Excerpt

This guideline was partially updated in June 2019.

This clinical guideline concerns the management of hypertensive disorders in pregnancy and their complications from preconception to the postnatal period. For the purpose of this guideline, ‘pregnancy’ includes the antenatal, intrapartum and postpartum (6 weeks after birth) periods. The guideline has been developed with the aim of providing guidance in the following areas: information and advice for women who have chronic hypertension and are pregnant or planning to become pregnant; information and advice for women who are pregnant and at increased risk of developing hypertensive disorders of pregnancy; management of pregnancy with chronic hypertension; management of pregnancy in women with gestational hypertension; management of pregnancy for women with pre-eclampsia before admission to critical care level 2 setting; management of pre-eclampsia and its complications in a critical care setting; information, advice and support for women and healthcare professionals after discharge to primary care following a pregnancy complicated by hypertension; care of the fetus during pregnancy complicated by a hypertensive disorder.

Contents

• Guideline development group membership and acknowledgements
• 1. Summary of recommendations and care pathway
  • 1.1. Key priorities for implementation
  • 1.2. Recommendations
  • 1.3. Key priorities for research
  • 1.4. Research recommendations
  • 1.5. Care pathways
  • 1.6. Contraindications and special warnings
• 2. Development of the guideline
  • 2.1. Hypertensive disorders of pregnancy
  • 2.2. Aim and scope of the guideline
  • 2.3. For whom is the guideline intended?
  • 2.4. Other relevant documents
  • 2.5. Who has developed the guideline?
  • 2.6. Guideline development methodology
  • 2.7. Specific considerations for this guideline
  • 2.8. Schedule for updating the guideline
• 3. Reducing the risk of hypertensive disorders in pregnancy
  • 3.1. Introduction
  • 3.2. Antiplatelet agents
  • 3.3. Other pharmaceutical agents
  • 3.4. Nutritional supplements
  • 3.5. Diet
  • 3.6. Lifestyle
• 4. Management of pregnancy with chronic hypertension
  • 4.1. Introduction
  • 4.2. Pre-pregnancy advice
  • 4.3. Prevention of pre-eclampsia
  • 4.4. Treatment of hypertension
  • 4.5. Fetal monitoring
  • 4.6. Antenatal consultations
  • 4.7. Timing of birth
  • 4.8. Postnatal investigation, monitoring and treatment
• 5. Assessment of proteinuria in hypertensive disorders of pregnancy
  • 5.1. Introduction
  • 5.2. Measurement of proteinuria
• 6. Management of pregnancy with gestational hypertension
  • 6.1. Introduction
  • 6.2. Frequency of blood pressure measurement
  • 6.3. Risk of progression to pre-eclampsia
  • 6.4. Prevention of pre-eclampsia
  • 6.5. Treatment of hypertension
  • 6.6. Fetal monitoring
  • 6.7. Timing of birth
  • 6.8. Postnatal investigation, monitoring and treatment
• 7. Management of pregnancy with pre-eclampsia
  • 7.1. Introduction
  • 7.2. Frequency of blood pressure measurement
  • 7.3. Assessment of proteinuria
  • 7.4. Biochemical tests
  • 7.5. Treatment of hypertension
  • 7.6. Fetal monitoring
  • 7.7. Timing of birth
  • 7.8. Postnatal investigation, monitoring and treatment (including after discharge from critical care)
• 8. Fetal monitoring
  • 8.1. Introduction
  • 8.2. Fetal biometry
  • 8.3. Umbilical artery Doppler velocimetry
  • 8.4. Cardiotocography
  • 8.5. Routine versus computerised cardiotocography in severe pre-eclampsia
  • 8.6. Biophysical profile
  • 8.7. Amniotic fluid index versus single deepest vertical pocket
  • 8.8. Fetal movements
  • 8.9. Uterine artery Doppler velocimetry in high-risk pregnancies
  • 8.10. Fetal monitoring in women with previous pre-eclampsia
• 9. Intrapartum care
  • 9.1. Introduction
  • 9.2. Blood pressure
  • 9.3. Haematological and biochemical monitoring
  • 9.4. Care during epidural analgesia
  • 9.5. Management of the second stage of labour
  • 9.6. Management of the third stage of labour
• 10. Medical management of severe hypertension or severe pre-eclampsia in a critical care setting
  • 10.1. Introduction
  • 10.2. Anticonvulsants
  • 10.3. Antihypertensives
  • 10.4. Corticosteroids for fetal lung maturation
  • 10.5. Corticosteroids to manage HELLP syndrome
  • 10.6. Fluid balance and volume expansion
  • 10.7. Caesarean section versus induction of labour
  • 10.8. Indications for referral to critical care levels
• 11. Breastfeeding
  • 11.1. Introduction
  • 11.2. Antihypertensive agents and breastfeeding
• 12. Advice and follow-up care at transfer to community care
  • 12.1. Introduction
  • 12.2. Long-term risk of cardiovascular disease
  • 12.3. Long-term risk of end-stage kidney disease
  • 12.4. Thrombophilia and the risk of pre-eclampsia
  • 12.5. Risk of recurrence of hypertensive disorders of pregnancy
  • 12.6. Interpregnancy interval and recurrence of hypertensive disorders of pregnancy
  • 12.7. Body mass index and recurrence of hypertensive disorders of pregnancy
• 13. References, abbreviations and glossary
  • 13.1 References
  • 13.2 Abbreviations
  • 13.3 Glossary
• Appendix A. Scope of the guideline
• Appendix B. Declarations of interest
• Appendix C. Registered stakeholder organisations
• Appendix D. Clinical questions
• Appendix E. Search strategies
• Appendix F. Excluded studies
• Appendix G. Evidence tables
• Appendix H. Cost effectiveness of aspirin compared with no aspirin in preventing pre-eclampsia in women at risk of developing pre-eclampsia
• Appendix I. Economic analysis of immediate birth (induction of labour) versus expectant management in women with mild to moderate gestational hypertension after 37 weeks of gestation
• Appendix J. Economic analysis of immediate birth (induction of labour) versus expectant management in women who have pre-eclampsia with mild or moderate hypertension at 34–37 weeks of gestation
• Appendix K. Cost effectiveness of using a 1+ dipstick urinalysis threshold versus a 2+ dipstick urinalysis threshold in screening for proteinuria in women with gestational hypertension
• Appendix L. Cost effectiveness of automated urinalysis compared with visual urinalysis in screening for proteinuria in women with gestational hypertension
• Appendix M. Cost effectiveness of quantifying proteinuria in women with gestational hypertension
• Appendix N. Safety data for antihypertensives in pregnancy
• Appendix O. Safety of commonly used antihypertensive drugs during breastfeeding

Revised reprint January 2011

While every effort has been made to ensure the accuracy of the information contained within this publication, the publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check current indications and accuracy by consulting other pharmaceutical literature and following the guidelines laid down by the manufacturers of specific products and the relevant authorities in the country in which they are practising.

This guideline has been developed by the National Collaborating Centre for Women’s and Children’s Health, which is an intercollegiate collaboration between the Royal College of Obstetricians and Gynaecologists, the Royal College of Paediatrics and Child Health and the Royal College of Midwives. The principal aim of the work undertaken by the National Collaborating Centre for Women’s and Children’s Health and its partners is to improve outcomes and choice for women, children and their families by producing national clinical guidelines that promote high-quality cost-effective care within the NHS.

This guideline has been fully funded by NICE. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. However, the guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient.

Implementation of this guidance is the responsibility of local commissioners and/or providers.