1^st line 

• Offer Enalapril to treat hypertension with appropriate monitoring of maternal renal function (including serum K+)

2^nd Line

• If BP not controlled with single medicine, consider a combination of Nifedipine (or Amlodipine) and Enalapril

If this combination is not tolerated or is ineffective, consider either

3^rd Line

• Adding Atenolol or Labetalol (preferred if breast feeding) to the combination treatment or
• Swapping 1 of the medicines already being used for Atenolol or Labetalol (preferred if breast feeding)

Women of Black African or African-Caribbean origin 

Monotherapy with ACE inhibitors or B blockers is less effective in this patient group.  Therefore, consider the following as first line agents:

• Nifedipine
• Amlodipine if the woman has previously used this to successfully control her BP

Important points to note:

• When treating women in the postnatal period use medicines that are once daily if possible
• Where possible, avoid using diuretics or angiotensin receptor blockers to treat hypertension in women who are breastfeeding or expressing
• In breastfeeding, antihypertensives can pass into breast milk. However, most medicines only lead to low levels in breast milk, therefore the amounts taken in by babies are very small and would be unlikely to have any clinical effect. The exception is atenolol and it is preferable to use an alternative agent in women who are breastfeeding
• ACE inhibitors can be used in breastfeeding women – enalapril is the drug of choice. In the context of severe preterm delivery discussion with the neonatal team may be appropriate
• When discharged home, advise women who are breastfeeding and taking antihypertensive medication to monitor their baby for drowsiness, lethargy, pallor, cold peripheries or poor feeding

• Maintain BP <150/100 , ideally <140/90 mmHg in the postnatal period
• For patients with end-organ damage (e.g. renal disease or diabetes) aim for target BP ≤ 130/80 mmHg
• For patients with chronic hypertension aim for target BP ≤ 135/85 mmHg
• Outpatient BP monitoring should be arranged e.g. Community Midwife, DCU or GP
• BP <130/80 mmHg-reduce medication (see appendix 1)
• BP <120/70 mmHg - stop medication

• Inform own consultant of any patient being discharged on antihypertensive medication.
• Women with chronic hypertension, or hypertension secondary to other medical conditions, will have a care plan defined by their obstetric/medical team.
  
  
• For women with PIH / PET:
  • Outpatient monitoring should be arranged - Community Midwife or GP.
  • Alternatively, home BP monitoring via DCU can be requested.
  • The care plan for home BP monitoring, to be documented by medical staff in BadgerNet, should include frequency of BP recordings; target BP and thresholds for stopping treatment and indications for referral to secondary care for BP review.
  • The Postnatal Discharge Letter for Women with Hypertension in Pregnancy should be completed and information sent to GP
    
    
• On discharge, the case notes of any woman whose pregnancy has been complicated by hypertension should be sent to the relevant consultant to decide if the woman requires consultant postnatal review at 6-8 weeks postpartum. If this is not felt to be required the woman should be reviewed by her GP at 6-8 weeks postpartum.
  
  
• Women who have had PIH / PET and remain on antihypertensive medications 2 weeks after transfer to community care should have a GP/medical review.
• Women who have had PIH / PET and remain on treatment at 12 weeks postpartum, should have a specialist medical assessment of their hypertension.

Post Natal Discharge Letter for Women with Hypertension in Pregnancy (pdf)