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Hypertension in pregnancy

Key sources
The following summarized guidelines for the evaluation and management of hypertension in pregnancy are prepared by our editorial team based on guidelines from the European Society of Hypertension (ESH 2023), the American Diabetes Association (ADA 2023), the American Academy of Family Physicians (AAFP 2023; 2016), the U.S. Preventive Services Task Force (USPSTF 2023; 2021; 2017), the International Society for the Study of Hypertension (ISSHP 2022), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2022), the American College of Obstetricians and Gynecologists (ACOG 2022), the Hypertension Canada (HC 2020), the World Health Organization (WHO 2020; 2018), the European Society of Cardiology (ESC 2018), the American College of Preventive Medicine (ACPM/PCNA/ABC/ASPC/ASH/AAPA/AGS/AHA/NMA/ACC/APhA 2018), the American Heart Association (AHA/ASA 2014), and the American College of Chest Physicians (ACCP 2012).
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Guidelines

1.Screening and diagnosis

Indications for screening: as per ESH 2023 guidelines, consider obtaining home BP monitoring as an alternative to conventional office BP measurement to detect new-onset hypertension in patients at risk for preeclampsia without preexisting hypertension.
C
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2.Diagnostic investigations

Blood pressure measurement: obtain BP measurement using a standardized technique, including patient's position (sitting, feet flat on the floor), cuff size (large if the mid-upper arm circumference is ≥ 33 cm), Korotkoff V for the DBP, and arm used (both, at least initially).
B
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More topics in this section

  • Evaluation for secondary hypertension

  • Screening for preeclampsia

3.Medical management

Indications for treatment: as per ISSHP 2022 guidelines, initiate antihypertensive therapy in pregnant patients with hypertension, irrespective of the underlying hypertensive disorder of pregnancy.
B

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  • BP targets

  • Choice of agent

  • Management of severe hypertension

  • Low-dose aspirin

  • Other agents

4.Nonpharmacologic interventions

Physical activity: advise exercising in all pregnant individuals to reduce the likelihood of gestational hypertension and preeclampsia unless contraindicated.
B

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  • Calcium supplementation

5.Therapeutic procedures

Timing of delivery
As per ISSHP 2022 guidelines:
Initiate delivery with any hypertensive disorder of pregnancy at any gestational age according to the following indications:
abnormal neurological features (such as eclampsia, severe intractable headache, or repeated visual scotomata)
repeated episodes of severe hypertension despite maintenance treatment with 3 classes of antihypertensive agents
pulmonary edema
progressive thrombocytopenia or platelet count < 50×10⁹/L
transfusion of any blood product
abnormal and rising serum creatinine
abnormal and rising liver enzymes
hepatic dysfunction (INR > 2 in the absence of DIC or warfarin), hematoma, or rupture
abruption with evidence of maternal or fetal compromise
non-reassuring fetal status, including death
B
Do not decide on delivery solely based on the degree of either proteinuria
D
or hyperuricemia.
D

6.Specific circumstances

Breastfeeding patients: offer the following antihypertensive agents in breastfeeding patients:
labetalol
methyldopa
long-acting nifedipine
enalapril
captopril
B

7.Patient education

Pre-pregnancy counseling
Provide preconception counseling in females with pre-pregnancy hypertension to advise on individualized antihypertensive medication management during pregnancy.
B
Consider discontinuing ACEIs and ARBs in females planning pregnancy.
C

8.Follow-up and surveillance

Monitoring during pregnancy: consider obtaining home BP monitoring as an alternative to conventional office BP measurement to achieve BP control in patients with gestational or preexisting hypertension.
C

More topics in this section

  • Postpartum management

  • Follow-up