Recommendation: Screen for Hypertensive Disorders of Pregnancy
Oct. 11, 2023, News Staff — An updated U.S. Preventive Services Task Force final recommendation statement, final evidence review and evidence summary expands screening for hypertensive disorders of pregnancy.
The recommendation, which received a “B” grade, calls for screening for hypertensive disorders in pregnant patients with blood pressure measurements throughout pregnancy. Whereas the previous version of the recommendation focused on screening for preeclampsia, the update expands screening to detect several additional conditions, including gestational hypertension, eclampsia and chronic hypertension.
The recommendation applies to all pregnant patients of all genders who do not have a known diagnosis of an HDP or chronic hypertension. The recommendation says blood pressure should be measured during each prenatal care visit throughout pregnancy. Elevated blood pressure readings should be confirmed with repeated measurements.
The recommendation also says that to achieve the benefit of screening, those who screen positive should receive evidence-based management of hypertensive disorders of pregnancy.
“The task force continues to find that measuring blood pressure at each prenatal visit is an effective way to screen for hypertensive disorders of pregnancy,” said task force member Esa Davis, M.D., M.P.H., a faculty member in the Department of Family and Community Medicine, associate vice president of community health, and senior associate dean for population health and community medicine at the University of Maryland School of Medicine in Baltimore, in a USPSTF bulletin. “Because these conditions can cause serious health issues, screening is an important way to keep pregnant people and their babies healthy.”
Story Highlights
The updated recommendation comes amid a recent uptick in HDPs. Between 2017 and 2019, the prevalence of HDPs among deliveries in a hospital increased from just over 13% to nearly 16%, according to a 2022 study, with the prevalence higher in women ages 35 years and older compared with younger women. The prevalence was also higher in Black and American Indian/Alaska Native women compared with women of other races and ethnicities. The same study found that nearly one-third of patients who died during delivery in a hospital had a documented diagnosis code for an HDP.
Review of Approaches
The evidence review that accompanied the recommendation examined the effectiveness of three types of screening protocols:
- home blood pressure measurements,
- prenatal care schedules with less frequent office visits than usual, and
- clinically indicated (rather than routine) urine screening tests.
Overall, the task force found no evidence to indicate that specific strategies for screening for HDPs (either in addition to or as an alternative to standard prenatal visit schedules with in-office blood pressure assessments) improved health outcomes or led to earlier or increased detection of HDPs relative to standard prenatal care.
The task force also found insufficient evidence that any other approach is more accurate or effective than regular office-based blood pressure measurements.
In addition, the task force noted that none of the studies in the evidence review evaluated screening for HDPs in the postpartum period. Given recent evidence suggesting that the risk of postpartum preeclampsia is higher in Black patients, the authors said routine screening during the postpartum period may be important for reducing health inequities.
More Work Needed to Reduce Health Inequities
The task force said factors such as structural and interpersonal racism can lead to disparities in access to high-quality health care, leading to HDPs and other adverse health effects. To address these disparities, the task force suggested a variety of approaches, including
- strong connections with community resources in the perinatal period;
- collaborative care in medical homes;
- multilevel interventions to address underlying health inequities such as chronic hypertension, type 2 diabetes and others that increase health risks during pregnancy; and
- telehealth and remote monitoring in prenatal care and postpartum care.
The task force said additional research is needed to evaluate these approaches, and also called for studies to, among other things,
- determine the best approaches for blood pressure monitoring to detect (and strategies to prevent the development of) superimposed preeclampsia in pregnant patients with chronic hypertension;
- evaluate the differences in timing of screening earlier or later in pregnancy and the postpartum period to decrease adverse outcomes; and
- reduce cardiovascular complications later in life in patients diagnosed with HDPs.
“Ensuring all pregnant people have their blood pressure taken is an important first step, but it is not enough to improve the inequities that our Black, Native American and Alaska Native patients face related to hypertensive disorders of pregnancy,” said task force chair Wanda Nicholson, M.D., M.P.H., M.B.A. “We are using this recommendation to call for more research in this important area and to highlight promising ways to address these inequities and improve the health of those at increased risk.”
Response to Public Comment
In response to public comments on a draft version of the recommendation, the task force clarified the definition of HDPs, added language on postpartum blood pressure monitoring and appropriate cuff sizes, and added several clinician resources.
More Resources Available
The task force provided links to several resources on HDPs, including a Community Preventive Services Task Force systematic review on exercise programs to prevent gestational hypertension, a CDC webpage on high blood pressure during pregnancy, a JAMA Patient Page review article on screening for high blood pressure disorders during pregnancy, a JN Learning podcast on the final recommendation statement, a National Institute of Child Health and Human Development webpage on preeclampsia and eclampsia, and the Million Hearts Initiative, a national program co-led by the CDC and CMS to reduce cardiovascular events in adults.
AAFP member resources on HDPs and related topics include
- the Center for Women’s Health, a collection of resources and stories;
- AFP by Topic collections on labor, delivery and postpartum issues and prenatal care;
- patient care pages on maternal health and breastfeeding;
- links to more than two dozen clinical recommendations and guidelines on maternity care; and
- a November 2022 edition of FP Essentials on hypertensive conditions.
In addition, the Women’s Preventive Services Initiative, a longstanding Academy partner, has published several recommendations and resources for providing timely, high-quality patient care during and after pregnancy.