Red Flags
- Severe hypertension (SBP ≥160 or DBP ≥110 mm Hg) sustained ≥15 minutes — admit; treat within 30–60 minutes; magnesium sulfate if pre-eclampsia features[1]
- Eclampsia (seizure in pregnancy or up to 6 weeks postpartum) — emergency; magnesium sulfate; controlled BP; deliver after stabilisation[1]
- HELLP syndrome (haemolysis, elevated liver enzymes, low platelets) — admit; deliver per gestation; corticosteroid for fetal lung maturity 24–34 weeks[1]
- Severe headache, visual disturbance, epigastric pain, or oliguria — emergency review for impending eclampsia or HELLP[1]
First-line treatment
Interventions
- Aspirin prophylaxis from 12 weeks[1]81–162 mg PO daily from 12+0 to 28+0 weeks (continue to delivery in some pathways) for women at high risk: prior PE, chronic HTN, T1/T2DM, autoimmune disease, twins, BMI ≥35, age ≥35, or ≥2 moderate-risk factors
- Antenatal management stratified by severity[1]Mild gestational HTN: outpatient monitoring weekly. Pre-eclampsia without severe features: weekly twice-bloods, biweekly maternal/fetal surveillance, deliver 37 weeks. With severe features: admit, deliver after stabilisation if ≥34 weeks
- Timing of delivery[1]Gestational HTN: 37 weeks. Pre-eclampsia without severe features: 37 weeks. Pre-eclampsia with severe features: 34 weeks (after stabilisation, magnesium, antihypertensive, betamethasone if 24–34 weeks). Eclampsia: deliver after seizure control
- Postpartum surveillance[1]Monitor BP for ≥72 h post-delivery and again at 7–10 days; pre-eclampsia can present de novo postpartum; continue antihypertensive titration; prepare for long-term cardiovascular risk follow-up
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Labetalol (oral or IV)[1] | Combined alpha-1 / non-selective beta-blocker | Oral 100–200 mg PO BD-TDS, max 1200 mg/day. IV severe HTN: 20 mg IV bolus, repeat 40, 80 mg every 10 min (max 220 mg) | — | First-line in pregnancy; avoid in asthma, bradycardia, heart block; safe in breastfeeding |
| Nifedipine[1] | Calcium channel blocker (DHP) | Immediate-release 10 mg PO for severe acute HTN (repeat at 20 min if needed); ER 30–60 mg PO daily for maintenance | — | First-line maintenance; useful in asthma; combine with labetalol for resistant; do not use sublingual immediate-release |
| Hydralazine (severe acute HTN)[1] | Direct arterial vasodilator | 5 mg IV bolus, repeat 5–10 mg every 20 min (max 30 mg) or infusion 0.5–10 mg/h | — | Severe pregnancy hypertension when labetalol contraindicated or not available; reflex tachycardia, headache |
| Magnesium sulfate (eclampsia prevention and treatment)[1] | Anticonvulsant / NMDA modulator | Loading 4–6 g IV over 15–20 min, maintenance 1–2 g/h IV for 24 h after delivery or last seizure | — | Severe pre-eclampsia and eclampsia; monitor patellar reflex, respiratory rate, urine output; calcium gluconate antidote for toxicity |
Labetalol (oral or IV)[1]
Combined alpha-1 / non-selective beta-blocker
- Adult
- Oral 100–200 mg PO BD-TDS, max 1200 mg/day. IV severe HTN: 20 mg IV bolus, repeat 40, 80 mg every 10 min (max 220 mg)
- Paediatric
- —
First-line in pregnancy; avoid in asthma, bradycardia, heart block; safe in breastfeeding
Nifedipine[1]
Calcium channel blocker (DHP)
- Adult
- Immediate-release 10 mg PO for severe acute HTN (repeat at 20 min if needed); ER 30–60 mg PO daily for maintenance
- Paediatric
- —
First-line maintenance; useful in asthma; combine with labetalol for resistant; do not use sublingual immediate-release
Hydralazine (severe acute HTN)[1]
Direct arterial vasodilator
- Adult
- 5 mg IV bolus, repeat 5–10 mg every 20 min (max 30 mg) or infusion 0.5–10 mg/h
- Paediatric
- —
Severe pregnancy hypertension when labetalol contraindicated or not available; reflex tachycardia, headache
Magnesium sulfate (eclampsia prevention and treatment)[1]
Anticonvulsant / NMDA modulator
- Adult
- Loading 4–6 g IV over 15–20 min, maintenance 1–2 g/h IV for 24 h after delivery or last seizure
- Paediatric
- —
Severe pre-eclampsia and eclampsia; monitor patellar reflex, respiratory rate, urine output; calcium gluconate antidote for toxicity
Safety-net
- Severe headache, vision changes, epigastric pain, vomiting, rapid swelling, or reduced fetal movements — call your maternity unit same day; these can precede eclampsia[1]
- Pre-eclampsia can present up to 6 weeks postpartum — monitor BP for 6 weeks after delivery and report severe headache or hypertensive symptoms[1]
- After a pregnancy with hypertension, your long-term cardiovascular risk is increased — annual BP, lipid, and diabetes screening are recommended[1]
Referral criteria
- Severe hypertension (≥160/110), eclampsia, HELLP, or impending eclampsiaEmergency obstetric admission; HDU/ITU[1]
- Pre-eclampsia (any severity)Obstetric admission per protocol; senior obstetric input[1]
- Chronic hypertension planning pregnancy or in early pregnancyJoint preconception/obstetric clinic; switch to pregnancy-safe agent[1]
- Postpartum hypertension persisting beyond 12 weeksHypertension clinic for chronic HTN management[1]
Clinical summary
Diagnosis and management of gestational hypertension, pre-eclampsia, eclampsia, and chronic hypertension in pregnancy and postpartum.