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Hypertension in pregnancy - Management
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How do I manage women with new proteinuria without hypertension at less than 20 weeks' gestation?

If the woman is 20 weeks' gestation or less and is found to have proteinuria but is not hypertensive:

  • Consider possible urinary tract infection (UTI):
    • If a woman has symptoms of a UTI, or urinary dipstick test is positive for nitrite, or is positive for both leukocyte esterase and blood, make a working diagnosis of UTI and manage appropriately. Urine should be sent for culture and sensitivity.
    • For detailed information on the diagnosis and management of UTI in pregnancy, see the CKS topic on Urinary tract infection (lower) - women.
  • If there is no evidence of a UTI and the woman has 1+ protein or more on repeat dipstick testing, consider underlying medical conditions and assess for chronic kidney disease. For more information, see the CKS topic on Chronic kidney disease - not diabetic.
Basis for recommendation
  • 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 for protein. However, it should be noted that 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.
  • Assessing for chronic kidney disease
    • National guidelines on early identification and management of chronic kidney disease recommend that all people with an incidental finding of proteinuria or haematuria (not due to UTI) should be tested for possible chronic kidney disease, and underlying medical conditions should be considered [NICE, 2008a]. For further information, see the CKS topic on Chronic kidney disease - not diabetic.

How do I manage women with new proteinuria without hypertension after 20 weeks' gestation?

If the woman is over 20 weeks' gestation and has new proteinuria but no hypertension:

  • If she has symptoms of pre-eclampsia, arrange same-day hospital assessment.
  • If there are no symptoms of pre-eclampsia:
    • Consider possible urinary tract infection (UTI).
      • If there is 1+ protein: if the woman has symptoms of a UTI, or the dipstick test is positive for nitrite or is positive for both leukocyte esterase and blood, make a working diagnosis of UTI and manage appropriately. Urine should be sent for culture and sensitivity. Ensure follow up within 1 week and reassess. For detailed information on the diagnosis and management of UTI, see the CKS topic on Urinary tract infection (lower) - women.
      • If there is 2+ protein or more on dipstick testing: even if the woman has symptoms of a UTI or the dipstick test is positive for nitrite, or is positive for both leukocyte esterase and blood, seek same day specialist advice.
    • If there is no evidence of a UTI:
      • If there is 1+ protein on dipstick testing of urine, review 1 week later. If proteinuria is persistent, seek specialist advice.
      • If there is 2+ protein or more on dipstick testing, seek same day specialist advice.
Symptoms of pre-eclampsia
  • Symptoms of pre-eclampsia
    • Severe headaches (increasing frequency unrelieved by regular analgesics).
    • Vision problems, such as blurred vision, flashing lights, double vision, or floating spots.
    • Persistent new epigastric pain or pain in the right upper quadrant.
    • Vomiting.
    • Breathlessness.
    • Sudden swelling of the face, hands, or feet.
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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