Introduction

This quality standard covers pre-pregnancy advice for women with pre-existing hypertension, as well as the antenatal, intrapartum and postnatal care of women at risk of or with hypertensive disorders of pregnancy. For more information, see the scope for this quality standard.

Why this quality standard is needed

Hypertension in pregnancy can occur for several reasons. Women might have pre-existing hypertension when they become pregnant. This includes women with hypertension at the booking appointment or before 20 weeks of pregnancy. New-onset hypertension (presenting after 20 weeks of pregnancy) is known as gestational hypertension. It can occur in isolation, or in association with proteinuria when it is known as pre-eclampsia. Pre-eclampsia is a multisystem disorder that can affect almost all maternal organ systems and the unborn baby. Women with either pre-existing hypertension or gestational hypertension are at increased risk of developing pre-eclampsia.

Hypertensive disorders in pregnancy carry risks for both the mother and the baby. They can result in substantial maternal morbidity and place women at an increased lifetime risk of cardiovascular disease. Reports on maternal and perinatal deaths show that 5% of stillbirths without congenital abnormality occurred in infants whose mothers had pre-eclampsia. Hypertension in pregnancy is associated with 8–10% of all preterm births and more than half of women with severe pre-eclampsia give birth preterm. Most children born of pregnancies affected by preterm pre-eclampsia will have restricted growth.

Pre-eclampsia becomes eclampsia when the mother develops seizures. In the UK over the last century, the rates of eclampsia appear to have fallen. Maternal deaths due to pre-eclampsia have also fallen, although hypertension in pregnancy remains one of the leading causes of maternal death in the UK. Effective and safe control of severe hypertension in pregnancy is an important aspect of critical care management.

An enquiry into maternal deaths found that the main failings in managing pre-eclampsia were lack of routine observations of blood pressure and failure to treat significantly elevated levels of blood pressure. There were a number of women with severe hypertension in pregnancy for whom junior obstetricians had failed to consult with senior staff, and there were delays in involving anaesthetic or critical care services sufficiently early.

Women with pre-existing hypertension, diabetes, chronic kidney disease or autoimmune disease, and women who had hypertension in a previous pregnancy, are at high risk of hypertension in their current pregnancy.

How this quality standard supports delivery of outcome frameworks

NICE quality standards describe high-priority areas for quality improvement in a defined care or service area. Each standard consists of a prioritised set of specific, concise and measurable statements. They draw on existing guidance, which provides an underpinning, comprehensive set of recommendations, and are designed to support the measurement of improvement. This quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following 2 outcomes frameworks published by the Department of Health:

Tables 1–2 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.

Table 1 NHS Outcomes Framework 2013/14

Domain

Overarching indicators and improvement areas

1 Preventing people from dying prematurely

Overarching indicator

1a Potential years of life lost (PYLL) from causes considered amenable to healthcare

Improvement areas

Reducing premature mortality from the major causes of death

1.1 Under-75 mortality rate from cardiovascular disease*

Reducing deaths in babies and young children

1.6i Infant mortality*

1.6ii Neonatal mortality and stillbirths

3 Helping people to recover from episodes of ill health or following injury

Overarching indicator

3a Emergency admissions for acute conditions that should not usually require hospital admission

4 Ensuring that people have a positive experience of care

Overarching indicator

4a.i Patient experience of GP services

4c Friends and family test (placeholder)

Improvement area

Improving women and their families' experience of maternity services

4.5 Women's experience of maternity services

5 Treating and caring for people in a safe environment and protecting them from avoidable harm

Overarching indicators

5a Patient safety incidents reported.

5b Safety incidents involving severe harm or death.

Improvement areas

Reducing the incidence of avoidable harm

5.4 Incidence of medication errors causing serious harm

Improving the safety of maternity services

5.5 Admission of full-term babies to neonatal care

Alignment across the health and social care system

* Indicator shared with Public Health Outcomes Framework (PHOF)

Table 2 Public health outcomes framework for England, 2013-2016

Domain

Objectives and indicators

2 Health improvement

Objective

People are helped to live healthy lifestyles, make healthy choices and reduce health inequalities

Indicator

2.1 Low birth weight of term babies

4 Healthcare public health and preventing premature mortality

Objective

Reduced numbers of people living with preventable ill health and people dying prematurely, while reducing the gap between communities

Indicators

4.1 Infant mortality*

4.3 Mortality from causes considered preventable**

4.4 Mortality from all cardiovascular diseases (including heart disease and stroke)

Alignment across the health and social care system

* Indicator shared with NHS Outcomes Framework

** Indicator complementary with NHS Outcomes Framework

Coordinated services

The quality standard for hypertension in pregnancy specifies that services should be commissioned from and coordinated across all relevant agencies encompassing the whole hypertension in pregnancy care pathway. A person-centred, integrated approach to providing services is fundamental to delivering high-quality care to women with hypertension in pregnancy.

The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning and delivering services, as part of a general duty to secure continuous improvement in quality. Commissioners and providers of health and social care should refer to the library of NICE quality standards when designing high-quality services. Other quality standards that should also be considered when choosing, commissioning or providing a high-quality hypertension in pregnancy service are listed in related quality standards.

Training and competencies

The quality standard should be read in the context of national and local guidelines on training and competencies. All healthcare practitioners involved in assessing, caring for and treating women at risk of or with hypertension in pregnancy should have sufficient and appropriate training and competencies to deliver the actions and interventions described in the quality standard.