[CG] Hypertension, antenatal & daycare guideline

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New Hypertension in Pregnancy
Chronic Hypertension outwith pregnancy

Criteria for referral :

BP ≥ 150/90mm Hg
DBP ≥90mmHg SBP ≥ 150mm Hg
20 mmHg rise in diastolic BP and ≥ 1 + proteinuria
Epigastric pain and headache are potential red flag symptoms and merit medical review

Investigations of referrals

Note importance of Systolic BP (SBP)

Check BP Profile (BP x 3 at no less than 15 minute intervals)
Routine AN observations
Test urine using automated reagent strip reading device; if proteinuria ≥+1 then send urine for urinary Protein Creatinine Ratio (uPCR) for quantification

1. If Normotensive, asymptomatic, <2++proteinuria

Return to ANC (No medical review)

2. If initial BP ≥140/90 and proteinuria <+2: follow Table 1 for investigation / management

Table 1.

	Mild 140-149/90-99mmHg	Moderate 150-159/100-109 mmHg	Severe ≥160/110 mmHg
Admit	No	No	Yes
Treat BP If treatment given in daycare, recheck BP in 45 mins	No	Oral Labetalol* Aim for systolic <150mmHg, diastolic 80-100mmHg	Oral Labetalol* Aim for systolic <150mmHg, diastolic 80-100mmHg
Follow-up BP review frequency	Not more than once / week; unless <32/40 at first review or “high risk” for pre- eclampsia – then twice weekly review	Twice a week	Four times a day
Test proteinuria (Automated strip reader or uPCR)	Each visit	Each visit	Daily
Test proteinuria (Automated strip reader or uPCR)	If significant proteinuria (≥+2 on strip or >30mg/mmol) develops then follow Table 2 (pre-eclampsia management)
Blood tests	Only routine AN blood tests	At initial visit: FBC, U&E, LFTs. Subsequent visits: only if significant proteinuria develops	At presentation & then weekly: FBC, U&E, LFTs
Scans If abnormal result – inform consultant	If <34/40: growth, liquor volume, Doppler. If normal scan do not routinely repeat. If ≥34/40 only scan if clinically indicated	If <34/40: growth, liquor volume, Doppler. If normal scan do not routinely repeat. If ≥34/40 only scan if clinically indicated	Growth, liquor volume, Doppler. If normal then repeat fortnightly.
CTG monitoring If not reassuring – inform consultant	Only perform if abnormal fetal activity or abnormal scan findings	Only perform if abnormal fetal activity or abnormal scan findings	Yes Repeat if develops: decreased fetal movement, abdominal pain, vaginal bleeding, deterioration in maternal condition
Delivery	By EDD	By EDD	From 37⁺⁰weeks, earlier if indicated

Ideally, the woman’s consultant should be involved in the planning of her antenatal care.

3. If BP ≥140/90 with significant proteinuria (≥+2 on automated reagent strip testing or uPCR >30mg/mmol): follow Table 2 below.

Table 2: Investigation & management of pre-eclampsia (gestational hypertension & significant proteinuria)

	Mild 140-149/90-99mmHg	Moderate 150-159/100-109 mmHg	Severe ≥160/110 mmHg
Admit	Yes	Yes	Yes
Treat BP If treatment given in daycare, recheck BP in 45 mins	No	Oral Labetalol* Aim for systolic <150mmHg, diastolic 80-100mmHg	Oral Labetalol* Aim for systolic <150mmHg, diastolic 80-100mmHg
BP measurements	At least 4 times / day	At least 4 times / day	4 hourly, depending on clinical circumstances
Test for proteinuria (Automated strip reader or uPCR)	Following initial quantification indicating significant proteinura (>30mg/mmol), do not repeat uPCR.
Blood tests: FBC, U&E, LFTs	Twice weekly	Three times a week	Three times a week
Scans If abnormal result – inform consultant	Growth, liquor volume, Doppler at diagnosis. If normal - repeat fortnightly.	Growth, liquor volume, Doppler at diagnosis. If normal - repeat fortnightly.	Growth, liquor volume, Doppler at diagnosis. If normal - repeat fortnightly.
CTG monitoring If not reassuring – inform consultant	Yes	Yes	Yes
CTG monitoring If not reassuring – inform consultant	Repeat if develops: decreased fetal movement, pain, vaginal bleeding, deterioration in maternal condition
Delivery	Offer delivery from 34⁺⁰to 36⁺⁶weeks depending on maternal / fetal condition, risk factors, availability of NNU cots		Recommend delivery if ≥34⁺⁰weeks once BP controlled / steroids complete (if appropriate)
Delivery	Recommend delivery within 24-48 hours if ≥37⁺⁰weeks

Inform the on call obstetric consultant of any woman requiring admission.

Antihypertensive treatment*

First line drug is Labetalol (unless contraindicated e.g. Asthma)

Chronic Hypertensives may need small dose only therefore start them on 100 mg b.d. or t.i.d. (depending on build)
New Hypertensives may be started at 200 mgs t.i.d.
Stepwise incremental escalation may be employed to maximum of 300 mgs qid. It is at this point that Second line drugs may be considered, after discussion with senior obstetrician.

Second Line (as adjunct or when Labetalol contraindicated)

Nifedipine Retard - 10 mg bd. May be increased incrementally to 20 mg bd.

Methyldopa - Start at 250 mg bd. (Takes 48 hrs to maximum effect) Increase incrementally to 250mg qid then if necessary to 500mg qid.

Postnatal daycare review

Patients with PIH who were not on medication prior to discharge do not require daycare review.
Methyldopa should be stopped (changed to alternative medication if necessary) within 2 days of delivery due to the increased risk of postnatal depression.
Postnatal patients should have 3 BP checks within 1 hour and their medication reduced accordingly.
GP follow up suggested if more convenient for the patient.
Occasionally ACE inhibitors may be required POST-NATALLY ONLY
Occasionally "resistant" hypertensives may require review by Renal or Hypertension Physicians.
See separate post natal hypertension guideline.

References

NICE. Hypertension in pregnancy: diagnosis and management. [CG107] August 2010, last updated January 2011.

Last reviewed: 26 June 2018

Next review: 01 July 2023

Author(s): Dr. V. Brace - Obstetric Consultant

Approved By: Obstetric Guideline Group