Obstetrics & Gynaecology · FOGSI

Hypertensive disorders of pregnancy

FOGSI

Source:FOGSI-GESTOSIS-ICOG Good Clinical Practice Recommendations on Hypertensive Disorders in Pregnancy (2019, refreshed)ISSHP 2021 Classification and DiagnosisNICE NG133 (2021)

Verified Apr 2026

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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.

References

1.FOGSI-GESTOSIS-ICOG Good Clinical Practice Recommendations on Hypertensive Disorders in Pregnancy (2019, refreshed); ISSHP 2021 Classification and Diagnosis; NICE NG133 (2021)

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