NICE has issued new draft guidance on the management of hypertension in pregnancy. The guideline includes a number of new or amended recommendations in relation to the assessment of proteinuria, the treatment of chronic hypertension, the monitoring and treatment of gestational hypertension and the assessment and treatment of pre-eclampsia.
Citing an over-reliance on proteinuria result, NICE has amended the 2010 recommendation on automated dipstick tests to emphasise that this should be used as a screening tool. Protein:creatinine ratio and albumin:creatinine ratio can both be used, at thresholds 30 and 8 mg/mmol, respectively. Using both tests together does not have additional diagnostic benefit.
The guideline committee noted that there was very little evidence on treatment initiation thresholds for chronic hypertension in pregnancy. Hence, the committee based their recommendations on the values specified in the Control of Hypertension in Pregnancy Study and the NICE guideline on hypertension in adults.
Labetalol is suggested as the first-line option, with nifedipine as the next alternative and methyldopa as the third option.
NICE has also updated the table from the previous guideline on the management of pregnancy with pre-eclampsia. The fullPIERS and PREP-S models can be used to identify women requiring hospitalisation, with a suggested threshold of 30% for both models when considering place of care.
Based on the data from HYPITAT-II study, the committee also agreed that pregnancies in women with pre-eclampsia could be managed with continued surveillance to 37 weeks, unless there were specific concerns or indications to offer a planned early birth before then.
In the postnatal period, NICE recommends the use of an angiotensin-converting enzyme inhibitor as the first-line treatment, except in women of African or Caribbean origin, in whom a calcium-channel blocker should be used as first-line.
The full guideline is available here. The updated recommendations are now open for comment.