Prevention and Treatment of Hypertension in Pregnancy

Recommendation

Strength

Definitions And Classification

HDPs should be classified according to the criteria and definitions presented in “Glossary”

GPS

Diagnose Hypertension in pregnancy when systolic blood pressure is ≥140mmHg and/or diastolic blood pressure is ≥90mmHg, based on the average of at least 2 measurements, taken at least 15minutes apart, using the same arm.

Strong

Severe hypertension (sBP ≥ 160 and/or dBP ≥ 110 mmHg), can be confirmed within a short interval (minutes) to facilitate timely antihypertensive therapy

Conditional

Gestational hypertension is hypertension that develops for the first time at > 20 weeks, without evidence of preeclampsia

Conditional

Women with gestational hypertension should undergo testing for preeclampsia to rule it out.

Strong

Diagnose preeclampsia in women with new onset hypertension after 20 weeks and new-onset proteinuria or one/more adverse conditions (defined as a maternal end organ complication or evidence of uteroplacental dysfunction)

Strong

Preeclampsia superimposed on chronic hypertension is diagnosed by the development of 1 or more characteristics of preeclampsia (i.e., new-onset proteinuria or 1 or more adverse conditions) superimposed on chronic hypertension

Strong

Do not use an elevation in BP to make a diagnosis of preeclampsia superimposed on chronic hypertension.

Conditional

Risk factors

Risk factors for developing preeclampsia should be included in the antenatal assessment of all pregnant women.

GPS

Screening

All pregnant women should be screened for their risk of developing preeclampsia early in the pregnancy.

Strong

The screening tool utilized should be determined based on the locally available resources

Conditional

Blood Pressure measurement

During every antenatal visit, screening for preeclampsia in pregnant women with blood pressure measurements throughout pregnancy is strongly recommended

Strong

Testing For Proteinuria

Screen for proteinuria with urinary dipstick at first visit and at each subsequent visit

Conditional

More definitive testing for proteinuria (by urinary protein:creatinine ratio or 24-hour urine collection) is encouraged when there is a suspicion of preeclampsia, including: ≥1+ dipstick proteinuria in women with hypertension and rising blood pressure and in women with normal blood pressure, but symptoms or signs suggestive of preeclampsia       

Conditional

When quantitative methods are not available or rapid decisions are required, a urine protein dipstick reading can be substituted using 2+ as the discriminant value

Conditional

Proteinuria testing does not need to be repeated once significant proteinuria in the setting of confirmed pre-eclampsia has been detected

Conditional

Biomarkers and ultrasonography screening

The use of a combined first trimester screen (combined maternal features, biomarkers and sonography) to identify women at risk of developing preeclampsia is conditionally recommended based on local availability and access to the required resources

Conditional

Risk Reduction

Low dose Aspirin

To reduce the risk of developing preeclampsia, pregnant women with one high risk factor or two or more moderate risk factors for developing preeclampsia should receive low dose aspirin (100 mg -150 mg daily) beginning at 12 weeks gestation and till delivery.

Strong

The use of aspirin at bedtime is conditionally recommended

Conditional

Cessation of aspirin between 34 weeks gestation and birth is conditionally recommended. Exact timing of cessation should be based on individualized clinical judgment and informed, shared decision taking with the women

Conditional

Oral calcium Supplementation

The use of supplemental calcium is strongly recommended in pregnant women with low dietary calcium intake (<1g/day) for the prevention of preeclampsia, preterm birth, and gestational hypertension

Strong

Calcium supplementation at doses of 1.5–2.0 g elemental calcium/day is recommended from the first antenatal visit till delivery, to reduce the risk of developing preeclampsia

Strong

Education

Pregnant women with hypertension or with risk factors for developing preeclampsia should be educated about the symptoms and signs that require immediate attention and referral to health care facilities.

Strong

A clear referral plan should be discussed with each woman

Conditional

Educate pregnant women to seek a healthcare professional immediately if they experience any of the symptoms of pre-eclampsia

Strong

Exercise and diet

Moderate intensity exercise, in the form of aerobic, stretching and/or muscle resistance exercises, for a total of 2.5-5 hours a week, as recommended exercise regimen for general pregnancy wellbeing is encouraged.

Conditional

What is Not recommended for risk reduction

Dietary salt restriction, for prevention of preeclampsia, is not recommended given the lack of evidence of benefit

Conditional

The use of oral omega-3 long-chain polyunsaturated fatty acids LCPUFA supplementation for the prevention of preeclampsia, is not recommended until more data are available

Conditional

The use of oral garlic supplementation, specifically for the prevention of preeclampsia, is not recommended until more data are available

Conditional

The use of oral vitamin C and E supplementation, specifically for the prevention of preeclampsia, is not recommended until more data are available

Conditional

There is inadequate data to recommend for the use or against the use of oral magnesium supplementation specifically for the prevention of preeclampsia. More data on the safety profile is required

Conditional

The use of progesterone replacement, specifically for the prevention of preeclampsia, is not recommended until more data are available

Conditional

The use of statins, specifically for the prevention of preeclampsia, is not recommended until more data are available

Conditional

The use of low molecular weight heparin (LMWH) alone (without aspirin) in women without a history of thrombophilia or APLS can be considered if a contraindication to aspirin is present. The decision to use LMWH (at a prophylactic dose) should be individualized based on women’s clinical and obstetric history and through a shared, informed decision-making process

Conditional

LMWH should not replace the use of aspirin in women without contraindications to aspirin

Conditional

The use of low molecular weight heparin (LMWH) in addition to aspirin for prevention of preeclampsia in women without a history of thrombophilia or APLS is not recommended

Conditional

The use of nitric oxide (either in donor or precursor forms) for the prevention of preeclampsia is not recommended until more data are available

Conditional

The use of metformin, specifically for the prevention of preeclampsia is not recommended until more data are available

Conditional

The use of oral vitamin D supplementation for the prevention of preeclampsia, is not recommended until more data are available

Conditional

The use of proton pump inhibitors for prevention of preeclampsia is not recommended until more data are available

Conditional

The use of clopidogrel for prevention of preeclampsia is not recommended until human data are available

GPS

TREATMENT OF PRE-ECLAMPSIA SYNDROME AND GESTATIONAL HYPERTENSION

Hospital Admission Versus Ambulatory Outpatient Management

Ambulatory outpatient management at home is an option only for women with mild to moderate gestational hypertension and requires frequent fetal and maternal evaluation

Strong

Hospitalization is appropriate for Women with gestational hypertension in whom adherence to frequent monitoring is a concern and for patients diagnosed with preeclampsia

Strong

Ambulatory outpatient management

At each antenatal care visit, following the detection of hypertension in pregnancy, a systematic clinical evaluation of symptoms, signs, laboratory investigations and fetal wellbeing must be performed

Strong

Frequency of appointments is based on the individual clinical needs; suggested review is initially weekly to fortnightly (every 2 weeks) at a minimum

Conditional

Women with non-severe hypertension during pregnancy should not be offered antihypertensive drug treatment when adequate resources for good quality antenatal care follow-up may be lacking

Conditional

Inpatient Care

Women with preeclampsia should have additional tests to detect multisystem involvement, and should have fetal surveillance to assure fetal wellbeing

Strong

A clear referral plan for patients with severe preeclampsia must be developed and implemented in every health care unit

GPS

Complete bed rest is not advised for fear of thromboembolism, however minimal activities with 2 hours afternoon nap and 8 hours night sleep is recommended.

GPS

Non-severe hypertension should be treated with the first-line agents oral methyldopa, labetalol, or nifedipine

Conditional

Severe hypertension in pregnancy (i.e., sBP ≥ 160 mmHg or dbp ≥ 110 mmHg) requires urgent antihypertensive therapy, in a monitored setting

Strong

Severe hypertension should be treated with the first-line agents oral nifedipine, oral labetalol, IV labetalol, or IV hydralazine

Conditional

The target BP for antihypertensive therapy should be a dBP of 85 mmHg, regardless of sBP

Conditional

Use of corticosteroid (either betamethasone or dexamethasone) is recommended in women with preeclampsia who are at risk of birth at < 34 weeks’ gestation

Conditional

There are insufficient data to recommend routine use of corticosteroid in women with preeclampsia who are at risk of birth between 34- and 36-weeks’ gestation. Delivery should not be delayed for the administration of steroids in the late preterm period

Conditional

The use of magnesium sulphate for fetal neuroprotection in women with preeclampsia at risk of preterm birth at < 30 weeks’ gestation is strongly recommended

Strong

As part of expectant management, in-utero transfer to a tertiary-level centre with neonatal intensive care capacity should be considered

GPS

Inpatient Expectant care versus Delivery

Inpatient Expectant care

Women with mild to moderate gestational hypertension or preeclampsia without severe features, expectant management up to 37 0/7 weeks of gestation is recommended

Conditional

In low-resource setting where maternal and neonatal care and adequate resources for close monitoring by healthcare personnel may be lacking or is not available, the GDG recommend against expectant management for preeclampsia with severe hypertension or other severe features

Conditional

Capabilities for the evaluation of fetal wellbeing and detection of fetal compromise should be available in healthcare facilities providing care for pregnant women with hypertensive disorders

Conditional

Transfer of women with hypertension of pregnancy should be considered in situations where the health care provider believes that the health care facility is unequipped to manage the complications of hypertension of pregnancy

GPS

Birth and Delivery

Time of Birth

Initiate birth at ≥ 37 weeks gestation, in women with preeclampsia

Conditional

At < 37 weeks gestation, the decision on expectant management with continued surveillance is appropriate for women with non-severe preeclampsia.

Conditional

At 34+0 till 36+6 weeks gestation for women with preeclampsia in presence of any feature of severity initiation of delivery should is considered. Delivery should not be delayed for the administration of steroids in the late preterm period

Conditional

From fetal viability until <34+0 weeks gestation, Expectant management should be considered, but only in hospitals where very preterm infants and sick mothers can be cared for. Initiation of birth is considered in the absence of available resources for maternal and neonatal care

Conditional

Maternal stabilization and labor management of pre-eclampsia and eclampsia

Prevention and treatment of convulsions

The prevention of eclampsia is empirically based on the timely delivery once preeclampsia has been diagnosed

GPS

Prophylactic magnesium sulphate with an intravenous loading dose of 4g followed by maintenance at 1g/hr for 24 hours in total or time of last seizure is strongly recommended in women at risk of eclampsia or recurrent eclampsia

Conditional

There is inadequate evidence to support an alternative magnesium regimen or the use of anticonvulsants for the prevention of eclampsia

Conditional

It is recommended that magnesium sulfate should be used for the prevention and treatment of seizures in women with severe hypertension or severe preeclampsia, or eclampsia and birth is planned within 24 hours

Conditional

The prophylactic use of magnesium sulfate for the prevention of seizures in women with gestational hypertension or preeclampsia without severe features is Conditionally recommended

GPS

Women with eclampsia should receive magnesium sulphate to prevent recurrent seizures

Conditional

Control of acute severe hypertension

Severe hypertension in pregnancy (i.e., sBP ≥ 160 mmHg or dBP ≥ 110 mmHg) requires urgent antihypertensive therapy, in a monitored setting

Conditional

Severe hypertension should be treated with the first-line agents oral nifedipine, oral labetalol, intravenous (IV) labetalol, or IV hydralazine

Strong

The target BP for antihypertensive therapy should be a dBP of 85 mmHg, regardless of sBP

Conditional

Non-severe hypertension should be treated with the first-line agents oral methyldopa, labetalol, or nifedipine

Conditional

Control of other complications: HELLP syndrome

For women with severe preeclampsia with features of HELLP expectant management is harmful. Plan birth as soon as feasible

Strong

Platelet transfusion should be considered if a woman’s platelet count is <20 _ 109/L before vaginal delivery or <50 _ 109/L before cesarean delivery, or at any time if there is excessive active bleeding, known platelet dysfunction, rapidly falling platelet count, or coagulopathy

Conditional

Vaginal delivery is the preferred modality, unless urgent delivery is necessary for maternal stabilization or for fetal indications. The delivery options should be discussed by a multidisciplinary team and consider the safest mode of delivery to the mother, how fast she is expected to deliver, what are the resources of blood products and other supportive mechanisms available, and can she sustain a surgery

Conditional

In rapidly progressing preeclampsia with severe features or HELLP syndrome, vaginal delivery may be attempted if cervical conditions are favorable and delivery is anticipated within a short timeframe (e.g., ≤2 hours). If labor progress is slow (>6 hours) or maternal/fetal status worsens, immediate cesarean delivery is indicated

Conditional

In small to medium size health care facilities, it is important to estimate whether their blood bank can support a massive blood trans fusion and, if necessary, contact regional or larger hospitals for assistance or for transferring the patient

GPS

Mode of Birth

For women with any HDP, vaginal delivery should be considered unless a cesarean delivery is required for obstetrical indications.

Strong

Vaginal delivery may require early cervical ripening and induction

Conditional

If urgent or emergent delivery is required for maternal and/or fetal indications, an emergency cesarean delivery may be indicated

Strong

Urgency ot Birth

Health facilities in Egypt should provide local protocols of management for their health care providers in accordance with WHO recommendations.

Strong

GDG recommends to nationally adopt a color-triage system for acute obstetric emergencies (Modified Early obstetric warning score -MEOWS)

GPS

TREATMENT OF CHRONIC HYPERTENSION

Expectant Management

Offer expectant management for women with Chronic hypertension who are <37 weeks and, whose blood pressure is lower than 160/110 mmHg with or without antihypertensive treatment, unless there are other medical indications62

Strong

Offer antihypertensive treatment to pregnant women who have chronic hypertension and who are not already on treatment if they have sustained systolic blood pressure of 140 mmHg or higher or sustained diastolic blood pressure of 90 mmHg or higher

Strong

The target BP for antihypertensive therapy should be a dBP of 85 mmHg, regardless of sBP

Strong

Consider labetalol to treat chronic hypertension in pregnant women. Consider nifedipine for women in whom labetalol is not suitable or methyldopa if both labetalol and nifedipine are not suitable. Base the choice on any pre-existing treatment, side-effect profiles, risks (including fetal effects) and the woman's preference

Conditional

Continue with existing antihypertensive treatment if safe in pregnancy, or switch to an alternative treatment, unless sustained systolic blood pressure is less than 110 mmHg or sustained diastolic blood pressure is less than 70 mmHg or the woman has symptomatic hypotension

Conditional

Offer pregnant women with chronic hypertension aspirin 150 mg once daily from 12 weeks

Strong

Give the same advice on rest, exercise and work to women with chronic hypertension or at risk of hypertensive disorders during pregnancy as healthy pregnant women

Conditional

Offer PLGF testing between 20–36+6 weeks to rule out pre-eclampsia in women with chronic hypertension if clinical suspicion arises

Conditional

In chronic hypertension with suspected pre-eclampsia, monitor proteinuria 1–2x weekly alongside BP checks

Strong

A complete blood count and levels of serum transaminases, lactate dehydrogenase, and uric acid should be checked on diagnosis then weekly

Conditional

Timing of birth

Do not offer planned early birth (before 37 weeks) to women with chronic hypertension whose blood pressure is lower than 160/110 mmHg, with or without antihypertensive treatment, unless there are other medical indications

Strong

Offer planned birth to women with chronic hypertension whose blood pressure is lower than 160/110 mmHg with or without antihypertensive treatment after 37 weeks

Strong

Determination of timing should be agreed between the woman and the obstetrician. Initiation of delivery can be offered at 38+0 to 39+6 weeks

Conditional

Offer planned early birth before 37 weeks to women with chronic hypertension or gestational hypertension if inability to control maternal blood pressure despite using 3 or more classes of antihypertensives in appropriate doses or if any of the known features of severe superimposed preeclampsia develop

Strong

Care for women with hypertension during labor and postpartum

Intrapartum Care

During labour, measure blood pressure hourly. In women with severe hypertension measure blood pressure every 15 to 30 minutes until blood pressure is less than 160/110 mmHg.

Conditional

Continue use of antenatal antihypertensive treatment during labour

Conditional

Do not preload women who have severe pre-eclampsia with intravenous fluids before establishing low-dose epidural analgesia or combined spinal epidural analgesia

Conditional

Do not routinely limit the duration of the second stage of labour in women with controlled hypertension

Conditional

Consider operative or assisted birth in the second stage of labour for women with severe hypertension whose hypertension has not responded to initial treatment

Conditional

As women with preeclampsia are at increased risk of postpartum hemorrhage, the third stage of labour should be actively managed

Conditional

Ergometrine should not be administered to women with any hypertensive disorder of pregnancy, particularly preeclampsia or gestational hypertension; alternative oxytocic drugs should be considered

Strong

Postpartum care for women with HDP

There remains inadequate data to suggest the superiority of a single agent or group of agents in selecting antihypertensives for the management of hypertension in the postpartum period. The choice of antihypertensive (beta-blockers, methyldopa, hydralazine, nifedipine, enalapril, clonidine) should be made through a shared decision-making process, particularly in breastfeeding/lactating women

Conditional

Women should be informed of the long-term risks associated with preeclampsia, gestational hypertension and chronic hypertension and the importance of postpartum follow up prior to discharge from hospital

Conditional

Antihypertensive therapy administered antepartum should be continued after birth. Also, consideration should be given to administering antihypertensive therapy for any hypertension diagnosed before six days postpartum

Conditional

The target dBP for postpartum antihypertensive treatment should be 85 mmHg, as antenatally

Conditional

Non-steroidal anti-inflammatory drugs (NSAIDs) for postpartum analgesia may be used in women with pre-eclampsia if other analgesics are ineffective, and there is no acute kidney injury (AKI) or other risk factors for it

Conditional

Breastfeeding is recommended

Strong

Counselling should be provided about the risks of gestational hypertension (at least 4%) or pre-eclampsia (at least 15%) in future pregnancy

Conditional

At 3 months postpartum, all women should be reviewed to ensure that BP, urinalysis, and any laboratory abnormalities have normalised. If proteinuria or hypertension persist, then appropriate referral for further investigations should be initiated

Conditional

At 6 months postpartum, where possible, all women should be reviewed again, at which point we suggest that BP ≥ 120/80 mmHg lead to discussion of lifestyle change

Conditional

Following hypertensive pregnancy, particularly pre-eclampsia, counselling should be provided about the heightened health risks for the mother (particularly cardiovascular) and the offspring

Strong