Management of gestational hypertension (new hypertension presenting at 20 weeks' gestation or more without proteinuria)

• These recommendations are based on expert opinion from the National Institute for Health and Clinical Excellence (NICE) [National Collaborating Centre for Women's and Children's Health, 2010], which recommends:
• That all women with gestational hypertension should be offered an integrated package of care that may include hospital admission, regular measurement of blood pressure, testing for proteinuria, and relevant blood tests.
• Admission to hospital if blood pressure is 160/110 mmHg or greater.
• Expert assessment is also recommended as pre-eclampsia may present atypically; 20% of women with atypical eclampsia have minimal or absent proteinuria [Young et al, 2010].

Management of pre-eclampsia

• These recommendations are based on expert opinion from NICE [National Collaborating Centre for Women's and Children's Health, 2010], which recommends:
• That all women with pre-eclampsia should be offered immediate admission and an integrated package of care, regular measurements of blood pressure, testing for proteinuria, and relevant blood tests.

Dipstick analysis of proteinuria and decision to refer

• NICE reviewed the evidence and recommended that an automated dipstick is used for diagnosing pre-eclampsia in secondary care and that a 1+ protein result or more on an automated dipstick should be quantified by using a 24-hour urine collection or a spot urinary protein:creatinine sample [National Collaborating Centre for Women's and Children's Health, 2010]. There are no recommendations for primary care clinicians who may only have access to visual dipstick testing. NICE based its decision on a review of the available evidence and concluded that:
• Visual dipstick testing is a poor test for the diagnosis of pre-eclampsia.
• A negative dipstick result does not exclude significant proteinuria.
• NICE based its recommendation mainly on evidence from a meta analysis of six trials and a subsequent prospective study that showed visual dipstick analysis of urine with a 1+ threshold is unreliable for detecting clinically significant proteinuria [Waugh et al, 2004]. Its use in clinical decision making is therefore of limited usefulness. Although accuracy may be improved by using a higher cut-off point (such as 2+), there are only limited data of poor methodological quality for this threshold. Accuracy was improved by using an automated dipstick device.
• Most primary care physicians will only have access to visual dipstick analysis of urine and will need to make a clinical decision taking into account the result. In addition, accurate quantification of proteinuria by collection of a 24-hour urine sample or by urinary protein:creatinine ratio would take an unacceptable length of time. Therefore, CKS recommends that primary care clinicians seek immediate specialist advice for pregnant women who are more than 20 weeks' gestation who present with new hypertension and a trace or more of protein in their urine on visual dipstick urinalysis. If access to the more accurate automated dipstick testing is available, then a threshold of 1+ protein is recommended, in keeping with NICE guidelines.