Red Flags
- Severe hypertension (SBP ≥160 or DBP ≥110) — admit; treat within 30–60 minutes; antihypertensive plus 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 if 24–34 weeks[1]
- Severe headache, visual disturbance, epigastric pain, sudden swelling, oliguria — emergency review for impending eclampsia[1]
First-line treatment
Interventions
- Aspirin prophylaxis from 12 weeks[1]150 mg PO at night from 12+0 to 36+0 weeks for women at high risk: prior PE, chronic HTN, T1/T2DM, autoimmune disease, twins, age ≥40, BMI ≥35, family history
- Calcium supplementation in low-intake populations[1]1.5–2 g elemental calcium PO daily from 20 weeks where dietary calcium <600 mg/day; reduces pre-eclampsia and severe outcomes
- Antenatal monitoring stratified by severity[1]Mild gestational HTN: BP weekly + bloods. Pre-eclampsia: admit or daycare; bloods 2× weekly; fetal Doppler weekly. Severe: admit; deliver per maternal/fetal status and gestation
- Timing of delivery[1]Gestational HTN or pre-eclampsia without severe features: deliver at 37 weeks. Severe pre-eclampsia: deliver after stabilisation regardless of gestation if ≥34 weeks; corticosteroids and consider delivery at 24–34 weeks per maternal-fetal status
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) or infusion 1–2 mg/min | — | First-line in pregnancy; avoid in asthma, bradycardia, heart block; safe in breastfeeding |
| Nifedipine (extended release)[1] | Calcium channel blocker (DHP) | 10 mg PO immediate-release for severe acute hypertension (repeat at 30 min if needed); 30–60 mg PO daily ER for maintenance | — | First-line maintenance; useful in asthma; combine with labetalol for resistant; do not use sublingual immediate-release |
| Methyldopa[1] | Centrally-acting alpha-2 agonist | 250 mg PO BD-TDS; titrate to 1000–3000 mg/day in divided doses | — | Long safety record in pregnancy; sedation, depression — avoid postpartum if mood-affecting |
| 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 g IV over 5–10 min, maintenance 1 g/h IV (or 5 g IM each buttock then 5 g IM 4-hourly Pritchard regimen) 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) or infusion 1–2 mg/min
- Paediatric
- —
First-line in pregnancy; avoid in asthma, bradycardia, heart block; safe in breastfeeding
Nifedipine (extended release)[1]
Calcium channel blocker (DHP)
- Adult
- 10 mg PO immediate-release for severe acute hypertension (repeat at 30 min if needed); 30–60 mg PO daily ER for maintenance
- Paediatric
- —
First-line maintenance; useful in asthma; combine with labetalol for resistant; do not use sublingual immediate-release
Methyldopa[1]
Centrally-acting alpha-2 agonist
- Adult
- 250 mg PO BD-TDS; titrate to 1000–3000 mg/day in divided doses
- Paediatric
- —
Long safety record in pregnancy; sedation, depression — avoid postpartum if mood-affecting
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 g IV over 5–10 min, maintenance 1 g/h IV (or 5 g IM each buttock then 5 g IM 4-hourly Pritchard regimen) 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, visual 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 daycare or 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.