Hypertensive Disorders of Pregnancy

 


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Am Fam Physician. 2016 Jan 15;93(2):121-127.

  Patient information: See related handout on high blood pressure during pregnancy, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Elevated blood pressure in pregnancy may represent chronic hypertension (occurring before 20 weeks' gestation or persisting longer than 12 weeks after delivery), gestational hypertension (occurring after 20 weeks' gestation), preeclampsia, or preeclampsia superimposed on chronic hypertension. Preeclampsia is defined as hypertension and either proteinuria or thrombocytopenia, renal insufficiency, impaired liver function, pulmonary edema, or cerebral or visual symptoms. Proteinuria is not essential for the diagnosis and does not correlate with outcomes. Severe features of preeclampsia include a systolic blood pressure of at least 160 mm Hg or a diastolic blood pressure of at least 110 mm Hg, platelet count less than 100 × 103 per μL, liver transaminase levels two times the upper limit of normal, a doubling of the serum creatinine level or level greater than 1.1 mg per dL, severe persistent right upper-quadrant pain, pulmonary edema, or new-onset cerebral or visual disturbances. Preeclampsia without severe features can be managed with twice-weekly blood pressure monitoring, antenatal testing for fetal well-being and disease progression, and delivery by 37 weeks' gestation. Preeclampsia with any severe feature requires immediate stabilization and inpatient treatment with magnesium sulfate, antihypertensive drugs, corticosteroids for fetal lung maturity if less than 34 weeks' gestation, and delivery plans. Preeclampsia can worsen or initially present after delivery. Women with hypertensive disorders should be monitored as inpatients or closely at home for 72 hours postpartum.

Hypertensive disorders affect up to 10% of pregnancies in the United States.1 Elevated blood pressure (BP) in pregnancy may represent chronic hypertension (occurring before 20 weeks' gestation or persisting longer than 12 weeks after delivery), gestational hypertension (occurring after 20 weeks' gestation), preeclampsia, or preeclampsia superimposed on chronic hypertension.1 National guidelines eliminate the requirement for proteinuria in the diagnosis of preeclampsia, recommend delivery at 37 weeks in women who have gestational hypertension or preeclampsia without severe features, recommend seizure prophylaxis with magnesium sulfate (MgSO4) only when preeclampsia has severe features, and call for increased awareness of postpartum hypertension risks.1

WHAT IS NEW ON THIS TOPIC: HYPERTENSIVE DISORDERS OF PREGNANCY

The U.S. Preventive Services Task Force recommends that pregnant women at high risk of preeclampsia take low-dose aspirin (81 mg per day) after 12 weeks' gestation.

Delivery is generally indicated at 37 weeks' gestation for women who have gestational hypertension or preeclampsia without severe features.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Women with gestational hypertension or preeclampsia without severe features should have planned delivery at 37 weeks' gestation.

B

1, 25

Magnesium sulfate is the treatment of choice to prevent eclamptic seizures (NNT = 100) and placental abruption (NNT = 100) in women who have preeclampsia with severe features.

A

23, 24, 29

Magnesium sulfate is more effective than diazepam (Valium) or phenytoin (Dilantin) for preventing recurrent eclamptic seizures and decreasing maternal mortality.

A

31, 32

Intravenous labetalol or hydralazine or oral nifedipine may be used to treat severe hypertension during pregnancy.

B

36

For women who have preeclampsia with severe features between 24 and 34 weeks' gestation, expectant management with close monitoring of the mother and fetus reduces neonatal complications and days in the intensive care unit.

B

40

Low-dose aspirin has small to moderate benefits in the prevention of preeclampsia among at-risk women (NNT = 72). The NNT falls to 19 among those at greatest risk.

A

50

Calcium supplementation may decrease the incidence of hypertension, preeclampsia, and mortality among high-risk women with low calcium intake. However, women in the United States or other developed countries are unlikely to benefit.

B

1, 52


NNT = number needed to treat.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Women with gestational hypertension or preeclampsia without severe features should have planned delivery at 37 weeks' gestation.

B

1, 25

Magnesium sulfate is the treatment of choice to prevent eclamptic seizures (NNT = 100) and placental abruption (NNT = 100) in women who have preeclampsia with severe features.

A

23, 24, 29

Magnesium sulfate is more effective than diazepam (Valium) or phenytoin (Dilantin) for preventing recurrent eclamptic seizures and decreasing maternal mortality.

A

31, 32

Intravenous labetalol or hydralazine or

The Authors

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LAWRENCE LEEMAN, MD, MPH, is a professor of family and community medicine and of obstetrics and gynecology at the University of New Mexico School of Medicine in Albuquerque. He is the director of Family Medicine Maternal and Child Health Service and co-medical director of the mother-baby unit at the University of New Mexico Hospital. Dr. Leeman is managing editor of the Advanced Life Support in Obstetrics (ALSO) program....

LEE T. DRESANG, MD, is a professor and maternity care clinical coordinator in the Department of Family Medicine and Community Health at the University of Wisconsin School of Medicine and Public Health, Madison. He is a member of the ALSO Editorial Board and the Family Physicians Inquiry Network Board.

PATRICIA FONTAINE, MD, MS, is a senior clinical research investigator at the HealthPartners Institute for Education and Research in Bloomington, Minn. She is a member of the ALSO Advisory Board.

Address correspondence to Lawrence Leeman, MD, MPH, University of New Mexico, 2400 Tucker NE, 3rd Floor, Albuquerque, NM 87131 (e-mail: lleeman@salud.unm.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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