Hypertensive pregnancy disorders

Hypertensive pregnancy disorders are among the most common complications during pregnancy and the early postpartum period. There are four major types of hypertensive pregnancy disorders: chronic hypertension, gestational hypertension, preeclampsia, and eclampsia. The most common type is gestational hypertension, also referred to as pregnancy-induced hypertension, which is hypertension that occurs after 20 weeks' gestation. Chronic hypertension describes hypertension that is diagnosed prior to pregnancy or in early pregnancy. Preeclampsia is a condition in which preexisting or new-onset hypertension is complicated by proteinuria and/or other features of end-organ dysfunction after 20 weeks' gestation. Preeclampsia may also progress to the life-threatening HELLP syndrome, which is characterized by hemolysis, elevated liver enzymes, and low platelet count. Eclampsia is a severe convulsive manifestation of hypertensive pregnancy disorders that is characterized by new-onset eclamptic seizures (tonic-clonic, focal, or multifocal).

These disorders are usually diagnosed during regular prenatal care, which includes routine surveillance of blood pressure, weight, and urine tests. Management depends on the severity of the condition. Nonurgent hypertensive pregnancy disorders (chronic hypertension, gestational hypertension, or preeclampsia without severe features) are generally managed with careful monitoring, possibly antihypertensive medications in chronic hypertension, and delivery at 37 weeks if there is no progression to severe preeclampsia. Patients with urgent hypertensive pregnancy disorders (preeclampsia with severe features, eclampsia, or HELLP), which are associated with increased maternal and fetal morbidity and mortality, require urgent maternal stabilization, magnesium sulfate for seizure prophylaxis, and expedited delivery of the fetus. Delivery is the only curative option for urgent hypertensive pregnancy disorders.

• Gestational hypertension ^[2]
  • Pregnancy-induced hypertension (defined as systolic blood pressure ≥ 140 mm Hg or diastolic blood pressure ≥ 90 mm Hg on two separate measurements at least 4 hours apart) without proteinuria or end-organ dysfunction
  • Diagnosed after 20 weeks' gestation in patients without a prior history of hypertension.
  • Does not persist longer than 12 weeks postpartum.
• Chronic hypertension: hypertension diagnosed before pregnancy or in the first 20 weeks of pregnancy
• Hypertensive crisis: systolic blood pressure > 160 mm Hg or diastolic pressure > 110 mm Hg that persists for ≥ 15 min
• Preeclampsia: new-onset gestational hypertension with proteinuria or end-organ dysfunction ^[3]
  • Superimposed preeclampsia: preeclampsia that occurs in a patient with chronic hypertension
  • HELLP syndrome
    • A life-threatening form of preeclampsia characterized by Hemolysis, Elevated Liver enzymes, and Low Platelets
    • May occur without hypertension or proteinuria
  • Occurrence of new-onset hypertension, proteinuria, or end-organ dysfunction at < 20 weeks' gestation is suggestive of gestational trophoblastic disease.
• Eclampsia: new-onset seizures (tonic-clonic, focal, or multifocal) in the absence of other causes ; a convulsive manifestation of hypertensive pregnancy disorders ^[2]
• Postpartum hypertension ^[4][5]
  • Hypertension that persists after delivery
  • Generally resolves within 12 weeks.
  • If hypertension lasts > 12 weeks postpartum, a secondary cause should be considered.

Gestational hypertension can only be diagnosed if the patient was normotensive prior to 20 weeks' gestation. Otherwise, high blood pressure during pregnancy is classified as chronic hypertension.

The three primary features of PREeclampsia are Proteinuria, Rising blood pressure (hypertension), and End-organ dysfunction.

• Hypertensive pregnancy disorders occur in 6–8% of pregnancies. ^[6][7]
  • Preeclampsia: 5–7% of pregnancies ^[8]
  • Eclampsia: < 0.1% of all deliveries
  • HELLP syndrome: 0.5–0.9% of all pregnancies ^[9]

Epidemiological data refers to the US, unless otherwise specified.

• Etiology: not fully understood
• Risk factors ^[1][10]
  • General risk factors
    • Thrombophilia (e.g., antiphospholipid syndrome)
    • < 20 or > 35 years of age
    • Black individuals ^[1][11]
    • Diabetes mellitus or gestational diabetes
    • Chronic hypertension
    • Chronic renal disease (e.g., SLE)
    • Obesity (BMI ≥ 30)
  • Pregnancy-related risk factors
    • Nulliparity
    • Multiple gestation (e.g., twins)
    • Hydatidiform mole
    • Previous preeclampsia
    • Chromosomal anomalies or congenital structural anomalies
    • Family history

• Overview: Multiple maternal, fetal, and placental factors are involved in placental hypoperfusion, which leads to maternal hypertension and other consequences.
  • Uterine spiral arteries normally develop into high-capacity blood vessels. This process is defective in patients with preeclampsia, which leads to acute atherosis of the decidual vessels (presence of arterial wall fibrinoid necrosis and lymphocytic infiltration) and abnormal blood flow (high pressure, pulsatile flow) of the placenta and fetus (see “Placenta” for more information on normal placenta formation). ^[12]
  • Arterial hypertension with systemic vasoconstriction causes placental hypoperfusion → release of vasoactive substances → ↑ maternal blood pressure to ensure sufficient blood supply of the fetus
  • Systemic endothelial dysfunction causes placental hypoperfusion → ↑ placental release of factors; → endothelial lesions that lead to microthrombosis
  • Abnormal placental (or trophoblast) implantation or development in the uterus
• Consequences of vasoconstriction and microthrombosis
  • Organ ischemia and damage
    • Preeclampsia: multiorgan involvement (primarily renal)
    • Eclampsia: predominantly cerebral involvement
    • HELLP syndrome; : severe systemic inflammation with multiorgan hemorrhage and necrosis (thrombotic microangiopathy of the liver)
  • Chronic hypoperfusion of the placenta → insufficiency of the uteroplacental unit and fetal growth restriction

Gestational hypertension

• Asymptomatic hypertension
• Nonspecific symptoms (e.g., morning headaches, fatigue, dizziness) can occur.

Preeclampsia ^[8]

• Onset
  • ∼ 90% occur after 34 weeks' of gestation.
  • In approx. 5% of individuals with preeclampsia, the condition is not diagnosed during pregnancy and symptoms only develop postpartum (postpartum preeclampsia). ^[15]

Preeclampsia without severe features

• Usually asymptomatic
• Nonspecific symptoms may include:
  • Headaches
  • Visual disturbances
  • RUQ or epigastric pain
  • Rapid development of edema
• Hypertension
• Proteinuria

Preeclampsia with severe features ^[16]

• Severe hypertension (systolic BP ≥ 160 mm Hg or diastolic BP ≥ 110 mm Hg)
• Proteinuria, oliguria
• Headache
• Visual disturbances (e.g., blurred vision, scotoma)
• RUQ or epigastric pain
• Pulmonary edema
• Cerebral symptoms (e.g., altered mental status, nausea, vomiting, hyperreflexia, clonus)

HELLP syndrome ^[17]

• Onset: most commonly > 27 weeks' gestation (∼ 30% occur postpartum)
• Preeclampsia usually present (∼ 85%)
• Nonspecific symptoms: nausea, vomiting, diarrhea
• RUQ pain (liver capsule pain; liver hematoma)
• Rapid clinical deterioration (DIC, pulmonary edema, acute renal failure, stroke, abruptio placentae)

Hypertension and proteinuria may be mild or even absent in patients with HELLP syndrome. Patients may present primarily with nonspecific symptoms. ^[18]

Eclampsia

• Onset: The majority of cases occur intrapartum and postpartum.
• Most often associated with severe preeclampsia
• Eclamptic seizures: generalized tonic-clonic seizures (usually self-limited) ^[7]

Deterioration with headaches, RUQ pain, hyperreflexia, and visual changes are warning signs of a potential eclamptic seizure.

Approach ^{[1][2][19][20]}

• At each prenatal care appointment, screen all patients for features of hypertensive pregnancy disorders, e.g.:
  • Blood pressure ≥ 140/90 mm Hg
  • Rapid weight gain and/or new severe edema
  • Urine dipstick: > 2+ protein
  • Symptoms of preeclampsia
• If any features of hypertensive pregnancy disorders are present:
  • Repeat blood pressure measurement.
  • Assess for proteinuria.
  • Assess for end-organ damage (e.g., CBC, BMP, liver chemistries).
  • Confirm diagnosis based on diagnostic criteria for hypertensive pregnancy disorders.
  • Assess fetal health via antepartum fetal surveillance.

In patients with chronic hypertension, conduct baseline 24-hour urine protein, serum liver, and renal function tests at the initial prenatal care visit; an upward trend may indicate superimposed preeclampsia. ^[2]

Hispanic, Native American, and Alaska Native patients have a higher risk of preeclampsia complications, including stroke, and may benefit from additional screening and monitoring. ^[1]

Diagnostic workup ^[1][2][21]

The initial workup for all suspected hypertensive pregnancy disorders is the same.

Serial blood pressure measurement ^[2]

• Hypertension: systolic blood pressure ≥ 140 mm Hg or diastolic blood pressure ≥ 90 mm Hg (on 2 separate measurements at least 4 hours apart) ^{[1][2][19][22]}
• Severe hypertension: systolic blood pressure ≥ 160 mm Hg or diastolic blood pressure ≥ 110 mm Hg ^[2]
• Suspected white coat hypertension ^[19]
  • Consider ambulatory blood pressure monitoring to rule out chronic hypertension.
  • Confirmed white coat hypertension: Monitor blood pressure regularly.

Ensure that an appropriately sized blood pressure cuff is used and that the patient has not used tobacco or caffeine within 30 minutes of the readings, as these may lead to inaccurate values. ^[23]

Hypertension should not be diagnosed on the basis of a single abnormal value; repeat blood pressure readings at least once, 4 hours apart (may be reduced to 15 minutes in severe hypertension requiring urgent treatment). ^[2]

Urine studies ^[2][20]

Any of the following may be used to assess for proteinuria.

• 24-hour urine collection (gold standard): proteinuria (urinary protein excretion ≥ 300 mg/day)
• Urine protein:creatinine ratio: ≥ 0.3
• Urine dipstick: > 2+ protein (low accuracy; consider only if other tests are not feasible) ^[1]

Once a diagnosis of preeclampsia has been established, additional tests for proteinuria are unnecessary as the degree of proteinuria does not correlate with maternal or fetal outcome or affect management. ^[2]

Blood tests ^[2][19]

Routine studies

Perform the following in all patients to assess for end-organ dysfunction.

• CBC: ↓ Hb; ↓ platelets may be seen in severe preeclampsia or HELLP
• Liver chemistries: ↑ Transaminases are suggestive of severe preeclampsia or HELLP.
• Renal function tests: Declining eGFR is indicative of severe preeclampsia.
• Lactate dehydrogenase: Levels may be elevated in HELLP.

Additional studies (selected patients)

• Chronic hypertension ^[19]
  • Serum electrolytes
  • ECG in patients with long-standing hypertension
  • Consider serum uric acid levels: Abnormal elevation suggests preeclampsia. ^[2]
• Suspected HELLP (thrombocytopenia and/or liver function impairment)
  • Peripheral smear: Schistocytes indicate hemolysis.
  • Coagulation studies: ↑ D-dimer, ↑ PT/aPTT, ↓ fibrinogen, and ↓ antithrombin III suggest DIC
• Intractable headache or neurological symptoms: CT head to rule out intracranial hemorrhage or alternative pathology

Diagnostic criteria ^[1][2][19]

RUQ pain is the most common symptom in HELLP. In 15% of cases, hypertension and proteinuria are not present. ^[2]

Proteinuria is not required to diagnose severe preeclampsia! ^[2][20]

Fetal assessment ^[2][25]

Fetal evaluation should be conducted in parallel with maternal workup. See “Antepartum fetal surveillance” and “Overview of maternal and fetal vessel doppler ultrasound.”

• Cardiotocography: to monitor fetal heart rate and uterine contractions
• Ultrasound to assess:
  • Blood flow to the placenta and fetus; findings on Doppler ultrasound include:
    • Increased resistance and abnormal flow pattern in atypical uterine arteries ^[26]
    • Bilateral notches (i.e., early diastolic indentation) in the uterine artery flow profile ^[27]
  • Signs of fetal distress: e.g., reduced movement, abnormal or absent breathing, reduced or absent tone ^[28]
  • Evidence of complications ^[2][26]
    • Fetal growth restriction
    • Placental abruption
    • Oligohydramnios

Ultrasound and CTG parameters may be used to calculate a biophysical profile score to help guide decisions regarding preterm delivery. ^[28]

Differential diagnoses of altered liver chemistries ^[29][30]

See “Pregnancy-associated liver diseases” for details.

• Hyperemesis gravidarum ^[31]
• Intrahepatic cholestasis of pregnancy
• Acute fatty liver of pregnancy (AFLP)
• HELLP syndrome

Differential diagnoses of eclampsia

Seizure disorders during pregnancy can be caused by any of the following:

• Epilepsy
• Encephalitis
• Metabolic disorders (e.g., hypoglycemia, hyponatremia)
• Hemorrhagic stroke
• Ischemic stroke
• Withdrawal syndromes

Differential diagnoses of HELLP syndrome

• Other causes of thrombocytopenia: thrombotic microangiopathy (TTP, HUS)
• Other pregnancy-associated liver diseases
  • Acute fatty liver of pregnancy
  • Intrahepatic cholestasis of pregnancy
• Other causes of acute liver failure not specific to pregnancy (e.g., fulminant viral hepatitis)

The differential diagnoses listed here are not exhaustive.

Antihypertensives in pregnancy

Specific indications for these agents are detailed in the relevant sections below. Generally, parenteral antihypertensives are used in acute-onset severe hypertension and urgent hypertensive pregnancy disorders, and oral antihypertensives are used, as clinically indicated, during expectant management. ^[2]

Antihypertensives for urgent blood pressure control in pregnancy ^[2]

• Parenteral labetalol (avoid in patients with contraindications to β-blockers) ^[19]
• Nifedipine (immediate release) ^[19]
• Parenteral hydralazine ^[19]

Antihypertensives should be given within 30–60 minutes of diagnosis in urgent hypertensive pregnancy disorders. ^[2]

Common oral antihypertensives in pregnancy ^{[19] [2][32]}

The following can be used alone or in combination.

• Labetalol ^[19]
• Nifedipine (extended release) ^[19]
• Methyldopa ^[19]

Avoid ACE inhibitors and angiotensin receptor blockers during pregnancy (especially during the 1^st trimester) because of their teratogenic effect. ^[19]

Antihypertensives used in pregnancy can be remembered with the mnemonic “Hypertensive Moms Need Love”: Hydralazine, Methyldopa, Nifedipine, or Labetalol

Magnesium sulfate for seizure prophylaxis ^[2][32][33]

• Indications
  • Eclampsia
  • HELLP syndrome
  • Preeclampsia with severe features
• Administration: magnesium sulfate (IV or IM ; )^[2][33]
  • Contraindicated in patients with myasthenia gravis
  • Should be administered with care in patients with renal insufficiency
• Monitoring
  • Monitor all patients for signs of hypermagnesemia (e.g., decreased deep tendon reflexes, respiratory depression).
  • Signs of hypermagnesemia: Administer calcium gluconate (see “Hypermagnesemia” for clinical features and more information on management of hypermagnesemia).^[2]

Continue magnesium sulfate infusion for 24 hours after delivery or last seizure. ^[2]

All patients receiving magnesium need close monitoring (including continuous telemetry) for signs of hypermagnesemia.

Preeclampsia prophylaxis

Assess all patients with chronic hypertension and gestational hypertension for risk factors for preeclampsia.

Aspirin for preeclampsia prophylaxis ^{[1][2][11][19]}

• Indications ^[11]
  • Recommended in individuals with ≥ 1 high-risk feature or ≥ 2 moderate-risk factors for preeclampsia.
  • Consider in individuals with 1 moderate-risk factor for preeclampsia.
• Regimen
  • Initiate low-dose aspirin ; between 12–20 weeks' gestation (optimally before 16 weeks) ^[2][11][19]
  • Continue prophylaxis till delivery.

Educate at-risk patients on the symptoms of preeclampsia. If preeclampsia does develop, management depends on the severity.

Consider starting preeclampsia prophylaxis with low-dose aspirin for all Black individuals who are pregnant. ^[1]

Corticosteroids for fetal lung maturity

• Indications: anticipated delivery between 24 and 34 weeks' gestation ^[2][35]
• Agents: betamethasone or dexamethasone ^[2][35]

Do not delay delivery for glucocorticoid administration if immediate delivery is indicated (e.g., eclampsia, DIC, pulmonary edema, intractable severe hypertension, placental abruption). ^[2][18][35]

Administer glucocorticoids immediately in stable patients if preterm delivery is anticipated. Even a single dose of antenatal glucocorticoids reduces neonatal mortality and morbidity. ^[2][35]

Patients with preeclampsia with severe features, HELLP, or eclampsia require immediate control of hypertension and management of complications (ideally in a tertiary care center) to minimize maternal and fetal mortality and morbidity. See “Hypertensive crises“ for general information.

Approach ^[2][18]

• Perform an ABCDE assessment and treat time-critical complications (e.g., seizure, hemorrhage).
• Initiate continuous maternal and fetal monitoring.
• Obtain urgent maternal-fetal medicine, obstetric, and critical care consults.
• Admit or transfer the patient to a tertiary care center depending on available local resources.
• Admit to ICU if there is evidence of dysfunction in ≥ 2 organ systems or need for ventilatory support. ^[18]
• Initiate antihypertensives for urgent blood pressure control in pregnancy.
• Administer magnesium sulfate for seizure prophylaxis.
• Assess for indications for immediate delivery regardless of gestational age.
  • If present: urgent delivery after maternal hemodynamic stabilization
  • If absent, management depends on disease severity and gestational age; in general:
    • ≥ 34 weeks' gestation: Deliver.
    • 24–34 weeks' gestation: Administer corticosteroids for fetal lung maturity followed by expedited delivery.
    • Before fetal viability: Continuation of pregnancy is not recommended because of the significant risk of maternal life-threatening complications. ^[18]

Administer antihypertensives within 30–60 minutes of diagnosis of an urgent hypertensive pregnancy disorder, if feasible. ^[2]

Aggressive fluid therapy can precipitate pulmonary edema in patients with preeclampsia; use fluid judiciously and monitor urine output!

Delivery is the only cure for preeclampsia, eclampsia, and HELLP syndrome. ^[18]

Indications for expedited delivery in hypertensive pregnancy disorders

Immediate delivery ^[2][18][33]

Assess frequently for indications for immediate delivery regardless of gestational age. The presence of any of the following is an indication for immediate delivery after maternal stabilization:

• Eclampsia (cerebral symptoms)
• Pulmonary edema
• Disseminated intravascular coagulation
• Placental abruption
• Severe hypertension refractory to antihypertensives
• Signs of fetal distress
• Fetal demise or fetus unlikely to survive

Do not delay delivery to administer corticosteroids if immediate delivery is indicated. ^[2][18]

Urgent delivery ^[2][18]

Delivery should be expedited after administration of corticosteroids for fetal lung maturity if any of the following are present:

• Labor or premature rupture of membranes
• Severe oligohydramnios
• Reversed end-diastolic flow on umbilical artery Doppler
• New-onset or worsening renal impairment
• Moderate or severe thrombocytopenia
• Abnormal liver chemistries

Previously, fetal growth restriction was considered an indication for expedited delivery. However, according to the 2020 ACOG guidelines, expectant management may be continued in the absence of other abnormalities (e.g., Doppler findings, amniotic fluid volume). ^[2]

Continuously monitor maternal and fetal status. If there is any sign of deterioration, immediately expedite delivery without completing the corticosteroid course. ^[2][18]

Medical management ^[2][18]

• Start antihypertensives for urgent blood pressure control in pregnancy.
• Administer magnesium sulfate for seizure prophylaxis.
• Monitor blood pressure, oxygen saturation, and urine output.
• Manage complications (e.g., pulmonary edema, headache, renal insufficiency).

Obstetric management ^[2][18]

• Start continuous fetal monitoring.
• Indications for immediate delivery regardless of gestational age present: Deliver.
• Indications for immediate delivery absent: Determine gestational age.
  • Prior to fetal viability: Stabilize the mother and terminate the pregnancy. ^[18]
  • ≥ 34 weeks' gestation: Deliver.
  • Between fetal viability and 34 weeks' gestation: Assess maternal and fetal status.
    • Unstable: Stabilize the mother and proceed to delivery.
    • Stable
      • Administer corticosteroids for fetal lung maturity (betamethasone or dexamethasone ). ^[2][35]
      • Consider a trial of expectant management (via shared-decision making).
        • Admit or transfer to a hospital with maternal and neonatal ICU availability.
        • Strictly monitor maternal and fetal status.
        • Serially monitor laboratory studies (e.g., CBC, liver chemistries, serum creatinine).
        • Any decline in maternal or fetal stability: Deliver immediately.

Vaginal delivery is preferred, but often cesarean delivery is needed in the case of younger gestational age, immature cervix, or poor maternal or fetal condition.

Medical management ^[2][18]

• Treat eclamptic seizures.
  • Initiate airway management.
  • Administer supplemental oxygen.
  • Place patient in the left lateral decubitus position to:
    • Prevent placental hypoperfusion due to IVC compression
    • Reduce the risk of aspiration
  • Start anticonvulsive therapy.
    • First line: magnesium sulfate (see “Magnesium for eclampsia” for dosage and monitoring) ^[2]
    • Seizures unresponsive to magnesium sulfate
      • Amobarbital or phenytoin ^[2]
      • Consider intubation and assisted ventilation.
      • Persistent postictal low GCS scores or focal neurological signs: Consult neurology.
• Start antihypertensives for urgent blood pressure control in pregnancy.

Managing the airway in pregnancy can be challenging; consult anesthesia early.

Obstetric management ^[2][18]

• Start continuous fetal monitoring.
• Eclampsia is an indication for immediate delivery regardless of gestational age. ^[2][18][33]
• Delivery should occur only after the mother is stable and seizures have stopped. ^[2]
• Eclampsia is not an indication for cesarean delivery. ^[2][33]

Fetal distress often occurs during eclamptic seizures. However, delivery should occur only after maternal stabilization, as fetal status typically returns to normal once seizures have been controlled. ^[2][18]

Medical management ^[2][18]

• Consult hematology, hepatology, and critical care (depending on symptoms and severity).
• Administer blood products (e.g., platelets, PRBCs, FFP) as needed to manage hemorrhage and coagulopathy; additionally transfuse platelets: ^[18]
  • Prior to cesarean delivery if platelet count is < 50,000/mm³
  • Prior to vaginal delivery if platelet count is < 20,000/mm³–25,000/mm³
• Initiate antihypertensives for urgent blood pressure control in pregnancy.
• Administer magnesium sulfate for seizure prophylaxis.
• Administer IV fluid therapy and electrolyte repletion as needed.
• Manage complications: See “Management of DIC”, “Management of AKI”, and “Management of acute liver failure” as needed.
• Provide supplemental oxygen or mechanical ventilation as appropriate.
• Monitor vitals closely.
• Repeat laboratory studies every 12 hours during delivery and postpartum period (see “Blood tests” under “Diagnostics”). ^[2]

Patients with HELLP syndrome are at increased risk of DIC, pulmonary edema, ARDS, and acute renal failure and therefore close monitoring is essential. ^[2]

Obstetric management ^[2][18]

• Start continuous fetal monitoring.
• Expedited delivery is indicated for all patients regardless of gestational age.
  • ≥ 34 weeks' gestation: Deliver immediately.
  • 24–34 weeks' gestation: Administer corticosteroids for fetal lung maturity, if feasible (betamethasone or dexamethasone ). ^[2][35]
    • Delivery may be delayed until 24–48 hours after corticosteroid administration if maternal and fetal status remains stable.
    • Do not delay delivery for corticosteroid administration if complications arise.
  • Before fetal viability: Consider termination of pregnancy.

Urgent cesarean delivery is recommended for patients who develop DIC to prevent disease progression. ^[18]

This checklist is applicable for patients with preeclampsia with severe features, HELLP, or eclampsia. ^[2][18]

Initial maternal and fetal management

• ABCDE assessment
• Provide supplemental oxygen or mechanical ventilation as appropriate.
• Keep NPO until the management plan has been decided (emergency cesarean delivery may be required).
• Start continuous maternal and fetal monitoring.
• Consult obstetrics, maternal-fetal medicine, and critical care urgently.
• Admit or transfer to a tertiary care hospital; consider ICU admission.
• Initiate antihypertensives for urgent blood pressure control in pregnancy.
• Administer magnesium sulfate for seizure prophylaxis.
• Administer IV fluid therapy and electrolyte repletion as needed.
• Manage end-organ failure (e.g., acute renal failure, acute liver failure, DIC) if present.
• Perform full obstetrical ultrasound.
• Assess for indications for immediate delivery regardless of gestational age.

Fetal management

• Indications for immediate delivery regardless of gestational age present: urgent delivery after maternal hemodynamic stabilization
• Indications for immediate delivery regardless of gestational age absent
  • ≥ 34 weeks' gestation: Deliver.
  • 24–34 weeks' gestation
    • Administer corticosteroids for fetal lung maturity.
    • Initiate serial monitoring (including nonstress test and biophysical profile) if expectant management is planned.
    • Serially assess for indications for immediate delivery; if present, deliver immediately.
    • Expedite delivery after administration of corticosteroids.
  • Before fetal viability: Continuation of pregnancy is not recommended.

Intrapartum and postpartum management

• Serially monitor maternal vital signs and laboratory studies until normalized.
• Pain management: NSAIDs are preferred over opioids for analgesia.
• Continue magnesium sulfate for 24 hours after delivery.
• Continue antihypertensives; titrate dosage to maintain blood pressure within the normal range.

This section provides an overview of the management of chronic hypertension, gestational hypertension, or preeclampsia without severe features. See relevant subsections for details. ^[2][19]

• Consult obstetrics and maternal-fetal medicine specialists.
• Perform a full maternal and fetal assessment to determine severity.
• Assess gestational age using a reliable method.
  • Gestational age ≥ 37 weeks: Deliver. ^[2][19]
  • Gestational age < 37 weeks
    • Expectant management until ≥ 37 weeks (unless expedited delivery in hypertensive pregnancy disorders is indicated)
    • Monitor patients 1–2 times weekly (including blood pressure, laboratory studies, and fetal assessment).
    • Initiate antihypertensives if clinically indicated.
    • Chronic hypertension and gestational hypertension: Initiate aspirin for preeclampsia prophylaxis if clinically indicated.
    • Anticipated delivery between 24 and 34 weeks' gestation: Administer corticosteroids for fetal lung maturation (betamethasone or dexamethasone ). ^[2][35]
    • Educate patients to recognize features of severe preeclampsia and signs of fetal distress and to seek prompt medical attention if they develop.

Management of hypertension ^[19]

• All patients: Encourage lifestyle modifications for hypertension.
• Threshold to initiate antihypertensives (in treatment-naive patients):blood pressure ≥ 140/90 mm Hg ^[36][37]
• Target blood pressure
  • Titrate antihypertensives to maintain blood pressure between 120/80 and 140/90 mm Hg. ^[19][36][37]
  • Lower blood pressure targets may be appropriate in patients with comorbidities (e.g., diabetes mellitus, renal dysfunction); consult specialists for optimal management. ^[19]
• Suspected secondary hypertension: Refer for specialist management. ^[19]

Prophylaxis against superimposed preeclampsia ^[11][19]

Patients with chronic hypertension are at high risk of developing preeclampsia. ^[24]

• Educate patients on the symptoms of preeclampsia.
• Start aspirin prophylaxis against preeclampsia.

If superimposed preeclampsia develops, it should be managed based on severity. See “Preeclampsia without severe features” or “Preeclampsia with severe features” as needed.

Obstetric management ^[19]

Prenatal care

• Assess patients for preeclampsia at every visit (see “Diagnostics”).
• Perform an ultrasound assessment of fetal growth in the third trimester.

Timing of delivery

• Chronic hypertension without superimposed preeclampsia: Deliver between 37 and 39 weeks' gestation. ^[19]
• Superimposed preeclampsia without severe features: Consider expectant management till 37 weeks' gestation with close maternal and fetal surveillance. ^[19]
• Severe hypertension refractory to therapy or superimposed preeclampsia with severe features: Deliver immediately; see “Management of preeclampsia with severe features.”

Intrapartum management

• Continue antihypertensives.
• Monitor blood pressure.
• Interdisciplinary care is recommended for patients with severe hypertension and/or end-organ dysfunction.

Approach ^[2]

• ≥ 37 0/7 weeks' gestation: Hospitalize and deliver.
• ≤ 36 6/7 weeks' gestation
  • Perform a full obstetric ultrasound (estimating fetal weight and amniotic fluid volume).
  • Screen for indications for expedited delivery in hypertensive pregnancy disorders.
    • If present: Deliver; administer corticosteroids for fetal lung maturity if indicated and feasible.
    • If absent
      • Manage expectantly; deliver at 37 0/7 weeks.
      • Follow-up 1–2 times weekly for maternal and fetal monitoring.
      • Initiate antihypertensives if clinically indicated (see below).
      • Initiate aspirin for preeclampsia prophylaxis in patients with gestational hypertension if clinically indicated.

Patients with systolic BP ≥ 160 mm Hg and/or diastolic BP ≥ 110 mm Hg) should be diagnosed with preeclampsia with severe features and managed accordingly. ^[2]

Hospitalization and delivery ^[2][33]

• Delivery is recommended at ≥ 37 0/7 weeks' gestation.
• Expedited delivery is recommended, regardless of gestational age, if there is evidence of maternal or fetal deterioration (see “Indications for expedited delivery in hypertensive pregnancy disorders”).

If feasible, administer corticosteroids for fetal lung maturation if delivery of a viable fetus between 24 and 34 weeks' gestation is indicated. ^[2]

Outpatient management ^[2][38]

Patients at ≤ 36 6/7 weeks' gestation with gestational hypertension or preeclampsia without severe features can be managed in an ambulatory setting.

Maternal and fetal monitoring ^[2]

Weekly in-clinic or hospital visits are recommended for maternal and fetal evaluation and should include the following:

• Serial blood pressure monitoring
• Assessment for the development or worsening of preeclampsia (e.g., development of severe features).
• Serial laboratory studies
  • Weekly assessment of platelet count, serum creatinine, and liver chemistries
  • In addition, weekly assessment for proteinuria is recommended for patients with gestational hypertension. ^[2]
  • Consider more frequent testing if there is concern for disease progression.
  • See “Blood tests” under “Diagnostics” for details.
• Fetal monitoring
  • Weekly assessment of amniotic fluid index
  • Fetal nonstress test once or twice weekly; if nonreactive, perform a biophysical profile (see “Fetal assessment” under “Diagnostics”)
  • Ultrasound assessment of fetal growth every 3–4 weeks
• Educate patients to recognize features of severe preeclampsia or signs of fetal distress and to seek prompt medical attention if they develop.

Follow proper techniques for blood pressure measurement (e.g., use of appropriate cuff sizes, resting for 10 minutes before measurement, and avoiding caffeine and tobacco use 30 minutes before measurement) to ensure accurate results. ^[2]

Preeclampsia without severe features can progress to preeclampsia with severe features within days and, therefore, should be closely monitored. ^[2]

Antihypertensives ^[2][32]

• Antihypertensives are not routinely recommended in patients with blood pressure < 160/110 mm Hg and no evidence of end-organ damage. ^[2][32][39]
• Severe hypertension (≥ 160/110 mm Hg): Recategorize as preeclampsia with severe features and manage accordingly. ^[2]
• Nonsevere hypertension ≥ 140/90 mm Hg but < 160/110 mm Hg with evidence of end-organ damage: Start antihypertensives; see “Oral antihypertensives in pregnancy.” ^[2][32]

Preeclampsia prophylaxis ^[2]

• Assess patients with gestational hypertension for risk factors for preeclampsia.
• Initiate aspirin for preeclampsia prophylaxis if indicated.

Obstetric management ^[2][38]

• Deliver at 37 weeks 0/7 days (unless clinically indicated earlier).
• Vaginal delivery is preferred, if feasible.
• Closely monitor for progression to preeclampsia with severe features during the intrapartum and postpartum period.
• Consider magnesium sulfate for seizure prophylaxis if severe features develop.

In patients who develop gestational hypertension or preeclampsia without severe features at term, delivery within 24 hours of diagnosis is recommended. ^[33]

Inpatient management ^[2]

• Serial maternal input/output monitoring and monitoring of vital signs and laboratory studies until normalized.
• NSAIDs are preferred over opioids for analgesia.
• Continue magnesium sulfate for 24 hours after delivery in patients with urgent hypertensive pregnancy disorders. ^[40]
• Antihypertensive treatment: Continue acute therapy medications, adjusting as needed to maintain blood pressure within the normal range.

Eclampsia can manifest for the first time in the postpartum period! ^[2][38]

Discharge planning ^[38]

• Switch to oral antihypertensives.
• Review patient within 7–10 days postpartum to check blood pressure.
• Educate patients on the risk of recurrence in subsequent pregnancies.
• Address modifiable risk factors for cardiovascular disease. ^[2]

While symptoms usually resolve within 3 months of delivery for the majority of patients, approximately one-third of patients with preeclampsia remain hypertensive a year after delivery. ^[41][42][43]

• Maternal complications
  • Placental abruption
  • DIC
    • Injury to placenta → tissue factor release → unregulated activation of the coagulation cascade
    • ∼ 20% of patients with HELLP syndrome develop DIC.
  • Cerebral hemorrhage, ischemic stroke
  • Acute respiratory distress syndrome (ARDS)
  • Acute renal failure
  • Hepatic subcapsular hematoma
    • Complication of severe preeclampsia and HELLP syndrome
    • Severe hypotension may occur due to rupture of hematoma.
  • Aspiration pneumonia
  • Retinal detachment
  • Long-term: increased risk for cardiovascular disease, diabetes mellitus, and chronic kidney disease ^[44]
  • Maternal death ^[45]
• Fetal complications: occur due to insufficient placental perfusion
  • Fetal growth restriction
  • Preterm birth
  • Seizure-induced fetal hypoxia
  • Fetal death

Ischemic stroke, cerebral hemorrhage, and ARDS are the most common causes of death in patients with preeclampsia.

References:^[46]

We list the most important complications. The selection is not exhaustive.

The prognosis of hypertensive pregnancy disorders depends on the severity of the condition and the complications that occur. In the majority of cases, the conditions resolve within hours or days after delivery.

• Recurrence rate in following pregnancies
  • Preeclampsia: 10–20% ^[47]
  • Eclampsia: 1–2% ^[48]
  • HELLP syndrome: 3–5% ^[49]
• Maternal mortality
  • Eclampsia: 5–10%
  • HELLP syndrome: 1–3.5% ^[50]
• Fetal mortality
  • Eclampsia: 5–11% ^[51]
  • HELLP syndrome: up to 24%

• One-Minute Telegram 84-2023-1/3: Continue monitoring BP during pregnancy

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