Management in secondary care

• The expert opinion of the National Institute for Health and Clinical Excellence (NICE) is that assessment of women with pre-eclampsia should always be done by a healthcare professional trained in the management of hypertensive disorders of pregnancy [National Collaborating Centre for Women's and Children's Health, 2010].
• NICE recommends that all women with pre-eclampsia with a blood pressure of 140/90 mmHg or greater be admitted.

Monitoring and review

• NICE reviewed the available evidence and concluded that [National Collaborating Centre for Women's and Children's Health, 2010]:
• There are no data to inform the frequency of blood pressure monitoring, and this should depend on the severity of hypertension and the presence of risk factors. There is no evidence to support a change from the routine practice of measuring blood pressure at least four times a day in women with mild or moderate new hypertension and proteinuria while an inpatient. Blood pressure should be recorded more frequently in women with severe pre-eclampsia to detect rises in blood pressure and to monitor response to therapy. The risk of stroke is increased if hypertension is severe.
• Once the diagnosis of significant proteinuria has been made, there is little benefit from repeating the analysis. There is only a weak association between more than 5 g of protein in the urine per 24 hours and stillbirth, admission to neonatal intensive care unit, and small-for-gestational-age infants. The degree of protein in the urine does not seem to be related to outcome for the mother. Therefore, NICE considers that the evidence does not support repeated measurement of urinary protein once significant proteinuria is established.
• There is sufficient evidence that in women with pre-eclampsia, measuring platelet count, serum creatinine, and transaminases is useful in monitoring progression to more severe disease. Although rising serum uric acid is associated with severe pre-eclampsia this test has not been shown to be of additional value. Available evidence shows that a coagulation screen is not helpful if the platelet count is above 100 x 10⁹/L.

Drug treatment of pre-eclampsia

• NICE reviewed the available evidence and concluded that [National Collaborating Centre for Women's and Children's Health, 2010]:
• There is limited good-quality evidence about treatment of pre-eclampsia. There is no evidence that lowering blood pressure in women with mild or moderate pre-eclampsia improves pregnancy outcomes compared with starting treatment once the woman has developed severe hypertension. However, there is insufficient evidence to know whether antihypertensive treatment prevents rarer outcomes such as a stroke or placental abruption.
• There is some evidence about appropriate target blood pressure. There seems to be an increased risk of severe hypertension with less tight control (diastolic values above 90 mmHg or 100 mmHg).
• There is some evidence from a randomized controlled trial that labetalol reduces the risk of progression to severe hypertension.
• There is little evidence on the use of calcium-channel blockers.
• NICE considered that the association of beta-blockers with reduced fetal growth was a result of excessive lowering of blood pressure.
• Expert opinion from NICE is that:
• Labetalol seems to be as effective and safe as other drugs used for hypertension for managing pre-eclampsia and it is licensed for use in pregnancy.
• Labetalol should be used as first-line treatment.
• Alternative treatment includes methyldopa and nifedipine, and these should be offered after considering adverse effect profiles for the woman, fetus, and newborn baby. NICE recommends using these treatments in women of Afro–Caribbean origin, as it is not known whether they respond well to beta-blockers in pregnancy (a poor response to beta-blockers has been recognized in people of Afro–Caribbean origin who are not pregnant).

Timing of the birth

• These recommendations are based on expert advice from NICE after their review of the available evidence [National Collaborating Centre for Women's and Children's Health, 2010].