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CHAPTER 26  Pregnancy-induced hypertension (PIH) or gestational HT

Prevalence and background Risks or complications

• New hypertension presenting after 20 weeks without significant proteinuria. • Fetal – higher rate of perinatal mortality, preterm birth, and LBW.
• Incidence of PIH – 4.2–7.9%. • Maternal – See Chapter 27 Pre-eclampsia (PET) and eclampsia
• Up to 10% of pregnancies are complicated by hypertensive disorders and there is evidence that
the rate may be increasing.

History
• Any severe headache, severe pain just below ribs, problems with
vision such as blurring or flashing before eyes, vomiting, sudden
swelling of face, hands or feet.
Full assessment in a secondary care facility
Risk factors
• PET or gestational HT disease during a previous pregnancy, chronic HT, chronic kidney
disease, type 1 or type 2 diabetes, autoimmune disease such as SLE or APA syndrome.
• Give 75 mg of aspirin daily from 12 weeks until delivery.
• Do not use the following to prevent hypertension in pregnancy: * Nitric oxide donors.
* Diuretics. * Progesterone. * Supplements of magnesium. * Restricting salt intake.
* Antioxidants (vitamins C and E). * Fish or algal oils. * Garlic.
• The following risk factors require additional assessment and follow-up: nulliparity, age
≥ 40 years, pregnancy interval of > 10 years, family history of PET, multiple pregnancy,
BMI ≥ 35, pre-existing vascular disease.

Investigations • Any proteinuria – See Chapter 27 Pre-eclampsia (PET) and

• BP and proteinuria eclampsia.
• Proteinuria – an automated reagent-strip reading device or urinary
protein:creatinine ratio (uPCR).

97 CHAPTER 26  Pregnancy-induced hypertension

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98 SECTION 3  Antenatal Care

BP

Mild hypertension Moderate hypertension Severe hypertension

(BP 140/90–149/99 mmHg) (BP 150/100–159/109 mmHg) (BP ≥ 160/110 mmHg)
• Outpatient monitoring. • Outpatient monitoring. • Inpatient care until BP ≤ 159/109.
• BP weekly. • Oral labetalol to keep BP < 150/100 mmHg. • Oral labetalol to keep BP < 150/100.
• Test for proteinuria at each visit. • BP, proteinuria at least 2 times a week. • BP at least 4 times a day.
• Routine antenatal blood tests. • Test RFT, FBC, LFTs. • Proteinuria daily.
• If < 32 weeks or at high risk of PET – test for proteinuria and • No further blood tests if no subsequent proteinuria. • Test RFT, FBC, LFTs at presentation and then weekly.
measure BP 2 times/week.

Mild or moderate hypertension • USS for fetal growth and AFV + UtAD at diagnosis – If conservative management is planned:
repeat every 2 weeks.
• If < 34 weeks – USS for fetal growth and AFV, UtAD.
• CTG – carry out at diagnosis. If the results of all fetal monitoring are normal, do not
• If USS normal – do not repeat after 34 weeks unless clinically indicated.
routinely repeat CTG more than weekly.
• Do not carry out USS for fetal growth and AFV, UtAD if diagnosis is confirmed
• Repeat CTG if – change in fetal movement, vaginal bleeding, abdominal pain, deterioration
after 34 weeks, unless otherwise clinically indicated.
in maternal condition.
• CTG only if fetal activity abnormal.

• Alternative antihypertensives – nifedipine or methyldopa. Only offer after considering side-effect

profiles for the woman, fetus, and newborn baby.
• Care plan – the timing and nature of fetal monitoring; fetal indications for birth and if and when
corticosteroids should be given; when discussion with neonatal paediatricians and obstetric
anaesthetists should take place.

Timing of birth
• Women whose BP is < 160/110 mmHg, with or without antihypertensive treatment:
* Do not offer birth before 37 weeks.
* After 37 weeks – timing of birth, and maternal and fetal indications for birth should be agreed between the woman and the senior obstetrician.
• Offer birth to women with refractory severe PIH after a course of corticosteroids (if required) has been completed.
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Intrapartum care

Mild and moderate hypertension Severe hypertension

• Measure BP hourly. • Measure BP continually.

• Continue antenatal hypertensive treatment. • Continue antenatal hypertensive treatment.
• Carry out haematological and biochemical monitoring according to criteria • If BP controlled within target ranges, do not routinely limit duration of second
from antenatal period. stage of labour.
• Do not routinely limit duration of second stage of labour if BP is stable. • If BP does not respond to initial treatment, advise operative vaginal delivery in
second stage.

Postnatal care
• Measure BP :
* Daily for first 2 days after birth.
* At least once 3–5 days after birth.
* As clinically indicated if anti-HT treatment changed.
• If methyldopa was used during pregnancy, stop within 2 days of birth.
• Continue antenatal antihypertensive treatment:
* Start antihypertensive treatment if BP ≥ 150/100.
* If BP falls to < 130/80, reduce anti-HT treatment.
* If BP falls to < 140/90, consider reducing anti-HT treatment.
• If breastfeeding – avoid diuretic treatment for hypertension.
• Assess wellbeing of baby, especially adequacy of feeding, at least daily for first 2 days after birth.

Follow-up care What not to do

• At transfer to community care, write a care plan that includes who will provide follow- • Use of the following to prevent hypertension in pregnancy: *  Nitric oxide donors.
up care, frequency of BP monitoring, thresholds for reducing or stopping treatment, * Diuretics. * Progesterone. *  Supplements of magnesium. *  Restricting salt intake.
indications for referral to primary care for BP review. *  Antioxidants (vitamins C and E). *  Fish or algal oils. * Garlic.
• If antihypertensive treatment is to be continued – review 2 weeks after transfer to • Bed rest in hospital as a treatment.
community care. Mild or moderate hypertension -
• Postnatal review at 6–8 weeks. • USS for fetal growth and AFV, UmAD if diagnosis is confirmed after 34 weeks.
• If antihypertensive treatment is to be continued after 6–8 weeks postnatal review – • Repeat USS after 34 weeks unless clinically indicated.
specialist assessment. Severe hypertension
• Routine repeat USS more than every 2 weeks.
• Routine repeat CTG more than weekly.

Hypertension in Pregnancy: The management of hypertensive disorders during pregnancy; NICE CGN 107, August 2010.

99 CHAPTER 26  Pregnancy-induced hypertension