Open Access Original Article

Society of Obstetricians and Gynaecologists Pakistan

ORIGINAL ARTICLES
Society of Obstetricians and Gynaecologists Pakistan (SOGP)
Hypertensive Disorders in Pregnancy Guidelines- 2022
Shehla M Baqai, Rehana Rahim*, Hasan Ala**, Shahida Husain Tarar***, Fareesa Waqar****, Haleema Yasmeen*****, Anam Waheed******
CMH Lahore Medical College, Lahore/National University of Medical Sciences (NUMS) Pakistan, *Lady Reading Hospital, Peshawar Pakistan,
**Dow University of Health Sciences, Karachi Pakistan, ***Nawaz Sharif Medical College, Gujrat Pakistan, ****Riphah International University, Islamabad
Pakistan, *****Jinnah Postgraduate Medical Center, Karachi Pakistan, ******Brigham and Women’s Hospital, Boston, USA

ABSTRACT
The Society of Obstetricians & Gynecologist Pakistan Hypertensive Disorders of Pregnancy (SOGP-HDP) guideline is
evidence based practical clinical guide to the management of pregnant women with hypertension. It defines hypertension,
preeclampsia & severe hypertension, encourages measuring blood pressure (BP) accurately, preferably by automated/
mercury blood pressure monitors. The guideline gives an approach to screening, risk prediction and prevention of pre-
eclampsia and management of hypertensive disorders of pregnancy. The guideline emphasizes experienced team manage-
ment approach and mandatory hospital protocols for the management of pregnant women with hypertension. The aim is to
have locally tailored easy to follow protocols for preconception care, screening, prevention and management of women at risk
of preeclampsia; management of chronic hypertension in pregnancy, antihypertensive therapy for severe and non-severe
hypertension. In addition, it discusses post-partum management, contraception, follow-up, discusses risk of recurrence and
long-term follow up for women with preeclampsia to mitigate future cardio-metabolic risks to maternal health associated with
hypertensive disorders of pregnancy.
Keywords: Guideline, Hypertension, Pregnancy, Pregnancy outcome, Preeclampsia, Prognosis.

How to Cite This Article: Baqai SM, Rahim R, Ala H, Tarar SH, Waqar F, Yasmeen H, Waheed A. Society of Obstetricians and Gynaecologists Pakistan (SOGP) -
Hypertensive Disorders in Pregnancy Guidelines 2022. Pak Armed Forces Med J 2022; 72(3): 731-753. DOI: [Link] 10.51253/pafmj.v72i3.8600

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ([Link] which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

1. OVERVIEW AND GUIDELINE health care professionals (HCPs) including obstetri-

DEVELOPMENT METHODOLOGY cians, general physicians, primary health care provid-
Hypertensive disorders in pregnancy (HDP) are ers and nurse practitioners. It has been developed with
a leading cause of maternal and perinatal morbidity the input from a team of obstetricians from various
and mortality globally.1 Despite awareness about HDP regions of the country. The writing group members
women continue to develop complications/die as a were drawn from a variety of clinical settings-public,
result of hypertension more so in low and middle private and Armed forces, from high-and low-income
income countries (LMIC).2 Evidence is building to sug- urban settings, regional and rural/remote settings,
gest that lifestyle interventions are useful in reducing having expertise in hypertension in pregnancy. There
the risk of cardiovascular disease in women whose was no funding available and work was completed on
pregnancy was complicated by hypertension.3 Consen- a purely voluntary basis.
sus on diagnostic criteria, classification of HDP, when The International literature including educational
to treat hypertension in pregnancy and timing of deli- resources (Medline, Cochrane Database of Systematic
very has been difficult to achieve. The uncertainty has Reviews (CDSR) and UpToDate) and multiple guide-
led to differences in rates of adverse maternal and fetal lines for managing HDP were reviewed. Each member
outcomes for the various HDP, particularly preeclam- of the guideline group was assigned a section of the
psia between different health care facilities.4 This pro- guideline to write; with few writing multiple sections.
mpted SOGP to develop national, updated, evidence Sections were then reviewed by all members in multi-
based, user friendly consensus document. ple weekly zoom meetings, and a consensus was achie-
This guideline is pragmatic, evidence and consen- ved. Final editing was done by a group of 4 members.
sus based, locally adapted, practical guidance to all The document was peer reviewed by international and
national reviewers and was pilot tested.
Correspondence: Dr Shehla M Baqai, Professor & HOD of Obs &
Gynae Dept, CMH Lahore Medical College, Lahore Pakistan
Keeping in view rapidly developing medical
Received: 20 Apr 2022; revision received: 27 Apr 2022; accepted: 28 Apr 2022 evidence, the guidelines are proposed to be a living
mellowmelamiine@[Link]

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 Society of Obstetricians and Gynaecologists Pakistan

document, to be reviewed and updated 2 years from very.11 Given the known relationship between HDP
publication. and poor pregnancy outcomes, there needs to be a
2. EXECUTIVE SUMMARY greater focus on prevention, early identification (scree-
ning, diagnosis), PE risk prediction and management
Hypertensive disorders of pregnancy (HDP) are
of HDP.5,11 Considering the role of in-utero genetic
one of the commonest medical disorders encountered
imprinting in increasing the risk of cardiovascular dis-
by pregnant women worldwide with a global preva-
orders in the off springs of mothers with HDP, as well
lence of 10% in the obstetric population with LMIC
as increasing maternal vulnerability to future diabetes
affected the most.3,5 The prevalence of maternal
and cardio-metabolic disorders; Pregnancy offers a
chronic hypertension has increased many fold, largely
unique opportunity not to be missed, for primary
secondary to the obesity, gestational diabetes (GDM)
prevention of adverse consequences of hypertension
epidemic and increasing maternal age. The trend is
and reduce the future burden of Hypertension.12,13
expected to continue.6-8 Preeclampsia (PE) is the pre-
dominant gestational hypertensive disorder, with a HDP practice survey amongst HCPs recently
significant impact on maternal and neonatal health carried out in public sector hospitals revealed wide
including severe morbidity, long term disability and variation in diagnosis, admission, management and
death particularly if early in onset (PE <32 weeks ges- timing of delivery practices for HDP. This stimulated
tation).3,5,6 The majority of complications due to pre- the idea for the national guideline with the objective to
eclampsia and eclampsia are avoidable through timely equip all HCPs with strategies for earlier identification
and effective care.3,5 The document clarifies the criteria and timely management of women with HDP, imp-
used to define and diagnose different types of HDP rove clinical practice and prevent hypertension and its
and recommends practical evidence based best practice long term sequelae later in life by continued postpar-
recommendations based on available literature, new tum follow up, BP monitoring timely referral and
research data and expert opinion. Optimizing health treatment.
care to prevent and treat women with HDP will help Preconception care is recommended for all
achieve Sustainable Development Goals. women with pre-existing hypertension to optimize BP
The major challenge in management of HDP is to control, general health and weight; assess for comp-
balance achieving fetal maturation in utero with the lications; review of medications; folic acid supplemen-
maternal & fetal risks of continuing the pregnancy. The tation and patient education.14
risks include progression to eclampsia, development of The guideline recommends early universal
placental abruption and HELLP (hemolysis, elevated screening for HDP in all pregnant women at booking
liver enzyme, low platelet) syndrome.9 On the other using automated/mercury BP monitors.3 All women
hand, preterm delivery is associated with higher peri- diagnosed to be hypertensive are offered screening for
natal and infant mortality and morbidity resulting preeclampsia in first trimester by maternal characteris-
from small for gestational age (SGA), thrombocytope- tics, mean arterial BP measurement (MAP) and Uterine
nia, broncho-pulmonary dysplasia, cerebral palsy, and artery Pulsality Index (UTPI). Risk is calculated by web
significant long term morbidity (increased risk of -based FMF calculator available free of cost.11 Women
diabetes mellitus, obesity, coronary artery disease, and in low resource settings can be screened for preeclam-
hypertension in adult life).9 Women with PE, in the psia by two parameters namely maternal history and
long run face an increased risk of death from future MAP. Women with risk score of >1 in 100 are recomm-
cardiovascular disease, hypertension, stroke, renal ended to take 150 mg Aspirin and 1 gm Calcium to
impairment, metabolic syndrome, and diabetes. The prevent PE.11
life expectancy of women who develop preterm PE is Antenatal management commences with coun-
reduced by 10 years on average.10 seling and education of pregnant women with HDP
Despite the known association of HDP with along with their families. The focus is on optimizing
adverse maternal and perinatal outcomes, to date there BP control. Home BP monitoring/BP checks at nearby
has been confusion, disagreement and lack of consen- health care and 2 weekly antenatal visits are encou-
sus amongst international health organizations on raged. First line antihypertensive recommended is
screening and diagnostic criteria for HDP, requirement Labetalol, followed by Nifedipine and Methyl-Dopa.15
of proteinuria for diagnosis of preeclampsia, BP at Target BP recommended is 130/85 mmHg.3,5,6 Magne-
which treatment is to be started and timing of deli- sium Sulphate is recommended for seizure prophylaxis

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 Society of Obstetricians and Gynaecologists Pakistan

and treatment.3,5 In utero transfer to tertiary care health SOGP HDP guideline recommendations are
care facility is encouraged in case of severe hyperten- based upon available literature and expert opinion and
sion or expected preterm delivery.7,8 Apart from will be reviewed after two years.
routine fetal surveillance growth scans and umbilical STRENGTHS
artery Doppler studies are recommended from 28
1. Written by experienced obstetricians belonging to
weeks of gestation. The guideline addresses each HDP
all health care settings nationwide.
separately in detail with a separate section devoted to
severe hypertension. 2. Peer reviewed by renowned international
Obstetrician and physicians.
Timing of delivery depends upon BP control,
associated complications, and fetal condition. The opti- 3. Endorsed by Pakistan Society of Internal Medicine
mal time of delivery for women with well controlled (PSIM) and Hypertension League of Pakistan.
simple gestational and uncomplicated chronic hyper- 4. Guideline has been Pilot tested.
tension is between 38-39 weeks of gestation.7 Timing of 5. All aspects including management for each dis-
delivery is earlier and individualized for women with order along with separate section on severe hyper-
PE and severe hypertension. No pregnancy compli- tension, intrapartum care, postpartum care, contra-
cated by HDP to go beyond 40 weeks of gestation.8 ception and long term care of women with HDP.
Vaginal delivery is encouraged. Caesarean section is
6. Implementing the guideline will enhance safe
recommended for obstetric reasons only.7,8
patient care, promote uniform practices and help
Considering postpartum risk of severe hyperten- achieve Sustainable Development Goals.
sion and eclampsia, in addition to routine postpartum LIMITATIONS
care, frequent monitoring of maternal BP and escala-
tion of care to Obstetric critical care unit (if required) is 1. The quality of evidence for the recommendations
offered.16 All women with hypertension are recommen- in the document has not been graded, although
ded to be monitored as inpatient for at least 48 hours. relevant references and explanations are provided
Methyl-Dopa if used antenatally is stopped within 48 for each recommendation.
hours of delivery and changed to safer options.7,8 At 2. Local references are few as local research is lacking
discharge patients are educated to identify red flag and this is the first national guideline.
symptoms and signs and asked to report in gynecology 3. PlGF based testing has not been discussed in detail
emergency/triage. Guideline issues guidance for as it is not available in the country at present.
breast feeding, contraception and long term follow up. 4. The guideline does not address routine pregnancy
It emphasizes that future pregnancy in a woman with care. It primarily addresses the specific issues per-
HDP needs to be planned. Women with HDP are coun- taining to hypertensive disorders in pregnancy.
seled to report in Preconception clinic when planning
5. The relationship between the social determinants of
pregnancy subsequently to optimize pregnancy outco-
mes. Effective long acting reversible contraception is hypertension and management in pregnancy is
beyond the scope of the guideline and has not been
recommended.
evaluated in the already lengthy clinical guideline.
Postpartum the woman is advised to continue life
6. The unique needs of women of different cultures
style modification and regular follow up in order to
and strata of society have not been catered for.
reduce development of hypertension and cardio-meta-
bolic complications, hence reducing the prevalence of 3. INTRODUCTION
non-communicable diseases (NCDs). An estimated 295,000 women died worldwide in
Guideline developing methodology along with 2017, as a result of pregnancy and childbirth or its
the strengths and limitations of the evidence based complication with 99% of the deaths occurring in low
consensus document are given. Future research recom- and middle income countries (LMIC).17 Hemorrhage,
mendations are suggested to better understand HDP hypertensive disorders and sepsis were responsible for
in the country and see the impact/change in clinical more than half of all maternal deaths. Globally comp-
practice by the implementation of the national SOGP- lications arising from HDP are among the leading cau-
HDP guidelines in the country. ses of preventable severe maternal and perinatal mor-
bidity and mortality.17 Timely and appropriate treat-
ment has the potential to significantly reduce hyper-

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 Society of Obstetricians and Gynaecologists Pakistan

tension-related complications.10,18 There is an ongoing o Use appropriate cuff size: medium/large/thigh

need to spread awareness, improve knowledge for cuff for morbidly obese. It should be 1.5 times
timely identification of HDP and PE even within the upper arm circumference.
medical fraternity because of variations in practice and o Avoid tobacco or caffeine intake 30 minutes
standards of care. Our objective is to formulate up preceding the measurement (lead to temporary
dated, evidence based, best practice, user friendly, easy rise in BP).
to implement tailored to the local context guidelines
o Outpatient setting: Sitting posture after a 10-
for all health care providers including nurse practi-
minute rest period.
tioners. This is to ensure all pregnant women are
screened for HDP, diagnosed timely and treated app- o Inpatient setting: Measure either sitting up or
ropriately to improve health outcomes.10,18 To improve lying in left lateral position with arm at the level
quality of care, reduce complications and minimize of the heart
risks healthcare managers, policy makers and HCPs o BP should be taken on both arms at the first
are strongly encouraged to adopt and deploy the antenatal visit. The right arm should be used
standard guidelines.19,20 The Guidelines emphasizes thereafter if there is no significant difference
measuring BP accurately by a validated calibrated BP between the arms.
apparatus (ideally automated) using the right Cuff size o When measuring BP, SBP should be palpated at
fulfilling all prerequisites. It is also recommended that the brachial artery before inflating the cuff to 20
hospitals provide education about preeclampsia to all mmHg above the recorded level. The cuff should
expectant mothers. then be deflated slowly. DBP is recorded as
The SOGP–HDP guidelines provides practical Korotk off phase V (K5) / IV (K4) if K5 is absent.
guidance on classification, diagnostic criteria, and When a woman with Hypertension is encounte-
management for all clinicians, everywhere, who are red by a HCP, the first step should be to classify it
involved in the management of women with HDP. It so as to tailor feto-maternal surveillance and
helps to coordinate and standardize the care provided management.
to women with HDP during pregnancy and the post- Recommended Classification for HDP
partum period nationwide in all health care settings. It
outlines clinical evidence based practices that should  Preeclampsia –eclampsia
be disseminated, adapted and implemented in every  Gestational hypertension
maternity care setting, there by reducing confusion  Chronic hypertension essential secondary white
around diagnosis and management of women with coat
HDP and making practice uniform.  Preeclampsia superimposed on chronic
4. DEFINITION AND CLASSIFICATION OF hypertension
HYPERTENSION IN PREGNANCY ( 3,5,7) Gestational Hypertension:
 Hypertension in pregnancy is defined as systolic BP New onset hypertension after 20 weeks of gesta-
(SBP) ≥140 mmHg or diastolic BP (DBP) ≥90 mmHg tion in a previously normotensive woman without
on at least 2 occasions at least 4 hours apart, in a proteinuria or features of end organ damage (throm-
previously normotensive woman or SBP ≥160 bocytopenia, renal insufficiency, elevated liver transa-
mmHg or DBP ≥110 mmHg reconfirmed within 15 minases, pulmonary edema, cerebral or visual symp-
minutes. toms) followed by return of bp to normal within 3
 Recommended technique for BP measurement months’ post-partum.5
o BP should be measured by a calibrated automated Preeclampsia:
/mercury spy manometer. SOGP- HDP group New onset hypertension after 20 weeks gestation
recognizes that in many areas of the country only in association with new-onset one or more of the
aneroid devices are available and despite their following conditions:
inaccuracy aneroid devices will need to be used. 1. Proteinuria (spot urine protein/creatinine >30
Regardless of the method used, we recommend a mg/mmol [0.3 mg/mg] or >300 mg/24 hours o[‘2
minimum of two BP measurements to diagnose + ’] on dipstick testing)
hypertension. 2. Evidence of maternal end organ dysfunction:

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 Society of Obstetricians and Gynaecologists Pakistan

 Thrombocytopenia (platelet count  Impaired liver function as indicated by liver

<100,000/dL). transaminase levels at least twice the normal
 Renal insufficiency (serum creatinine of >1.1 concentration or severe persistent right upper
mg/dL [97 micromol/L]. quadrant or epigastric pain unresponsive to
medication and not accounted for by alternative
 Impaired liver function (raised liver
diagnoses, or both.
transaminases at least twice the normal or
severe persistent right upper quadrant or  New-onset or worsening renal insufficiency.
epigastric pain unresponsive to medication).  Pulmonary edema
 Pulmonary edema.  Persistent cerebral or visual disturbances.5
 Persistent neurological (altered mental 5. SCREENING AND PREVENTION OF
status/hyperreflexia/clonus, severe headaches) PREECLAMPSIA
or visual symptoms.5 5.1 First trimester screening for PE
3. Uteroplacental dysfunction (fetal growth Early identification of ‘women at risk of PE’ will
restriction). allow for prevention, heightened/ individualized ante-
Proteinuria is not essential for the diagnosis of PE. natal maternal and fetal surveillance, early recognition
4.4 Eclampsia: of PE and prompt intervention. All pregnant women
diagnosed to be hypertensive are offered screening for
In a patient with preeclampsia, generalized
preeclampsia in first trimester.11,21,22
seizures that cannot be attributed to other causes (5)
5.1-2: Universal Screening for early identification of
4.5 HELLP syndrome (hemolysis, elevated liver
pregnant women at risk of PE in first trimester (11–14
enzymes, low platelets):
weeks) using maternal characteristics, Mean Arterial
HELLP is considered a variant of preeclampsia).5 pressure (MAP) and Uterine artery pulsatility index
4.6 Chronic Hypertension: (UtPI) for is recommended.11,23 (local detailed PE scree-
Hypertension diagnosed before pregnancy or ning and prevention guidelines are under publication).
before 20 weeks of gestation or that is first diagnosed 5.1-3: Data is entered into the web based FMF2012
during pregnancy and persists at least 12 weeks post- software tool available free of charge at https://
delivery.5 [Link]/research/assess/[Link]
4.7 Chronic hypertension with superimposed is calculated automatically.24
preeclampsia 5.1-4: Individualized Risk assessment is done. The cut
Any of the following in a patient with chronic of risk is taken to be “1 in 100”.24
hypertension: 5.1-5: In low resource settings screening to be done by
 A sudden increase in blood pressure that was at least two parameters - maternal factors and MAP.
previously well-controlled or an escalation of Maternal risk factors alone should not be used for
antihypertensive therapy to control blood pressure first trimester PE screening as this would lower the
performance of the screening. Adding PlGF where
 New onset of proteinuria or sudden increase in
available will improve risk prediction.
proteinuria in a patient with known proteinuria
before or early in pregnancy.5 5.2-Prevention
4.8 Chronic hypertension with superimposed There is no cure for PE other than delivery; therefore
preeclampsia with severe features interventions to prevent PE will have a significant
Any of these findings in a patient with chronic impact on maternal and infant health worldwide.11,21
hypertension and superimposed preeclampsia: 5.2-1: Offer tablet Aspirin 150 mg at bedtime initiating
 Systolic blood pressure ≥160 mmHg or diastolic before 16 weeks and continue till 36 weeks.22,23
blood pressure ≥110 mmHg despite escalation of 5.2-2: Tablet Calcium 1 gram daily from 16th week.24
antihypertensive therapy. 5.3-3: Educate all at risk women about signs and
 Thrombocytopenia (platelet count <100,000/ symptoms of PE.
microL). 5.4-4: Close fetal and maternal surveillance enabling
early detection and timely intervention.

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 Society of Obstetricians and Gynaecologists Pakistan

Preventive strategies will work to prevent preterm PE. 9.3: Fetal heart assessment by sonicaid/ fetoscope at
It will not prevent term PE.24,25 each visit.
6. MID TRIMESTER RISK PREDICTION FOR PE 9.4: Fetal movement counts is reassuring for mothers
A 100 percent reliable test for mid trimester but not sensitive. If woman reports with less fetal
screening for PE is not available .Mid trimester Uterine movements initiate fetal surveillance by ultrasound.5
artery Doppler ultrasonography at 22–24 weeks 9.5: In women with non-severe hypertension, ultra-
predicts risk of developing PE/IUGR with an accuracy sound assessment of fetal well-being and growth (fetal
of 60%.26 Test like PIGF (placental growth factor) biometry measured using Head circumference HC,
sFlt-1 (soluble Fms-like tyrosine kinase 1), and sEng Abdominal circumference AC, Femur length FL), um-
(soluble Endoglin), are still under research.27 bilical artery Doppler velocimetry (by expert operator
PIERS clinical predictive model, can predict the to detect reduced, absent or reverse flow) at diagnosis
likelihood of severe adverse maternal outcome using and if normal, repeat every 2-4 weeks.29
the following variables 6–48 h after admission with 9.6: CTG offered after 30 weeks where clinically indi-
PE: gestational age, chest pain or dyspnoea, oxygen cated (decreased fetal movements, vaginal bleeding,
saturation, platelet count, serum creatinine, AST.27 sudden abdominal pain, sudden rise in BP, unstable
7. ASSESSMENT OF PROTEINURIA (5) maternal condition.30 CTG (after 30 weeks) is done at
presentation and repeated twice weekly in PE comp-
7.1: Accurate assessment of proteinuria is important
licated with FGR or more frequently if clinically
for identifying risk to pregnancy and to make decision
indicated.
for admission and management.
9.7: In women with severe hypertension, ultrasound
7.2: Screening is done at each antenatal visit by
assessment of fetal well-being and growth (fetal bio-
dipstick testing using an automated/ visual reagent
metry measured using Head circumference-HC, Abdo-
strip.
minal circumference-AC, Femur length -FL), umbilical
7.3: Quantification of proteinuria is done if dipstick artery Doppler velocimetry (by expert sonologist to
screening is positive (1+ or more) by spot Urine Pro- detect reduced, absent or reverse flow) at diagnosis,
tein Creatinine Ratio (cut-off >30 mg/mmol) or spot repeat 1-2 weekly.
Urine Albumin Creatinine Ratio (cut-off 8 mg/ mmol).
10. TARGET BP
First morning urine should not be tested. 24-hour urine
collection are cumbersome and not recommended.10 Target BP recommended is 130 / 85 mmHg.5
8. MATERNAL INVESTIGATIONS IN HDP (5) 11. MANAGEMENT OF CHRONIC
HYPERTENSION
8.1: In women with non-severe hypertension, measure
full blood count, liver function test, renal function tests It is important to manage chronic HTN to
at presentation then 1- 2 weekly. prevent adverse maternal, fetal and neonatal outcomes
(Table-I).
8.2: In women with severe hypertension, measure full
blood count, liver function test, renal function tests at Table-I: Chronic Hypertension complications.
presentation then twice weekly. Elevated serum uric Pre eclampsia 17-25% (31–34)
acid > 5.2 mg/dl increases risk of PE.5 Fetal growth restriction with superimposed pre-eclampsia
9. FETAL INVESTIGATIONS IN HDP 41%
Fetal growth restriction without superimposed
Risk of perinatal morbidity and mortality is preeclampsia 21%(35)
higher in pregnancies complicated with HDP. Careful Placental abruption 1.5%(36)
fetal surveillance can prevent complications or can Preterm delivery 12-34%(31)
reduce their severity.28 Intrauterine demise 0.8% (37)
Neonatal deaths 0.5% (37)
9.1: Accurate dating of pregnancy is important to Caesarean section rate 50-70% (35)
detect growth restriction later in pregnancy.
9.2: Measurement of symphysio-fundal height is less 11.1 Pre pregnancy counseling and advice
sensitive and a poor predictor of fetal growth 11.1.1: Advice women with chronic hypertension to
restriction so not recommended. keep BP < 130/85 mmHg.

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 Society of Obstetricians and Gynaecologists Pakistan

11.1.2: Inform women with chronic hypertension that FBC,Renal ultrasound, ECG, Echocardiography to
adverse pregnancy outcomes are more common in assess end organ damage.39
women with co-morbidities (mainly renal). Women Offer women 75 gm 2 h oral glucose tolerance test.
with chronic hypertension should be seen by multi-
Offer first trimester dating ultrasound to estimate
disciplinary team. Offer Ophthalmic, renal and cardiac
period of gestation as planned early birth may be
status assessment.
required and to rule out any malformations.
11.1.3: Educate women to optimize weight, adopt
11.2.5: Offer expert medical consultation if Cushing
healthy life style with regular exercise and reduced salt
syndrome, autoimmune disease, or Pheochromocy-
intake.
toma is suspected.3
11.1.4: Review medication, stop Angiotensin-
[Link] Asessment and Monitoring
converting enzyme inhibitors (ACE), Angiotensin
11.3.1: Fetal surveillance by Fetal kick charts starting at
receptor blockers (ARBs), Renin inhibitors, Mine-
28 weeks which is reassuring for mothers. If FM are
ralocorticoid receptor antagonists (are teratogenic).
less than 10 in 12 hours ,then initiate further testing by
Switch to safer anti-hypertensives (Labetalol, Nife-
ultrasound and Doppler studies.
dipine or Methyldopa).
11.3.2: Symphysio-fundal height, serial growth
11.2 Antenatal Care
ultrasounds from 28 weeks and repeated at 2-4 weeks
11.2.1: All women with chronic hypertension must interval, depending about the fetal condition.3
book early, by 12 weeks of pregnancy.
11.3.3: Offer umbilical artery Doppler at 28, 32 and 36
11.2.2: Medication are reviewed and safe antihyper- weeks in women with Chronic hypertension and twice
tensives initiated at the earliest.5 Labetalol, Nifidepine weekly if there is evidence of fetal compromise and
and Methyldopa are safe in pregnancy.5 ACE inhibi- superimposed preeclampsia.5
tors, ARBs are avoided because of risk of nephroto-
[Link]
xicity in fetus. Thiazides diuretics should not be used
as it may restrict the natural plasma volume expansion 11.4.1: Offer pharmacological treatment in blood
of pregnancy.5 pressure less than 140/90 mmHG in two occasion
admission/referral to a tertiary care hospital in women
11.2.3: Women with chronic hypertension should
with severe hypertension (BP of 160/110 mm HG) or
maintain home record of BP with automated device.
symptoms and signs of super-imposed preeclampsia,
Objective of monitoring is to identify severe hyper-
clinical or ultrasound evidence of fetal compromise.
tension and superimposed early onset PE.
11.4.2: Once maternal and fetal condition is stabilized
11.2.4: Clinical Assessment
expectant management can be continued till 37 weeks
History: Detailed history about duration of gestation.
hypertension, control of BP, medication being used,
11.4.3: Offer multidisciplinary input especially for
comorbidities (Diabetes, Renal disease, SLE, Auto-
women with secondary hypertension.
immune disease), Poor lifestyle (sedentary lifestyle,
smoking, poor diet, increased salt intake). 11.4.4: Offer corticosteroids and Magnesium sulphate
for fetal lung maturity and neuroprotection if indicated
Examination: Estimate BMI, BP by automated/
according to standard protocols mentioned in
mercury apparatus, auscultate heart and lungs, eval-
guideline.
uate for cardiac dysfunction (raised JVP, basal crepts in
lungs) and obstetric exam. Refer for fundoscopy. 11.4.5: Consider repeating investigating in 24 -48 hours
depending upon the severity of super imposed pre
Investigations: dipstick testing for proteinuria
eclampsia. (FBC, RFTs, LFTs, spot urinary protein
as screening and if found to be >+1, urine protein
creatinine ratio).
creatinine ratio/Albumin creatinine ratio should be
obtained as baseline to quantify severity of proteinuria 11.4.6: Assessment of fetal compromise should include
and to serve as reference for future diagnosis of super ultrasound assessment of fetal growth and umbilical
imposed preecalampsia. artery Doppler. CTG should be advised if clinically
indicated.5
Renal function tests to test for electrolytes, creatinine,
and uric acid. 11.4.7: ICU /HDU care should be offered to women
with severe hypertension, Eclampsia, symptoms of

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 Society of Obstetricians and Gynaecologists Pakistan

severe preclampsia, hyperreflexia, HELLP syndrome, Drug of choice is labetalol, followed by Nifedipine and
impaired biochemical investigations, falling oxygen Methyldopa.
saturation requiring ventilation, cardiac failure, severe (Table-II for dosage).
oliguria.
11.5: For delivery, intra partum care, post natal care, Table-II: Maternal History
Extremes of maternal age <18 and > 40 years or older,
long term care, contraception, Refer to section 16,17,21,
Nulliparity
22 of this guideline.3,5,9,32 Inter pregnancy interval of more than 10 years or less than 2
12. MANAGEMENT OF GESTATIONAL years
HYPERTENSION Family history of pre-eclampsia in a first degree relative
Multiple pregnancy,
Pregnancy outcomes are generally good in Gestation at presentation,
women with gestational hypertension. However, 50% Multifetal pregnancy
women with early onset gestational hypertension Previous history of pre-eclampsia or gestational hypertension
develop preeclampsia. It is difficult to predict who will Preexisting vascular or kidney disease
develop PE so there is a need for close follow up.10
Aim for target BP <135/85 mmHg.
Ideally all asymptomatic women with mild to mode-
rately elevated BP and no proteinuria should have Offer CBC, RFT and LFT. Get urine dipstick for
the appropriate laboratory investigations to exclude proteinuria. If it is positive, quantify proteinuria with
maternal organ dysfunction to exclude PE. urine PCR.10
12.1 Antenatal Care In case of severe gestational hypertension (BP
>160/110 mmHg), offer admision to tertiary care.
12.1.1: Women with gestational hypertension should
Assess for signs and symptom of PE and fetal compro-
have antenatal visit 1 to 2 weekly depending upon BP
mise. First stabilize maternal BP with multidisciplinary
control. Objective of antenatal visits is early identifica-
input.42 Admit to ICU /HDU/obstetric critical care if
tion of PE and monitoring of fetal growth.40,41
has preeclampsia with severe features, HELLP synd-
12.1.2: Maternal assessment rome, falling oxygen saturation requiring ventilation,
Review home BP record and medication at each evidence of cardiac failure, severe oliguria, impaired
antenatal visit. biochemical investigations.10
Enquire about symptoms at each visit At each visit do Women in whom delivery is contemplated before
urine dipstick test for proteinuria. If it is positive, 34 weeks, offer steroid cover for fetal lung maturity
quantify with spot urine PCR. (Table-III) and magnesium sulphate for fetal neuro-
Investigations- complete blood count, serum creati- protection (Table-IV).
nine, serum uric acid, Liver function tests are done
Table-III: Investigations (Section 7).
every 2-4 weeks.
FBC (thrombocytopenia <150,000/ul) and blood film for
Consider diagnosis of PE if new onset proteinuria hemolysis (schistocytes, or red cell fragments) 44
and/or features of multi-organ involvement are LFTS (raised ALT (over 70IU/lit), raised LDH (> 600
recognized in a woman with gestational hypertension MIU/L), raised Bilirubin
RFTS (Serum creatinine>90 umol/l)44
12.1.3 Fetal Assessment Dipstick testing as a screening test for proteinuria and if
Offer anomaly scan at 20-22 weeks of gestation proteinuria is evident on dipstick testing,offer a spot urinary
with uterine artery pulsatility index (PI) by trained protein creatinine ratio.
Spot urinary protein creatinine ratio >30mg/mmol is
sonologist.
significant proteinuria.6
From 28 weeks, assess symphysio-fundal height (serial APTT/PT should not be done routinely in the absence of
assessment) at each visit. thrombocytopenia.
Do Obstetrical ultrasound for fetal wellbeing, fetal growth,
Fetal growth scan should be done at 2 week interval amniotic fluid index and Umbilical artery Doppler
starting at 28 weeks. velocimetry at time of presentation.
In case of suspected fetal compromise, offer ultrasound Uric acid level of more than 6 mg /dl is cut off value in
for biophysical profile and Umbilical artery Doppler. preeclampsia6
Serum uric acid is not considered to be a diagnostic criteria
12.1.4: Offer antihypertensive treatment if BP is > 140/ for preeclampsia6,15 and should not considered for delivery.
90 mmHg.

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Table-IV: Red Flag signs steroids and MagSO4, planning for delivery and
1. Proteinuria intensive postnatal care.
2. Other maternal organ dysfunction, including:
Acute kidney injury (AKI) (creatinine ≥90 μmol/L; 1 This section of the guideline will provide infor-
mg/dL) mation to all HCPs regarding counseling, risk stratifi-
liver involvement (elevated transaminases e.g. ALT or cation, triaging of patients with or without severe fea-
AST>40 IU/L) with or without right upper quadrant or tures, home/out patient monitoring, admission crite-
epigastric abdominal pain)
rion in patients with severe features and monitoring in
3. Neurological complications (examples include
eclampsia, altered mental status, blindness, stroke, hospital, delivery planning, post natal stay in hospital
clonus, persistent visual scotomata) and postnatal follow up.
4. Haematological complications (thrombocytopenia – [Link] and Counseling
platelet count below 150,000/μL, DIC, hemolysis)
5. Decreased urine output( Less than 80ml over 4 hours) All patients presenting with preeclampsia are
6. Uteroplacental dysfunction (such as fetal growth counseled for following:
restriction, abnormal umbilical artery Doppler wave 13.1.1: Red flag symptoms-headache, epigastric pain
form analysis, or stillbirth)
vomiting, blurring of vision, swelling of body, reduced
fetal movements or abdominal pain associated with
For delivery timing, intra partum care, post-
vaginal bleeding.
partum care and long term care refer to sections 16, 17,
21 and 22. 13.1.2: Need for admission to hospital for monitoring
of maternal and fetal.
12.1.5 Discharge Plan:
13.1.3: Frequent antenatal visits for early detection of
Measure BP daily for the first 2 days (24–48
complications.
hours) after birth and keep target BP of 130/80 mmHg.
40 Woman can be discharged home if BP is <140/90 13.1.4: Regular home BP monitoring, reporting to
mmHg.42 Counsel women for the risk of gestational hospital if red flag symptoms develop or BP worsens.
hypertension in future pregnancy is 16 and 47% and 13.1.5: Need for early delivery in case of maternal or
risk of preeclampsia is 2-7 %.41 fetal compromise and consequent admission of baby to
Educate couple about importance of family NICU.
planning, optimization of maternal health and need to 13.1.6: Need for admission to critical care.
follow up.43 13.1.7: Need for postnatal visits which can be at
Woman should be guided to use automated BP local health center/district hospital/family doctor for
apparatus to check BP daily at home. 6 weeks and a tertiary care hospital if BP has not
Follow up at 1 week after delivery to assess BP control. settled in 3 months to investigate other causes of
Adjust medication if required for BP control.41 hypertension.
13. MANAGEMENT OF PREECLAMPSIA 13.1.8: Risk of recurrence of preeclampsia in future
pregnancies is 16-23%.5
Preeclampsia is new onset hypertension with
multiorgan involvement presenting after 20 weeks. 13.1.9: Risk of future cardiovascular disease is
The disease tends to be severe with a progressive increased approximately 1.5-3 times.5
unpredictable course, requires enhanced antenatal care 13.1.10: Healthy life style.
and monitoring as the condition can change rapidly. 13.2 Antenatal Care
The role of pharmacotherapy is to prevent the 13.2.1: Take detailed history (Table-II), perform exami-
complications arising as a result of multiorgan nation at first and each subsequent antenatal visit to
involvement and to gain time for fetal maturity in triage.
pregnancies less than 37 weeks of gestation. Delivery is
13.2.2: Assess Symptoms 5,16,44
the cure and can be considered even at earlier gestation
if there is maternal compromise.  Swelling of face, hands, body or rapid weight
gain.
The mainstay of antenatal care is earlier
identification of pregnancies progressing to severe  Persistent headache, visual disturbances,
preeclampsia. Aim is to control hypertension, prevent blindness.
seizures, optimize fetal outcomes by administration of  Irritability, altered mental status, stroke.

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 Epigastric pain or right upper quadrant pain tation by an experienced obstetrician once diagnosis of
with nausea and vomiting. PE has been established and plan of antenatal care
 Chest pain or dyspnea. should be discussed and documented.
 Loss or reduced fetal movements. 13.3.1: Consider asymptomatic women with mild
features of PE to be treated on outpatient basis keeping
 Vaginal bleeding with abdominal pain. in view the compliance for antenatal visits, financial
Red Flag signs (Table-III), Signs of severe pre- and social constraints and hence should be individ-
eclampsia (Table-V). ualized.
Table-V: Signs of severe pre-eclampsia.
13.3.2: Offer hospitalization for observation and
Sustained systolic blood pressure of >160 mmHg and monitoring in antenatal ward for symptomatic PE or if
diastolic of >110 mm HG there are concerns for fetal well-being.
A new and persistent rise in creatinine >90 micromol/litrer 13.3.3: Admit women with severe PE or impending
/ >1.0 mg/ ml
eclampsia to obstetric critical care/HDU for stabiliza-
Elevated ALT or AST > 40 IU with or without right upper
quadrant pain or epigastric pain tion and early delivery.
Platelet count < 100000/microlitre is a feature of severe pre- 13.3.4: Offer referral/ in utero transfer to a tertiary
eclampsia. care hospital in the presence of the Red Flag Signs if
Uteroplacental dysfunction (Fetal growth restriction,
working in a district or secondary care hospital.
abnormal umbilical artery doppler waveform with
increased resistance, absent or reversed end diastolic flow) 13.3.5: Offer Magnesium sulfate for seizure
Signs of impending pulmonary oedema or oxygen prophylaxis before referral/in utero transfer to tertiary
saturation of <90%. care.5
Signs of impending eclampsia (sustainable clonus, evidence
of hyperreflexia) [Link] Care Plan for Pre-Eclampsia without
Severe Features
13.2.3: Examination 13.4.1: Evaluation in antenatal care clinic Antenatal
 Measure height & weight, BMI, BP should be care visits are planned every 1-2 week for asymp-
checked twice (4 hours) in standard way by a tomatic patients with well controlled blood pressure of
calibrated and reliable device. 135/85 mm HG or less.
 Examine for pitting oedema in feet and non- 13.4.2: At every antenatal visit, check BP, evaluation of
dependent areas such as face, hands and symptoms, obstetrical examination and investigations
abdominal wall. (Table-III).
 Auscultation of heart for any cardiac 13.4.3: Fetal heart auscultation at every appointment
dysfunction and chest to exclude pulmonary and fetal kick chart for maternal reassurance only but
oedema. Measure oxygen saturation if pulse has insufficient evidence.47 Consider CTG if woman
oximeter is available. reports a change in fetal movement.
 Abdominal examination for liver tenderness in 13.4.4: Offer ultrasound every 2 weeks for fetal growth
right upper quadrant assessment.
 Clinical assessment for sustained ankle clonus > Consider Umbilical artery Doppler in case of fetal
3 beats.6 compromise / FGR.5
 (Fundoscopy for hypertensive changes 13.5 Blood Pressure Control/ Antihypertensives
associated with retinal vasospasm and 13.5.1: Aim for target BP 135/85 mmHg or less.1 Care
papilledema should be taken not to lower blood pressure too much
 Obstetrical examination: Assess as this will negatively affect placental perfusion and
Symphysiofundal height and auscultate for compromise fetus.
fetal heart. 13.5.2: Home BP monitoring once a day.
13.2.4: Investigations:15,44,45 (Table-III) 13.5.3: Offer antihypertensive if BP is > 140/90 on two
[Link] occasions six hours apart.5
Triage patient, according to disease severity for 13.5.4: Offer labetalol, followed by Nifedipine and
hospital admission/outpatient care. Offer first consul- Methyldopa.46,47,5

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Dosage: Labetelol (100-2400 mg daily), Nifedipine Table-VII: Intravenous Hydralazine dose.

(20mg-60 mg daily), and Methyldopa (250-750 mg 8 Dosage Regimen of Intravenous Labetalol
Intravenous Hydralazine Hydralazine infusion
hourly).
Make a solution of 80
Dilute 20mg (1 ampoule) hydralazine
mg (4 ampoules)
[Link] monitoring in PE without severe features in 20ml of water for injection
hydralazine in 90 ml
Administer 5mg (5ml) Hydralazine as
13.6.1: Assess fetal well being by ultrasound for fetal an IV bolus
0.9% N/S.
biometry, amniotic fluid (AFI) and umbilical artery Commence hydralazine
Monitor and record BP every 10
infusion via infusion
Doppler. Diagnose fetal growth restriction if EFW minutes
pump/ dial flow at a
<10th centile or abnormal UA Doppler.48 Perform continuous CTG monitoring
rate of 5 mg/hr , i.e
If after 20 minutes severe BP persists,
13.6.2: Offer assessment of fetal growth , amniotic fluid Administer second dose of 5 mg (5ml)
30ml/hr
volume, and uterine artery Doppler at two weekly increase infusion by 10
Hydralazine as an IV bolus
intervals if initial assessment was normal and no ml every 30 minutes to
If after 20 minutes severe BP persists
a maximum of 90
evidence of maternal or fetal compromise till 37 Administer third dose of 5 mg (5ml)
ml/hr.(i.e 15mg/hr),
weeks.5,44 Hydralazine as an IV bolus
aiming for systolic BP
If severe hypertension persists after 3
140-160mmHg and
boluses of IV hydralazine, start
13.7 Antenatal Care of Pre-Eclampsia with Severe diastolic BP 90-
hydralazine infusion
Features of Pre-Eclampsia 100mmHg
13.7.1: Offer admission in HDU/Obstetric critical care Table-VIII: Nifedipine dose.
if BP >160/110 mmHg, or patient develops RED FLAG Dosage Regimen of Nifedipine
symptoms and signs (Table-IV and Table-V). Starting Dose Maximum Dose
Tablet Nifedipine 10mg TDS, can be
The aim of management for hospitalized increased up to 20mg three to four times 120mg/day
patients with severe PE is: stabilization of BP, prophy- daily
laxis of seizures, maternal and fetal monitoring and Extending Release Tablet Nifedipine:
120mg/day
early delivery if any maternal or fetal compromise is 30 to 90mg orally once a day
evident. Table-IX: Seizure prophylaxis by Magnesium sulphate54.
13.7.2: Consider continuous monitoring of blood pres- Loading Dose Maintenance Dose
Intravenous dose of 4g Maintenance dose of 1-2g
sure by electronic monitors. In case electronic monitors
slowly over 20min every hour given by an
are not available BP should be checked every 15-30 Using a 20 mL syringe, infusion pump
minutes until BP is <160/100 mmHg, then every six draw 4g of MgSO4 50% Add 4g MgSO4 in 200ml N/S
hours until the patient is stabilized.5 (8 mL). Add 12 mL sterile IV infusion@ 1g per hour (i.e.
water or saline to make a 50ml/h) until 24 hours after
13.7.3: Antihypertensive in PE with severe features
20% solution. delivery or since the last fit
BP of >160/110 mmHg requires prompt treatment
because of risk of cerebral haemorrhage and eclampsia. 13.7.5: Offer Prophylaxis with magnesium sulphate
5,49–51
where there are signs and symptoms of Impending
13.7.4: Use oral/IV Labetalol or Oral Nifedipine in eclampsia (Table-IX).54 MgSO4 toxicity (Table-X).
controlling BP in pregnant women with severe.52,53
Intravenous labetalol dose (Table-VI). Intravenous Hy- Table-X: MgSO4 toxicity54.
dralazine dose (Table-V). Nefidipine dose (Table-VIII). Measurement of serum MgSO4 levels is not necessary unless
signs of toxicity
Seizure prophylaxis (Table-IX). 1. Signs of MgSO4 toxicity
Respiratory rate <10/min or Sao2 <92% (24- 30mg/dL)
Table-VI: Intravenous Labetalol dose.
Muscle paralysis (9.6-12mg /dl),
Dosage Regimen of Intravenous Labetalol Reflexes absent (9.6-12mg/dl)
Intravenous Labetalol Labetalol Infusion Urine output <30ml/hour
20ml (1 ampoule) 20ml (1 ampoule)=100mg 2. If toxicity suspected
=100mg Infusion to be given @1- Stop infusion
2ml=10mg 2mg/min(Level II) Take sample for MgSO4 level
Give 10 to 20mg IV Add 200mg labetalol (40ml) to 3. Treatment of MgSO4 toxicity:
then 20 to 80mgevery 60ml of NaCl 0.9% to make 100ml. Administer Calcium gluconate ,10ml in 100 ml normal
20 to 30minutes, saline IV over 10-20 minutes
Label ‘’labetalol 2mg /ml in NaCl
*The therapeutic reference range for serum Magnesium in adults is 5-8
maximum of 300mg 0.9% (labetalol 200mg /100ml)
mg/dl (4-7mEq/L)10

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[Link] Balance 13.10.2: At 37 weeks or more, delivery is recom-

13.8.1: In women with severe pre eclampsia, limit IV mended. Birth should be initiated within 24-48 hours
fluid to 80ml/hour, unless indicated otherwise.44 Accu- of hospitalization.50,5
rate measurement of fluid intake and output. Fluid Timing of Birth with Severe Features of PE:
overload can lead to maternal death. 13.10.3: Consider early delivery irrespective of
13.8.2: Fluids should be given by infusion pumps or gestation, if there are concerns regarding maternal
dial flows. wellbeing such as uncontrolled hypertension despite
13.8.3: Do regular auscultation of lungs in patients on optimal treatment, BP of >160/110 mm HG, HELLP
IV fluids to detect pulmonary edema early. Syndrome, deteriorating blood tests, reduced oxygen
saturation less than 90%, or signs and symptoms of
13.8.4: Diuretics should not be used in the absence of
placental abruption, impending eclampsia or abnormal
pulmonary edema.
velocimetry.
13.8.5: Urinary output should be measured hourly by
13.10.4: At <26 weeks of gestation/pre viable, delivery
an in dwelling urinary catheter.
is advised to avoid serious maternal morbidity and
13.8.6: Do not use volume expansion unless mortality after counselling and informed consent.58
Hydralazine is used.5
13.10.5: At <34 weeks of gestation if delivery is plan-
13.8.7: Fluid administration should be monitored by ned because of maternal or fetal compromise, appro-
intensivist. priate NICU services should be ensured in the hospital
13.8.8: Offer mechanical thromboprophylaxis by TEDS or in utero transfer arranged after discussion with neo-
stockings.55 natologist. Mg SO4 neuroprotection should be offered
[Link] Monitoring with FGR if delivery is imminent within 24 hours at <32 weeks of
gestation,59 and corticosteroid should be administered
13.9.1: If the umbilical artery Doppler demonstrates
according to protocols.
increased resistance (Pulsatility Index >95th centile),
the ultrasound surveillance by Doppler is recommen- 13.11 Labour management: Refer to section 16 of this
ded twice weekly. guideline for Intra partum care
13.9.2: If there is absent end-diastolic flow in the 13.12: Post Natal Care Plan
umbilical artery (AEDF) prior to 34 weeks’ gestation 13.12.1: Hospital stay and management plan Advice
monitoring by daily UA Doppler, amniotic fluid Women with PE to stay in hospital for 48 to 72 hours
volume assessment and CTG are recommended. These because of 40% risk of post natal eclampsia.
women should be discussed with consultant daily. 13.12.2: BP should be checked 4 hourly during in
13.9.4: If there is reversed end-diastolic flow in the hospital stay.
umbilical artery (REDF) expedite delivery with arran- 13.12.3: Ask for Red Flag Symptoms (Table-III).
gements for NICU or in utero transfer.
13.12.4: Antihypertensive should be started if BP is
13.9.5: Prenatal corticosteroids for fetal lung matura- >150/100 mm HG in women who were not taking anti
tion should be considered between 28 ± 0 and 34 ± 0 hypertensives in antenatal period.
weeks gestation, but may be given up until 38 ± 0
13.12.5: In women, who were on antihypertensive,
weeks in cases of elective delivery by Caesarean
continue if BP is >150/100 mmHG, and consider redu-
section.56,57 Multiple courses of steroids should not be
cing dosage if BP is <140/90 mmHG.60,61
administered.
13.12.6: Offer Enalapril in post-natal period with
13.10. Delivery
appropriate monitoring of renal function and maternal
Timing of birth without severe features of PE: serum potassium.62,63 Nifedipine, Atenolol/labetalol/
13.10.1: From 34-36 +6 weeks of gestation, pro-longing metoprolol can be safely used in postnatal period.64-66
the pregnancy is considered for fetal benefit, as long Dosage of Postnatal Antihypertensives (Table-
as the maternal assessments are satisfactory and there XI)
is no clinical or laboratory evidence of maternal
13.12.7: If BP is not well controlled with one medicine,
compromise.5
offer a combination of Nifedipine and Labetelol.44

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Table-XI: Dosage of postnatal Antihypertensives.5 14. MANAGEMENT OF ACUTE SEVERE

Enalapril initial dose is 5 to 10 mg once daily, usual HYPERTENSION IN PREGNANCY
maintenance dose is 20 mg and maximum maintenance
dose is 40 mg daily. Severe hypertension in pregnancy can be life
Nifedipine 30 to 60 mg orally once a day maximum of 120 threatening requires prompt treatment and close sur-
mg per day. veillance. The main aim is to control BP and prevent
Atenolol 25-50 mg /day maximum to 100 mg /day seizures. Uncontrolled high BP can lead to Myocardial
Labetalol 100 mg twice daily, maximum of 2400 mg. ischemia, heart failure, stroke and acute renal injury.
(Figure).
13.12.8: If BP is found to be <130/80 mmHg during
hospital stay for 72 hours no need to start antihyper-
tensive therapy.
13.12.9: Women on antihypertensive therapy wishing
to breast feed should be explained that antihyperten-
sive can pass into breast milk in very low levels,
unlikely to have any clinical effects but diuretics and
ARBs should be avoided.
13.12.10 : Hematological and biochemical investiga-
tions should be repeated 48-72 hours after delivery. If
investigations are normal do not repeat again. If
investigations are outside the reference range, then
repeat as clinically indicated.
[Link] Plan
13.13.1: Discharge women with pre-eclampsia if all of
the following criteria are met:
No symptoms of pre-eclampsia.
BP, with or without treatment, is < 150/100 mmHg.
Blood test results are stable or improving.
13.13.2: Home BP monitoring daily at nearby health
facility or by health care worker.
13.13.3: Self-monitoring for symptoms: headaches,
visual disturbances, nausea, vomiting, epigastric, Figure: Algorithm of Emergency management for patient with
feeling faint or convulsions. Eclampsia/Severe preeclampsia/ Severe Hypertension.
13.13.4: Report to hospital if BP rises >150/100 mmHg 14.1 Control of BP
with antihypertensive therapy or symptomatic.
If BP is >160/110 mmHg, admit the patient. Initiate
13.13.5: Offer postnatal checkup in hospital at 2 weeks anti-hypertensive urgently within 15 minutes. Use any
for BP & proteinuria check. Refer women who con- one of the following to treat severe hypertension
tinue to take antihypertensives for specialist review.
1. Immediate release Oral Nifedipine: 10 mg orally,
13.13.6: Offer postnatal checkup again to all women then 10-20 mg 2-6 hourly. Continuous BP monito-
with PE at 6 weeks and at 12 weeks. Assess clinically ring (or at least every 20 minutes) is encouraged.
check BP & proteinuria. Advice regarding life style Max dose: 180mg. Side effects are maternal tachy-
modifications, risk of hypertension and cardiovascular cardia and headaches. Get review by fetal medi-
disease in later life. Risk of recurrence in future preg- cine, anesthesia and internal medicine.4
nancies is approximately 1 in 5.5
2. Labetalol (oral or intravenous) Protocol for IV
13.13.7: If hypertension/proteinuria persist at 12 weeks Labetalol: Give 10-20 mg then 20-80 mg IV every
postpartum refer to nephrologist. 20 to 30 minutes or administer as infusion 1-2 mg/
13.13.8: Offer contraception after discussing women minute. Monitor BP. second anti-hypertensive hy-
preferences according to MEC WHO. dralazine is initiated. Max dose: 300mg. Avoid in

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Bronchial Asthma, Cardiac disease, Heart failure, and there is no clinical or laboratory evidence of
Heart block & bradycardia. maternal compromise.10
3. Intravenous hydralazine: 5-10mg is given IV over 15.1.4: Consider early delivery irrespective of gesta-
2 minutes then 5-10 mg IV every 20-40 minutes. tion, in cases there are concerns regarding maternal
Alternatively IV infusion 0.5 to 10mg/hour can be wellbeing such as uncontrolled hypertension despite
used. BP is monitored by electronic monitor or optimal treatment, BP of >160/110 mm HG, HELLP
every 20 mins Use upto 500 ml crystalloid fluid Syndrome, deteriorating blood tests, reduced oxygen
before or at the same time as the first dose of saturation less than 90%, or signs and symptoms of
intravenous hydralazine,4 max dose: 20 mg. Risks placental abruption, impending eclampsia or abnormal
include maternal hypotension & headaches and UA velocimetry. Delivery should not be delayed for
Abnormal FHR tracings. If BP remains >160/110, the administration of steroids in late preterm
get anesthesia and medical review. gestations.
14.2 Monitoring Once BP is Controlled 15.1.5: At <34 weeks of gestation: if delivery is planned
If BP thresholds are achieved, monitor BP every because of maternal or fetal compromise, appropriate
15 minutes for 1 hour then half hourly for 1 hour, NICU services should be ensured in the hospital or in
then hourly for 4 hours. Further monitoring of BP is utero transfer arranged. Antenatal corticosteroid (<36
indivualized. weeks) and Mag SO4 for neuroprotection (if delivery
is imminent within 24 hours at gestations <34 weeks)
14.3 Assess for Super Imposed Preeclampsia by
Following Investigations should be offered.21

1. Hematocrit 15.1.6: At pre viable gestation (<26 weeks), delivery

is advised to avoid serious maternal morbidity and
2. Platelet count mortality after counselling and informed consent.18,19
3. Creatinine 15.2: Ensure Patient Safety
4. Serum uric acid levels  Hypertensive disorders pose increased risk to
5. Liver function testing mother and baby
6. Urine PCR  Ensure presence of multidisciplinary team.5
14.4 Timing of Delivery  Delivery plan should be made and documented
If woman is at 34 weeks, and BP does not respond during antenatal period.
to treatment or woman develops severe PE, then ini- All women with HDP require delivery in a health
tiate delivery. This is due to high risk of complications care facility that provides emergency obstetric and
including placental abruption, pulmonary edema, neonatal care while women with maternal complica-
eclampsia.5 If delivery is indicated at earlier gestation, tions require delivery in a center capable of providing
steroid cover for fetal lung maturation and Magnesium obstetric critical care. Those with preterm gestations
sulphate for fetal neuroprotection must be considered.5 require settings with the highest available level of
Delivery is recommended > 37 weeks. neonatal care (Table-XII).
15. INTRAPARTUM CARE
Table-XII: Summary: Indications for delivery in women with
15.1 Timing of Delivery gestational hypertension- preeclampsia spectrum.
15.1.1: Delivery plans are individualized tailored to Maternal Fetal
clinical condition, severity of maternal disease and Gestational age ≥ 37 weeks Placental abruption
gestational age. Severe uncontrolled hypertension Severe FGR
15.1.2: At 37 weeks or more : Irrespective of the type Deteriorating platelet count
of HDN delivery is recommended. Birth should be Deteriorating renal function
initiated within 24-48 hour of seeing the patient.10 It Deteriorating liver function
results in reduction in severe hypertension without an Persistent neurological symptoms
increase in caesarean section rate.10 Suspicion of HELLP syndrome
(Persistent epigastric pain, nausea or
15.1.3: From 34 to 36 +6 weeks of gestation: prolonging
vomiting with abnormal LFTs)
the pregnancy is considered to improve fetal progno-
Pulmonary edema
sis, as long as the maternal assessments are satisfactory

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15.3 Clinical Assessment and Care in Labor concentrated dose via a syringe driver pump or a
 Assess symptomatology. Check for red flag signs. dialflow.
(Table-I). 15.6.3: For pain relief in labour, epidural analgesia is
 Monitor BP, pulse and respiratory rate. considered.22,23
 In patients with severe hypertension, assess mater- 15.6.4: If a caesaren section is performed ,regional
nal blood pressure on admission, every 15 minutes, anaesthesia is considered if there is no coagulo-
until patient is stabilized then every 30 minutes in pathy.24,25
initial phase of assessment, then 4 hourly if patient 15.6.5: If a general anaesthetic is used, care should
remains stable and asymptomatic.5 be taken to prevent the hypertensive response to
 Check reflexes in severe hypertension intubation and extubation, and problems of laryngeal
oedema.24,25,26
 Monitor fetal heart rate with sonicaid every 15 to 30
minutes Offer active management of third stage of labour,
avoiding use of ergometrine or syntometrine.
 Do CTG every 2 hours. In women with evidence of
15.6.7: Consider sending placenta for histopathology
abnormal Umbilical uterine Doppler, continuous
and cord blood for PH and lactate levels in cases of
CTG monitoring is considered if resources are
FGR if facilities are available.
available
16. POSTPARTUM CARE
 Maintain intake/output record every 4hours
Women with preeclampsia are considered at high
 Check urinary proteins at admission into labor
risk for developing eclampsia and other preeclamptic
suite.
complications upto 3 days and rarely six weeks post-
 Patient should be placed in left lateral position. partum.5 Women with HDP are recommended to stay
15.4 Anti Hypertensives in health care facility for 24 to 48 hours [ref WHO,
12.3-1: Oral antihypertensives Labetalol/Nifedipine ISSHP]. Even in busy maternity units with heavy
are given at start of labor demand for postnatal beds, women with preeclampsia
should not be discharged early.
12.3-2: Treat severe hypertension (BP is >160/110
mm Hg) with Nifedipine/Intravenous Labetalol or In women with HDP in addition to routine
Hydralazine. postpartum care, following is recommended.
15.5 Fluids 16.1 Maternal Surveillance: Monitor their BP and
clinical condition closely.
Limit fluid intake to 60 to 80 ml /hour to avoid
risks of pulmonary edema. Do not dehydrate a pre- 16.1.1: Closely monitor women with HDP clinically for
eclamptic women as she is already at risk of acute symptoms and signs for impending eclampsia (40% of
Kidney injury (AKI). eclampsia occurs postpartum).5
15.6 Conduct of Labor 16.1.2: Ask about headache, visual disturbances,
vomiting and epigastric pain each time blood pressure
 Standard labor and delivery care.
is measured.
 Use Labor Care Guide to monitor labor. If
16.1.3: Record BP hourly for first 02 hours in the labor
unavailable, partogram may be used.
room, then 6 to 8 hourly for 48 hours postpartum, as
 Avoid ergometrine in third stage of labor. in-patient.
 Aim for Vaginal delivery. 16.1.4: Recommended target Postpartum BP is <140/90
 Offer caesarean section for standard obstetric mmHg.
indications. 16.2: Antihypertensive treatment:
15.6.1: Intermittent auscultation is considered every 16.2.1: Antihypertensive treatment is recommended at
2 hours in first stage of labour, and after every con- BP >140/90.
traction in second stage of labour if CTG facilities are 16.2.2: Medication choices: Nifedipine, Enalapril,
not available. Amlodipine alone or in combination with appropriate
15.6.2: If augmentation of labour is undertaken with monitoring of maternal renal function and maternal
oxytocin, an oxytocin infusion must be delivered in a

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serum potassium. For uncontrolled BP, atenolol or  Lifelong follow up as given in section on long term
labetalol can be added.5 Care.
16.2.3: Avoid using diuretics or angiotensin receptor 16.4.2: Recommend checkup at
blockers in mothers who are breast feeding.5  7 days postpartum for women discharged on Anti-
16.2.4: If woman with HDP was taking methyldopa hypertensives and
antenatally, stop within 2 days post-delivery and  6 weeks postpartum.
change to an alternative treatment if required.5
 12 weeks postpartum by which time BP, labs and
16.3: Analgesia. urine analysis should have normalized.
16.3.1: Recommend Acetaminophen for pain relief 16.4.3: Offer Medical review to:
postpartum.
 All women with HDP with high BP persisting at 12
16.3.2: Avoid Non-steroidal Anti-inflammatory Drugs
weeks postpartum
(NSAIDs) as they may increase maternal BP.7
 Women with chronic hypertension a medical
16.4 Laboratory Investigations in Women with
review 6–8 weeks after the birth with their GP or
Preeclampsia:
specialist as appropriate.
 Platelet count, transaminases and serum creatinine
 Offer specialist consultation earlier if BP target is
are measured 24–48 hours after birth. Repeat testing
not achieved with 2 anti-hypertensive drugs [guide-
is required only if levels are not within normal
line group consensus].
range.
17. PRETERM BIRTH
 Urine dipstick at 6–8 weeks postnatal. If proteinuria
is detected, review by physician is requested. 17.1. Antenatal Maternal Corticosteroids
16.4.1: Every woman should be given written detailed 1- Offer a single course of antenatal corticosteroids
follow up/documents to provide to the primary health from 28 to 36 weeks gestation in low resource
care facility for close follow-up and as reference for settings.
future. At discharge all women with HDP are counse- 2- Use of antenatal corticosteroids enhances fetal
led for lung maturity, reduces intraventricular hemorrh-
 Home BP monitoring age and neonatal morbidity& mortality at gesta-
tion <36 weeks’ if delivery is likely within the
 Self-assessment of symptoms and asked to report to next 7 days.1,2
gynae emergency/triage in case of red flag sym-
3- After administering antenatal corticosteroids,
toms (headache, visual symptoms, pain abdomen,
nausea/vomiting, feeling of fainting, general maximum benefit is achieved within 2-7 days
irritability or convulsions) (Table-IV). 4- Repeat dose of antenatal corticosteroids is not
recommended.2,5
 Continued Postpartum follow up and BP
monitoring.5,10 5- Antenatal corticosteroids used are betamethasone
and dexamethasone.
 Long term risks. Risk of cardiovascular morbidity&
mortality, stroke and hypertension is increased two 6- Betamethasone is preferred to dexamethasone
times.10 due to greater surfactant production and less
neurological side effects.
 Pre pregnancy care in subsequent pregnancy.
Recurrence riskof hypertensive disorder in a future 7- Dosage
pregnancy is 1 in 5.5,17  Injection betamethasone is given intramuscular
 Reinforce the importance of early booking and 12mg, two doses 24 hours apart or
antenatal care in the next pregnancy because of risk  Injection dexamethasone is given intramuscular
of recurrent preeclampsia. 6mg every 6 hours, total of 4 doses.
 Lifestyle interventions so as to keep BMI between 17.2 Magnesium Sulphate
18.5–24.9 kg/m2. This can modify risk for long term 1. Offer intravenous Magnesium sulphate from 28
complications.5 to <34 weeks gestation for neuroprotection where
preterm birth is likely within 24 hours.10

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 Society of Obstetricians and Gynaecologists Pakistan

2. Dose is 4 gm in 20 ml N Saline as infusion given damage.67 HDP is associated with long term health
over 30 minutes, then 1gm per hour till delivery.5 problems. Coronary heart disease (CHD) is the leading
18. NEONATAL CARE cause of death for women and is increasing in younger
women aged 35 to 54 years.10,7,17 Women with history
Essential and routine neonatal care to be provided
of PE are four times more likely to develop high BP,
according to gestational age and condition at birth.
twice more prone to have heart disease, diabetes,
19. BREAST FEEDING stroke, renal disease and eye problems.68
13.3.1: Encourage all women with HDP to breast 21.2: Following are recommended at six weeks
feed. postnatal visit:
13.3.2: Counsel woman that antihypertensive 21.2.1: Health Education and Counseling
medicines can pass into breast milk in small
a. Pregnancy presents a window of opportunity to
amounts.
the HCPs to educate women with HDP about the
13.3.3: Advise women with HDP to monitor associated long term risks. Advice women that
their babies for drowsiness, lethargy, pallor, cold they are at increased risk of CHD, stroke, T2DM,
peripheries or poor feeding.17 Renal disease, venous thromboembolism and
20. CONTRACEPTION death as compared to normotensive women.
1. Counseling for contraception should be done b. Emphasize the immense value of lifestyle
during the antenatal care. Contraceptive plan modification in preventing them.
should be endorsed on the antenatal card and c. Better understanding of the disease will lead to
implemented with consent postnatal in each greater compliance for follow up, treatmentand
woman before she leaves the health care facility. prime the patient for life-long care of her health.
2. If missed then when she comes back at 6 weeks 21.2.2: Lifestyle Interventions.69
postpartum or for infant immunization or family
Following practical lifestyle recommendations are
planning consultation.
offered:
3. All pregnancies in a woman with HDP should be
 Adequate Physical activity. Exercising lowers the
planned at optimized health status with well
risk for pre-diabetes and type 2 diabetes (T2DM).
controlled BP.
Recommend to walk for 30 minutes five times a
4. Use WHO medical eligibility criteria to guide week and do muscle-strengthening exercises two
contraceptive choices to three times a week.
5. Link [Link]  Heart healthy eating habits – Diet rich in fiber
6. Long term reversible contraception-LARC is vegetables and fruits with avoidance of fried and
encouraged with consent of the woman. Copper sugary snacks. This will reduce the risk of heart
IUD, Levonorgesteral IUS, Progestogen implants disease, stroke, and diabetes.
may be initiated in the immediate postpartum  Optimize weight. Maintain BMI between 18 and
period to ensure compliance. Progesterone only 25. A BMI greater than 25 may increase the risk for
pills are safe options in women unwilling for heart disease.70
LARC.
 Stop active and passive smoking. Tobacco
7. If BP is 160/100 mmHg or more, combined damages blood vessels and raises blood pressure.71
hormonal contraceptive and injectable progesto-
gen must be avoided.10,17 21.3: Regular Follow up

8. Advise women who have had preeclampsia to 6.3-1: All women with HDP should be reviewed at 3
plan family in the next 2 to 4 years, as the months postpartum to ensure that BP, urinalysis, and
likelihood of recurrence increases with an inter- any laboratory abnormalities have normalized. If pro-
teinuria or hypertension persists, then referral to phy-
pregnancy interval greater than 10 years.
sician for further investigations to rule out secondary
21. LONG TERM CARE OF WOMEN WITH HDP causes of hypertension should be initiated.
21.1: Women with HDP in LMIC are often lost to 6.3.2: All women with HDP are advised regular long
follow up, remain unaware and book in subsequent term follow up with obstetrician and Physician.
pregnancy with high BP and evidence of end organ

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 Society of Obstetricians and Gynaecologists Pakistan

21.3: Recommend regular BP checks every three to six 2. Evaluate for secondary causes of
months for life. Explain that healthy blood pressure is hypertension: Refer younger women age <30
120/80 mm Hg or lower.69 Advise to consult physician years with no family history of hypertension to
if BP above 130/90 mm Hg.72 medical specialist for evaluation of cause.41
21.3.1: Counsel that annual BP &medical checkups 3. Evaluate for end-organ dysfunction:
with their HCP and annual Lab tests are essential for Retinopathy, nephropathy.5,41
early problem identification and intervention.  Renal Evaluation: Serum Creatinine Urine
21.3.2: Educate about blood tests to be done annually protein/creatinine ratio
with target values.72  Cardiac evaluation: Baseline cardiac
Fasting Blood Glucose (FBG). High BP raises the evaluation by echocardiography/twelve lead
risk for T2DM. electrocardiogram
FBG levels to be between 95-126 mg/dl.  Ophthalmic review- Fundoscopy
Lipid Profile annually. Theoptimal levels are:  Retinoscopy
 Total cholesterol: less than 200 mg/dl 4. Assess for comorbidities: Diabetes, Obesity,
 Triglycerides: less than 150 mg/dl renal disease, SLE and autoimmune disorders. The
comorbidities increase the risk of still birth, fetal
 LDL (bad cholesterol): less than 100 mg/dl
growth restriction, intra uterine fetal demise and
 HDL (good cholesterol): more than 50 mg/dl.73 maternal morbidity.
21.3: Advise contraception according to WHO Medical 5. Review medication.5,6,41,51,75
eligibility criteria so that every pregnancy is planned.74
5.1 Antihypertensive Treatment: optimize blood
21.3: Recommend to seek pre-pregnancy care to ensure pressure control and shift to safer antihypertensive
BP control, correct medicine choices and optimization drugs.
of general health, hence improving pregnancy outco-
Advise to stop: Angiotensin-converting enzyme
mes and avoiding preventable maternal morbidity and
(ACE) inhibitors
mortality.
Angiotensin II receptor blockers (ARBs)
21.3: Recommend to book early and take Aspirin in
(increased risk of congenital abnormalities :renal
future pregnancy. Counsel women with preeclampsia
dysgenesis and calvarial hypoplasia, fetal growth
(PE) that risk of developing PE is 15% and gestational
restriction and oligohydramnios) Thiazide or thiazide-
hypertension is 15% in a subsequent pregnancy; In
like diuretics (increased risk of congenital
gestational hypertension risk of PE is 4% and gesta-
abnormalities and neonatal complications).
tional hypertension 25% in a future pregnancy.5
Offer alternative antihypertensive treatment with
[Link] Conception Care
safer pregnancy safety profile for planned pregnancy:
Encourage woman with Chronic HTN or past Labetalol/ Nifedipine/Methyldopa.
history of HDP to report in preconception clinic.5,6,41
5.2 Stop statins
1. Offer Counseling41: Educate woman about the
6. Offer Lifestyle interventions: Preconception
 Pregnancy risks of chronic hypertension and weight loss reduces the risk of developing
the potential interventions to minimize these preeclampsia in overweight and obese patients.
risks,
7. Advice to women about–weight management;
 Anticipated course of pregnancy, exercise; healthy eating; lowering the amount of
 Need for heightened maternal and fetal salt in their diet, cessation of smoking &
surveillance, alcohol.
 Need for more frequent obstetric visits 8. Preconception Folic Acid supplementation
 Need for possible early delivery. 22. RECOMMENDATIONS
 Need for referral to a tertiary care during 23. FUTURE RESEARCH RECOMMENDATION
pregnancy if required 1. To find out prevalence of chronic hypertension,
gestational hypertension, preeclampsia and

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 Society of Obstetricians and Gynaecologists Pakistan

eclampsia in women of reproductive age in trimester for risk prediction (age, parity, BMI,
Pakistan. booking BP)
2. To find out the sensitivity and specificity ABBREVIATIONS
ofscreening and recommended risk predictive Abbreviation Definition
model for prediction of preeclampsia in women of ACOG: American College of Obstetrics and Gynaecology
Pakistan. ACR: Albumin:creatinine ratio
3. To identify strategies that will enhance the AE: Adverse event
proportion of women reporting before 16 weeks ALT: Alanine aminotransferase
(Women in LMIC do not usually seek antenatal
AMSTAR: Assessing the Methodological Quality of
care before 20 weeks) so as to employ screening Systematic Reviews
and implement aspirin prophylaxis and calcium
ACE: Angiotensin converting enzyme
supplementation before 16 weeks.
ACEI: Angiotensin converting enzyme inhibitor
4. For women at risk of preeclampsia, does the use of
ARB: Angiotensin II receptor blocker
150 mg Aspirin, compared with the use of 75 mg
AST: Aspartate transaminase
Aspirin, have greater benefit for maternal and
perinatal outcomes? AUC: Area under the curve
AUROC: Area under the receiver operating curve
5. For women at risk of preeclampsia, does the use of
aspirin earlier than 12 weeks’ gestation, compared BCW: British Columbia Women
with the use of aspirin from 12-16 weeks’ BID: Twice a day
gestation, is associated with better maternal and BMI: Body mass index
perinatal outcomes? BNF:British National Formulary
6. For women at risk of preeclampsia, does adjusting BP: Blood pressure
the dose of Aspirin with weight and BMI, have BW: Birthweight
greater benefit for maternal and perinatal CASP: Critical Appraisal Skills Programme
outcomes? CEAC: Cost-effectiveness acceptability curves
7. For women at risk of preeclampsia and on aspirin CCB: Calcium channel blocker
preventative treatment, does discontinuing aspirin CHIPS: Control of hypertension in pregnancy study
at 36 weeks’ gestation, compared with the
CH(T): Chronic hypertension
discontinuing at the time of delivery, reduce the
CI: Confidence interval
adverse events in the mother or neonate?
CPR: Clinical prediction rule
8. For women at risk of preeclampsia, does the use of
CP: Cerebral palsy
aspirin initiated at > 20 weeks’ gestation have the
same anticipated beneficial effects for preventing CNS: Central nervous system
preeclampsia as initiated at <16 weeks? CrI: Credible interval
9. Will the implementation of the SOGP-HDP CTG: Cardiotocography
guidelines impact clinical practices and reduce CVD: Cardiovascular disease
maternal and perinatal mortality? DBP: Diastolic blood pressure
10. In women with HDP who need treatment for high dL: Decilitre
blood pressure postpartum, what is the safety and DTA: Diagnostic test accuracy
effectiveness of antihypertensive agents in achie- EFM: Electronic fetal monitoring
ving adequate blood pressure control? eMIT: Electronic market information tool
11. What percentage of patients with HDP (gestational FN: False negative
hypertension and preeclampsia), at 12 weeks FP: False positive
followup visit have persistence of hypertension. G: Gramme
12. To find out characteristics of women with chronic GA: Gestational age
hypertension developing pre eclampsia in second GC: Guideline committee
GH(T): Gestational hypertension

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 Society of Obstetricians and Gynaecologists Pakistan

GP: General Practitioner NNT: Number needed to treat

GRADE: Grading of Recommendations Assessment, NNU: Neonatal unit
Development and Evaluation NR: Not reported
h, hr: Hour NRCT: Non-randomised controlled trial
HBPT: Home blood pressure telemonitoring Ns: Not significant
HDP: Hypertensive disorders of pregnancy NST: Non-stress test
HDU: High dependency unit OD: Once a day
HELLP: Haemolysis, elevated liver enzymes, low platelet O:E: Observed: expected
count
O-E: Observed minus expected
HR: Hazard ratio, heart rate
OECD: Organization of economic co-operation and
HRG: Healthcare Resource Group development
HRQoL: Health-related quality of life ONS: Office for National Statistics
HTA: Health Technology Assessment OR: Odds ratio
ICD: International classification of diseases PCR: Protein:creatinine ratio
ICER: Incremental cost-effectiveness ratio PDI: Psychomotor development index
INR: International normalised ratio PE: Pre-eclampsia
IPD: Individual patient data PICO: Population, intervention, comparison, outcome
IQR: Interquartile range PICOTS: Population, intervention, comparator, outcome,
ISSHP: International Society for the Study of Hypertension timing and setting
in Pregnancy PlGF: Placental growth factor
ITT: Intention to treat PO: By mouth, orally
IV: Intravenous PRISMA: Preferred Reporting Items for Systematic
K: Number of studies or publications Reviews and Meta-Analyses
K4, K5: Korotkoff 4, Korotkoff 5 sounds PROMS: Patient-reported outcome measures
LR: Negative likelihood ratio PSA: Probabilistic sensitivity analysis
LR+: Positive likelihood ratio QALY: Quality-adjusted life year
M: Mean QoL: Quality of life
MACE: Major adverse cardiovascular event QUIPS: Quality in prognostic studies
MAP: Mean arterial pressure RCOG: Royal College of Obstetricians and Gynaecologists
MD: Mean difference RCT: Randomised controlled trial
MDI: Mental development index ROBIS: Risk of bias in systematic reviews
Mg: Milligramme ROC: Receiver operating characteristics
MID: Minimally important difference RCT: Randomised controlled trial
mmHg: Millimetres of mercury RR: Relative risk/risk ratio
mmol: Millimole SACR: Spot albumin creatinine ratio
MR: Mean ratio SBP: Systolic blood pressure
N, n: Number of participants SD: Standard deviation
N/A: Not applicable SE: Standard error
N/C: Not calculable Sens: Sensitivity
NGA: National Guideline Alliance SL: Sub-lingual
NHS: National Health Service SFLT-1: Soluble tyrosine kinase 1
NICE: National Institute of Health and Care Excellence SGA: Small for gestational age
NIHR: National Institute of Health Research SGOT: Serum glutamic oxaloacetic transaminase
NMB: Net monetary benefit SPCR: Spot protein creatinine ratio
NNH: Number needed to harm Spec: Specificity

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 Society of Obstetricians and Gynaecologists Pakistan

SpO2: Oxygen saturation (peripheral) 2. Davis GK, Henry A, Arnott C, Brown MA. The long-term cardiovas-
cular impact of hypertension in pregnancy - a missed opportunity.\
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ACKNOWLEDGMENTS et al. Prevalence of hypertension among pregnant women when
using the 2017 American College of Cardiology/American Heart
Sincere gratitude to Prof. Razia Korejo President SOGP
Association Blood Pressure Guidelines and association with maternal
for initiation of idea, guidance, advice to prepare national and fetal outcomes. JAMA Netw. open 2021; 4(3): e213808. doi:
Hypertensive disorders in Pregnancy guidelines for Pakistan 10.1001/jamanetworkopen.2021.3808.
and for placing the trust on chairperson guideline committee, 8. Wang W, Xie X, Yuan T, Wang Y, Zhao F, Zhou Z, et al. Epidemio-
Prof. Shehla M Baqai and the collaborative group of authors. logical trends of maternal hypertensive disorders of pregnancy at the
global, regional, and national levels: a population‐based study. BMC
Special thanks to the dedicated guideline authors for wor-
Pregnancy and Childbirth 2021; 21(1): 1–10.
king long hours, academic contribution and editing of the 9. Vidaeff A, Espinoza J, Simhan H, Pettker CM. ACOG practice
document. Special acknowledgment and deep gratitude to bulletin No. 203: Chronic Hypertension in Pregnancy. Obstet Gynecol
Dr. Zaheer, Dr Qurat ul Ann and Dr Anam Akbar for comp- 2019; 133(1): e26–e50. doi: 10.1097/ AOG.0000000000003020.
iling the document, reference setting and final review along 10. Gestational Hypertension and Preeclampsia: ACOG Practice Bulletin,
Number 222. Obstet Gynecol 2020; 135(6): e237–e260. doi: 10.1097/
with corresponding author. Thanks to Dr. Zaheer for the
AOG.0000000000003891.
similarity check. Big thank you to Dr Maham Akbar for 11. Poon LC, Shennan A, Hyett JA, Kapur A, Hadar E, Divakar H, et al.
her valuable help in literature search. Sincere thanks to Prof The International Federation of Gynecology and Obstetrics (FIGO)
Shahida for coordination and zoom support. Sincere acknow- initiative on pre-eclampsia: A pragmatic guide for first-trimester
ledgement to Prof Javed Akram president PSIM and Prof screening and prevention. Int J Gynaecol Obstet 2019; 145(Suppl 1):
1–33. doi: 10.1002/ijgo.12802
Ahmed Bilal Pakistan Hypertension League for their in-
12. Ekawati FM, Licqurish S, Gunn J, Brennecke S, Lau P. Hyper-tensive
sightful remarks and endorsement of the guideline. Profound disorders of pregnancy (HDP) management pathways: results of a
thanks to Sir Sabaratnam Arulkumaran for his support and Delphi survey to contextualise international recom-mendations for
nomination of international reviewers. Indonesian primary care settings. BMC Pregnancy and Childbirth
2021; 21(1): 1–12.
Conflict of Interest: None. 13. Odigboegwu O, Pan LJ, Chatterjee P. Use of antihypertensive drugs
Author’s Contribution during preeclampsia. Front. Cardiovasc Med 2018; 5(50): 1-4. doi:
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SMB: Concept, Design, writing & Drafting initial document, 14. Suresh SC, Duncan C, Kaur H, Mueller A, Tung A, Perdigao JL, et al.
review of literature cirtical review & final editing of docum- Postpartum outcomes with systematic treatment and management of
ent, RR: Draft sections on chronic hypetension and PE findal postpartum hypertension. Obstet Gynecol 2021; 138(5): 777–787. doi:
editing, HA: Draft sections on chronic hypertension and PE 10.1097/AOG.0000000000004574.
final editing, SHT: Draft sections on gestational hyperten- 15. Côté AM, Brown MA, Lam E, von Dadelszen P, Firoz T, Liston RM,
et al. Diagnostic accuracy of urinary spot protein: Creatinine ratio for
sion, final editing, FW: Drafts section on severe hyperten- proteinuria in hypertensive pregnant women: systematic review. BMJ
sions, final editing, HY: Drafted sections on investigation 2008; 336(7651): 1003-1006. doi: 10.1136/[Link].
for HDP, proteinuria assessment fand fetal well being, final 16. Bartsch E, Medcalf KE, Park AL, Ray JG, Al-Rubaie ZTA, Askie LM,
editing, AW: Peer reviewed the whole guidelines docuemnts, et al. Clinical risk factors for pre-eclampsia determined in early preg-
contributing to drafting sections on chronic HTN, PE, Severe nancy: systematic review and meta-analysis of large cohort studies.
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