Hypertension in Pregnancy: The NICE Guidelines
Hypertension in pregnancy may indicate a chronic medical problem, gestational hypertension (new hypertension without proteinuria) or pre-eclampsia (new hypertension with new proteinuria). Chronic hypertension can mimic gestational hypertension and strongly predisposes to superimposed pre-eclampsia. Gestational hypertension is often benign but may also be an early stage in the development of pre-eclampsia.
Pre-eclampsia is not benign. Previously the first cause of maternal death in the UK, it is now the second. Maternal deaths from pre-eclampsia have not fallen recently and, most disturbingly, are associated with the highest rates of substandard care, of all causes of maternal deaths. It is also the most important reason for iatrogenic prematurity, a major contributor to perinatal mortality and a substantial cause of fetal growth restriction, especially with preterm disease. Pre-eclampsia cannot be reliably prevented or reversed once it is established except by delivery, which removes the cause—namely, the placenta. Nevertheless, the past 30 years have seen considerable advances in its management. For both mother and baby the outlook is better than it was, at least in the developed world.
The new NICE guidelines for the management of hypertension in pregnancy (available on line at http://www.nice.org.uk/guidance/CG1), comprising more than 1000 pages including appendices, ambitiously review every aspect of management and the evidence upon which recommendations are based. The breadth of the guidelines reflects the complexities of their subject. They deal with many specific obstetric issues but of course the management of hypertension itself is a primary focus. Cardiovascular, obstetric or intensive care doctors will, or may be, involved at some stage, and these guidelines are also addressed to them.
Hypertension is defined as in Table 1. Methods of measuring blood pressure are specified separately in the NICE guidelines on antenatal care, where the need to use devices validated specifically for use in pregnancy is highlighted. The grading of hypertension is important because the guidelines adopt the principle that moderate hypertension requires treatment (Table 1), except for women with chronic hypertension and end-organ damage for whom the blood pressures should be normalised. It is not stated how many readings within what time frame are needed to change a pregnant woman's classification.
Body and Introduction
Introduction
Hypertension in pregnancy may indicate a chronic medical problem, gestational hypertension (new hypertension without proteinuria) or pre-eclampsia (new hypertension with new proteinuria). Chronic hypertension can mimic gestational hypertension and strongly predisposes to superimposed pre-eclampsia. Gestational hypertension is often benign but may also be an early stage in the development of pre-eclampsia.
Pre-eclampsia is not benign. Previously the first cause of maternal death in the UK, it is now the second. Maternal deaths from pre-eclampsia have not fallen recently and, most disturbingly, are associated with the highest rates of substandard care, of all causes of maternal deaths. It is also the most important reason for iatrogenic prematurity, a major contributor to perinatal mortality and a substantial cause of fetal growth restriction, especially with preterm disease. Pre-eclampsia cannot be reliably prevented or reversed once it is established except by delivery, which removes the cause—namely, the placenta. Nevertheless, the past 30 years have seen considerable advances in its management. For both mother and baby the outlook is better than it was, at least in the developed world.
The new NICE guidelines for the management of hypertension in pregnancy (available on line at http://www.nice.org.uk/guidance/CG1), comprising more than 1000 pages including appendices, ambitiously review every aspect of management and the evidence upon which recommendations are based. The breadth of the guidelines reflects the complexities of their subject. They deal with many specific obstetric issues but of course the management of hypertension itself is a primary focus. Cardiovascular, obstetric or intensive care doctors will, or may be, involved at some stage, and these guidelines are also addressed to them.
Hypertension is defined as in Table 1. Methods of measuring blood pressure are specified separately in the NICE guidelines on antenatal care, where the need to use devices validated specifically for use in pregnancy is highlighted. The grading of hypertension is important because the guidelines adopt the principle that moderate hypertension requires treatment (Table 1), except for women with chronic hypertension and end-organ damage for whom the blood pressures should be normalised. It is not stated how many readings within what time frame are needed to change a pregnant woman's classification.
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