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Obstetrics

Pre-eclampsia (without severe features)

IN REVIEWv4🇮🇳 India-firstPENDING CLINICAL VERIFICATION
De novo hypertension after 20 wks + proteinuria OR end-organ dysfunction; ISSHP advises avoiding “mild/severe” labels in ongoing pregnancy — stratify instead by gestation and trajectory; birth at 37 weeks for stable disease.

Admission & discharge ↓

Reviewer note: Medication regimens and dependent emergency instructions checked 17 October 2026. These targeted checks do not certify every statement in the module. Admission/discharge guidance checked 18 October 2026. This adds a scoped clinical synthesis and does not certify every statement in the module.

Admission & discharge

Care setting: Hospital assessment; severe disease needs admission and possible critical care

Admission/discharge guidance checked 2026-10-18 against the linked sources. This is a clinical checklist for an individual decision, not an automatic discharge order.

When admission or continued hospital care is needed

  • Admit for severe/persistent hypertension, seizure or neurological symptoms, pulmonary oedema, renal/liver/platelet deterioration, significant pain or fetal compromise.
  • Eclampsia/HELLP or organ-support needs require appropriate high-dependency/critical-care monitoring, with transfer after initial stabilisation when necessary.

When clinic, day care or home care may be suitable

  • Antenatal outpatient care is a specialist decision only when maternal/fetal assessment and reliable surveillance support it; recent eclampsia or HELLP is not a routine outpatient pathway.

Before going home

  • Postnatal NICE transfer criteria: no pre-eclampsia symptoms, BP ≤150/100 mmHg with or without treatment, and blood results stable or improving; all criteria must be met.
  • Following eclampsia/HELLP, complete indicated seizure prophylaxis/monitoring and document neurological, respiratory, urine-output and blood-test recovery before considering home care. Critical-care step-down and discharge home are separate decisions.

Discharge medicines and treatment changes

  • Continue the selected oral antihypertensive. Stop methyldopa within 2 days after birth; document replacement and review.
  • The prescriber should consider reduction below 140/90 and reduce below 130/80 mmHg under NICE; provide an individual written adjustment plan. Magnesium loading/infusions are inpatient treatment, not take-home medication.
Medicine doses — use only when indicated

Use the medicines selected for this patient. Listed alternatives are not instructions to prescribe all of them together. Confirm the actual remaining course, pregnancy/postnatal context and monitoring plan.

One selected oral BP option; do not prescribe every alternative together.

Labetalol oralMSFchecked
DoseStart 100 mg twice daily; increase by 100–200 mg increments according to BP; higher daily doses divided three times daily
RouteOral
FrequencyTwice daily initially; three divided doses if higher doses needed
DurationContinue while clinically required; titrate down rather than stop abruptly, with a postpartum review plan
Preparation100 mg or 200 mg tablets; prescribe the strength, dose and administration times
Max dose2400 mg/day
  • Indication: Maintenance hypertension during pregnancy/postpartum
Monitoring
  • BP/heart rate, postural symptoms; neonatal glucose/heart-rate observation after late-pregnancy exposure
Contraindications: Asthma, heart block, marked bradycardia, decompensated heart failure

Alternative/adjunct only within the documented BP plan.

Nifedipine extended releaseGovernment of India, MoHFW / NHMchecked
DoseStart sustained-release nifedipine 10 mg twice daily; titrate according to BP and the exact release formulation
RouteOral extended release
FrequencyTwice daily for the cited sustained-release regimen
DurationWhile hypertension persists; reassess after birth and reduce when BP allows
PreparationUse the specified sustained-release tablet, swallowed intact. Other extended-release products may use different strengths/schedules; do not interchange them or use them for acute oral loading.
Max dose80 mg/day for the NHM CEmONC sustained-release regimen
  • Indication: Maintenance hypertension in pregnancy/postpartum
Monitoring
  • BP, headache, flushing, oedema and pulse
Contraindications: Maternal hypotension or significant cardiac outflow obstruction

Postpartum only when prescribed, with renal function/potassium monitoring.

Enalapril — postpartum hypertensionMilpharm / emcchecked
DoseStart 5 mg once daily; use a lower supervised initial dose if volume depleted or renally impaired; titrate to BP response
RouteOral
FrequencyOnce daily initially
DurationReview BP and dose after birth; reduce/stop as hypertension resolves or continue for persistent hypertension after medical review
Preparation5 mg tablet swallowed with water, with or without food. Correct volume depletion; check creatinine and potassium before starting
Max dose40 mg/day in the product label; usual maintenance 20 mg/day, not an automatic postpartum target
  • Indication: After birth only; NICE recommends enalapril with maternal renal-function and potassium monitoring
  • Renal / hepatic: Renal impairment requires a lower initial dose and adjustment from the product renal table, not the unadjusted 5 mg starter.
  • NICE NG133 supplies the postpartum choice. Breastfeeding requires extra caution with premature/very young infants; use a suitable alternative when clinically indicated.
Monitoring
  • BP, symptoms, creatinine/eGFR and potassium before and after initiation/dose changes; infant feeding, alertness and urine output if breastfeeding
Contraindications: Pregnancy, prior ACE-inhibitor angioedema, significant hyperkalaemia; avoid starting in unresolved AKI or severe volume depletion

Tests, pending results and their reviewer

  • Review platelet count, transaminases and creatinine at 48–72 hours after birth/critical-care step-down; abnormal results need a repeat plan until recovery.
  • At 6–8 weeks check urine protein; persistent proteinuria (1+ or more) needs a 3-month renal review and referral if kidney function is abnormal.

Home care and counselling

  • Provide the BP schedule, named reviewer, medicine list and explicit severe-symptom instructions. Discuss recurrence, future-pregnancy planning and long-term cardiovascular risk.

Follow-up: when and what to review

WhenAction / responsible service
If on antihypertensives: every 1–2 days for up to 2 weeks after transfer
NICE BP surveillance until off treatment with no hypertension; adapt intensity to findings.
If not on antihypertensives: day 3–5 after birth
Check BP; repeat on alternate days if abnormal.
2 weeks if still on treatment; 6–8 weeks for all
Review medicines, BP, recovery and urine protein; arrange renal follow-up when indicated.

Return urgently

  • Seizure, severe/persistent headache, visual disturbance, epigastric pain, dyspnoea, chest pain or severe BP: return immediately; postpartum onset can occur after discharge.

Open the complete discharge checklist →

Sources for this plan:
NICE · NG133checkedMSFcheckedGovernment of India, MoHFW / NHMcheckedMilpharm / emcchecked

Treatment

① Immediate stabilization — first minutes
  • Admit (hospital-based care standard for PE)
  • IV access; bloods sent; urinalysis
  • Start antihypertensive if BP ≥140/90 (target SBP ≤140, DBP 80–90)
  • MgSO4 ONLY if severe features/neurology (not routine in stable non-severe disease)
  • Continuous fetal monitoring if compromised or intrapartum
③ First-line treatment & drug regimens

For non-severe hypertension choose one maintenance agent according to the maternal assessment; severe BP requires the separate emergency regimens. Magnesium prevents/treats seizures and does not replace antihypertensive treatment.

Labetalol oralMSFchecked
DoseStart 100 mg twice daily; increase by 100–200 mg increments according to BP; higher daily doses divided three times daily
RouteOral
FrequencyTwice daily initially; three divided doses if higher doses needed
DurationContinue while clinically required; titrate down rather than stop abruptly, with a postpartum review plan
Preparation100 mg or 200 mg tablets; prescribe the strength, dose and administration times
Max dose2400 mg/day
  • Maintenance hypertension during pregnancy/postpartum
Monitoring
  • BP/heart rate, postural symptoms; neonatal glucose/heart-rate observation after late-pregnancy exposure
Contraindications: Asthma, heart block, marked bradycardia, decompensated heart failure
Nifedipine extended releaseGovernment of India, MoHFW / NHMchecked
DoseStart sustained-release nifedipine 10 mg twice daily; titrate according to BP and the exact release formulation
RouteOral extended release
FrequencyTwice daily for the cited sustained-release regimen
DurationWhile hypertension persists; reassess after birth and reduce when BP allows
PreparationUse the specified sustained-release tablet, swallowed intact. Other extended-release products may use different strengths/schedules; do not interchange them or use them for acute oral loading.
Max dose80 mg/day for the NHM CEmONC sustained-release regimen
  • Maintenance hypertension in pregnancy/postpartum
Monitoring
  • BP, headache, flushing, oedema and pulse
Contraindications: Maternal hypotension or significant cardiac outflow obstruction
MethyldopaMSFchecked
Dose250 mg twice or three times daily for 2 days; increase by 250 mg every 2–3 days to response
RouteOral
FrequencyTwo or three divided doses initially; prescribed divided doses thereafter
DurationDuring pregnancy if required; NICE recommends stopping within 2 days after birth and substituting another agent if needed
Preparation250 mg tablets. Do not abruptly discontinue ongoing therapy without a replacement/reduction plan
Max dose3 g/day
  • Maintenance hypertension during pregnancy; not emergency BP rescue
  • Postpartum stopping recommendation: NICE NG133.
Monitoring
  • BP, sedation/mood; blood count and LFTs for fever, jaundice or suspected toxicity
Contraindications: Active liver disease, previous methyldopa hepatitis, severe depression
Definitive treatment
  • Birth = definitive treatment
  • Vaginal birth preferred if attainable safely; caesarean for obstetric indications or rapid deterioration
  • Regional anaesthesia preferred when platelets/coagulation permit
Monitoring
ParameterInpatient schedule (non-severe, expectant)
BP
q4h (more if trending up)
Symptom review
Each shift — headache/vision/epigastric
Platelets + LFTs + creatinine
2–3×/week minimum; daily if trending
Proteinuria
On admission; repeat if change
Fetal CTG
Daily if expectant preterm
Growth/Doppler
Every 2 weeks (earlier if FGR)
Fluid balance
Strict input/output chart
Response assessment
  • Stable labs/BP without symptom evolution
  • Reassuring fetal surveillance
Treatment failure
  • ANY severe feature emerging → escalate to severe pathway (hdp-severe-features)
  • Lab deterioration or growth arrest → expedite birth
Rescue treatment
  • Eclamptic seizure → emergency-seclampsia protocol (MgSO4 immediately)
  • Pulmonary oedema → sit up, O₂, stop fluids, frusemide 40 mg IV, consider delivery
Procedure / surgery

Induction of labour with favourable/unfavourable cervix per iol module; continuous CTG in labour; third-stage active management (oxytocin 10 IU) — PE increases PPH risk modestly.

Escalation
  • Ward → HDU: severe BP, oliguria, neurology
  • HDU → ICU: refractory severe HTN, pulmonary oedema, DIC, stroke, renal failure
  • Transfer to tertiary centre if <32–34 wks expectancy needed beyond capability
⑮ Complications & their management
Eclampsia

Immediate MgSO4 + supportive care (dedicated emergency protocol)

HELLP syndrome

See hdp-hellp

Pulmonary oedema
  • Sit upright, O₂, cease crystalloid
  • Frusemide 40 mg IV (repeat if needed)
  • Consider severe-pathway delivery
  • CXR + echo if unclear
AKI

Fluid stewardship, avoid NSAIDs, nephrology input if creatinine climbing/anuric

Stroke/intracranial haemorrhage

Emergency imaging + BP control to SBP <160 (then ~130–150); neurosurgery consult; deliver once stabilised

Placental abruption

See aph-abruption

Post-treatment care
  • Continue MgSO4 24 h postpartum if it was started
  • Postnatal BP monitoring: daily while inpatient; review 1–2 weeks + 6 weeks
  • Breastfeeding-compatible antihypertensives (labetalol/nifedipine/enalapril)
  • Thromboprophylaxis assessment (post-PE women are VTE high risk)
  • 3-month postpartum review: BP, urine, labs normalised? (ISSHP)
  • Annual cardiovascular review; lifetime CVD risk discussion
  • Recurrence risk counselling: future PE ≥15%, GH ≥4%

Classification

Stratification (FOGSI 2026 uses non-severe/severe; ISSHP prefers trajectory-based)
DomainNon-severe presentationSevere-feature trigger (act now)
BP
140–159 / 90–109
≥160/110 (confirmed 15 min–4 h)
Symptoms
None
Cerebral/visual symptoms, epigastric pain
Platelets
>100×10⁹/L
<100×10⁹/L
LFTs
Normal
AST/ALT >×2 ULN; severe RUQ pain
Renal
Creatinine normal
>97 µmol/L or doubled; oliguria
Pulmonary
Clear
Pulmonary oedema
Gestation
≥37 wks
Any gestation with instability

Diagnosis & assessment

Red flags:
  • Seizure (→ eclampsia NOW)
  • Severe-range BP
  • Persistent headache unrelieved by paracetamol / visual scotomata / drowsiness
  • Epigastric pain + vomiting + abnormal LFTs
  • Platelets <100×10⁹/L
  • Creatinine >97 µmol/L (or doubling)
  • Pulmonary oedema
  • Stroke/TIA focal signs
  • Abnormal CTG / stillbirth threat

Definition: Multisystem disorder: new hypertension (≥140/90 ×2, ≥4h apart) after 20 weeks WITH ≥300 mg/day proteinuria (or PrCr ≥30 mg/mmol, ACR ≥8 mg/mmol, or dipstick 2+ only if quantitative tests unavailable) AND/OR end-organ features (thrombocytopenia, renal insufficiency, impaired liver function, pulmonary oedema, cerebral/visual symptoms, uteroplacental dysfunction such as FGR) (ISSHP 2021; FOGSI 2026 recognises atypical/no-proteinuria variants).

Risk factors

PrimigravidaPrevious PE/HDPMultifetal pregnancyCKD/autoimmune (SLE/APS)Pregestational DMObesity BMI>30 (score 1)/>35 (score 2)Maternal age >35/<19IVF conceptionFamily historyLong inter-pregnancy interval >7 yPCOSMaternal hypothyroidism (score 2)Low calcium diet

Presentation

  • Routine detection at ANC: rising BP + proteinuria
  • Headache, visual blurring/scotomata, epigastric/RUQ pain, sudden oedema face/hands
  • FGR/reduced movements as placental manifestation
  • Some are asymptomatic until labs derange

Initial assessment

  1. ABC + vitals incl. BP both arms, HR, RR, SpO₂, temperature
  2. Symptom screen (headache, visual, epigastric pain, chest pain, dyspnoea)
  3. Reflexes/clonus examination
  4. Confirm BP + quantify proteinuria
  5. Bloods: CBC+platelets, LFT (AST/ALT, bilirubin, LDH), creatinine, urate, coagulation if platelets <100 or bleeding tendency
  6. Fetal: CTG, growth/Doppler, amniotic fluid

Investigations

TestLooking for
CBC + platelets
Thrombocytopenia (<100 = severe feature; trend matters)
AST/ALT, bilirubin, LDH
Hepatic involvement / haemolysis
Creatinine
>97 µmol/L or doubling = severe feature
Coagulation (PT/APTT/fibrinogen)
DIC screen if platelets <100, bruising, or bleeding
Urinary PrCr/ACR or 24h protein
Diagnostic confirmation
CTG + growth/UA Doppler ± MCA/DV
Uteroplacental dysfunction severity
Chest X-ray if dyspnoea
Pulmonary oedema

Differential diagnosis

ConditionClue
Chronic/superimposed HTN
Baseline proteinuria known; BP before 20 wks
Flare of lupus nephropathy
Known SLE; low complement, anti-dsDNA
Primary renal disease
Longstanding proteinuria/raised creatinine pre-pregnancy
HELLP with minimal BP
Platelets + haemolysis dominate picture

Algorithm

Entry pointNew HTN + proteinuria/organ signs after 20 wks
DecisionRed flags? (severe BP, neurology, epigastric pain, platelets<100, creatinine↑, pulm oedema, fetal compromise)
YESSEVERE PATHWAY: admit HDU, MgSO4 if neuro, IV/oral antihypertensives, steroids <34+6, deliver (≥34 wks; individualise 24–33+6; ≤24 consider birth) ↓NOAdmit ward; oral antihypertensives; surveillance schedule ↓
ActionSEVERE PATHWAY: admit HDU, MgSO4 if neuro, IV/oral antihypertensives, steroids <34+6, deliver (≥34 wks; individualise 24–33+6; ≤24 consider birth)
ActionAdmit ward; oral antihypertensives; surveillance schedule
NextStable? ↓
DecisionStable?
YESBirth at 37 wks (vaginal induction preferred) ↓deteriorationSEVERE PATHWAY: admit HDU, MgSO4 if neuro, IV/oral antihypertensives, steroids <34+6, deliver (≥34 wks; individualise 24–33+6; ≤24 consider birth) ↓
OutcomeBirth at 37 wks (vaginal induction preferred)

Principles & follow-up

Management principles

Sources (13)

FOGSI / GESTOSIS-India / ICOG — Hypertensive Disorders in Pregnancy — Good Clinical Practice Recommendations (GCPR), 3rd Edition
2026-01 · checked 2026-08-23 · verified-live
Open source ↗

PDF served from fogsi.org (2026 upload path) — definitions, HDP-Gestosis score, treatment threshold ≥140/90 (WOG), targets ≤140/90, delivery timing (GH term; mild PE 37 wks; severe PE after 34 wks; eclampsia deliver once stabilised post-MgSO4; ≤24 wks immediate delivery better; individualise 24–33+6…

ISSHP — The 2021 ISSHP classification, diagnosis & management recommendations for international practice
2021 (publ 2022 Hypertension) · checked 2026-08-23 · verified-live
Open source ↗

Full PDF: standardised BP measurement; proteinuria PrCr ≥30 mg/mmol, ACR ≥8 mg/mmol or ≥300 mg/day or dipstick 2+ if confirmatory testing unavailable; no 'mild/severe' PE label in ongoing pregnancy; treat all HDP with antihypertensives; severe HTN ≥160/110 treat within minutes-hours monitored; targe…

RCOG — Antenatal Corticosteroids to Reduce Neonatal Morbidity and Mortality (Green-top Guideline No. 74)
2022-02 · checked 2026-08-23 · pending-verification
Open source ↗

Cited via RCOG GTG73 update note; direct PDF audit pending — flag

MSF — Labetalol oral
· checked 2026-10-17 · verified-live
Open source ↗

100 mg twice daily with increments, divided higher dosing, 2400 mg/day limit and beta-blocker cautions.

Government of India, MoHFW / NHM — Revised CEmONC Curriculum 2024, Part 1 — chapter 4
· checked 2026-10-17 · verified-live
Open source ↗

Scanned primary PDF pages 103–104 examined by OCR and visual review: labetalol prose sequence/cumulative 300 mg, sustained-release nifedipine 10 mg twice daily/max 80 mg, and internal prose/flowchart differences for acute nifedipine and labetalol. The app exposes rather than merges the differences.

MSF — Methyldopa oral
· checked 2026-10-17 · verified-live
Open source ↗

250 mg twice/three times daily, slow increments, 3 g/day maximum, hepatic/depression cautions. NICE NG133 supplies the separate postpartum stopping recommendation.

NICE — NG133 — hypertension in pregnancy
25 June 2019 · updated 17 April 2023 · checked 2026-10-18 · verified-live
Open source ↗

Scope: additional clinical-detail explanation for hdp-postpartum. Checked the assessment, management-decision and follow-up statements in that section against this source. This does not certify all pre-existing regimens, calculations or recommendations in the module. Targeted medication audit: Table…

Milpharm / emc — Enalapril 5 mg tablets — SmPC
· checked 2026-10-17 · verified-live
Open source ↗

Hypertension initial 5 mg with volume/renal caution, 40 mg/day maintenance ceiling, creatinine/potassium and pregnancy/feeding warnings. NICE NG133 supplies the separately cited postpartum recommendation.

NICE — Postnatal care — NG194
· checked 2026-10-18 · verified-live
Open source ↗

Maternal/newborn transfer assessment, first void and effective feeding, handover, support/safeguarding, first midwife visit within 36 hours after transfer, postnatal danger symptoms. Full recommendations page read.

India MoHFW / NHM — District Hospital Standard Operating Procedures — LaQshya
· checked 2026-10-18 · verified-live
Open source ↗

Normal-delivery discharge not less than 48 hours: full primary SOP PDF normal-delivery/discharge passages read. Corroborated by NHM CEmONC 2024 Part 1, chapter 8. This does not define a universal post-caesarean or complicated-case stay.

WHO — WHO recommendations on quality postnatal care — official recommendation summary
· checked 2026-10-18 · verified-live
Open source ↗

Official WHO summary read: at least 24-hour facility care after birth; additional contacts at 48–72 hours, 7–14 days and week 6; individual assessment/support. Summary facts only, not a claim that the full 242-page PDF was reviewed.

RCOG — Laparoscopy — recovering well
· checked 2026-10-18 · verified-live
Open source ↗

Full primary patient recovery page read: pain control, wounds, activity/VTE, urinary/bowel and infection warning signs, adult support and no driving/important decisions during the first 24 hours after general anaesthesia. Used as general recovery/handover principles, not operation-specific discharge…

NICE — Acutely ill adults in hospital — CG50
· checked 2026-10-18 · verified-live
Open source ↗

Full primary recommendations read, focusing on critical-care-to-ward transfer: structured written handover, shared plan, monitoring, rehabilitation and receiving-team capability. Step-down is distinct from home discharge; no universal organ-support discharge cutoff is asserted.