Measure full blood count, liver function and renal function at presentation and then weekly
Placental growth factor (PLGF)-based testing	Carry out PLGF-based testing on 1 occasion (in accordance with NICE guidance, see recommendation 1.4.4) if there is suspicion of pre-eclampsia	Carry out PLGF-based testing on 1 occasion (in accordance with NICE guidance, see recommendation 1.4.4) if there is suspicion of pre-eclampsia
Fetal assessment	Offer fetal heart auscultation at every antenatal appointment Carry out ultrasound assessment of the fetus at diagnosis and, if normal, repeat every 2 to 4 weeks, if clinically indicated Carry out a cardiotocography (CTG) only if clinically indicated (For advice, see the section on fetal monitoring)	Offer fetal heart auscultation at every antenatal appointment Carry out ultrasound assessment of the fetus at diagnosis and, if normal, repeat every 2 weeks, if severe hypertension persists Carry out a CTG at diagnosis and then only if clinically indicated (For advice, see the section on fetal monitoring

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 36 weeks and 6 days of pregnancy. (See the NICE diagnostics guidance on PLGF-based testing to help diagnose suspected preterm pre-eclampsia.) [2019, amended 2023]

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

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. See NICE's information on prescribing medicines.

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

For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see the rationale and impact section on monitoring and treatment of gestational hypertension.

Full details of the evidence and the committee's discussion are in evidence review B: monitoring gestational hypertension.

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 in the section on timing of birth), offer a course of antenatal corticosteroids and magnesium sulfate if indicated, in line with the NICE guideline on preterm labour and birth. [2010, amended 2019]

Postnatal investigation, monitoring and treatment

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

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

1.4.11 In women with gestational hypertension who have given birth:

continue antihypertensive treatment if required (for choice of antihypertensive during the postnatal period, see the section on antihypertensive treatment during the postnatal period, including during breastfeeding)
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 (for choice of antihypertensive during the postnatal period, see the section on antihypertensive treatment during the postnatal period, including during breastfeeding). [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 to 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]

For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see the rationale and impact section on assessment of women with pre-eclampsia.

Full details of the evidence and the committee's discussion are in evidence review C: prediction of complications in pre-eclampsia.

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**
Management	Hypertension: blood pressure (BP) of 140/90 to 159/109 mmHg	Severe hypertension: blood pressure of 160/110 mmHg or more
Admission to hospital	Admit if any clinical concerns for the wellbeing of the woman or baby (see recommendation 1.5.2) or if high risk of adverse events suggested by the fullPIERS or PREP‑S risk prediction models	Admit, but if BP falls below 160/110 mmHg, then manage as for hypertension
Antihypertensive pharmacological treatment	Offer pharmacological treatment if BP remains above 140/90 mmHg	Offer pharmacological treatment to all women
Target blood pressure once on antihypertensive treatment	Aim for BP of 135/85 mmHg or less	Aim for BP of 135/85 mmHg or less
Blood pressure measurement	At least every 48 hours, and more frequently if the woman is admitted to hospital	Every 15 to 30 minutes until BP is less than 160/110 mmHg, then at least 4 times daily while the woman is an inpatient, depending on clinical circumstances
Dipstick proteinuria testing (Use an automated reagent-strip reading device for dipstick screening for proteinuria in a secondary care setting)	Only repeat if clinically indicated, for example, if new symptoms and signs develop or if there is uncertainty over diagnosis	Only repeat if clinically indicated, for example, if new symptoms and signs develop or if there is uncertainty over diagnosis
Blood tests	Measure full blood count, liver function and renal function twice a week	Measure full blood count, liver function and renal function 3 times a week
Fetal assessment	Offer fetal heart auscultation at every antenatal appointment Carry out ultrasound assessment of the fetus at diagnosis and, if normal, repeat every 2 weeks Carry out a cardiotocography (CTG) at diagnosis and then only if clinically indicated (For advice, see the section on fetal monitoring)	Offer fetal heart auscultation at every antenatal appointment Carry out ultrasound assessment of the fetus at diagnosis and, if normal, repeat every 2 weeks Carry out a CTG at diagnosis and then only if clinically indicated (For advice, see the section on fetal monitoring)

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 if labetalol or nifedipine are not suitable. Base the choice on any pre-existing treatment, side-effect profiles, risks (including fetal effects) and the woman's preference. [2010, amended 2019]

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. See NICE's information on prescribing medicines.

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]

Be aware that some pulse oximeters can underestimate or overestimate oxygen saturation levels, especially if the saturation level is borderline. Overestimation has been reported in people with dark skin. See also the NHS England Patient Safety Alert on the risk of harm from inappropriate placement of pulse oximeter probes.

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

For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see the rationale and impact section on monitoring and treatment of pre-eclampsia and timing of birth.

Full details of the evidence and the committee's discussion are in evidence review D: interventions for pre-eclampsia.

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

Blood pressure

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

at least 4 times a day while the woman is an inpatient
at least once between day 3 and day 5 after birth
on alternate days until normal, if blood pressure was abnormal on days 3 to 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 to 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 (for choice of antihypertensive during the postnatal period, see the section on antihypertensive treatment during the postnatal period, including during breastfeeding)
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 (for choice of antihypertensive during the postnatal period, see the section on antihypertensive treatment during the postnatal period, including during breastfeeding). [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 to 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 to 72 hours after birth or step-down
do not repeat platelet count, transaminases or serum creatinine measurements if results are normal at 48 to 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 to 8 weeks after the birth. [2010]

1.5.26 Offer women who had pre-eclampsia and still have proteinuria (1+ or more) at 6 to 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. [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 10^th centile
intrauterine death
placental abruption. [2010]

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

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 to 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:

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 g to 4 g given intravenously over 5 to 15 minutes. [2010, amended 2019]

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 to 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.

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
intravenous hydralazine. [2010, amended 2019]

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. See NICE's information on prescribing medicines.

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**
Critical care level	Clinical criteria
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 hypertension 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

For the indications in recommendations 1.9.4, 1.9.6 and 1.9.8, in 2009, the Medicines and Healthcare products Regulatory Agency (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 stating that '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'.

For the indications in recommendations 1.9.5 and 1.9.6, 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.

See NICE's information on prescribing medicines.

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, 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
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 amlodipine) and enalapril. If this combination is not tolerated or is ineffective, consider either:

adding atenolol or labetalol to the combination treatment or
swapping 1 of the medicines already being used for atenolol or labetalol. [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 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]

For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see the rationale and impact section on antihypertensive treatment during breastfeeding.

Full details of the evidence and the committee's discussion are in evidence review E: postnatal management of hypertension.

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**
Prevalence of hypertensive disorder in a future pregnancy	Any hypertension in previous or current pregnancy	Pre-eclampsia in previous or current pregnancy	Gestational hypertension in previous or current pregnancy
Any hypertension	Approximately 21% (1 in 5 women)	Approximately 20% (1 in 5 women)	Approximately 22% (1 in 5 women)
Pre-eclampsia	Approximately 14% (1 in 7 women)	Up to approximately 16% (1 in 6 women) If birth was at 28 to 34 weeks: approximately 33% (1 in 3 women) (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) If birth was at 34 to 37 weeks: approximately 23% (1 in 4 women)	Approximately 7% (1 in 14 women)
Gestational hypertension	Approximately 9% (1 in 11 women)	Between approximately 6 and 12% (up to 1 in 8 women)	Between approximately 11% and 15% (up to 1 in 7 women)
Chronic hypertension	Not applicable	Approximately 2% (up to 1 in 50 women)	Approximately 3% (up to 1 in 34 women)

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**
Risk of future cardiovascular disease	Any hypertension in current or previous pregnancy	Pre-eclampsia in current or previous pregnancy	Gestational hypertension in current or previous pregnancy	Chronic hypertension in current or previous pregnancy
Major adverse cardiovascular event	Risk increased (up to approximately 2 times)	Risk increased (approximately 1.5 to 3 times)	Risk increased (approximately 1.5 to 3 times)	Risk increased (approximately 1.7 times)
Cardiovascular mortality	Risk increased (up to approximately 2 times)	Risk increased (approximately 2 times)	(no data)	(no data)
Stroke	Risk increased (up to approximately 1.5 times)	Risk increased (approximately 2 to 3 times)	Risk may be increased	Risk increased (approximately 1.8 times)
Hypertension	Risk increased (approximately 2 to 4 times)	Risk increased (approximately 2 to 5 times)	Risk increased (approximately 2 to 4 times)	(not applicable)

Notes: Risks described are overall estimates, summarised from risk ratios, odds ratios and hazard ratios.

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 tobacco
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]

For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see rationale and impact section on risk of recurrence of hypertensive disorders of pregnancy and long-term cardiovascular disease.

Full details of the evidence and the committee's discussion are in evidence review F: advice at discharge.

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 to 24.9 kg/m²). See also the NICE guideline on obesity. [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 to 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.