HDP Clinical Decision Tool

HDP Clinical Decision Tool — FOGSI-GESTOSIS-ICOG 2026

🔍 Risk Scoring

📋 Classification

💊 BP Management

⚗️ MgSO₄ Protocol

🏥 Delivery Timing

⚠️ Maternal Alerts

🧪 Lab Reference

📋Classification of Hypertensive Disorders in Pregnancy

Condition	Definition / Criteria	Timing	Severity
Gestational HTN	BP ≥140/90 on 2 occasions ≥4 hrs apart; no proteinuria/end-organ signs	After 20 weeks; resolves by 6 weeks postpartum	Mild–Moderate
Preeclampsia (without severe features)	BP ≥140/90 & ≤160/110 + proteinuria or end-organ dysfunction; no premonitory symptoms	After 20 weeks	Moderate
Preeclampsia (with severe features)	BP ≥160/110 ± symptoms/labs, OR BP ≥140/90 + premonitory symptoms and/or abnormal labs	After 20 weeks	Severe
Eclampsia	Generalised tonic-clonic seizures in association with preeclampsia	Any time	Life-threatening
Chronic HTN	HTN before pregnancy or before 20 weeks; persists beyond 6 weeks postpartum	Pre-existing or <20 weeks	Variable
Superimposed PE	Preeclampsia developing in a woman with chronic hypertension	After 20 weeks	High risk
White Coat HTN	BP ≥140/90 in clinic; <135/85 at home or ABPM	Any time	Low
Masked HTN	BP <140/90 in clinic; ≥135/85 at home or ABPM	Any time	Monitor closely
Postpartum HTN	BP ≥140/90 after delivery (de novo or continuation)	Post-delivery	Monitor

🕐Early vs Late Onset PE

Early Onset

Before 34 weeks
More severe maternal complications
FGR, low birth weight common
Iatrogenic prematurity risk
May need early delivery
Higher CVD recurrence risk

Late Onset

After 34 weeks
Often metabolic factors
Generally less severe
Lower FGR incidence
Better maternal/fetal outcomes
Lower recurrence risk

🔁Recurrence Risk

Overall HDP recurrence20.7%

Preeclampsia recurrence13.8%

Gestational HTN recurrence8.6%

HELLP syndrome recurrence0.2%

Early-onset severe PE25–65%

PE without severe features5–7%

🎯BP Targets

135/85

Target BP in non-severe HTN (antihypertensive therapy)

140/90

Threshold to initiate antihypertensive therapy (ISSHP/WOG)

160/110

Severe HTN — treat within 1 hour urgently

💊Non-Severe Hypertension — Oral Agents

Labetalol (α+β blocker)

1st LineHigh pulse >100

Start: 100–200 mg BD/TID → titrate up
Add second agent at: 1200 mg/day
Maximum: 2400 mg/day in divided doses

⚠️ Contraindicated: asthma, CCF, DM, bradycardia | Monitor neonate for bradycardia/hypoglycaemia

Nifedipine SR (CCB)

1st LineLow pulse <100

Start: 10–20 mg slow-release BD/TID
Maximum: 120 mg/day
Never administer sublingually

⚠️ Maternal tachycardia, flushing | Contraindicated in aortic stenosis, CCF, SA/AV node abnormalities

Methyldopa (Central α-agonist)

1st LineMost time-tested

Start: 250–500 mg/day orally TID/QID
Maximum: 2250 mg/day
Do NOT use postpartum (causes depression)

⚠️ Depression, postural hypotension | Avoid postpartum

🚨Severe Hypertension — IV/Urgent Agents

IV Labetalol

Severe HTNPreferred

Bolus: 20 mg IV slow, then double every 20–30 min (max single dose 80 mg)
Total max: 300 mg
Infusion: 1–2 mg/min after loading dose, titrate to effect

⚠️ Contraindicated: CCF, DM, Asthma, bradycardia

Oral Nifedipine (acute)

Severe HTN

10–30 mg orally (NOT sublingually)
Repeat in 30–45 min if needed
Max total: 120 mg | Switch to SR formulation once controlled

IV Hydralazine

Severe HTN3rd choice

5 mg IV or IM → 5–10 mg every 20–40 min
Once controlled: repeat every 3 hours
Infusion: 0.5–10 mg/hr | If >20 mg IV uncontrolled → switch drug

⚠️ Associated with more maternal hypotension, abruption, oliguria vs labetalol/nifedipine

IV Nicardipine

Severe HTNTitratable

Start: 1.5 mg/hr IV infusion
Titrate up to 6 mg/hr as needed (0.5 μg/kg/min increments)
100× more water-soluble than nifedipine — easily titratable IV CCB

⛔Absolutely Contraindicated in HDP

ACE Inhibitors — fetotoxic ARBs — fetotoxic Ergometrine / Methylergometrine (3rd stage) Sublingual Nifedipine Methyldopa postpartum

⚗️ Pritchard Regimen (Preferred)

IV Loading: 4 g in 20 mL (20% solution) slow IV over 5–10 min
Preparation: 4 ampoules of 50% MgSO₄ + 12 mL distilled water in 20 mL syringe

IM Loading (simultaneous): 5 g in each buttock (10 g total IM)
5 ampoules 50% MgSO₄ + 0.5 mL 2% lignocaine — deep IM with 20G long needle

Recurrent seizure (within 15 min): 2 g slow IV over 10 min

Maintenance: 5 g deep IM in alternate buttock every 4 hours

Duration: 24 hours after delivery OR last convulsion (whichever is later)

🧪 Zuspan Regimen

IV Loading: 4 g slow IV over 5–10 min (same as Pritchard)

Maintenance: 1 g/hour IV infusion (preferably via infusion pump)
Ready-made 4 g/100 mL solution: only 6 bags needed for 24 hr maintenance (600 mL total)

Monitor hourly: RR >16/min + patellar reflexes present + urine >30 mL/hr

⚠️Monitoring Checklist (Every 4 hrs)

Respiratory rate>16 / min ✓

Patellar reflexesPresent ✓

Urine output (Pritchard)>100 mL in 4 hrs ✓

Urine output (Zuspan)>30 mL/hr ✓

⚠️ Serum Mg monitoring NOT required routinely — clinical monitoring is sufficient

📊Serum Magnesium Levels

Therapeutic range4.0 – 7.0 mEq/L

Loss of tendon reflexes>7–10 mEq/L

Respiratory depression>10–12 mEq/L

Cardiac arrest risk>20–24 mEq/L

🚨Toxicity Management

Respiratory depression:
→ Stop MgSO₄
→ Calcium gluconate 10 mL of 10% solution IV over 10 min (with pulse oximetry + ECG)
→ O₂ by mask at 8–10 L/min
→ Maintain airway

Respiratory arrest:
→ Intubate and ventilate immediately
→ 1 g Calcium gluconate IV with monitoring

Absent patellar reflex only:
→ Withhold next dose until reflexes return

Urine <100 mL / 4 hrs:
→ Check catheter patency
→ Reduce IM to 2.5 g OR IV to 0.5 g/hr

🏥Delivery Timing Guide

37–38
weeks

Gestational HTN (isolated, not on antihypertensives, occasional mild BP)

Also: Chronic HTN on medication — aim 37–38 completed weeks

37
weeks

Gestational HTN with comorbidities (DM, obesity, frequent BP rises)

Also: Preeclampsia without severe features — delivery generally indicated at 37 completed weeks

34–37
weeks

Preeclampsia with complications

Depending on clinical features and rate of deterioration

NOW
immediate

Deliver immediately after maternal stabilisation

Eclampsia/impending eclampsia • Severe HTN despite 3 antihypertensive classes • HELLP syndrome • Worsening thrombocytopenia or liver dysfunction • Abruption • Renal dysfunction • Pulmonary oedema • DIC • Non-reassuring fetal status • IUFD

🩺Induction of Labour

Recommended methods:
• Misoprostol oral/vaginal (25–50 μg PV q4h or 50–100 μg oral q2h)
• Dinoprostone (gel/pessary)
• Mechanical methods (balloon catheter)

Scarred uterus: Prostaglandins/misoprostol are NOT recommended → Use mechanical + oxytocin (concurrent or sequential)

Augmentation: Oxytocin after amniotomy only

Not recommended: Buccal/sublingual misoprostol with viable pregnancy

💉Anaesthesia & 3rd Stage

Preferred: Regional/epidural/spinal — with normal coagulation and platelets >70–80 ×10⁹/L

GA indicated when: Abnormal FHR, fetal asphyxia, abruption, pulmonary oedema, HELLP, severe thrombocytopenia

⚠️ GA risk: laryngeal oedema → intubation failure

AMTSL — Preferred uterotonics:
✅ Oxytocin 10 IU IM/slow IV
✅ Heat-stable Carbetocin 100 μg IM/IV
✅ Misoprostol 400–600 μg oral/PR
❌ Ergometrine / Methylergometrine — contraindicated
❌ Injectable prostaglandins — not recommended

👶Fetal Surveillance Frequency

Condition	Growth Scan	Doppler	CTG/BPP
Mild disease, no FGR	Every 3–4 weeks	With growth scan	As required
FGR or abnormal UA Doppler	Every 2 weeks	1–2× per week	NST/mBPP 2–3×/week
AEDF/REDF or abnormal DV	More frequent	Daily assessment	Daily CTG — consider inpatient
Severe PE	2 weekly	Weekly or alternate day	CTG on diagnosis + as indicated
Chronic HTN / severe prev PE	From 28 wks, 4 weekly	Every 4 weeks	As clinically indicated

🚨Maternal Danger Symptoms (Patient-reported)

😵 Severe persistent headache

👁️ Blurred vision, flashing lights, photophobia

😮‍💨 Shortness of breath / orthopnoea

🤢 Epigastric or right upper quadrant pain

⚖️ Sudden weight gain ≥1–2 kg/week

😶 General malaise / nausea & vomiting

🤚 Significant facial / hand / periorbital oedema

🩸 Easy bruising / bleeding gums

🔍Clinical Signs to Monitor

Blood Pressure≥140/90 mmHg

Deep tendon reflexesBrisk = concerning

ConsciousnessAny alteration

OedemaSudden massive onset

ProteinuriaSignificant on dipstick

Urine outputReduced = alert

Fetal movementsReduced = alert

Vaginal bleeding + uterine tendernessAbruption?

🧬Biochemical / Biophysical Alerts

SpO₂<95% → act

LDH≥600 U/L or rising trend

Serum Creatinine≥1 mg/dL

AST / ALT≥2× ULN

Platelets<150,000/mm³

Serum Uric Acid>5 mg/dL

PlGF (spot)<12 pg/mL = high risk

sFlt-1/PlGF ratio>85 = high risk

📞Eclampsia Referral Checklist (before transfer)

✅ MgSO₄ loading dose (Pritchard regimen) given + documented in writing for receiving centre

✅ Oral Nifedipine 20 mg SR or Labetalol 200 mg + regular antihypertensives given

✅ Corticosteroids (1st dose) if GA <34 weeks

✅ Transfer with attendant + monitoring en route + info to receiving centre

✅ Eclampsia kit sent with patient

✅ No sublingual nifedipine — strictly oral route only

🧪Baseline Labs — When BP ≥140/90 (or first visit with known chronic HTN)

Minimum Required

Urine albuminDipstick or Spot P:Cr ratio

CBC (Hb + platelets)Assess anaemia + thrombocytopenia

Liver enzymesAST (SGOT), ALT (SGPT)

LDHHaemolysis marker

Serum creatinineRenal function

Additional (when indicated)

Coagulation profileWhen platelets <150,000

Serum electrolytesSevere disease

Uric acidDisease activity marker

sFlt-1/PlGF ratioConfirms PE diagnosis, prognosis

2D Echo maternalLV dysfunction assessment

📊Diagnostic Thresholds

Parameter	Normal Pregnancy	Concerning	Severe Feature
Platelets	Usually ≥150 ×10⁹/L	<150 ×10⁹/L	<100 ×10⁹/L (HELLP if with LDH↑)
Creatinine	Falls; often ≤0.8 mg/dL	>1.1 mg/dL or doubling from baseline	Meets severe feature criteria
AST/ALT	Stable / slightly low	≥2× ULN	≥2× ULN with RUQ pain
LDH	Unchanged	Rising trend	≥600 U/L (HELLP criterion)
Uric Acid	Falls 1st trimester, rises later	>5 mg/dL	Rapid rise → worse prognosis
Urine Protein:Cr	Negative/trace	≥0.3 (30 mg/mmol)	Not required for diagnosis if severe features present
Bilirubin	Unchanged/slight fall	Rising = hepatic involvement	Marked rise → HELLP/AFLP

🔴HELLP Syndrome Criteria

Haemolysis (LDH)≥600 U/L

Elevated Liver enzymes (AST)≥70 U/L

Low Platelets<100 ×10⁹/L

Manage as severe preeclampsia. Anticipate coagulopathy and hepatic complications. Do NOT use corticosteroids to resolve HELLP.

🟡AFLP — Swansea Criteria (≥6 positive)

📅Lab Monitoring Frequency by Stage

Stage	Panel	Repeat Frequency
Booking / 1st trimester	CBC, LFT, renal, uric acid, urine protein, HbA1c if risk factors	Repeat at 20–24 wk if HTN or risk factors
2nd trimester (20–28 wk)	CBC, LFT, renal, uric acid, spot P:Cr	Weekly (stable) or twice weekly (severe BP/symptoms)
3rd trimester (28–36 wk)	CBC, LFT, renal, uric acid, spot P:Cr	Weekly; every 48–72 h if rapidly evolving
Term / Intrapartum	CBC, LFT, renal, spot P:Cr	At admission; every 24–48 h or sooner
Early postpartum (48–72 h)	CBC, LFT, renal, uric acid, spot P:Cr	Once within 48–72 h; repeat if abnormal

HDP Clinical Decision Tool

For Educational Purpose Only

⚗️ Pritchard Regimen (Preferred)

🧪 Zuspan Regimen

Pregnancy Care

Labour

Women’s Health

Adolescent Care

Obs & Gynae Emergencies

Infertility

Screening for Cancers