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["Baseline assessment: Hypertension in "]
["pregnancy: diagnosis and management"]
["NG133"]
[]
[]
["Published: 25 June 2019"]
["Updated: 17 April 2023"]

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["Baseline assessment tool for hypertension in pregnancy: diagnosis and management (NICE guideline NG133)"]
["This baseline assessment tool can be used to evaluate whether practice is in line with the recommendations in Hypertension in pregnancy: diagnosis and management.  It can also help to plan activity to meet the recommendations."]
["The tool can be used by individual services or organisations. Alternatively, an assessment completed with the involvement of all relevant services or organisations would help to develop a picture of activity in the local area."]
["It should be used in conjunction with hypertension in pregnancy: diagnosis and management (NICE guideline NG133)."]
["In the first instance, consider whether the guideline is relevant and record the conclusion in the box below."]
["Is the guideline relevant?"]
[]
["The data sheet contains the recommendations from the guideline. Information can be entered about current activity relevant to the recommendation, actions needed to meet the recommendation, deadlines and the names of the responsible leads.  Useful documents can be added as hyperlinks."]
["The table can be adapted to include any other local information that is thought to be useful."]
["If it would be helpful to group the recommendations, for example those that are key priorities for implementation or by deadline, use the filter function in the data menu. "]
["Tools and resources to help put the guidance into practice are available on the NICE website. "]
["National Institute for Health and Care Excellence\nLevel 1A, City Tower, Piccadilly Plaza, Manchester M1 4BT; www.nice.org.uk\n\nCopyright\n© NICE 2023. All rights reserved. Subject to Notice of rights.\n"]

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["Baseline assessment tool for hypertension in pregnancy: diagnosis and management (NICE guideline NG133)"]
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[]
["NICE recommendation","Guideline reference","Year of recommendation","Is the recommendation relevant?","Current activity/evidence","Recommendation met?","Actions needed to implement recommendation","Is there a risk associated with not implementing this recommendation?","Is there a cost or saving?","Deadline","Lead"]
["1.1  Reducing the risk of hypertensive disorders in pregnancy"]
["Symptoms of pre-eclampsia"]
["Advise pregnant women to see a healthcare professional immediately if they experience symptoms of pre-eclampsia. Symptoms include:\n•\tsevere headache\n•\tproblems with vision, such as blurring or flashing before the eyes\n•\tsevere pain just below the ribs\n•\tvomiting\n•\tsudden swelling of the face, hands or feet. \nSee the NICE guideline on antenatal care for advice on risk factors and symptoms of pre-eclampsia. ","1.1.1","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."]
["Advise pregnant women at high risk of pre-eclampsia to take 75–150 mg of aspirin daily from 12 weeks until the birth of the baby. Women at high risk are those with any of the following:\n•\thypertensive disease during a previous pregnancy\n•\tchronic kidney disease\n•\tautoimmune disease such as systemic lupus erythematosus or antiphospholipid syndrome\n•\ttype 1 or type 2 diabetes\n•\tchronic hypertension. ","1.1.2","2010, amended 2019"]
["Advise pregnant women with more than 1 moderate risk factor for pre-eclampsia to take 75–150 mg of aspirin daily from 12 weeks until the birth of the baby. Factors indicating moderate risk are:\n•\tfirst pregnancy\n•\tage 40 years or older\n•\tpregnancy interval of more than 10 years\n•\tbody mass index (BMI) of 35 kg/m2 or more at first visit\n•\tfamily history of pre-eclampsia\n•\tmulti-fetal pregnancy. ","1.1.3","2010, amended 2019"]
["Other pharmaceutical agents"]
["Do not use the following to prevent hypertensive disorders during pregnancy:\n•\tnitric oxide donors\n•\tprogesterone\n•\tdiuretics\n•\tlow molecular weight heparin.","1.1.4",2010]
["Nutritional supplements"]
["Do not recommend the following supplements solely with the aim of preventing hypertensive disorders during pregnancy:\n•\tmagnesium\n•\tfolic acid\n•\tantioxidants (vitamins C and E)\n•\tfish oils or algal oils\n•\tgarlic. ","1.1.5",2010]
["Diet"]
["Do not recommend salt restriction during pregnancy solely to prevent gestational hypertension or pre-eclampsia. ","1.1.6",2010]
["Lifestyle"]
["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. ","1.1.7","2010, amended 2019"]
["Diabetes"]
["For women with pre-existing diabetes or gestational diabetes, see the NICE guideline on diabetes in pregnancy. ","1.1.8",2019]
["1.2   Assessment of proteinuria in hypertensive disorders of pregnancy"]
["Interpret proteinuria measurements for pregnant women in the context of a full clinical review of symptoms, signs and other investigations for pre-eclampsia.","1.2.1",2019]
["Use an automated reagent-strip reading device for dipstick screening for proteinuria in pregnant women in secondary care settings. ","1.2.2",2019]
["If dipstick screening is positive (1+ or more) use albumin:creatinine ratio or protein:creatinine ratio to quantify proteinuria in pregnant women.","1.2.3",2019]
["Do not use first morning urine void to quantify proteinuria in pregnant women. ","1.2.4",2019]
["Do not routinely use 24-hour urine collection to quantify proteinuria in pregnant women. ","1.2.5",2019]
["If using protein:creatinine ratio to quantify proteinuria in pregnant women:\n•\tuse 30 mg/mmol as a threshold for significant proteinuria\n•\tif 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. ","1.2.6",2019]
["If using albumin:creatinine ratio as an alternative to protein:creatinine ratio to diagnose pre-eclampsia in pregnant women with hypertension:\n•\tuse 8 mg/mmol as a diagnostic threshold\n•\tif 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. ","1.2.7",2019]
["1.3  Management of chronic hypertension in pregnancy"]
["Pre-pregnancy advice"]
["Offer women with chronic hypertension referral to a specialist in hypertensive disorders of pregnancy to discuss the risks and benefits of treatment. ","1.3.1","2010, amended 2019"]
["Advise women who take angiotensin-converting enzyme (ACE) inhibitors or angiotensin-II receptor blockers (ARBs):\n• that there is an increased risk of congenital abnormalities if these drugs are taken during pregnancy\n• to discuss alternative antihypertensive treatment with the healthcare professional responsible for managing their hypertension, if they are planning pregnancy\n• 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. ","1.3.2","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'."]
["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. ","1.3.3",2010]
["Advise women who take thiazide or thiazide-like diuretics:\n•\tthat there may be an increased risk of congenital abnormalities and neonatal complications if these drugs are taken during pregnancy\n•\tto discuss alternative antihypertensive treatment with the healthcare professional responsible for managing their hypertension, if they are planning pregnancy. ","1.3.4","2010, amended 2019"]
["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. ","1.3.5","2010, amended 2019"]
["Treatment of chronic hypertension"]
["Offer pregnant women with chronic hypertension advice on: \n• weight management\n• exercise\n• healthy eating\n• lowering the amount of salt in their diet. \nProvide this advice in line with the NICE guideline on hypertension in adults: diagnosis and treatment. ","1.3.6",2019]
["\tContinue with existing antihypertensive treatment if safe in pregnancy, or switch to an alternative treatment, unless:\n•\tsustained systolic blood pressure is less than 110 mmHg or \n•\tsustained diastolic blood pressure is less than 70 mmHg or\n•\tthe woman has symptomatic hypotension. ","1.3.7",2019]
["\tOffer antihypertensive treatment to pregnant women who have chronic hypertension and who are not already on treatment if they have:\n•\tsustained systolic blood pressure of 140 mmHg or higher or\n•\tsustained diastolic blood pressure of 90 mmHg or higher. ","1.3.8",2019]
["When using medicines to treat hypertension in pregnancy, aim for a target blood pressure of 135/85 mmHg. ","1.3.9",2019]
["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. ","1.3.10",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."]
["Offer pregnant women with chronic hypertension aspirin 75–150 mg once daily from 12 weeks. ","1.3.11",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."]
["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 pre-term pre-eclampsia). ","1.3.12","2019, amended 2023"]
["Antenatal appointments"]
["In women with chronic hypertension, schedule additional antenatal appointments based on the individual needs of the woman and her baby. This may include:\n•\tweekly appointments if hypertension is poorly controlled\n•\tappointments every 2 to 4 weeks if hypertension is well-controlled. ","1.3.13","2010, amended 2019"]
["Timing of birth"]
["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. ","1.3.14","2010, amended 2019"]
["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. ","1.3.15",2010]
["If planned early birth is necessary (see recommendation 1.5.7) offer a course of antenatal corticosteroids and magnesium sulfate if indicated, in line with the NICE guideline on preterm labour and birth. ","1.3.16","2010, amended 2019"]
["Postnatal investigation, monitoring and treatment"]
["In women with chronic hypertension who have given birth, measure blood pressure:\n•\tdaily for the first 2 days after birth\n•\tat least once between day 3 and day 5 after birth\n•\tas clinically indicated if antihypertensive treatment is changed after birth. ","1.3.17",2010]
["In women with chronic hypertension who have given birth:\n•\taim to keep blood pressure lower than 140/90 mmHg \n•\tcontinue 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)\n•\toffer a review of antihypertensive treatment 2 weeks after the birth, with their GP or specialist.","1.3.18","2010, amended 2019"]
["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). ","1.3.19","2010, amended 2019"]
["Offer women with chronic hypertension a medical review 6–8 weeks after the birth with their GP or specialist as appropriate. ","1.3.20","2010, amended 2019"]
["1.4  Management of gestational hypertension"]
["Assessment and treatment of gestational hypertension"]
["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.","1.4.1","2010, amended 2019"]
["In women with gestational hypertension, take account of the following risk factors that require additional assessment and follow-up:\n•\tnulliparity\n•\tage 40 years or older\n•\tpregnancy interval of more than 10 years\n•\tfamily history of pre-eclampsia\n•\tmulti-fetal pregnancy\n•\tBMI of 35 kg/m2 or more\n•\tgestational age at presentation\n•\tprevious history of pre-eclampsia or gestational hypertension\n•\tpre-existing vascular disease\n•\tpre-existing kidney disease. ","1.4.2",2010]
["Offer women with gestational hypertension the tests and treatment listed in table 1. ","1.4.3",2019]
["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 pre-term pre-eclampsia.) ","1.4.4","2019, amended 2023"]
["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. ","1.4.5","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."]
["Do not offer bed rest in hospital as a treatment for gestational hypertension.","1.4.6",2010]
["Timing of birth"]
["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. ","1.4.7","2010, amended 2019"]
["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. ","1.4.8","2010, amended 2019"]
["If planned early birth is necessary (see recommendation 1.5.7) offer a course of antenatal corticosteroids and magnesium sulfate if indicated, in line with the NICE guideline on preterm labour and birth. ","1.4.9","2010, amended 2019"]
["Postnatal investigation, monitoring and treatment"]
["In women with gestational hypertension who have given birth, measure blood pressure:\n•\tdaily for the first 2 days after birth\n•\tat least once between day 3 and day 5 after birth\n•\tas clinically indicated if antihypertensive treatment is changed after birth. ","1.4.10",2010]
["In women with gestational hypertension who have given birth:\n•\tcontinue 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)\n•\tadvise women that the duration of their postnatal antihypertensive treatment will usually be similar to the duration of their antenatal treatment (but may be longer) \n•\treduce antihypertensive treatment if their blood pressure falls below 130/80 mmHg. ","1.4.11","2010, amended 2019"]
["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).","1.4.12","2010, amended 2019"]
["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. ","1.4.13","2010, amended 2019"]
["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:\n•\twho will provide follow-up care, including medical review if needed\n•\tfrequency of blood pressure monitoring needed\n•\tthresholds for reducing or stopping treatment\n•\tindications for referral to primary care for blood pressure review. ","1.4.14",2010]
["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. ","1.4.15","2010, amended 2019"]
["Offer all women who have had gestational hypertension a medical review with their GP or specialist 6–8 weeks after the birth. ","1.4.16","2010, amended 2019"]
["1.5  Management of pre-eclampsia"]
["Assessing pre-eclampsia"]
["Assessment of women with pre-eclampsia should be performed by a healthcare professional trained in the management of hypertensive disorders of pregnancy. ","1.5.1","2010, amended 2019"]
["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:\n•\tsustained systolic blood pressure of 160 mmHg or higher\n•\tany maternal biochemical or haematological investigations that cause concern, for example, a new and persistent:\n-\trise in creatinine (90 micromol/litre or more, 1 mg/100 ml or more), or\n-\trise in alanine transaminase (over 70 IU/litre, or twice upper limit of normal range), or\n-\tfall in platelet count (under 150,000/microlitre)\n•\tsigns of impending eclampsia\n•\tsigns of impending pulmonary oedema\n•\tother signs of severe pre-eclampsia\n•\tsuspected fetal compromise\n•\tany other clinical signs that cause concern. ","1.5.2",2019]
["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.","1.5.3",2019]
["When using a risk prediction model, take into account that: \n• fullPIERS is intended for use at any time during pregnancy\n• PREP-S is intended for use only up to 34 weeks of pregnancy\n• fullPIERS and PREP-S models do not predict outcomes for babies. ","1.5.4",2019]
["Treatment of pre-eclampsia"]
["Offer women with pre-eclampsia the tests and treatments listed in table 2. ","1.5.5",2019]
["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. ","1.5.6","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"]
["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:\n• inability to control maternal blood pressure despite using 3 or more classes of antihypertensives in appropriate doses\n• maternal pulse oximetry less than 90%\n• progressive deterioration in liver function, renal function, haemolysis, or platelet count\n• ongoing neurological features, such as severe intractable headache, repeated visual scotomata, or eclampsia\n• placental abruption\n• reversed end-diastolic flow in the umbilical artery doppler velocimetry, a non-reassuring cardiotocograph, or stillbirth. \nOther features not listed above may also be considered in the decision to plan early birth.\nBe 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.","1.5.7",2019]
["Involve a senior obstetrician in any decisions on timing of birth for women with pre-eclampsia. ","1.5.8","2010, amended 2019"]
["Discuss with the anaesthetic team if birth is planned in a woman with pre-eclampsia. ","1.5.9","2010, amended 2019"]
["Discuss with the neonatal team if birth is planned in a woman with pre-eclampsia, and neonatal complications are anticipated. ","1.5.10","2010, amended 2019"]
["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. ","1.5.11","2010, amended 2019"]
["Decide on timing of birth in women with pre-eclampsia as recommended in table 3. ","1.5.12",2019]
["Postnatal investigation, monitoring and treatment (including after discharge from critical care)"]
["Blood pressure"]
["In women with pre-eclampsia who did not take antihypertensive treatment and have given birth, measure blood pressure:\n• at least 4 times a day while the woman is an inpatient\n• at least once between day 3 and day 5 after birth\n• on alternate days until normal, if blood pressure was abnormal on days 3–5. ","1.5.13",2010]
["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.","1.5.14",2010]
["Ask women with pre-eclampsia who have given birth about severe headache and epigastric pain each time blood pressure is measured. ","1.5.15",2010]
["In women with pre-eclampsia who took antihypertensive treatment and have given birth, measure blood pressure:\n•\tat least 4 times a day while the woman is an inpatient\n•\tevery 1–2 days for up to 2 weeks after transfer to community care until the woman is off treatment and has no hypertension. ","1.5.16",2010]
["For women with pre-eclampsia who have taken antihypertensive treatment and have given birth:\n•\tcontinue antihypertensive treatment (for choice of antihypertensive during the postnatal period, see the section on antihypertensive treatment during the postnatal period, including during breastfeeding)\n•\tconsider reducing antihypertensive treatment if their blood pressure falls below 140/90 mmHg\n•\treduce antihypertensive treatment if their blood pressure falls below 130/80 mmHg. ","1.5.17","2010, amended 2019"]
["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).","1.5.18","2010, amended 2019"]
["Offer women with pre-eclampsia who have given birth transfer to community care if all of the following criteria have been met:\n•\tthere are no symptoms of pre-eclampsia\n•\tblood pressure, with or without treatment, is 150/100 mmHg or less\n•\tblood test results are stable or improving. ","1.5.19","2010, amended 2019"]
["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:\n•\twho will provide follow-up care, including medical review if needed\n•\tfrequency of blood pressure monitoring\n•\tthresholds for reducing or stopping treatment\n•\tindications for referral to primary care for blood pressure review\n•\tself-monitoring for symptoms. ","1.5.20",2010]
["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. ","1.5.21","2010, amended 2019"]
["Offer all women who have had pre-eclampsia a medical review with their GP or specialist 6–8 weeks after the birth. ","1.5.22","2010, amended 2019"]
["Haematological and biochemical monitoring"]
["In women who have pre-eclampsia with mild or moderate hypertension, or after step-down from critical care:\n•\tmeasure platelet count, transaminases and serum creatinine 48–72 hours after birth or step-down\n•\tdo not repeat platelet count, transaminases or serum creatinine measurements if results are normal at 48–72 hours. ","1.5.23",2010]
["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. ","1.5.24","2010, amended 2019"]
["In women with pre-eclampsia who have given birth, carry out a urinary reagent-strip test 6–8 weeks after the birth. ","1.5.25",2010]
["Offer women who had pre-eclampsia and still have proteinuria (1+ or more) at 6–8 weeks after the birth a further review with their GP or specialist at 3 months after the birth to assess kidney function. ","1.5.26","2010, amended 2019"]
["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. ","1.5.27","2010, amended 2019"]
["1.6  Fetal monitoring"]
["Fetal monitoring in chronic hypertension"]
["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.","1.6.1","2010, amended 2019"]
["In women with chronic hypertension, only carry out cardiotocography if clinically indicated. ","1.6.2","2010, amended 2019"]
["Fetal monitoring in gestational hypertension"]
["In women with gestational hypertension, carry out an ultrasound for fetal growth and amniotic fluid volume assessment and umbilical artery doppler velocimetry at diagnsis and if normal repeat every 2 to 4 weeks, if clinically indicated. ","1.6.3","2010, amended 2019"]
["In women with gestational hypertension, only carry out cardiotocography if clinically indicated. ","1.6.4","2010, amended 2019"]
["Fetal monitoring in pre-eclampsia or severe gestational hypertension"]
["Carry out cardiotocography at diagnosis of pre-eclampsia or severe gestational hypertension. ","1.6.5",2010]
["If conservative management of pre-eclampsia or severe gestational hypertension is planned, carry out all the following tests at diagnosis:\n•\tultrasound for fetal growth and amniotic fluid volume assessment\n•\tumbilical artery doppler velocimetry. ","1.6.6",2010]
["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. ","1.6.7","2010, amended 2019"]
["\tIn women with pre-eclampsia or severe gestational hypertension, repeat cardiotocography if any of the following occur:\n•\tthe woman reports a change in fetal movement\n•\tvaginal bleeding\n•\tabdominal pain\n•\tdeterioration in maternal condition. ","1.6.8",2010]
["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. ","1.6.9","2010, amended 2019"]
["For women with pre-eclampsia or severe gestational hypertension, write a care plan that includes all of the following:\n•\tthe timing and nature of future fetal monitoring\n•\tfetal indications for birth and if and when antenatal corticosteroids should be given\n•\tplans for discussion with neonatal paediatricians and obstetric anaesthetists. ","1.6.10","2010, amended 2019"]
["Women who need additional fetal monitoring"]
["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:\n• severe pre-eclampsia\n• pre-eclampsia that resulted in birth before 34 weeks\n• pre-eclampsia with a baby whose birth weight was less than the 10th centile\n• intrauterine death\n• placental abruption. ","1.6.11",2010]
["In women who need additional fetal monitoring (see recommendation 1.6.11), carry out cardiotocography only if clinically indicated. ","1.6.12","2010, amended 2019"]
["1.7  Intrapartum care"]
["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. ","1.7.1","2010, amended 2019"]
["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. ","1.7.2",2019]
["Blood pressure"]
["During labour, measure blood pressure:\n•\thourly, in women with hypertension\n•\tevery 15–30 minutes until blood pressure is less than 160/110 mmHg in women with severe hypertension. ","1.7.3","2010, amended 2019"]
["Continue use of antenatal antihypertensive treatment during labour. ","1.7.4",2010]
["Haematological and biochemical monitoring"]
["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. ","1.7.5",2010]
["Care during epidural analgesia"]
["Do not preload women who have severe pre-eclampsia with intravenous fluids before establishing low-dose epidural analgesia or combined spinal epidural analgesia. ","1.7.6","2010, amended 2019"]
["Management of second stage of labour"]
["Do not routinely limit the duration of the second stage of labour in women with controlled hypertension. ","1.7.7","2010, amended 2019"]
["Consider operative or assisted birth in the second stage of labour for women with severe hypertension whose hypertension has not responded to initial treatment. ","1.7.8","2010, amended 2019"]
["1.8  Medical management of severe hypertension, severe pre-eclampsia or eclampsia in a critical care setting"]
["Anticonvulsants"]
["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. ","1.8.1",2010]
["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. ","1.8.2",2010]
["Consider the need for magnesium sulfate treatment, if 1 or more of the following features of severe pre-eclampsia is present:\n•\tongoing or recurring severe headaches\n•\tvisual scotomata \n•\tnausea or vomiting\n•\tepigastric pain\n•\toliguria and severe hypertension\n•\tprogressive deterioration in laboratory blood tests (such as rising creatinine or liver transaminases, or falling platelet count).","1.8.3","2010, amended 2019"]
["Use the Collaborative Eclampsia Trial regimen for administration of magnesium sulfate:\n• 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,\n• Recurrent fits should be treated with a further dose of 2–4 g given intravenously over 5 to 15 minutes. ","1.8.4","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."]
["Do not use diazepam, phenytoin or other anticonvulsants as an alternative to magnesium sulfate in women with eclampsia.","1.8.5","2010, amended 2019"]
["Antihypertensives"]
["Treat women with severe hypertension who are in critical care during pregnancy or after birth immediately with 1 of the following:\n•\tlabetalol (oral or intravenous)\n•\toral nifedipine \n•\tintravenous hydralazine. ","1.8.6","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."]
["In women with severe hypertension who are in critical care, monitor their response to treatment:\n•\tto ensure that their blood pressure falls\n•\tto identify adverse effects for both the woman and the baby\n•\tto modify treatment according to response. ","1.8.7",2010]
["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. ","1.8.8",2010]
["Corticosteroids for fetal lung maturation"]
["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. ","1.8.9","2010, amended 2019"]
["Corticosteroids to manage HELLP syndrome"]
["Do not use dexamethasone or betamethasone for the treatment of HELLP syndrome. ","1.8.10",2010]
["Fluid balance and volume expansion"]
["Do not use volume expansion in women with severe pre-eclampsia unless hydralazine is the antenatal antihypertensive. ","1.8.11",2010]
["In women with severe pre-eclampsia, limit maintenance fluids to 80 ml/hour unless there are other ongoing fluid losses (for example, haemorrhage). ","1.8.12",2010]
["Caesarean section versus induction of labour"]
["Choose mode of birth for women with severe hypertension, severe pre-eclampsia or eclampsia according to the clinical circumstances and the woman's preference. ","1.8.13",2010]
["Referral to critical care"]
["Refer women with severe hypertension or severe pre-eclampsia to the appropriate critical care setting using the criteria in table 4. ","1.8.14",2010]
["1.9  Antihypertensive treatment during the postnatal period, including during breastfeeding"]
["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. ","1.9.1",2019]
["Explain to women with hypertension who wish to breastfeed that:\n• antihypertensive medicines can pass into breast milk\n• 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\n• 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.\nMake decisions on treatment together with the woman, based on her preferences. ","1.9.2",2019]
["As antihypertensive agents have the potential to transfer into breast milk:\n•\tconsider monitoring the blood pressure of babies, especially those born preterm, who have symptoms of low blood pressure for the first few weeks\n•\twhen discharged home, advise women to monitor their babies for drowsiness, lethargy, pallor, cold peripheries or poor feeding. ","1.9.3",2019]
["Offer enalapril to treat hypertension in women during the postnatal period, with appropriate monitoring of maternal renal function and maternal serum potassium. ","1.9.4",2019]
["For women of black African or Caribbean family origin with hypertension during the postnatal period, consider antihypertensive treatment with:\n•\tnifedipine or\n•\tamlodipine if the woman has previously used this to successfully control her blood pressure. ","1.9.5",2019]
["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:\n•\tadding atenolol or labetalol to the combination treatment or\n•\tswapping 1 of the medicines already being used for atenolol or labetalol. ","1.9.6",2019]
["When treating women with antihypertensive medication during the postnatal period, use medicines that are taken once daily when possible. ","1.9.7",2019]
["Where possible, avoid using diuretics or angiotensin receptor blockers to treat hypertension in women in the postnatal period who are breastfeeding or expressing milk. ","1.9.8","2010, amended 2019"]
["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. ","1.9.9",2019]
["1.10   Advice and follow-up at transfer to community care"]
["Risk of recurrence of hypertensive disorders of pregnancy"]
["Advise women with hypertensive disorders of pregnancy that the overall risk of recurrence in future pregnancies is approximately 1 in 5 (see table 5). ","1.10.1",2019]
["Long-term risk of cardiovascular disease"]
["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).","1.10.2",2019]
["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:\n• avoiding smoking, as recommended in the NICE guideline on stop smoking interventions and services \n• maintaining a healthy lifestyle, as recommended in the NICE guideline on cardiovascular disease\n• maintaining a healthy weight, as recommended in the NICE guideline on obesity. ","1.10.3",2019]
["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. ","1.10.4",2019]
["Body mass index and recurrence of hypertensive disorders of pregnancy"]
["Advise women who have had pre-eclampsia to achieve and keep a BMI within the healthy range before their next pregnancy (18.5–24.9 kg/m2). See also the NICE guideline on obesity: identification, assessment and management. ","1.10.5","2010, amended 2019"]
["Inter-pregnancy interval and recurrence of hypertensive disorders of pregnancy"]
["Advise women who have had pre-eclampsia that the likelihood of recurrence increases with an inter-pregnancy interval greater than 10 years. ","1.10.6","2010, amended 2019"]
["Long-term risk of end-stage kidney disease"]
["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. ","1.10.7",2010]
["Thrombophilia and the risk of pre-eclampsia"]
["Do not routinely perform screening for thrombophilia in women who have had pre-eclampsia. ","1.10.8",2010]

{"sheet":"Table 1","index":3,"n_rows":14,"n_cols":3,"rows_kept":14,"cut":false,"hidden":false,"merged":[]}
["Table 1 Management of pregnancy with gestational hypertension"]
[null,"Degree of hypertension"]
[null,"Hypertension: \nblood pressure of 140/90–159/109 mmHg","Severe hypertension: \nblood pressure of 160/110 mmHg or more"]
["Admission to hospital ","Do not routinely admit to hospital","Admit, but if BP falls below 160/110 mmHg then manage as for hypertension"]
["Antihypertensive pharmacological treatment","Offer pharmacological treatment if BP remains above 140/90 mmHg","Offer pharmacological treatment to all women"]
["Target blood pressure once on antihypertensive treatment","Aim for BP of 135/85 mmHg or less","Aim for BP of 135/85 mmHg or less"]
["Blood pressure measurement","Once or twice a week (depending on BP) until BP is 135/85 mmHg or less","Every 15–30 minutes until BP is less than 160/110 mmHg"]
["Dipstick proteinuria testinga","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"]
["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\nCarry out ultrasound assessment of the fetus at diagnosis and, if normal, repeat every 2 to 4 weeks, if clinically indicated\nCarry out a CTG only if clinically indicated\n(See section 1.6 for advice on fetal monitoring)","Offer fetal heart auscultation at every antenatal appointment\nCarry out ultrasound assessment of the fetus at diagnosis and, if normal, repeat every 2 weeks, if severe hypertension persists\nCarry out a CTG at diagnosis and then only if clinically indicated\n(See section 1.6 for advice on fetal monitoring)"]
["aUse an automated reagent-strip reading device for dipstick screening for proteinuria in a "]
["secondary care setting."]
["Abbreviations: BP, blood pressure; CTG, cardiotocography; PlGF, placental growth factor"]

{"sheet":"Table 2","index":4,"n_rows":13,"n_cols":3,"rows_kept":13,"cut":false,"hidden":false,"merged":[]}
["Table 2 Management of pregnancy with pre-eclampsia"]
[null,"Degree of hypertension"]
[null,"Hypertension: \nblood pressure of 140/90–159/109 mmHg","Severe hypertension: \nblood pressure of 160/110 mmHg or more"]
["Admission to hospital","Admit if any clinical concerns for the wellbeing of the woman or baby (see recommendation 1.5.2) or if high risk of adverse events suggested by the fullPIERS or PREP‑S risk prediction models","Admit, but if BP falls below 160/110 mmHg then manage as for hypertension"]
["Antihypertensive pharmacological treatment","Offer pharmacological treatment if BP remains above 140/90 mmHg","Offer pharmacological treatment to all women"]
["Target blood pressure once on antihypertensive treatment","Aim for BP of 135/85 mmHg or less","Aim for BP of 135/85 mmHg or less"]
["Blood pressure measurement","At least every 48 hours, and more frequently if the woman is admitted to hospital","Every 15–30 minutes until BP is less than 160/110 mmHg, then at least 4 times daily while the woman is an inpatient, depending on clinical circumstances"]
["Dipstick proteinuria testinga","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\nCarry out ultrasound assessment of the fetus at diagnosis and, if normal, repeat every 2 weeks\nCarry out a CTG at diagnosis and then only if clinically indicated\n(See section 1.6 for advice on fetal monitoring)","Offer fetal heart auscultation at every antenatal appointment \nCarry out ultrasound assessment of the fetus at diagnosis and, if normal, repeat every 2 weeks\nCarry out a CTG at diagnosis and then only if clinically indicated\n(See section 1.6 for advice on fetal monitoring)"]
["a Use an automated reagent-strip reading device for dipstick screening for proteinuria in a "]
["secondary care setting."]
["Abbreviations: BP, blood pressure; CTG, cardiotocography"]

{"sheet":"Table 3","index":5,"n_rows":5,"n_cols":2,"rows_kept":5,"cut":false,"hidden":false,"merged":[]}
["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) for planned early birth. Offer intravenous magnesium sulfate and a course of antenatal corticosteroids in line with the NICE guideline on preterm labour and birth"]
["From 34 to 36+6 weeks","Continue surveillance unless there are indications (see recommendation 1.5.7) for planned early birth.\nWhen 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 24–48 hours."]

{"sheet":"Table 4","index":6,"n_rows":4,"n_cols":2,"rows_kept":4,"cut":false,"hidden":false,"merged":[]}
["Table 4 Clinical criteria for choice of critical care level"]
["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:\n•\teclampsia\n•\tHELLP syndrome\n•\thaemorrhage\n•\thyperkalaemia\n•\tsevere oliguria\n•\tcoagulation support\n•\tintravenous antihypertensive treatment\n•\tinitial stabilisation of severe hypertension\n•\tevidence of cardiac failure\n•\tabnormal neurology"]
["Level 1 care","Pre-eclampsia with hypertension\nOngoing conservative antenatal management of severe preterm hypertension\nStep-down treatment after the birth"]

{"sheet":"Table 5","index":7,"n_rows":10,"n_cols":4,"rows_kept":10,"cut":false,"hidden":false,"merged":[]}
["Table 5 Likelihood of recurrence of hypertensive disorders of pregnancy"]
[null,"Type of hypertension in previous or current pregnancy"]
["Prevalence of hypertensive disorder in a future pregnancy","Any hypertension in pregnancy","Pre-eclampsia","Gestational hypertension"]
["Any hypertension","Approximately 21%\n(1 in 5 women)","Approximately 20%\n(1 in 5 women)","Approximately 22%\n(1 in 5 women)"]
["Pre-eclampsia","Approximately 14%\n(1 in 7 women)","Up to approximately 16%\n(1 in 6 women)\n\nIf birth was at 28–34 weeksa: approximately 33%\n(1 in 3 women)\n\nIf birth was at 34–37 weeks: approximately 23%\n(1 in 4 women)","Approximately 7%\n(1 in 14 women)"]
["Gestational hypertension","Approximately 9%\n(1 in 11 women)","Between approximately 6 and 12%\n(up to 1 in 8 women)","Between approximately 11 and 15%\n(up to 1 in 7 women)"]
["Chronic hypertension","Not applicable","Approximately 2%\n(up to 1 in 50 women)","Approximately 3%\n(up to 1 in 34 women)"]
["a No evidence was identified for women who gave birth at less than 28 weeks, but the "]
["committee agreed that the risk was likely to be at least as high, if not higher, than that for"]
[" women who gave birth between 28 and 34 weeks."]

{"sheet":"Table 6","index":8,"n_rows":11,"n_cols":5,"rows_kept":11,"cut":false,"hidden":false,"merged":[]}
["Table 6 Cardiovascular risk in women who have had a hypertensive disorder of pregnancy"]
[null,"Type of hypertension in current or previous pregnancy "]
["Risk of future cardiovascular diseasea, b","Any hypertension in pregnancy","Pre-eclampsia","Gestational hypertension","Chronic hypertension"]
["Major adverse cardiovascular event","Risk increased \n(up to approximately 2 times)","Risk increased\n(approximately 1.5–3 times)","Risk increased\n(approximately 1.5–3 times)","Risk increased \n(approximately 1.7 times)"]
["Cardiovascular mortality","Risk increased \n(up to approximately 2 times)","Risk increased\n(approximately 2 times)","(no data)","(no data)"]
["Stroke","Risk increased \n(up to approximately 1.5 times) ","Risk increased\n(approximately 2–3 times)","Risk may be increased","Risk increased\n(approximately 1.8 times)"]
["Hypertension","Risk increased \n(approximately 2–4 times)","Risk increased \n(approximately 2–5 times)","Risk increased \n(approximately 2–4 times)","(not applicable)"]
["a Risks described are overall estimates, summarised from risk ratios, odds ratios and hazard ratios."]
["b Increased risk is compared to the background risk in women who did not have hypertensive disorders "]
["during pregnancy. Absolute risks are not reported, because these will vary considerably, depending on "]
["the follow-up time (range from 1 to 40 years postpartum)."]