1. Why this matters for MRCGP

• Hypertension in pregnancy is a classic AKT threshold-and-urgency topic.
• SCA cases test whether you can recognise possible pre-eclampsia, act quickly, and explain risk without alarming the patient.
• The GP risk is treating it like ordinary adult hypertension or missing postpartum pre-eclampsia.
• Practical use matters because aspirin, antihypertensive switching, proteinuria testing, referral timing and postnatal monitoring are all safety-critical.

2. GP Bottom Line

• Before 20 weeks or at booking: think chronic hypertension and refer for consultant-led care.
• New BP ≥140/90 mmHg after 20 weeks needs secondary care assessment within 24 hours.
• Severe hypertension — BP ≥160/110 mmHg — needs urgent same-day secondary care / obstetric assessment.
• If pre-eclampsia is suspected, arrange emergency secondary care assessment.
• Key trap: pre-eclampsia can present postpartum, up to 4 weeks after birth.

3. 60 Second Exam Snapshot

• Hypertension: systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg.
• Severe hypertension: systolic BP ≥160 mmHg or diastolic BP ≥110 mmHg.
• Chronic hypertension: present at booking, before 20 weeks, or already treated when referred to maternity care.
• Gestational hypertension: new hypertension after 20 weeks without significant proteinuria.
• Pre-eclampsia: new hypertension after 20 weeks plus significant proteinuria, maternal organ dysfunction or uteroplacental dysfunction. Dipstick 1+ triggers protein:creatinine ratio or albumin:creatinine ratio; it is not by itself the full diagnosis.
• Pre-eclampsia can also be superimposed on chronic hypertension.
• Significant proteinuria: protein:creatinine ratio ≥30 mg/mmol or albumin:creatinine ratio ≥8 mg/mmol.
• Women at high risk of pre-eclampsia should be referred for consultant-led care at booking, and aspirin 75–150 mg daily should be prescribed from 12 weeks until birth.

4. Recognition and Diagnosis

• Classify by timing, blood pressure, significant proteinuria and symptoms.
• Chronic hypertension is present at booking, before 20 weeks, or already treated when referred to maternity care. Gestational hypertension is new hypertension after 20 weeks without significant proteinuria.
• Pre-eclampsia is suggested by new hypertension after 20 weeks with significant proteinuria or new maternal organ dysfunction, including renal, liver, neurological or haematological features, or uteroplacental dysfunction. It can also be superimposed on chronic hypertension.
• Ask specifically about severe headache, visual disturbance, persistent epigastric or right upper quadrant pain, vomiting, breathlessness, and sudden swelling of the face, hands or feet.
• HELLP syndrome means Haemolysis, Elevated Liver enzymes and Low Platelets. Eclampsia is one or more seizures in a woman with pre-eclampsia.

5. AKT Essentials: What Changes the Answer

Diagnosis / recognition

• Before 20 weeks: chronic hypertension pathway.
• After 20 weeks: gestational hypertension unless pre-eclampsia features are present.
• Pre-eclampsia requires significant proteinuria, maternal organ dysfunction or uteroplacental dysfunction; dipstick protein alone is not the full diagnosis.
• Proteinuria alone after 20 weeks can be impending pre-eclampsia.

Investigation / interpretation

• BP and urine dipstick at presentation and each antenatal visit.
• Dipstick 1+ or more: quantify with protein:creatinine ratio or albumin:creatinine ratio.
• Do not use first morning urine to quantify proteinuria.
• Do not routinely use 24-hour urine collection.
• In suspected preterm pre-eclampsia between 20+0 and 36+6 weeks, the specialist pathway may use placental growth factor-based testing to help rule out pre-eclampsia; this does not replace clinical assessment or referral.

Management / next best step

• New hypertension after 20 weeks: secondary care within 24 hours.
• Severe hypertension, BP ≥160/110 mmHg: urgent same-day secondary care / obstetric assessment.
• Suspected pre-eclampsia: emergency secondary care.
• Chronic hypertension: consultant-led care.
• Women at high risk of pre-eclampsia: consultant-led care at booking plus aspirin from 12 weeks until birth.

Medicines / safety

• For chronic hypertension while awaiting specialist care, offer treatment if sustained BP is ≥140/90 mmHg and the woman is not already treated.
• When using medicines to treat hypertension in pregnancy, aim for 135/85 mmHg.
• Continue existing antihypertensive treatment if safe in pregnancy unless sustained systolic BP is below 110 mmHg, sustained diastolic BP is below 70 mmHg, or there is symptomatic hypotension.
• Stop ACE inhibitors (ACEi) and Angiotensin II Receptor Blockers (ARBs) if pregnancy occurs; preferably within 2 working days of pregnancy notification.
• Review thiazide or thiazide-like diuretics and use alternatives if needed.
• Pregnancy options are usually labetalol, then nifedipine, then methyldopa if earlier options are unsuitable.

Follow-up

• Postnatal hypertension needs active monitoring, not discharge-and-forget review.

6. SCA Consultation Essentials

• Likely tasks: raised BP at antenatal visit, a pregnant woman on ramipril/losartan, new headache at 34 weeks, or postpartum headache and swelling.
• Gather: gestation, BP, urine dipstick result, symptoms, fetal movement concern if volunteered, current medicines, previous hypertensive pregnancy, kidney disease, diabetes, autoimmune disease, and breastfeeding plans postpartum.
• Communication pivot: explain that high BP in pregnancy can be more than “blood pressure”; it may signal pre-eclampsia, which can affect the mother and baby.
• Useful wording: “Because this is new high blood pressure after 20 weeks, you need maternity assessment within 24 hours. If the blood pressure is very high or there are features of pre-eclampsia, this needs assessment today.”
• Do not negotiate away referral if pre-eclampsia is suspected.

7. Red Flags / Escalation / Referral

• Arrange emergency secondary care assessment for suspected pre-eclampsia.
• Arrange secondary care assessment within 24 hours for new-onset hypertension after 20 weeks.
• Arrange urgent same-day secondary care / obstetric assessment for severe hypertension: systolic BP ≥160 mmHg or diastolic BP ≥110 mmHg.
• Refer chronic hypertension in pregnancy for consultant-led care.
• Arrange same-day obstetric assessment if proteinuria after 20 weeks is accompanied by symptoms of pre-eclampsia.
• Proteinuria 2+ or more after 20 weeks needs urgent secondary care assessment, even if urinary tract infection is possible.
• Suspected postpartum pre-eclampsia or eclampsia up to 4 weeks after birth needs hospital admission for immediate assessment.

8. What the GP Should Do Today

1. Confirm gestation and repeat BP carefully.
2. Dipstick urine for protein.
3. Ask directly about headache, visual symptoms, epigastric/right upper quadrant pain, vomiting, breathlessness and sudden swelling.
4. Check current antihypertensives, especially ACE inhibitors, ARBs, thiazides and thiazide-like diuretics.
5. Decide the pathway: chronic hypertension, new hypertension after 20 weeks, severe hypertension, suspected pre-eclampsia, isolated proteinuria, or postpartum concern.
6. Arrange the correct referral urgency.
7. If high risk for pre-eclampsia, refer for consultant-led care at booking. If specialist review will be after 12 weeks, prescribe aspirin 75–150 mg daily from 12 weeks until birth, unless specialist advice is needed first.
8. Safety-net explicitly for pre-eclampsia symptoms during pregnancy and the first 4 weeks postpartum.

9. Practical Use in GP: How to Apply This Topic

Before acting

• Establish gestation.
• Measure BP and dipstick urine.
• Review medicines.
• Identify high-risk and moderate-risk pre-eclampsia factors.

Aspirin

• Women at high risk of pre-eclampsia should be referred for consultant-led care at booking, and aspirin 75–150 mg daily should be prescribed from 12 weeks until birth.
  • High risk: one of previous hypertensive disease in pregnancy, chronic kidney disease, autoimmune disease, type 1 or type 2 diabetes, or chronic hypertension.
  • Moderate risk: more than one of first pregnancy, age ≥40, pregnancy interval >10 years, body mass index ≥35 kg/m², family history of pre-eclampsia, or multiple pregnancy.
• Aspirin must be prescribed for pre-eclampsia prevention in pregnancy; it is not a pharmacy-sale workaround for this indication in England.
• Seek specialist advice before prescribing aspirin to girls younger than 16, or in thrombophilia or uncontrolled BP.

Chronic hypertension while awaiting specialist care

• Refer for consultant-led care at booking.
• If the woman is not already on antihypertensive treatment, offer treatment if sustained BP is ≥140/90 mmHg.
• Aim for BP 135/85 mmHg when using medicines to treat hypertension in pregnancy.
• Continue existing antihypertensive treatment if it is safe in pregnancy, unless sustained systolic BP is below 110 mmHg, sustained diastolic BP is below 70 mmHg, or there is symptomatic hypotension.

Isolated proteinuria after 20 weeks

• With pre-eclampsia symptoms: same-day obstetric assessment.
• Dipstick 2+ or more: urgent secondary care.
• Dipstick 1+ without hypertension or symptoms: quantify proteinuria, check BP, reassess in 1 week and safety-net.
• For isolated 1+ proteinuria after 20 weeks, also consider urinary tract infection: if symptomatic or at relevant risk, send a midstream specimen of urine for culture and manage appropriately.

Postnatal essentials

• After chronic or gestational hypertension, BP should be measured daily for the first 2 days and at least once between days 3–5.
• After pre-eclampsia, transfer to community care only if there are no symptoms, BP is ≤150/100 mmHg and blood tests are stable or improving.
• If antihypertensives were used after pre-eclampsia, check BP every 1–2 days for up to 2 weeks after transfer until treatment is no longer needed and there is no hypertension.
• Aim for BP <140/90 mmHg.
• Start treatment at BP ≥150/100 mmHg in gestational hypertension or pre-eclampsia if not already treated.
• Reduce treatment if BP falls below 130/80 mmHg.
• Follow the discharge care plan.
• Review ongoing antihypertensives at 2 weeks if still treated.
• Offer 6–8 week review after chronic hypertension, gestational hypertension or pre-eclampsia.
• After pre-eclampsia, carry out a urinary reagent-strip test at the 6–8 week review. If proteinuria is 1+ or more, arrange further review at 3 months to assess kidney function and consider specialist kidney assessment if abnormal.
• At postnatal follow-up, advise that hypertensive disorders of pregnancy increase future hypertension and cardiovascular disease risk, and that recurrence in a future pregnancy is approximately 1 in 5; discuss risk reduction with the GP or specialist.

10. Medicines, Investigations and Intervention Safety

Pregnancy treatment options and licensing caveat

• Labetalol, nifedipine and methyldopa are not specifically licensed for hypertension in pregnancy, but they are the source-supported pregnancy options.

Labetalol

• First-line pregnancy option where treatment is needed.
• Do not use in asthma or bronchospasm history, uncontrolled heart failure, heart block/sick sinus syndrome, marked bradycardia, hypotension, cardiogenic shock, Prinzmetal’s angina, phaeochromocytoma, metabolic acidosis or severe peripheral circulatory disorders.
• Use caution in diabetes, renal impairment and hepatic impairment.

Nifedipine

• Use if labetalol is unsuitable.
• Use a modified-release preparation and prescribe the same brand during treatment.
• Some nifedipine brands were specifically contraindicated by the manufacturer at guideline publication, so check the individual Summary of Product Characteristics/product information before prescribing.

Methyldopa

• Use if labetalol and nifedipine are unsuitable.
• Avoid in active hepatic disease, depression, phaeochromocytoma/paraganglioma and acute porphyria.
• Stop within 2 days after birth and switch if needed.

ACE inhibitors / Angiotensin II Receptor Blockers

• Avoid in pregnancy planning unless essential.
• Stop promptly when pregnancy is confirmed and offer alternatives.
• If used for renal disease or another non-hypertension indication, seek specialist advice.

Thiazide or thiazide-like diuretics

• Review if used before or during pregnancy, and use alternatives if needed.

Postnatal breastfeeding

• Antihypertensive treatment can be adapted for breastfeeding.
• Postnatally, offer enalapril with monitoring of maternal renal function and serum potassium.
• For women of Black African or Caribbean family origin, consider nifedipine, or amlodipine if previously used successfully, as first-line treatment.
• Avoid diuretics and ARBs where possible during breastfeeding or expressing milk.
• Women who are breastfeeding should be advised to monitor babies for drowsiness, lethargy, pallor, cold peripheries or poor feeding.

11. How to Explain It to the Patient

• “Your blood pressure is high, and in pregnancy we take that seriously because it can sometimes be linked with pre-eclampsia.”
• “I need to check your urine because protein in the urine can change how urgently you need maternity assessment.”
• “Because this has happened after 20 weeks, you need assessment by the maternity team within 24 hours.”
• “If the blood pressure is very high, or if we are worried about pre-eclampsia, you need assessment today.”
• “If you develop a severe headache, changes in vision, pain below the ribs, vomiting, breathlessness, or sudden swelling of your face, hands or feet, seek medical help immediately.”
• “Some blood pressure medicines are not suitable in pregnancy, so we need to change them safely rather than just continue as before.”
• “Needing blood pressure tablets after birth does not automatically stop you breastfeeding; we can choose medicines around that.”

12. When the Plan Changes

Scenario	Why this changes the plan	What the GP does now
If new hypertension appears after 20 weeks	Gestational hypertension or pre-eclampsia becomes possible.	Arrange secondary care assessment within 24 hours.
If BP is 160/110 mmHg or more	This is severe hypertension.	Arrange urgent same-day secondary care / obstetric assessment.
If there are symptoms of pre-eclampsia	Maternal organ involvement may be present.	Arrange emergency secondary care assessment.
If dipstick protein is 2+ after 20 weeks	Significant disease may be developing even without hypertension.	Arrange urgent secondary care assessment.
If the woman is taking an ACE inhibitor or ARB	Pregnancy safety risk.	Stop promptly, offer alternatives if needed, and seek specialist advice if used for another condition.
If postpartum symptoms suggest pre-eclampsia	Eclampsia can occur up to 4 weeks after birth.	Arrange immediate hospital assessment.

13. Common AKT / SCA Traps

• Treating pregnancy hypertension like routine adult hypertension.
• Forgetting the 20-week distinction.
• Putting BP ≥160/110 mmHg into the routine 24-hour pathway rather than same-day obstetric assessment.
• Thinking pre-eclampsia requires proteinuria only.
• Not referring new hypertension after 20 weeks within 24 hours.
• Reassuring postpartum headache and swelling.
• Continuing ACE inhibitors or ARBs in pregnancy.
• Continuing methyldopa after birth.
• Giving aspirin advice without recognising it must be prescribed for this indication.

14. Common Exam Angles

• Angle: 28-week pregnant woman with BP 148/94.
  • Hidden challenge: New hypertension after 20 weeks.
  • What the candidate must not miss: Secondary care assessment within 24 hours.
• Angle: 30-week pregnant woman with BP 166/112.
  • Hidden challenge: Severe hypertension.
  • What the candidate must not miss: Urgent same-day secondary care / obstetric assessment.
• Angle: Pregnant woman on an angiotensin-converting enzyme inhibitor.
  • Hidden challenge: Medicine safety.
  • What the candidate must not miss: Stop promptly and switch/seek advice.
• Angle: 1 week postpartum with severe headache and visual symptoms.
  • Hidden challenge: Postpartum pre-eclampsia.
  • What the candidate must not miss: Immediate hospital assessment.

15. 90 Second Audio Summary Script

Hypertension in pregnancy is all about timing, proteinuria, symptoms and urgency. Before 20 weeks, think chronic hypertension and consultant-led care. After 20 weeks, new blood pressure of 140 over 90 or higher needs secondary care assessment within 24 hours. Severe hypertension — 160 over 110 or higher — needs urgent same-day secondary care or obstetric assessment. If pre-eclampsia is suspected, arrange emergency secondary care assessment.

Pre-eclampsia is not just protein in the urine. It means new hypertension after 20 weeks plus significant proteinuria, maternal organ dysfunction or uteroplacental dysfunction. It can also be superimposed on chronic hypertension. Ask about severe headache, visual symptoms, pain below the ribs, vomiting, breathlessness and sudden swelling.

Dipstick protein of 1+ or more should be quantified with protein:creatinine ratio or albumin:creatinine ratio. Aspirin 75 to 150 mg from 12 weeks until birth is used for women at high risk, or with more than one moderate risk factor, and high-risk women also need consultant-led care at booking.

Medicine safety is high yield: stop ACE inhibitors and ARBs when pregnancy is confirmed, and review thiazide or thiazide-like diuretics. Labetalol is usually first-line, then nifedipine, then methyldopa if needed. After birth, stop methyldopa within 2 days, follow the postnatal BP monitoring plan, and remember pre-eclampsia can still present up to 4 weeks postpartum.

References

• American College of Obstetricians and Gynecologists (2020) ‘Gestational hypertension and preeclampsia: ACOG Practice Bulletin, Number 222’, Obstetrics & Gynecology, 135(6), pp. e237–e260. doi: 10.1097/AOG.0000000000003891.
• Bellamy, L., Casas, J.P., Hingorani, A.D. and Williams, D.J. (2007) ‘Pre-eclampsia and risk of cardiovascular disease and cancer in later life: systematic review and meta-analysis’, BMJ, 335(7627), p. 974. doi: 10.1136/bmj.39335.385301.BE.
• Bramham, K., Parnell, B., Nelson-Piercy, C., Seed, P.T., Poston, L. and Chappell, L.C. (2014) ‘Chronic hypertension and pregnancy outcomes: systematic review and meta-analysis’, BMJ, 348, g2301. doi: 10.1136/bmj.g2301.
• Electronic Medicines Compendium (eMC) (2022) Methyldopa: Summary of Product Characteristics. Available at: https://www.medicines.org.uk/emc/product/4667/smpc (Accessed: 28 April 2026).
• Electronic Medicines Compendium (eMC) (2024) Labetalol hydrochloride: Summary of Product Characteristics. Available at: https://www.medicines.org.uk/emc/product/2647/smpc (Accessed: 28 April 2026).
• Electronic Medicines Compendium (eMC) (2016) Nifedipine modified-release: Summary of Product Characteristics. Available at: https://www.medicines.org.uk/emc/product/10/smpc (Accessed: 28 April 2026).
• Garovic, V.D., Dechend, R., Easterling, T., Karumanchi, S.A., McMurtry Baird, S., Magee, L.A., Rana, S., Vermunt, J.V. and August, P. (2022) ‘Hypertension in pregnancy: diagnosis, blood pressure goals, and pharmacotherapy: a scientific statement from the American Heart Association’, Hypertension, 79(2), pp. e21–e41. doi: 10.1161/HYP.0000000000000208.
• Joint Formulary Committee (2026a) British National Formulary: Labetalol hydrochloride. Available at: https://bnf.nice.org.uk/drugs/labetalol-hydrochloride/ (Accessed: 28 April 2026).
• Joint Formulary Committee (2026b) British National Formulary: Nifedipine. Available at: https://bnf.nice.org.uk/drugs/nifedipine/ (Accessed: 28 April 2026).
• Joint Formulary Committee (2026c) British National Formulary: Methyldopa. Available at: https://bnf.nice.org.uk/drugs/methyldopa/ (Accessed: 28 April 2026).
• Joint Formulary Committee (2026d) British National Formulary: Aspirin. Available at: https://bnf.nice.org.uk/drugs/aspirin/ (Accessed: 28 April 2026).
• Joint Formulary Committee (2026e) British National Formulary: Enalapril maleate. Available at: https://bnf.nice.org.uk/drugs/enalapril-maleate/ (Accessed: 28 April 2026).
• Medicines and Healthcare products Regulatory Agency (2014a) ACE inhibitors and angiotensin II receptor antagonists: not for use in pregnancy. Available at: https://www.gov.uk/drug-safety-update/ace-inhibitors-and-angiotensin-ii-receptor-antagonists-not-for-use-in-pregnancy (Accessed: 28 April 2026).
• Medicines and Healthcare products Regulatory Agency (2014b) ACE inhibitors and angiotensin II receptor antagonists: recommendations on how to use for breastfeeding. Available at: https://www.gov.uk/drug-safety-update/ace-inhibitors-and-angiotensin-ii-receptor-antagonists-recommendations-on-how-to-use-for-breastfeeding (Accessed: 28 April 2026).
• National Health Service (2024) High blood pressure and pregnancy. Available at: https://www.nhs.uk/pregnancy/existing-health-conditions/high-blood-pressure/ (Accessed: 28 April 2026).
• National Health Service (2026) Pre-eclampsia. Available at: https://www.nhs.uk/conditions/pre-eclampsia/ (Accessed: 28 April 2026).
• National Institute for Health and Care Excellence (2021) Antenatal care. NICE guideline NG201. Available at: https://www.nice.org.uk/guidance/ng201 (Accessed: 28 April 2026).
• National Institute for Health and Care Excellence (2022) PLGF-based testing to help diagnose suspected preterm pre-eclampsia. NICE HealthTech guidance HTG630. Available at: https://www.nice.org.uk/guidance/htg630 (Accessed: 28 April 2026).
• National Institute for Health and Care Excellence (2023) Hypertension in pregnancy: diagnosis and management. NICE guideline NG133. Available at: https://www.nice.org.uk/guidance/ng133 (Accessed: 28 April 2026).
• Royal College of General Practitioners (2025) Maternity and reproductive health: GP curriculum. Available at: https://www.rcgp.org.uk/mrcgp-exams/gp-curriculum/maternity-reproductive-health (Accessed: 28 April 2026).
• Wu, P., Green, M. and Myers, J.E. (2023) ‘Hypertensive disorders of pregnancy’, BMJ, 381, e071653. doi: 10.1136/bmj-2022-071653.

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