Clinical Management Questions
- ▸ Are there screening methods that are useful to identify women at risk of developing hypertensive disorders of pregnancy?
- ▸ Are there prevention strategies for reducing the risk of hypertensive disorders of pregnancy?
- ▸ What is the optimal treatment for women with gestational hypertension or preeclampsia?
- ▸ What is the optimal treatment for eclampsia?
- ▸ What is the management of acute complications for preeclampsia with HELLP?
- ▸ What are the risks of subsequent cardiovascular disease among women with hypertensive disorders of pregnancy and are there prevention strategies that modify this risk?
Clinical Considerations and Recommendations
The following recommendations are based on good and consistent scientific evidence (Level A):
- ▸ Women with any of the high-risk factors for preeclampsia (previous pregnancy with preeclampsia, multifetal gestation, renal disease, autoimmune disease, type 1 or type 2 diabetes mellitus, and chronic hypertension) and those with more than one of the moderate-risk factors (first pregnancy, maternal age of 35 years or older, a body mass index of more than 30, family history of preeclampsia, sociodemographic characteristics, and personal history factors) should receive low-dose (81 mg/day) aspirin for preeclampsia prophylaxis, initiated between 12 weeks and 28 weeks of gestation (optimally before 16 weeks of gestation) and continuing until delivery.
- ▸ In women with gestational hypertension or preeclampsia without severe features at or beyond 37 0/7 weeks of gestation, delivery rather than expectant management upon diagnosis is recommended.
- ▸ Magnesium sulfate should be used for the prevention and treatment of seizures in women with gestational hypertension and preeclampsia with severe features or eclampsia.
- ▸ Nonsteroidal anti-inflammatory medications should continue to be used preferentially over opioid analgesics. Postpartum patients on magnesium for seizure prophylaxis for preeclampsia did not show differences in blood pressure, antihypertensive requirements, or other adverse events for patients managed with NSAIDs in the postpartum period.
The following recommendations are based on limited or inconsistent scientific evidence (Level B):
- ▸ Delivery is recommended when gestational hypertension or preeclampsia with severe features is diagnosed at or beyond 34 0/7 weeks of gestation, after maternal stabilization or with labor or prelabor rupture of membranes. Delivery should not be delayed for the administration of steroids in the late preterm period.
- ▸ The expectant management of preeclampsia with severe features before 34 0/7 weeks of gestation is based on strict selection criteria of those appropriate candidates and is best accomplished in a setting with resources appropriate for maternal and neonatal care. Because expectant management is intended to provide neonatal benefit at the expense of maternal risk, expectant management is not advised when neonatal survival is not anticipated. During expectant management, delivery is recommended at any time in the case of deterioration of maternal or fetal condition.
- ▸ Antihypertensive treatment should be initiated expeditiously for acute-onset severe hypertension (systolic blood pressure of 160 mm Hg or more or diastolic blood pressure of 110 mm Hg or more, or both) that is confirmed as persistent (15 minutes or more). The available literature suggests that antihypertensive agents should be administered within 30–60 minutes. However, it is recommended to administer antihypertensive therapy as soon as reasonably possible after the criteria for acute-onset severe hypertension are met.
The following recommendations are based primarily on consensus and expert opinion (Level C):
- ▸ It is recommended that women with gestational hypertension in the absence of proteinuria are diagnosed with preeclampsia if they present with any of the following severe features: thrombocytopenia (platelet count less than 100,000 × 109/L); impaired liver function as indicated by abnormally elevated blood concentrations of liver enzymes (to twice the upper limit of normal concentration); severe persistent right upper quadrant or epigastric pain and not accounted for by alternative diagnoses; renal insufficiency (serum creatinine concentration more than 1.1 mg/dL or a doubling of the serum creatinine concentration in the absence of other renal disease); pulmonary edema, or new-onset headache unresponsive to acetaminophen and not accounted for by alternative diagnoses, or visual disturbances.
- ▸ Women with gestational hypertension who present with severe-range blood pressures should be managed with the same approach as for women with severe preeclampsia.
- ▸ Among women with gestational hypertension or preeclampsia without severe features, expectant management up to 37 0/7 weeks of gestation is recommended, during which frequent fetal and maternal evaluation is recommended. Fetal monitoring consists of ultrasonography to determine fetal growth every 3–4 weeks of gestation, and amniotic fluid volume assessment at least once weekly. In addition, an antenatal test one-to-two times per week for patients with gestational hypertension or preeclampsia without severe features is recommended.
- ▸ Epidural or spinal anesthesia is considered acceptable, and the risk of epidural hematoma is exceptionally low, in patients with platelet counts 70 × 109/L or more provided that the platelet level is stable, there is no other acquired or congenital coagulopathy, the platelet function is normal, and the patient is not on any antiplatelet or anticoagulant therapy.
- Systolic blood pressure of 160 mm Hg or more, or diastolic blood pressure of 110 mm Hg or more on two occasions at least 4 hours apart (unless antihypertensive therapy is initiated before this time)
- Thrombocytopenia (platelet count less than 100,000 × 109/L)
- Impaired liver function as indicated by abnormally elevated blood concentrations of liver enzymes (to twice the upper limit normal concentration), and severe persistent right upper quadrant or epigastric pain unresponsive to medication and not accounted for by alternative diagnoses
- Renal insufficiency (serum creatinine concentration more than 1.1 mg/dL or a doubling of the serum creatinine concentration in the absence of other renal disease)
- Pulmonary edema
- New-onset headache unresponsive to medication and not accounted for by alternative diagnoses
- Visual disturbances
Studies were reviewed and evaluated for quality according to the method outlined by the U.S. Preventive Services Task Force. Based on the highest level of evidence found in the data, recommendations are provided and graded according to the following categories:
Level A—Recommendations are based on good and consistent scientific evidence.
Level B—Recommendations are based on limited or inconsistent scientific evidence.
Level C—Recommendations are based primarily on consensus and expert opinion.
1. Steegers EA, von Dadelszen P, Duvekot JJ, Pijnenborg R. Pre-eclampsia. Lancet 2010;376:631–44.
2. Khan KS, Wojdyla D, Say L, Gülmezoglu AM, Van Look PF. WHO analysis of causes of maternal death: a systematic review. Lancet 2006;367:1066–74.
3. Wallis AB, Saftlas AF, Hsia J, Atrash HK. Secular trends in the rates of pre-eclampsia, eclampsia, and gestational hypertension, United States, 1987-2004. Am J Hypertens 2008;21:521–6.
4. Ananth CV, Keyes KM, Wapner RJ. Pre-eclampsia rates in the United States, 1980-2010: age-period-cohort analysis. BMJ 2013;347:f6564.
5. Stevens W, Shih T, Incerti D, Ton TGN, Lee HC, Peneva D, et al. Short-term costs of pre-eclampsia to the United States health care system. Am J Obstet Gynecol 2017;217:237–48.e16.