NICE recommendations on hypertension in pregnancy

  • NICE

  • curated by Pavankumar Kamat
  • Clinical Guidance Summaries
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Guideline name: Hypertension in pregnancy: diagnosis and management [NG133]

Update type: New guideline

Published: June 2019

Takeaway

  • NICE has published a new guideline which focuses on diagnosis and management of hypertension, including pre-eclampsia, during pregnancy, labour and birth.

Risk reduction for pre-eclampsia

  • Pregnant women should be advised to seek medical attention if they experience symptoms of pre-eclampsia such as:
    • Severe headache
    • Visual disturbances including blurring or flashing before the eyes,
    • Severe pain just below the ribs
    • Vomiting
    • Sudden swelling of the face, hands or feet.

Antiplatelet agents

  • Pregnant women at high risk of pre-eclampsia should be advised to take 75–150 mg of aspirin daily from 12 weeks until delivery. Factors for high risk include any of the following:
    • Hypertensive disease during earlier pregnancy
    • Chronic kidney disease
    • Chronic hypertension.
    • Diabetes (Type 1 or 2)
    • Autoimmune disease including lupus or antiphospholipid syndrome.
  • Pregnant women with >1 moderate risk factor for pre-eclampsia should be advised to take 75–150 mg of aspirin daily from 12 weeks until delivery. Factors for moderate risk include:
    • First pregnancy
    • Age ≥40 years
    • Pregnancy interval of more than 10 years
    • BMI ≥35 kg/m2 at first visit
    • Family history of pre-eclampsia
    • Multi-foetal pregnancy.

Assessment of proteinuria

  • Interpretation of proteinuria measurements for pregnant women should be done in the context of a complete clinical review of symptoms, signs and other investigations for pre-eclampsia.
  • A positive dipstick result (1+ or more) warrants the use of albumin:creatinine ratio or protein:creatinine ratio for quantifying proteinuria in pregnant women.
  • When using protein:creatinine ratio for quantifying proteinuria, consider 30 mg/mmol as a threshold for significant proteinuria.
  • When using albumin:creatinine ratio as an alternative to protein:creatinine ratio for diagnosis of pre-eclampsia, consider 8 mg/mmol as a diagnostic threshold. If the result is ≥8 mg/mmol and uncertainty about the diagnosis of pre-eclampsia persists, consider re-testing using a new sample.

Management of chronic hypertension in pregnancy

  • Women with chronic hypertension should be referred to a clinician specialising in hypertensive disorders of pregnancy to discuss the risks and benefits of treatment.
  • Use of angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blocker, and thiazide or thiazide-like diuretics during pregnancy may increase the risk of congenital abnormalities.
  • Alternative treatment for hypertension and other conditions such as renal disease should be considered and discussed by the healthcare professional with women planning a pregnancy.
  • Limited evidence has not shown other classes of antihypertensive drugs to increase the risk of congenital malformation.
  • For pharmacologic treatment of hypertension in pregnancy, aim for a target blood pressure of 135/85 mmHg.

Assessment of gestational hypertension

  • Women with gestational hypertension should be assessed in a secondary care setting by a clinician trained in the management of hypertensive disorders of pregnancy.

Assessment of pre-eclampsia

  • Women with pre-eclampsia should be assessed by clinicians trained in the management of hypertensive disorders of pregnancy.
  • A full clinical assessment should be performed at each antenatal appointment for women with pre-eclampsia. Concerns which call for hospital admission include:
    • Sustained systolic BP ≥160 mmHg
    • Biochemical or haematological abnormalities
      • Elevated creatinine (≥90 μmol/L, ≥1 mg/100 mL)
      • Elevated alanine transaminase (≥70 IU/L or twice upper limit of normal range)
      • Decreased platelet count (
    • Signs of impending eclampsia or pulmonary oedema
    • Suspected foetal compromise
    • Other signs of severe pre-eclampsia or clinical signs of concern.

This summary is reviewed by Prof. Rishabh Prasad MBBS, MA, MSC, FRCGP, FFCI, FRSA

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