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Hypertension in pregnancy - Management
Basis for recommendation

  • Admitting to hospital if there is proteinuria and symptoms of pre-eclampsia, even if the woman is not hypertensive
    • The Pre-eclampsia Community Guideline (PRECOG) development group reviewed the available evidence and concluded that proteinuria may be the first clinical indication of pre-eclampsia [PRECOG, 2004b]. Therefore, if the woman has symptoms suggestive of pre-eclampsia and proteinuria, then she should be assumed to have pre-eclampsia until proven otherwise.
  • Considering possible urinary tract infection (UTI)
    • It is good clinical practice to consider possible UTI in a woman who is pregnant and has a positive dipstick test for protein. However, although protein may occur in the urine of women with a UTI, the presence of protein does not independently predict a UTI [Little et al, 2009]. For detailed information on the diagnosis of UTI, see the CKS topic on Urinary tract infection (lower) - women.
  • Reassessment of normotensive women with 1+ protein who are well within 1 week, and seeking specialist advice if there is persistent proteinuria
    • The recommendation to re-assess in 1 week is based on expert advice from PRECOG [PRECOG, 2004a].
    • PRECOG does not give specific advice on what action to take if a woman has persistent 1+ protein and is otherwise well [PRECOG, 2004a]. However, there is evidence that significant proteinuria is predictive of developing pre-eclampsia and poor pregnancy outcomes, and national guidelines advise that the presence of proteinuria should alert the healthcare professional to the need for increased surveillance [National Collaborating Centre for Women's and Children's Health, 2008]. In the absence of guidance to inform management, CKS recommends seeking specialist advice if proteinuria persists, as specialist assessment and increased monitoring may be necessary.
  • Seeking same day specialist advice if there is 2+ proteinuria
    • PRECOG recommends that all women with 2+ protein or more on dipstick testing who are over 20 weeks' gestation should have early assessment in secondary care, as this may indicate impending pre-eclampsia or an underlying medical problem [PRECOG, 2004a]. Many of the CKS expert reviewers advised that all women with 2+ protein or more on dipstick testing should have hospital assessment within 48 hours regardless of whether or not a urinary tract infection may be the cause. Therefore CKS recommends that same-day specialist advice should be obtained.
  • Quantification of proteinuria by a 24-hour urine collection or spot albumin:creatinine ratio
    • CKS has not recommended that GPs initiate a 24-hour collection of urine or spot albumin:creatinine ratio for quantification of protein, as this will usually be initiated in secondary care. GPs should note that:

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