Hypertension in Pregnancy: Clarifying What to Do and When to Do It

Target Population: Obstetric care providers

Background and Objective

Guided by the latest evidence, ACOG's Task Force on Hypertension in Pregnancy has updated its diagnostic and therapeutic recommendations. The report includes clarifying points as well as paradigmatic shifts.

Key Points and Recommendations

Diagnosis and Classification

• Hypertensive disorders remain classified as preeclampsia–eclampsia, chronic hypertension, chronic hypertension with superimposed preeclampsia, and gestational hypertension.

• The requirement of proteinuria for diagnosing preeclampsia has been abandoned: Hypertension with associated laboratory abnormalities, pulmonary edema, or neurologic symptoms — even in the absence of proteinuria — should be considered indicative of preeclampsia.

• A urinary protein:creatinine ratio ≥0.3 is a diagnostic criterion for preeclampsia.

• No level of proteinuria should be used as a defining standard for severe preeclampsia.

Management of Chronic Hypertension

• Blood pressures (BPs) persistently above 160/105 should be treated to goals between 120/80 and 160/105.

• Ultrasound screening for fetal growth restriction is appropriate; antenatal fetal surveillance should be performed in women who require antihypertensive therapy or who have superimposed preeclampsia or fetal growth restriction.

Management of Preeclampsia

• Antihypertensive medications should not be administered unless BPs are persistently above 160/110.

• Women with mild gestational hypertension or with preeclampsia lacking severe features (the preferred terminology over “mild preeclampsia”) should be expectantly managed before 37 weeks' gestation.

• For women with severe preeclampsia before 34 weeks and stable maternal and fetal status, expectant management in appropriate care settings can be pursued; for those with laboratory abnormalities, fetal growth restriction, or preterm labor, planned delivery should be delayed for 48 hours to permit a complete course of antenatal steroids; for those with maternal or fetal instability, delivery should be initiated without delay.

• Expectant management is not recommended for women with severe preeclampsia preceding fetal viability.

• Magnesium sulfate should be administered intrapartum–postpartum to women with severe preeclampsia.

• When preeclampsia is diagnosed postpartum and is accompanied by neurologic symptoms or severe hypertension, magnesium sulfate should be administered.

• In women with gestational hypertension and/or preeclampsia, BP should be monitored for at least 72 hours postpartum and again 7 to 10 days after delivery.

Prevention of Preeclampsia

• Women with histories of preeclampsia that is recurrent or has previously developed before 34 weeks should be offered daily low-dose aspirin commencing at the end of the first trimester.

• Bed rest is not recommended for prevention or treatment of preeclampsia.

Ongoing Healthcare for Women with Histories of Preeclampsia

• Given their increased risk for cardiovascular disease, women who have experienced early or recurrent preeclampsia should have yearly assessments of BP, lipids, fasting glucose, and body-mass index.

What's Changed

• Proteinuria is no longer required to make a diagnosis of preeclampsia when hypertension occurs with one or more severe features of this condition; however, when proteinuria is used among other diagnostic criteria for preeclampsia, a protein:creatinine ratio of at least 0.3 is sufficient.

• Magnesium sulfate is now only recommended for women with preeclampsia with severe features.