Guideline name: Hypertension in pregnancy: diagnosis and management [NG133]
Update type: New guideline
Published: June 2019
- 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
- Sudden swelling of the face, hands or feet.
- 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.