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The following guidance is based on NICE NG133: Hypertension in pregnancy: diagnosis and management (June 2019)
Pregnant women, or women planning a pregnancy, who are taking ACE inhibitors, angiotensin-II receptor blockers (ARBs) or thiazide or thiazide-like diuretics need immediate review with their GP to discuss alternative antihypertensive therapy.
MHRA Drug Safety Update (December 2007): ACE inhibitors and angiotensin II receptor antagonists: not for use in pregnancy:
Offer women with chronic hypertension referral to a specialist in hypertensive disorders of pregnancy to discuss the risks and benefits of treatment.
Offer pregnant women with chronic hypertension advice on:
Provide this advice in line with Management of hypertension guidance
Aim for a target blood pressure of 135/85 mmHg
Continue with existing antihypertensive treatment if safe in pregnancy, or switch to an alternative treatment (see below).
Offer antihypertensive treatment to pregnant women who have chronic hypertension and who are not already on treatment if they have blood pressure of 140/90 mmHg or higher.
In women with other markers of potentially severe disease, treatment can be considered at lower degrees of hypertension.
Base the choice on any pre-existing treatment, side-effect profiles, risks (including foetal effects) and the woman's preference. NICE recommends the following:
For further information on the use of these medicines in pregnancy, refer to the UK Teratology Information Service
Offer pregnant women with chronic hypertension aspirin 75-150mg once daily (with evening meal) from 12 weeks until birth to prevent pre-eclampsia (unlicensed indication). Local specialists recommend 150mg once daily. See below for risk factors for pre-eclampsia.
Women with at least one high risk factor OR two moderate risk factors for pre-eclampsia should be prescribed aspirin 75-150mg once daily (with evening meal), from 12 weeks until birth (unlicensed indication). Local specialists recommend 150mg once daily.
Stop methyldopa within two days after the birth and change to a different drug if required. Continue other antenatal antihypertensives if required, and measure blood pressure daily for the first two days after birth, then at least once between day 3 and 5. Aim to keep blood pressure below 140/90 mmHg.
Women should be reviewed by their GP or specialist as appropriate, 2 weeks after birth and then again 6–8 weeks after the birth or as per discharge information.
Reduce antihypertensive treatment if blood pressure falls below 130/80mmHg.
Advise women with hypertension who wish to breastfeed that their treatment can be adapted to accommodate breastfeeding, and that the need to take antihypertensive medication does not prevent them from breastfeeding.
Additional information on the use of medicines in lactation is available from the UK Drugs in Lactation Advisory Service (UKDILAS)
For women who are not breastfeeding, and who require ongoing antihypertensive treatment, refer to management of hypertension
For breastfeeding women who received methyldopa during their pregnancy, or require postnatal commencement of antihypertensive consider:
Enalapril
Nifedipine (modified release)
OR
Amlodipine
Combination of:
Nifedipine (modified release) plus Enalapril
OR
Amlodipine plus Enalapril
If this combination is not tolerated or is ineffective, consider:
Adding Atenolol or Labetalol to the combination treatment
OR
Swapping one of the medicines already being used for Atenolol or Labetalol
See sections 2.4 Beta-adrenoceptor blocking drugs, 2.5.5 Drugs affecting the renin-angiotensin system, and 2.6.2 Calcium-channel blockers
Advise women who have had a hypertensive disorder of pregnancy that the overall risk of recurrence in future pregnancies is approximately 1 in 5
Prevalence of hypertensive disorder in a future pregnancy:
Advise women who have had pre-eclampsia:
Prevalence of hypertensive disorder in a future pregnancy:
Prevalence of hypertensive disorder in a future pregnancy:
Advise women who have had a hypertensive disorder of pregnancy that this is associated with an increased risk of hypertension and cardiovascular disease in later life
Risks described are overall estimates, summarised from risk ratios, odds ratios and hazard ratios. Increased risk is compared to the background risk in women who did not have hypertensive disorders during pregnancy.
Risk of future cardiovascular disease:
Risk of future cardiovascular disease:
Risk of future cardiovascular disease:
Risk of future cardiovascular disease: