Quality statement 4: Assessing women with severe hypertension in pregnancy

Quality statement

Pregnant women with severe hypertension are admitted for a full assessment, carried out by a healthcare professional trained in managing hypertension in pregnancy.

Rationale

Effective and safe control of severe hypertension is the most important aspect of critical care management, because the main causes of maternal death and severe maternal morbidity (including stroke) are the consequence of poorly controlled hypertension. Women with severe hypertension in pregnancy should be referred from primary care or emergency departments as soon as possible to receive assessment from healthcare professionals with expertise in managing hypertensive disorders. This is essential to ensure early identification of pre-eclampsia and the provision of critical care where it is needed.

Quality measures

Structure

Evidence of local arrangements for pregnant women with severe hypertension to be admitted for a full assessment, carried out by a healthcare professional trained in managing hypertensive disorders in pregnancy.

Data source: Local data collection.

Process

Proportion of women with severe hypertension who are admitted for a full assessment, carried out by a healthcare professional trained in managing hypertensive disorders in pregnancy.

Numerator – the number of women in the denominator who are admitted for a full assessment, carried out by a healthcare professional trained in managing hypertensive disorders in pregnancy.

Denominator – the number of pregnant women with severe hypertension.

Data source: Local data collection.

Outcome

Number of women with severe hypertension in pregnancy who have a stroke.

Data source: Local data collection.

What the quality statement means for different audiences

Service providers ensure that there are local arrangements for pregnant women with severe hypertension to be admitted for a full assessment, carried out by a healthcare professional trained in managing hypertensive disorders in pregnancy.

Healthcare practitioners admit pregnant women with severe hypertension for a full assessment, carried out by a healthcare professional trained in managing hypertensive disorders in pregnancy.

Commissioners ensure they commission services that admit pregnant women with severe hypertension for a full assessment, carried out by a a healthcare professional trained in managing hypertensive disorders in pregnancy.

Pregnant women with severe hypertension (high blood pressure) are admitted to hospital for a full assessment, carried out by a healthcare professional trained in managing high blood pressure and related conditions in pregnancy.

Source guidance

Hypertension in pregnancy: diagnosis and management (2019) NICE guideline NG133, recommendations 1.4.1 and 1.4.3

Definitions of terms used in this quality statement

Full assessment

This should include blood pressure measurements, proteinuria testing and blood tests in accordance with those set out for severe gestational hypertension and pre-eclampsia with severe hypertension in the NICE guideline on hypertension in pregnancy.

[NICE's guideline on hypertension in pregnancy, recommendation 1.4.3, table 1]

Hypertension in pregnancy

This definition includes chronic hypertension (present at the booking visit or before 20 weeks of pregnancy; this could include pre-existing hypertension), gestational hypertension (new hypertension presenting after 20 weeks without proteinuria) and pre-eclampsia (new hypertension presenting after 20 weeks of pregnancy and the coexistence of 1 or more of the following new-onset conditions:

  • proteinuria (urine protein:creatinine ratio 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/100ml 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.

[NICE's guideline on hypertension in pregnancy, terms used in this guideline]

Severe hypertension

Blood pressure over 160 mmHg systolic, or over 110 mmHg diastolic.

[NICE's guideline on hypertension in pregnancy, terms used in this guideline]