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Hypertensive Disorders of Pregnancy

This is a corrected version of the article that appeared in print.

Narges Farahi, MD
Fareedat Oluyadi, MD
Andrea B. Dotson, MD, MSPH

American Family Physician. 2024;109(3):251-260.

Author disclosure: No relevant financial relationships.

Hypertensive disorders of pregnancy are a major contributor to maternal morbidity and mortality in the United States and include chronic and gestational hypertension, preeclampsia, HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome, eclampsia, and chronic hypertension with superimposed preeclampsia. For patients with chronic hypertension, oral antihypertensive therapy should be initiated or titrated at a blood pressure threshold of 140/90 mm Hg or greater. Gestational hypertension and preeclampsia without severe features can be managed with blood pressure monitoring, laboratory testing for disease progression, antenatal testing for fetal well-being, and delivery at 37 weeks' gestation. The use of antihypertensive drugs to control nonsevere hypertension in the setting of gestational hypertension and preeclampsia does not improve outcomes and is not recommended. Antihypertensive therapy should be initiated expeditiously for acute-onset severe hypertension to prevent hemorrhagic stroke. Preeclampsia with severe features requires immediate stabilization and inpatient treatment with magnesium sulfate for seizure prophylaxis and antenatal corticosteroids (if preterm). Patients in the preterm period should receive antenatal corticosteroids without delaying delivery to complete courses. Hypertensive disorders of pregnancy can worsen or initially present after delivery and account for up to 44% of pregnancy-related deaths in the first six days postpartum. Patients should be monitored closely in the early postpartum period. Hypertensive disorders of pregnancy are linked to poor long-term maternal and fetal outcomes, including increased maternal lifetime risk of cardiovascular disease. Daily low-dose aspirin therapy starting at 12 to 16 weeks' gestation is safe and effective for reducing the risk of preeclampsia for patients with risk factors.

Hypertensive disorders of pregnancy affect 1 in 7 hospital deliveries in the United States, are strongly associated with maternal complications, and account for 7% of pregnancy-related deaths.1–3 Hypertensive disorders of pregnancy, which include chronic hypertension and pregnancy-associated hypertension (gestational hypertension, preeclampsia, HELLP [hemolysis, elevated liver enzymes, and low platelet count] syndrome, eclampsia, chronic hypertension with superimposed preeclampsia), increased in prevalence from 2017 to 2019.1,4 Pregnancy-associated hypertension more than doubles the risk of peripartum coronary disease, cardiomyopathy, and stroke, and accounts for 44% of maternal deaths in the first six days following delivery.4–6

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating Comments
In pregnant patients with gestational hypertension who develop severe-range blood pressure (≥ 160 mm Hg systolic or 110 mm Hg diastolic), preeclampsia with severe features should be diagnosed and managed.4,7 C Expert opinion and consensus guidelines
Pregnant patients with chronic hypertension should be treated to a blood pressure goal of < 140/90 mm Hg to reduce pregnancy outcomes without affecting fetal growth.11 B Single high-quality RCT
Pregnant patients with gestational hypertension or preeclampsia without severe features should have a planned delivery at 37 weeks' gestation.7,24 C Consensus guidelines
For pregnant patients who have preeclampsia with severe features between 24 and 34 weeks' gestation, inpatient expectant management to 34 weeks with close monitoring is recommended in the absence of deteriorating maternal or fetal status.7,24 C Consensus guidelines
Acute episodes of severe hypertension in pregnant and postpartum patients should be treated within 30 to 60 minutes with intravenous labetalol or hydralazine or oral nifedipine.4,7,29 C Consensus guidelines
Magnesium sulfate is the treatment of choice to prevent eclamptic seizures in pregnant women who have preeclampsia with severe features.25 A RCTs and systematic reviews
Low-dose aspirin (81 mg per day) initiated after 12 weeks' gestation until delivery is recommended to decrease the risk of developing preeclampsia among women who are at risk.5,35 B Systematic review of high-quality studies for U.S. Preventive Services Task Force

RCT = randomized controlled trial.

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 https://www.aafp.org/afpsort.

NARGES FARAHI, MD, is an associate professor in the Department of Family Medicine at the University of North Carolina School of Medicine, Chapel Hill.

FAREEDAT OLUYADI, MD, IBCLC, is an assistant professor in the Department of Family Medicine at Charles R. Drew University of Medicine and Science, Los Angeles, Calif.

ANDREA B. DOTSON, MD, MSPH, IBCLC, is an assistant professor in the Department of Family Medicine and Community Health at Duke University School of Medicine, Durham, N.C.

Address correspondence to Narges Farahi, MD, University of North Carolina at Chapel Hill, 590 Manning Dr., Chapel Hill, NC 27599 (narges_farahi@med.unc.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial relationships.

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