Management of hypertension in pregnancy

The following guidance is based on NICE CG107- Hypertension in pregnancy.

Risk factors for pre-eclampsia

Women with at least one high risk factor OR two moderate risk factors for pre-eclampsia should be advised to take aspirin 75mg daily from 12 weeks until birth.

High risk factors

  • Hypertensive disease during a previous pregnancy
  • Chronic kidney disease
  • Autoimmune disease (such as systemic lupus erythematosus (SLE) or antiphospholipid syndrome)
  • Type 1 or type 2 diabetes
  • Chronic hypertension

Moderate risk factors

  • Nulliparous
  • Being over 40 years of age
  • 10 years or more since a previous pregnancy
  • Family history of pre-eclampsia
  • BMI over 35kg/m² at booking
  • Multiple pregnancy

Pre-existing hypertensive disorder

  • Women who are taking ACE inhibitors, angiotensin-II receptor blockers (ARBs) or chlorothiazide diuretics need immediate review with their GP to discuss alternative antihypertensive therapy.
  • In pregnant women with uncomplicated chronic hypertension aim to keep blood pressure less than 150/100mmHg and in women with target organ damage aim to keep BP lower than 140/90mmHg.
  • Post-delivery - continue antenatal antihypertensives and measure the BP daily for the first two days after birth, then at least once between day 3 and 5. Aim to keep the BP below 140/90. Women should be reviewed by their GP post-delivery for a discussion regarding their long term antihypertensive therapy.

Oral antihypertensive treatments in pregnancy

Antihypertensive treatment should be started in women with a systolic blood pressure over 150 mmHg or a diastolic blood pressure over 100mmHg. In women with other markers of potentially severe disease, treatment can be considered at lower degrees of hypertension.

Labetalol
  • Better tolerated than methyldopa, but there is concern that it can inhibit fetal growth if used long term. To be reserved until the second or third trimesters.
  • Contra-indicated in asthma.
  • See 2.4 Beta-adrenoceptor blocking drugs
Methyldopa
  • Women should stop methyldopa within two days of delivery and change to a different drug if required.
  • Side effects including depression, sedation, and postural hypotension, which may restrict its use.
  • See 2.5.2 Centrally acting antihypertensive drugs
Nifedipine (Adalat Retard®)

Post-natal period and breastfeeding

Continue antenatal antihypertensives post-delivery and aim to reduce dosage if BP falls below 130/80mmHg.

Inform women who still need antihypertensive treatment in the postnatal period that the following antihypertensive drugs have no known adverse effects on babies receiving breast milk:

  • Labetalol
  • Nifedipine
  • Enalapril
  • Captopril
  • Atenolol
  • Metoprolol

Long-term health risks

This following advice summarised the potential future risks of a patient's hypertensive disorder and is intended to support counselling post-delivery.

Gestational Hypertension

Future risk of:

Gestational hypertension in future pregnancy: Risk ranges from about 1 in 6 to about 1 in 2

Pre-eclampsia in future pregnancy: Risk ranges from 1 in 50 to 1 in 14

Cardiovascular Disease: Increased risk of hypertension and its complications

Pre-eclampsia

Future risk of:

Gestational hypertension in future pregnancy: Risk ranges from about 1 in 8 to 1 in 2

Pre-eclampsia in future pregnancy: Risk up to 1 in 6, no additional risk if interval before next pregnancy less than 10 years

Cardiovascular Disease: Increased risk of hypertension and its complications

End-stage kidney disease: If no proteinuria or hypertension at 8 weeks postnatal, absolute risk is low. No follow up required

Severe PET*, HELLP^ or eclampsia

Future risk of:

Pre-eclampsia in future pregnancy

  • If required delivery less than 34 weeks risk is 1 in 4
  • If required delivery less than 28 weeks risk is 1 in 2

Cardiovascular Disease: Increased risk of hypertension and its complications

*PET= pre-eclampsia toxaemia

^HELLP= Haemolysis elevated liver low platelets

 

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