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High blood pressure and pregnancy: Know the facts

High blood pressure during pregnancy carries potential risks. Here’s what you need to know and how to take care of yourself and your baby.

Having high blood pressure (hypertension) during pregnancy needs close monitoring. Here's what to know about the potential risks. Also learn how to take care of yourself and your baby.

What are the types of high blood pressure during pregnancy?

Sometimes high blood pressure begins before pregnancy. In other cases, the condition develops during pregnancy.

• Chronic hypertension. In chronic hypertension, high blood pressure develops either before pregnancy or during the first 20 weeks of pregnancy. Because high blood pressure usually doesn't have symptoms, it might be hard to know exactly when it began.
• Chronic hypertension with superimposed preeclampsia. This condition occurs when chronic hypertension leads to worsening high blood pressure during pregnancy. People with this condition may develop protein in the urine or other complications.
• Gestational hypertension. People with gestational hypertension have high blood pressure that develops after 20 weeks of pregnancy. There's no excess protein in the urine and there are no other signs of organ damage. But in some cases, gestational hypertension can eventually lead to preeclampsia.
• Preeclampsia. Preeclampsia occurs when hypertension develops after 20 weeks of pregnancy. Preeclampsia is associated with signs of damage to other organ systems, including the kidneys, liver, blood or brain.

Untreated preeclampsia can lead to serious — even fatal — complications for mother and baby. Complications may include eclampsia, in which seizures develop.

Previously, preeclampsia was diagnosed only when both high blood pressure and protein in the urine were present. Experts now know that it's possible to have preeclampsia without having protein in the urine.

Why is high blood pressure a problem during pregnancy?

High blood pressure during pregnancy poses the following risks:

• Less blood flow to the placenta. If the placenta doesn't get enough blood, the fetus might receive less oxygen and fewer nutrients. This can lead to slow growth (intrauterine growth restriction), low birth weight or premature birth. Babies born early can have breathing problems, increased risk of infection and other complications.
• Placental abruption. In this condition, the placenta separates from the inner wall of the uterus before delivery. Preeclampsia and high blood pressure increase the risk of placental abruption. Severe abruption can cause heavy bleeding, which can be life-threatening for you and your baby.
• Intrauterine growth restriction. High blood pressure might result in slowed or decreased fetal growth.
• Injury to other organs. Poorly controlled high blood pressure can result in injury to the brain, eyes, heart, lungs, kidneys, liver and other major organs. In severe cases, it can be life-threatening.
• Premature delivery. Sometimes an early delivery is needed to prevent life-threatening complications from high blood pressure during pregnancy.
• Future cardiovascular disease. Having preeclampsia might increase the risk of future heart and blood vessel (cardiovascular) disease. The risk of future cardiovascular disease is higher if you've had preeclampsia more than once. It's also higher if you've had a premature birth due to having high blood pressure during pregnancy.

How will I know if I develop high blood pressure during pregnancy?

Monitoring your blood pressure is an important part of prenatal care. If you have chronic hypertension, your health care provider will consider these categories for blood pressure measurements:

• Elevated blood pressure. Elevated blood pressure is a systolic pressure ranging from 120 to 129 millimeters of mercury (mm Hg) and a diastolic pressure below 80 mm Hg. Elevated blood pressure tends to get worse over time unless steps are taken to control it.
• Stage 1 hypertension. Stage 1 hypertension is a systolic pressure ranging from 130 to 139 mm Hg or a diastolic pressure ranging from 80 to 89 mm Hg .
• Stage 2 hypertension. This stage is more severe. It's a systolic pressure of 140 mm Hg or higher or a diastolic pressure of 90 mm Hg or higher.

After 20 weeks of pregnancy, blood pressure that's higher than 140/90 mm Hg without any other organ damage is considered to be gestational hypertension. Blood pressure needs to be taken and documented on two or more occasions, at least four hours apart.

How will I know if I develop preeclampsia?

In addition to high blood pressure, other signs and symptoms of preeclampsia include:

• Extra protein in the urine or other signs of kidney problems
• Severe headaches
• Changes in vision, including temporary loss of vision, blurred vision or being sensitive to light
• Upper stomach pain, usually under the ribs on the right side
• Nausea or vomiting
• Decreased levels of platelets in the blood
• Impaired liver function
• Shortness of breath, caused by fluid in the lungs

Sudden weight gain and swelling — particularly in the face and hands — often occurs with preeclampsia. The swelling associated with preeclampsia is more severe than the typical swelling that happens during pregnancy.

Is it safe to take blood pressure medication during pregnancy?

Some blood pressure medications are considered safe to use during pregnancy. However, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers and renin inhibitors need to be avoided during pregnancy.

Treatment is important. High blood pressure increases your risk of heart attack, stroke and other major complications. And high blood pressure can be dangerous for your baby.

If you need medication to control your blood pressure during pregnancy, your health care provider will prescribe the safest medication and dose. Take the medication exactly as prescribed. Don't stop taking it or change the dose on your own.

Low-dose daily aspirin often is recommended to lower the risk of preeclampsia in those who are at high risk. Studies have found aspirin to be safe during pregnancy.

What should I do to prepare for pregnancy?

If you have high blood pressure, schedule a preconception appointment with a health care provider who has expertise in managing pregnancies complicated by hypertensive disorders. Also meet with other members of your health care team, such as your primary care provider or cardiologist. They'll look at how well you're managing your high blood pressure. They also may consider treatment changes before you get pregnant.

If you're overweight, your health care provider will recommend losing weight before becoming pregnant.

What can I expect during prenatal visits?

During pregnancy, you'll see your health care provider often. Your weight and blood pressure will be checked at every visit. You also might need frequent laboratory tests.

Your health care provider will closely monitor your baby's health, as well. Frequent ultrasounds might be used to track growth. Fetal testing might be used to evaluate your baby's well-being. Your health care provider might also recommend that you track your baby's daily movements.

What can I do to reduce the risk of complications?

Taking good care of yourself is the best way to take care of your baby. For example:

• Keep your prenatal appointments. Visit your health care provider on a regular basis throughout your pregnancy.
• Take your blood pressure medication and low-dose daily aspirin as prescribed. Your health care provider will prescribe the safest medication at the most appropriate dose.
• Stay active. Follow your health care provider's recommendations for physical activity.
• Eat a healthy diet. Ask to speak with a dietitian if you need help planning meals.
• Know what's off-limits. Avoid smoking, alcohol and illegal drugs. Talk to your health care provider before taking nonprescription medications.

Researchers continue to study ways to prevent preeclampsia. Studies suggest that low-dose aspirin lowers the risk of preeclampsia in those who are at high risk. The American College of Obstetricians and Gynecologists recommends that they take a daily low-dose aspirin (81 milligrams) starting late in the first trimester.

What about labor and delivery?

Your health care provider might recommend inducing labor before your due date to avoid complications. The timing is based on how well controlled your blood pressure is and whether you have end-stage organ damage. It also depends on whether your baby has complications, such as slow growth.

If you have preeclampsia and the condition is getting worse, you might be given medication during labor to help prevent seizures.

Will I be able to breastfeed my baby?

Breastfeeding is encouraged for most who have high blood pressure, even those who take medication. Discuss your medications with your health care provider before your baby is born.

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• Pregnancy and high blood pressure. National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/health/high-blood-pressure/pregnancy#:~:text=It's%20typically%20diagnosed%20after%2020,a%20condition%20known%20as%20eclampsia. Accessed May 16, 2022.
• Preeclampsia and high blood pressure during pregnancy. American College of Obstetricians and Gynecologists. https://www.acog.org/womens-health/faqs/preeclampsia-and-high-blood-pressure-during-pregnancy. Accessed May 16, 2022.
• Ferri FF. Preeclampsia. In: Ferri's Clinical Advisor 2022. Elsevier; 2022. https://www.clinicalkey.com. Accessed May 18, 2022.
• Melvin LM, et al. Gestational hypertension. https://www.uptodate.com/contents/search. Accessed My 16, 2022.
• Battarbee AN, et al. Chronic hypertension in pregnancy. American Journal of Obstetrics and Gynecology. 2020; doi:10.1016/j.ajog.2019.11.1243.
• Hypertension in pregnancy. Merck Manual Professional Version. https://www.merckmanuals.com/professional/gynecology-and-obstetrics/pregnancy-complicated-by-disease/hypertension-in-pregnancy?query=hypertension in pregnancy#. Accessed May 16, 2022.
• Gestational hypertension and preeclampsia: ACOG practice bulletin summary, number 222. Obstetrics and Gynecology. 2020; doi:10.1097/AOG.0000000000003892.
• Landon MB, et al., eds. Preeclampsia and hypertensive disorders. In: Gabbe's Obstetrics: Normal and Problem Pregnancies. 8th ed. Elsevier; 2021. https://www.clinicalkey.com. Accessed May 18, 2022.
• ACOG practice bulletin No. 203: Chronic hypertension in pregnancy. Obstetrics and Gynecology. 2019; doi:10.1097/AOG.0000000000003020.
• Reddy S, et al. Hypertension and pregnancy: Management and future risks. Advanced Chronic Kidney Disease. 2019; doi:10.1053/j.achkd.2019.03.017.

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Hypertension in Pregnancy

• Diagnosis |
• Treatment |
• Key Points |

Recommendations regarding classification, diagnosis, and management of hypertensive disorders (including preeclampsia) are available from the American College of Obstetricians and Gynecologists (ACOG [ 1 ]).

(See also Hypertension .)

In 2017, the American College of Cardiology (ACC) and the American Heart Association (AHA) released new guidelines for the evaluation of high blood pressure (BP). They lowered the definitions for hypertension as follows:

Elevated: 120 to 129/

Stage 1 hypertension: 130 to 139/80 to 89 mm Hg

Stage 2 hypertension: ≥ 140/90 mm Hg

ACOG defines chronic hypertension as systolic BP ≥ 140 mm Hg or diastolic BP ≥ 90 mm Hg on 2 occasions before 20 weeks gestation. Data on the effect of hypertension as defined by the ACC/AHA during pregnancy are limited. Thus, pregnancy management is likely to evolve.

Hypertension during pregnancy can be classified as one of the following:

Chronic: BP is high before pregnancy or before 20 weeks gestation. Chronic hypertension complicates about 1 to 5% of all pregnancies.

Gestational: Hypertension develops after 20 weeks gestation (typically after 37 weeks) and remits by 6 weeks postpartum; it occurs in about 5 to 10% of pregnancies, more commonly in multifetal pregnancy .

Both types of hypertension increase risk of preeclampsia and eclampsia and of other causes of maternal mortality or morbidity, including

Hypertensive encephalopathy

Renal failure

Left ventricular failure

HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count)

Risk of fetal mortality or morbidity increases because of decreased uteroplacental blood flow, which can cause vasospasm, growth restriction, hypoxia, and placental abruption. Outcomes are worse if hypertension is severe (systolic BP ≥ 160 mm Hg, diastolic BP ≥ 110 mm Hg, or both) or accompanied by renal insufficiency (eg, creatinine clearance < 60 mL/min, serum creatinine > 2 mg/dL [ > 180 μ mol/L]).

General reference

1. American College of Obstetricians and Gynecologists, Task Force on Hypertension in Pregnancy : Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet Gynecol 122 (5):1122–1131, 2013. doi: 10.1097/01.AOG.0000437382.03963.88

Diagnosis of Hypertension in Pregnancy

Tests to rule out other causes of hypertension

Blood pressure is measured routinely at prenatal visits. If severe hypertension occurs for the first time in pregnant women who do not have a multifetal pregnancy or gestational trophoblastic disease , tests to rule out other causes of hypertension (eg, renal artery stenosis , coarctation of the aorta , Cushing syndrome , systemic lupus erythematosus , pheochromocytoma ) should be considered.

Treatment of Hypertension in Pregnancy

For mild hypertension, conservative measures followed by antihypertensives if needed

For moderate or severe hypertension, antihypertensive therapy, close monitoring, and, if condition worsens, possibly termination of pregnancy or delivery, depending on gestational age

Recommendations for chronic and gestational hypertension are similar and depend on severity. However, chronic hypertension may be more severe. In gestational hypertension, the increases in BP often occur only late in gestation and may not require treatment.

Treatment of mild to moderate hypertension without renal insufficiency during pregnancy is controversial; the issues are whether treatment improves outcome and whether the risks of drug treatment outweigh risks of untreated disease. Because the uteroplacental circulation is maximally dilated and cannot autoregulate, decreasing maternal BP with medications may abruptly decrease uteroplacental blood flow. Diuretics reduce effective maternal circulating blood volume; consistent reduction increases risk of fetal growth restriction. However, hypertension with renal insufficiency is treated even if hypertension is mild or moderate.

For mild to moderate hypertension (systolic BP 140 to 159 mm Hg or diastolic BP 90 to 109 mm Hg) with labile BP, reduced physical activity may decrease BP and improve fetal growth, making perinatal risks similar to those for women without hypertension. However, if this conservative measure does not decrease BP, many experts recommend drug therapy. In pregnant women with mild chronic hypertension, a strategy of targeting a BP 1

For severe hypertension (systolic BP ≥ 160 mm Hg or diastolic BP ≥ 110 mm Hg), drug therapy is indicated. Risk of complications—maternal (progression of end-organ dysfunction, preeclampsia) and fetal (prematurity, growth restriction, stillbirth)—is increased significantly. Several antihypertensives may be required.

For systolic BP > 180 mm Hg or diastolic BP > 110 mm Hg, immediate evaluation is required. Multiple medications are often required. Also, hospitalization may be necessary for much of the latter part of pregnancy. If the woman’s condition worsens, pregnancy termination may be recommended.

All women with chronic hypertension during pregnancy should be taught to self-monitor BP, and they should be evaluated for target organ damage. Evaluation, done at baseline and periodically thereafter, includes

Serum creatinine, electrolytes, and uric acid levels

Liver function tests

Platelet count

Urine protein assessment

Usually funduscopy

Maternal echocardiography should be considered if women have had hypertension for > 4 years. After initial ultrasonography to evaluate fetal anatomy, ultrasonography is done monthly starting at about 28 weeks to monitor fetal growth; antenatal testing often begins at 32 weeks. Ultrasonography to monitor fetal growth and antenatal testing may start sooner if women have additional complications (eg, renal disorders) or if complications (eg, growth restriction) occur in the fetus. Delivery should occur by 37 to 39 weeks but may be induced earlier if preeclampsia or fetal growth restriction is detected or if fetal test results are nonreassuring.

Pharmacologic treatment

First-line medications for hypertension during pregnancy include

Beta-blockers

Calcium channel blockers

Several classes of antihypertensives are usually avoided during pregnancy:

ACE inhibitors are contraindicated because risk of fetal urinary tract abnormalities is increased.

ARBs are contraindicated because they increase risk of fetal renal dysfunction, lung hypoplasia, skeletal malformations, and death.

Aldosterone antagonists

Treatment reference

1. Tita AT, Szychowski JM, Boggess K, et al : Treatment for Mild Chronic Hypertension during Pregnancy.  N Engl J Med 386(19):1781-1792, 2022. doi:10.1056/NEJMoa2201295

Both chronic and gestational hypertension increase risk of preeclampsia, eclampsia, other causes of maternal mortality or morbidity (eg, hypertensive encephalopathy, stroke, renal failure, left ventricular failure, HELLP syndrome), and uteroplacental insufficiency.

Check for other causes of hypertension if severe hypertension occurs for the first time in a pregnant woman who does not have a multifetal pregnancy or gestational trophoblastic disease.

Do not use ACE inhibitors, ARBs, or aldosterone antagonists.

Consider hospitalization or termination of pregnancy if BP is > 180/110 mm Hg.

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High Blood Pressure During Pregnancy

What are high blood pressure complications during pregnancy, what should i do if i have high blood pressure before, during, or after pregnancy, what are types of high blood pressure conditions before, during, and after pregnancy, more information.

Some women have high blood pressure during pregnancy. This can put the mother and her baby at risk for problems during the pregnancy. High blood pressure can also cause problems during and after delivery. 1,2  The good news is that high blood pressure is preventable and treatable .

High blood pressure, also called hypertension , is very common. In the United States, high blood pressure happens in 1 in every 12 to 17 pregnancies among women ages 20 to 44. 3

High blood pressure in pregnancy has become more common. However, with good blood pressure control, you and your baby are more likely to stay healthy.

The most important thing to do is talk with your health care team about any blood pressure problems so you can get the right treatment and control your blood pressure— before you get pregnant. Getting treatment for high blood pressure is important before, during, and after pregnancy.

Complications from high blood pressure for the mother and infant can include the following:

• For the mother: preeclampsia , eclampsia , stroke , the need for labor induction (giving medicine to start labor to give birth), and placental abruption (the placenta separating from the wall of the uterus). 1,4,5
• For the baby: preterm delivery  (birth that happens before 37 weeks of pregnancy) and low birth weight (when a baby is born weighing less than 5 pounds, 8 ounces). 1,6 The mother’s high blood pressure makes it more difficult for the baby to get enough oxygen and nutrients to grow, so the mother may have to deliver the baby early.

Discuss blood pressure problems with your health care team before, during, and after pregnancy.

Learn what to do if you have high blood pressure before , during , or after pregnancy.

Before Pregnancy

• Any health problems you have or had and any medicines  you are taking. If you are planning to become pregnant, talk to your doctor. 7 Your doctor or health care team can help you find medicines that are safe to take during pregnancy.
• Ways to keep a healthy weight through healthy eating and regular physical activity. 1,7

During Pregnancy

• Get early and regular prenatal care . Go to every appointment with your doctor or health care professional.
• Talk to your doctor about any medicines  you take and which ones are safe. Do not stop or start taking any type of medicine, including over-the-counter medicines, without first talking with your doctor. 7
• Keep track of your blood pressure at home with a home blood pressure monitor . Contact your doctor if your blood pressure is higher than usual or if you have symptoms of preeclampsia . Talk to your doctor or insurance company about getting a home monitor.
• Continue to choose healthy foods and keep a healthy weight. 8

After Pregnancy

• Pay attention to how you feel after you give birth. If you had high blood pressure during pregnancy, you have a higher risk for stroke and other problems after delivery. Tell your doctor or call 9-1-1 right away if you have symptoms of preeclampsia after delivery. You might need emergency medical care. 9,10

Your doctor or nurse should look for these conditions before, during, and after pregnancy: 1,11

Chronic Hypertension

Chronic hypertension means having high blood pressure* before you get pregnant or before 20 weeks of pregnancy. 1 Women who have chronic hypertension can also get preeclampsia in the second or third trimester of pregnancy. 1

Gestational Hypertension

This condition happens when you only have high blood pressure* during pregnancy and do not have protein in your urine or other heart or kidney problems. It is typically diagnosed after 20 weeks of pregnancy or close to delivery. Gestational hypertension usually goes away after you give birth. However, some women with gestational hypertension have a higher risk of developing chronic hypertension in the future. 1,12

Preeclampsia/Eclampsia

Preeclampsia happens when a woman who previously had normal blood pressure suddenly develops high blood pressure* and protein in her urine or other problems after 20 weeks of pregnancy. Women who have chronic hypertension can also get preeclampsia.

Preeclampsia happens in about 1 in 25 pregnancies in the United States. 1,13 Some women with preeclampsia can develop seizures. This is called eclampsia , which is a medical emergency. 1,11

Symptoms of preeclampsia include:

• A headache that will not go away
• Changes in vision, including blurry vision, seeing spots, or having changes in eyesight
• Pain in the upper stomach area
• Nausea or vomiting
• Swelling of the face or hands
• Sudden weight gain
• Trouble breathing

Some women have no symptoms of preeclampsia, which is why it is important to visit your health care team regularly, especially during pregnancy.

You are more at risk for preeclampsia if: 1

• This is the first time you have given birth.
• You had preeclampsia during a previous pregnancy.
• You have chronic (long-term) high blood pressure, chronic kidney disease, or both.
• You have a history of thrombophilia (a condition that increases risk of blood clots).
• You are pregnant with multiple babies (such as twins or triplets).
• You became pregnant using in vitro fertilization.
• You have a family history of preeclampsia.
• You have type 1 or type 2 diabetes.
• You have obesity.
• You have lupus (an autoimmune disease).
• You are older than 40.

In rare cases, preeclampsia can happen after you have given birth. This is a serious medical condition known as postpartum preeclampsia . It can happen in women without any history of preeclampsia during pregnancy. 14  The symptoms for postpartum preeclampsia are similar to the symptoms of preeclampsia . Postpartum preeclampsia is typically diagnosed within 48 hours after delivery but can happen up to 6 weeks later. 9

Tell your health care provider or call 9-1-1 right away if you have symptoms of postpartum preeclampsia. You might need emergency medical care. 9,10

*In November 2017, the American College of Cardiology (ACC) and the American Heart Association (AHA) updated the definition of chronic stage 2 hypertension to mean having blood pressure at or above 140/90 mmHg. 15 The American College of Obstetricians and Gynecologists’ recommendations on hypertension in pregnancy predate the 2017 ACC/AHA’s guideline and definition of hypertension and stage 2 hypertension .

For more information about high blood pressure during pregnancy, see the following resources:

• Pregnancy Complications (CDC)
• Treating for Two: Medicine and Pregnancy (CDC)
• Heart Health and Pregnancy (National Heart, Lung, and Blood Institute)
• Preeclampsia and Eclampsia ( Eunice Kennedy Shriver National Institute of Child Health and Human Development)
• Pregnancy Complications (Office on Women’s Health)
• Preeclampsia and High Blood Pressure During Pregnancy (American College of Obstetricians and Gynecologists)
• High Blood Pressure During Pregnancy (March of Dimes)
• Preeclampsia Foundation
• American College of Obstetricians and Gynecologists, Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy . Obstet Gynecol. 2013;122(5):1122–31.
• Hutcheon JA, Lisonkova S, Joseph KS. Epidemiology of pre-eclampsia and the other hypertensive disorders of pregnancy . Best Pract Res Clin Obstet Gynaecol. 2011;25(4):391–403.
• Bateman BT, Shaw KM, Kuklina EV, Callaghan WM, Seely EW, Hernandez-Diaz S. Hypertension in women of reproductive age in the United States: NHANES 1999-2008 . PLoS ONE. 2012;7(4):e36171.
• Callaghan WM, Creanga AA, Kuklina EV. Severe maternal morbidity among delivery and postpartum hospitalizations in the United States . Obstet Gynecol. 2012;120(5):1029–36.
• Creanga AA, Berg CJ, Ko JY, Farr SL, Tong VT, Bruce FC, et al. Maternal mortality and morbidity in the United States: where are we now? J Womens Health (Larchmt) . 2014;23(1):3–9.
• Macdonald-Wallis C, Tilling K, Fraser A, Nelson SM, Lawlor DA. Associations of blood pressure change in pregnancy with fetal growth and gestational age at delivery: findings from a prospective cohort . 2014;64(1):36–44.
• Centers for Disease Control and Prevention. Treating for two: medicine and pregnancy . Accessed May 22, 2019.
• Liu Y, Croft JB, Wheaton AG, Kanny D, Cunningham TJ, Lu H, et al. Clustering of five health-related behaviors for chronic disease prevention among adults, United States, 2013 . Prev Chronic Dis. 2016;13:160054.
• Mayo Clinic. Postpartum preeclampsia . Accessed May 22, 2019.
• Matthys LA, Coppage KH, Lambers DS, Barton JR, Sibai BM. Delayed postpartum preeclampsia: an experience of 151 cases . Am J Obstet Gynecol. 2004;190(5):1464–6.
• Centers for Disease Control and Prevention. Data on selected pregnancy complications in the United States . Accessed May 22, 2019.
• American College of Obstetricans and Gynecologists. Preeclampsia and high blood pressure during pregnancy . Accessed May 22, 2019.
• S. Preventive Services Task Force. Screening for preeclampsia: U.S. Preventive Services Task Force recommendation statement . JAMA. 2017;317(16):1661–67.
• Bigelow CA, Pereira GA, Warmsley A, Cohen J, Getrajdman C, Moshier E, et al. Risk factors for new-onset late postpartum preeclampsia in women without a history of preeclampsia . Am J Obstet Gynecol. 2014;210(4):338.e1–8.
• Whelton PK, Carey RM, Aronow WS, Casey DE Jr., Collins KJ, Dennison Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines . 2017;71(6):e13–115.

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Key Points for Practice

• Medical treatment of chronic hypertension in pregnancy, that is, hypertension present before 20 weeks' gestation, is recommended at 160 mm Hg systolic or 110 mm Hg diastolic with labetalol or extended-release nifedipine, treating to 120 to 159 mm Hg systolic and 80 to 109 mm Hg diastolic.

• The decision of whether to treat chronic hypertension at lower blood pressure levels should be based on a discussion with the patient as well as the presence of comorbid conditions that might warrant lower blood pressure.

• Low-dose aspirin is recommended in patients with chronic hypertension in pregnancy from between 12 and 28 weeks' gestation to delivery.

• Without other indications, pregnant women with chronic hypertension should not be induced for delivery before 37 weeks' gestation.

From the AFP Editors

In pregnancy, chronic hypertension is defined as hypertension diagnosed before 20 weeks' gestation. Up to 1.5% of pregnant women have chronic hypertension, which can result in harm to the mother and infant. The rates of chronic hypertension are increasing and are predicted to continue because of obesity and older maternal age. Superimposed preeclampsia, the development of preeclampsia in a patient with chronic hypertension, occurs in 20% to 50% of pregnancies complicated by chronic hypertension. The American College of Obstetricians and Gynecologists (ACOG) has released an updated practice bulletin to outline diagnosis, effects on pregnancy outcomes, and approaches for management based on new evidence.

Recommendations

When assessing patients diagnosed with hypertension before pregnancy or when they present for pregnancy care, a complete blood count and measurements of transaminase, creatinine, electrolyte, and blood urea nitrogen levels should be obtained as well as a spot urine protein/creatinine ratio, with a 24-hour urine test for total protein if elevated. Electrocardiography or echocardiography may be helpful in patients with signs of decreased cardiac function. Some tests are affected by the physiologic changes of pregnancy, so are better performed before pregnancy.

Antihypertensive medications safe for the treatment of chronic hypertension during pregnancy include:

Labetalol, two times daily up to 2,400 mg per day in women without asthma, myocardial disease, decreased cardiac function, heart block, or bradycardia;

Extended-release nifedipine, up to 120 mg daily in women without tachycardia;

Methyldopa, two or three times daily up to 3,000 mg per day; or

Hydrochlorothiazide, 12.5 to 25 mg daily.

Labetalol and nifedipine are the preferred medications and hydrochlorothiazide and methyldopa are considered secondary options. Methyldopa has a long history of use in pregnancy, but has limited effectiveness and significant adverse effects. Use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, renin inhibitors, and mineralocorticoid receptor antagonists should be avoided in pregnancy.

STRONG EVIDENCE

Women with chronic hypertension should take 81 mg of aspirin daily from 12 to 28 weeks' gestation until delivery.

LIMITED EVIDENCE

Blood pressure control in pregnancy is challenging because of the uncertain risks of mild hypertension and potential uteroplacental insufficiency with overtreatment. Pregnant women with chronic hypertension should start antihypertensive medication when their blood pressure reaches 160 mm Hg systolic or 110 mm Hg diastolic, although it may be initiated earlier if the patient has concerning comorbidities or impaired renal function.

In the absence of other indications, women with chronic hypertension requiring medication should deliver between 37 and 39 weeks' gestation, and those not requiring medication should deliver between 38 and 39 weeks' gestation.

Acute hypertensive episodes in pregnancy can be dangerous to mother and infant. Pregnant women presenting with blood pressures higher than 160 mm Hg systolic or 110 mm Hg diastolic for 15 minutes should be given an antihypertensive medication as soon as possible, but at least within one hour. Women with severe acute hypertension resistant to medical treatment or superimposed preeclampsia with severe features who are at 34 weeks' gestation or more should proceed to delivery. In superimposed preeclampsia, patients with severe and uncontrolled hypertension, eclampsia, pulmonary edema, intravascular coagulation, renal insufficiency that continues to progress, placental abruption, or abnormal results on fetal testing should proceed to delivery regardless of gestational age. Superimposed preeclampsia is linked to an increased risk of adverse outcomes for mother and infant, including a 50% risk of fetal growth restriction as well as increased preterm delivery and perinatal mortality. In some situations, women who present before 34 weeks' gestation and have superimposed preeclampsia with severe features can be expectantly managed until 34 weeks' gestation if admitted to a facility with appropriate resources to care for mother and infant.

CONSENSUS OR EXPERT OPINION

Women with chronic hypertension should undergo an evaluation before becoming pregnant to evaluate for end-organ damage or comorbidities that will need to be managed before and during the pregnancy. It also may be beneficial to assess for secondary hypertension, which occurs in 11% to 14% of pregnant women with chronic hypertension. Those who become pregnant and are taking medications to treat chronic hypertension should have blood pressure goals set at 120 to 159 mm Hg systolic and 80 to 109 mm Hg diastolic.

Women with chronic hypertension requiring medication or who have comorbidities that could affect fetal outcomes, fetal growth restriction, or superimposed preeclampsia are recommended for antenatal fetal testing, although evidence is lacking on timing of testing. Because there is a higher risk of growth restriction in women with chronic hypertension, ultrasonography to assess fetal growth should be performed in the third trimester.

Women with superimposed preeclampsia without severe features can be expectantly managed until 37 weeks' gestation, if close monitoring can be provided.

Acute blood pressure elevations in pregnant women with chronic hypertension require hospital evaluation for superimposed preeclampsia with hematocrit, platelet, creatinine, and serum uric acid levels; liver function testing; and an evaluation for proteinuria as well as a fetal assessment. If maternal testing identifies hemoconcentration, thrombocytopenia, proteinuria, or increased creatinine or liver transaminase levels, a diagnosis of preeclampsia is likely. Monitoring blood pressure over four to eight hours can be beneficial for distinguishing acute severe from transient elevations.

Guideline source: American College of Obstetricians and Gynecologists

Evidence rating system used? Yes

Systematic literature search described? Yes

Guideline developed by participants without relevant financial ties to industry? Not reported

Recommendations based on patient-oriented outcomes? Yes

Published source:  Obstet Gynecol . January 2019;133(1):215–219

Available at:  https://journals.lww.com/greenjournal/fulltext/2019/01000/ACOG_Practice_Bulletin_No__203_Summary__Chronic.43.aspx

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Michael J. Arnold, MD, Assistant Medical Editor.

A collection of Practice Guidelines published in AFP is available at https://www.aafp.org/afp/practguide .

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Hypertension in Pregnancy

Apr 01, 2019

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Hypertension in Pregnancy. Teresa G. Berg, M.D. Maternal-Fetal Medicine University Medical Associates M3 Lecture Materials. OBJECTIVES. Be able to define hypertension in relationship to pregnancy Be able to classify hypertensive diseases in pregnant women

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• osmotic pressure
• impaired liver function
• proper cuff
• antiphospholipid syndrome

Presentation Transcript

Hypertension in Pregnancy Teresa G. Berg, M.D. Maternal-Fetal Medicine University Medical Associates M3 Lecture Materials

OBJECTIVES • Be able to define hypertension in relationship to pregnancy • Be able to classify hypertensive diseases in pregnant women • Be able to list criteria for the diagnosis of preeclampsia • Be able to list criteria for the diagnosis of severe preeclampsia/HELLP syndrome • Be able to discuss current management considerations • Understand and discuss the effects of hypertension on the mother and fetus

Hypertension • Sustained BP elevation of 140/90 or greater • Proper cuff size • Measurement taken while seated • Arm at the level of the heart • Use 5thKorotkoff sound

Hypertensive Disease Associated with Pregnancy Four Categories based on ACOG Executive Summary • Preeclampsia-eclampsia • Severe features • HEELP • Chronic hypertension • Chronic hypertension with superimposed preeclampsia • Gestational hypertension ACOG Executive Summary: Obstet Gynecol 2013; 122: 1122-31.

Hypertensive Disease Associated with Pregnancy • Preeclampsia • Associated with: • Proteinuria. • Thrombocytopenia. • Impaired liver function. • New onset renal insufficiency. • Pulmonary edema. • New onset cerebral or visual distrubances.

Hypertensive Disease Associated with Pregnancy • Chronic Hypertension • Predates the pregnancy. • Diagnosed before the 20th week or present before the pregnancy.

Hypertensive Disease Associated with Pregnancy • Chronic Hypertension with Superimposed Preeclampsia • Hypertension predates the pregnancy. • Features of preeclampsia noted after 20 weeks.

Hypertensive Disease Associated with Pregnancy • Gestational Hypertension • Hypertension after 20 weeks. • Absence of proteinuria. • Absence of systemic findings noted with preeclampsia.

Preeclampsia vs. Severe Preeclampsia • Previously normotensive woman • > 140 mmHg systolic • > 90 mmHg diastolic • Proteinuria: • >300 mg in 24 hour collection • Protein/creatinine ratio of 0.3 mg/dL. • Dipstick protein discouraged. • BP > 160 systolic or >110 diastolic • Thrombocytopenia <100,000 • Impaired liver function (LFT’s 2X normal) severe RUQ pain or epigastric pain or both • Progressive renal insufficiency (serum creatinine >1.1 mg/dL or doubling of serum creatininein the absence of renal disease) • Pulmonary edema • New onset cerebral or visual disturbances Criteria for Preeclampsia Criteria for Preeclampsia with Severe Features

Overlap/Disease Progression 25%

Risk Factors for Preeclampsia • Nulliparity • Multifetal gestations • Maternal age over 35 • Preeclampsia in a previous pregnancy • Chronic hypertension • Pregestational diabetes • Vascular and connective tissue disorders • Nephropathy • Antiphospholipid syndrome • Obesity • African-American race

Risk Factors

Morbidity and Mortality from Hypertensive Disease • Hypertension affects 12 to 22% of pregnant patients • Hypertensive disease is directly responsible for approximately 20% of maternal mortality in the United State

Pathophysiology • Vasospasm • Uterine vessels • Hemostasis • Prostanoid balance • Endothelium-derived factors • Lipid peroxide, free radicals and antioxidants

Pathophysiology • Vasospasm • Predominant finding in gestational hypertension and preeclampsia • Uterine vessels • Hemostasis • Prostanoid balance • Endothelium-derived factors • Lipid peroxide, free radicals and antioxidants

Pathophysiology • Vasospasm • Uterine vessels • Inadequate maternal vascular response to trophoblastic mediated vascular changes • Endothelial damage • Hemostasis • Prostanoid balance • Endothelium-derived factors • Lipid peroxide, free radicals and antioxidants

Pathophysiology • Vasospasm • Uterine vessels • Hemostasis • Increase platelet activation resulting in consumption • Increased endothelial fibronectin levels • Decreased antithrombin III and α2-antiplasmin levels • Allows for microthrombi development with resultant increase in endothelial damage • Prostanoid balance • Endothelium-derived factors • Lipid peroxide, free radicals and antioxidants

Pathophysiology • Vasospasm • Uterine vessels • Hemostasis • Prostanoid balance • Prostacyclin (PGI2):Thromboxane (TXA2) balance shifted to favor TXA2 • TXA2 promotes: • Vasoconstriction • Platelet aggregation • Endothelium-derived factors • Lipid peroxide, free radicals and antioxidants

Pathophysiology • Vasospasm • Uterine vessels • Hemostasis • Prostanoid balance • Endothelium-derived factors • Nitric oxide is decreased in patients with preeclampsia • As this is a vasodilator, this may result in vasoconstriction • Lipid peroxide, free radicals and antioxidants

Pathophysiology • Vasospasm • Uterine vessels • Hemostasis • Prostanoid balance • Endothelium-derived factors • Lipid peroxide, free radicals and antioxidants • Increased in preeclampsia • Have been implicated in vascular injury

Pathophysiologic Changes • Cardiovascular effects • Hematologic effects • Neurologic effects • Pulmonary effects • Renal effects • Fetal effects

Pathophysiologic Changes • Cardiovascular effects • Hypertension • Increased cardiac output • Increased systemic vascular resistance • Hematologic effects • Neurologic effects • Pulmonary effects • Renal effects • Fetal effects

Pathophysiologic Changes • Cardiovascular effects • Hematologic effects • Volume contraction/Hypovolemia • Elevated hematocrit • Thrombocytopenia • Microangiopathic hemolytic anemia • Third spacing of fluid • Low oncotic pressure • Neurologic effects • Pulmonary effects • Renal effects • Fetal effects

Pathophysiologic Changes • Cardiovascular effects • Hematologic effects • Neurologic effects • Hyperreflexia • Headache • Cerebral edema • Seizures • Findings of PRES on radiologic imaging • Pulmonary effects • Renal effects • Fetal effects

Pathophysiologic Changes • Cardiovascular effects • Hematologic effects • Neurologic effects • Pulmonary effects • Capillary leak • Reduced colloid osmotic pressure • Pulmonary edema • Renal effects • Fetal effects

Pathophysiologic Changes • Cardiovascular effects • Hematologic effects • Neurologic effects • Pulmonary effects • Renal effects • Decreased glomerular filtration rate • Glomerularendotheliosis • Proteinuria • Oliguria • Acute tubular necrosis • Fetal effects

Renal Effects • Decreased glomerular filtration rate • Glomerular endotheliosis • Proteinuria • Oliguria • Acute tubular necrosis

Pathophysiologic Changes • Cardiovascular effects • Hematologic effects • Neurologic effects • Pulmonary effects • Renal effects • Fetal effects • Placental abruption • Fetal growth restriction • Oligohydramnios • Fetal distress • Increased perinatal morbidity and mortality

Management • The ultimate cure is delivery • Assess gestational age • Assess cervix • Fetal well-being • Laboratory assessment • Rule out severe disease!!

Timing of Delivery • >39 0/7 weeks • Chronic hypertension • >37 0/7 weeks • Gestational hypertension • Preeclampsia without severe features • >34 0/7 weeks • Preeclampsia with severe features

Timing of Delivery • < 34 0/7 weeks • Deliver immediately for preeclampsia with severe features with unstable maternal or fetal conditions • This recommendation is made without regard to gestational age

Timing of Delivery • < 34 0/7 weeks (Viable Fetus) • Give steroids but do not delay delivery for preeclampsia with severe features complicated by any of the following: • Uncontrollable severe hypertension • Eclampsia • Pulmonary edema • Abruptio placenta • Disseminated intravascular coagulation • Evidence of non-reassuring fetal status • Intrapartum fetal demise

Timing of Delivery • < 34 0/7 weeks (Viable Fetus) • Deliver after steroid administration (48 hour delay) for preeclampsia with severe features with stable maternal and fetal condition and the following: • PPROM • Labor • Thrombocytopenia • Persistently abnormal LFT’s • IUGR (<5%) • Oligohydramnios • Reverse end-diastolic flow on umbilical artery Doppler studies • New-onset renal dysfunction or increasing renal dysfunction

Route of Delivery • Determined by: • Gestational age • Fetal presentation • Cervical status • Maternal condition • Fetal condition

Seizure Prophylaxis • Magnesium sulfate • Recommended for patients with preeclampsia with severe features • Not universally recommended for patients without severe features

Magnesium Sulfate • Is not a hypotensive agent • Works as a centrally acting anticonvulsant • Also blocks neuromuscular conduction • 4-6 g bolus • 1-2 g/hour • Monitor urine output and DTR’s • With renal dysfunction, may require a lower dose • Serum levels: 6-8 mg/dL are considered therapeutic

Toxicity • Respiratory rate < 12 • DTR’s not detectable • Altered sensorium • Urine output < 25-30 cc/hour • Antidote: 10 ml of 10% solution of calcium gluconate 1 v over 3 minutes

Treatment of Eclampsia • Few people die of seizures • Protect patient • Avoid insertion of airways and padded tongue blades • IV access • MGSO4 4-6 bolus, if not effective, give another 2 g

THE FIRST THING TO DO AT A SEIZURE IS TO TAKE YOUR OWN PULSE!

Alternate Anticonvulsants • Have not been shown to be as efficacious as magnesium sulfate and may result in sedation that makes evaluation of the patient more difficult • Diazepam 5-10 mg IV • Sodium Amytal 100 mg IV • Pentobarbital 125 mg IV • Dilantin 500-1000 mg IV infusion

After the Seizure • Assess maternal labs • Fetal well-being • Effect delivery • Transport when indicated • No need for immediate cesarean delivery

Hypertensive Emergencies • Fetal monitoring • IV access • IV hydration • The reason to treat is maternal, not fetal • May require ICU

Criteria for Treatment • Diastolic BP > 105-110 • Systolic BP > 160 • Avoid rapid reduction in BP • Do not attempt to normalize BP • Goal is DBP < 105 not < 90 • May precipitate fetal distress

Characteristics of Severe HTN • Crises are associated with hypovolemia • Clinical assessment of hydration is inaccurate • Unprotected vascular beds are at risk, eg, uterine

Key Steps Using Vasodilators • 250-500 cc of fluid, IV • Avoid multiple doses in rapid succession • Allow time for drug to work • Maintain LLD position • Avoid over treatment

Acute Medical Therapy • Hydralazine • Labetalol • Nifedipine

Hydralazine • Dose: 5-10 mg every 20 minutes • Onset: 10-20 minutes • Duration: 3-8 hours • Side effects: headache, flushing, tachycardia, lupus like symptoms • Mechanism: peripheral vasodilator

Labetalol • Dose: 20mg, then 40, then 80 every 20 minutes, for a total of 220mg • Onset: 1-2 minutes • Duration: 6-16 hours • Side effects: hypotension • Mechanism: Alpha and Beta block

Nifedipine • Dose: 10 mg po, not sublingual • Onset: 5-10 minutes • Duration: 4-8 hours • Side effects: chest pain, headache, tachycardia • Mechanism: CA channel block

Other Complications • Pulmonary edema • Oliguria • Persistent hypertension • DIC

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• NICE Guidance
• Conditions and diseases
• Cardiovascular conditions
• Hypertension

Hypertension in pregnancy: diagnosis and management

NICE guideline [NG133] Published: 25 June 2019 Last updated: 17 April 2023

• Tools and resources
• Information for the public

Recommendations

• Recommendations for research
• Rationale and impact
• Finding more information and committee details
• Update information
• Quality standard - Hypertension in pregnancy

This guideline covers diagnosing and managing hypertension (high blood pressure), including pre-eclampsia, during pregnancy, labour and birth. It also includes advice for women with hypertension who wish to conceive and women who have had a pregnancy complicated by hypertension. It aims to improve care during pregnancy, labour and birth for women and their babies.

For information on related topics, see our women's and reproductive health summary page .

In April 2023 , we updated our recommendations on when to offer placental growth factor (PLGF)-based testing for pre-eclampsia, in line with our diagnostics guidance on PLGF-based testing for pre-eclampsia . See the update information for more details. 

We’ve created a series of visual summaries to explain assessment, treatment and other aspects of care for various conditions relating to hypertension in pregnancy. These are available to download from tools and resources . 

This guideline includes new and updated recommendations on:

• assessing proteinuria
• managing chronic hypertension in pregnancy and  gestational hypertension
• managing pre-eclampsia, including severe pre-eclampsia in critical care settings
• treatment during the postnatal period (including breastfeeding)
• advice and follow-up in community care

It also includes recommendations on:

• reducing the risk of hypertension in pregnancy
• fetal monitoring and care of women during labour and birth

Who is it for?

• Healthcare professionals
• Women who develop hypertension during pregnancy, who have hypertension and wish to conceive, and who have had a pregnancy complicated by hypertension, and their relatives and carers

Guideline development process

How we develop NICE guidelines

This guideline updates and replaces NICE guideline CG107 (August 2010).

Your responsibility

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.

All problems (adverse events) related to a medicine or medical device used for treatment or in a procedure should be reported to the Medicines and Healthcare products Regulatory Agency using the Yellow Card Scheme .

Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.

Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

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Management of hypertension in pregnancy

Amanda beech.

1 Royal Hospital for Women, Sydney

George Mangos

2 St George and Sutherland Clinical School, St George Hospital, UNSW Sydney

Hypertensive disorders of pregnancy are common and can result in maternal and fetal morbidity and mortality. Women may have chronic hypertension, or develop hypertension during pregnancy.

Management involves close maternal and fetal surveillance. If an antihypertensive drug is needed, prescribe one that is safe in pregnancy.

Pre-eclampsia is a hypertensive disorder of pregnancy. Women at high risk of pre-eclampsia should start aspirin 150 mg daily at 12–16 weeks gestation and continue until 36 weeks gestation, to reduce the risk of preterm delivery.

There are long-term cardiovascular and mortality risks associated with pregnancies complicated by gestational hypertension and pre-eclampsia. Ongoing cardiovascular and metabolic risk surveillance should be undertaken by the woman’s general practitioner .

Introduction

In a normal pregnancy, blood pressure falls in the first trimester. The fall reaches a maximum of 10–15 mmHg (systolic) in mid-pregnancy, and returns to pre-pregnancy levels by term. Hypertensive disorders of pregnancy affect approximately 5–10% of pregnancies in Australia. These disorders are associated with both maternal and fetal morbidity and mortality.

Hypertension

Hypertension is defined as a systolic blood pressure 140 mmHg or above, or diastolic blood pressure 90 mmHg or above. This should be confirmed over four hours with repeated measures, or after overnight rest, to determine if there is true hypertension. Severe hypertension is classified as a systolic blood pressure 160 mmHg or above, or a diastolic blood pressure 110 mmHg or above. Severe hypertension (160/110 mmHg or above) requires urgent management in hospital.

Hypertensive disorders of pregnancy can be divided into four categories:

• gestational hypertension
• pre-eclampsia and eclampsia
• pre-eclampsia superimposed on chronic hypertension.

Chronic hypertension

Chronic hypertension predates the pregnancy or is first diagnosed before 20 weeks gestation. It includes both primary hypertension and less commonly secondary hypertension, related to an underlying cause, such as kidney disease. Routine testing for secondary causes is not recommended in pregnancy, but should be considered postpartum. For pregnant women with chronic hypertension, the initial recommended tests are 1 - 3 :

• full blood count
• urea, creatinine and electrolytes
• liver function tests
• urinalysis and microscopy
• urine protein:creatinine ratio (to establish a baseline)

Chronic hypertension is associated with adverse maternal and fetal outcomes:

• superimposed pre-eclampsia – 25%
• preterm delivery – 28%
• fetal growth restriction – 17%
• perinatal death – 4%. 4

Some women have white-coat hypertension. This is defined as a clinic blood pressure of at least 140/90 mmHg, but with normal blood pressure outside the clinic. It is diagnosed by 24-hour ambulatory blood pressure monitoring or home blood pressure monitoring. White-coat hypertension is not entirely benign and is associated with an increased risk of pre-eclampsia (8%). 5 Generally, treatment is not required if the clinic blood pressure is below 160/110 mmHg and the out-of-office blood pressure remains normal.

Women with chronic hypertension may be taking antihypertensive drugs before conception or conceive while taking them. Some of these drugs are contraindicated or not recommended in pregnancy ( Table 1 ). 6 Table 2 lists oral antihypertensive drugs that are safer in pregnancy. 2 , 6

The mainstay of management of chronic hypertension in pregnancy is regular maternal review and strict blood pressure control. Often the physiological fall in blood pressure in the first trimester will allow for a reduction or cessation of antihypertensive drug therapy.

Optimal management includes maintaining the blood pressure around 110–140/85 mmHg, regular assessment for the development of pre-eclampsia and close surveillance of fetal growth and wellbeing. Signs and symptoms suggestive of pre-eclampsia include headache, visual changes, epigastric or right upper quadrant pain and oedema (see Box ). Assessment also includes careful blood pressure measurement, ideally using automated office or a liquid crystal sphygmomanometer, and testing for proteinuria. Home blood pressure monitoring may form part of this assessment. Proteinuria is defined as a spot urine protein:creatinine ratio above 30 mg/mmol or urine protein excretion above 300 mg/24 hours. Dipstick urinalysis (automated or visual) is most commonly used to screen for proteinuria, with a ‘negative’ or ‘trace’ result being normal. One plus (1+) or more on dipstick is sensitive, but inaccurate and should be further evaluated with a spot urine protein:creatinine ratio.

Features of pre-eclampsia and eclampsia

Gestational hypertension.

Gestational hypertension is the development of hypertension at or after 20 weeks gestation, in the absence of other features of pre-eclampsia (see Box ). Gestational hypertension is associated with an increased risk of developing pre-eclampsia (up to 25%, depending on the gestation at presentation), as well as the future development of cardiovascular disease. 1 - 3 Fetal growth restriction is not typically a feature of gestational hypertension.

Regular blood pressure monitoring is necessary to ensure the blood pressure remains at 110–140/80–90 mmHg. There should be regular assessment for the development of pre-eclampsia and close surveillance of fetal growth and wellbeing. Once the blood pressure is controlled, gestational hypertension may continue to be managed with outpatient care, under close and regular review.

Pre - eclampsia

Pre-eclampsia is a complex multisystem disorder of pregnancy arising from abnormal placentation, resulting in an imbalance of angiogenic and anti-angiogenic factors, oxidative stress and immunological involvement. The maternal response to this is thought to involve systemic vascular endothelial dysfunction. Pre-eclampsia may be superimposed on chronic hypertension, or present as new onset hypertension, arising at or after 20 weeks gestation, with the presence of one or more of the typical clinical features (see Box ). 1 , 2

Risk factors for pre-eclampsia include maternal age, primiparity, previous pre-eclampsia, multiple gestation, prolonged interpregnancy interval and assisted reproduction therapies. Other factors are underlying renal disease or hypertension, antiphospholipid syndrome, systemic lupus erythematosus, diabetes and a maternal body mass index (BMI) above 30 kg/m 2 .

Adverse maternal outcomes include eclampsia, stroke, multiorgan failure, major haemorrhage and death. Fetal complications of pre-eclampsia include growth restriction, preterm delivery, placental abruption and perinatal death.

Whether pre-eclampsia is new onset or superimposed on chronic hypertension, a multidisciplinary approach optimises maternal and fetal outcomes as delivery is the only definitive cure. There is a balance between the welfare of the growing fetus and the ongoing risk of maternal complications. Management should occur at a specialist centre with the required protocols and expertise because inpatient care is usually required.

For severe hypertension urgent management is indicated and drugs are required to rapidly lower blood pressure ( Table 3 ). An infusion of magnesium sulphate can be considered as it reduces the rate of seizure by 50% ( Table 4 ). 7

Prediction and prevention

A number of options are available in the first trimester for predicting the risk of pre-eclampsia. These include using maternal blood pressure and risk factors or combined prediction models using additional tests of placental growth factor and doppler imaging of the uterine artery. These tests are readily available and consideration needs to be given to how they could be integrated into antenatal care. In Australia, however, the cost effectiveness of combined first trimester screening for pre-eclampsia has yet to be evaluated.

Although there is no current method of preventing pre-eclampsia, aspirin is recommended for women considered to be at high risk because of maternal risk factors or by clinical prediction models. The ASPRE trial used combined first trimester screening and found a 62% reduction in preterm pre-eclampsia at less than 37 weeks gestation in women who took aspirin 150 mg daily. 8 Women at high risk require early obstetric review, because starting aspirin before 16 weeks is most effective. If started for pre-eclampsia prophylaxis, aspirin should be continued until 36 weeks gestation. Aspirin reduces the risk of preterm birth, fetal growth restriction and fetal death, but may increase postpartum bleeding. 9 , 10

Women with an inadequate dietary calcium intake may have an increased risk of pre-eclampsia. They should aim to achieve the recommended daily allowance (1000 mg daily) through diet or calcium supplementation to reduce the risk. 11

Postpartum management

After delivery, hypertension typically resolves within 12 weeks for women with gestational hypertension or pre-eclampsia. If this does not occur, consideration should be given to investigation for primary or secondary hypertension . Regular monitoring of blood pressure postnatally should occur, with down titration of antihypertensive drugs when the systolic blood pressure drops below 120 mmHg. For women with chronic hypertension, the decision to return to their usual antihypertensive treatment will depend on its compatibility with breastfeeding, and their future pregnancy plans. It would be reasonable to transition them back to their usual treatment early, provided they remain aware of the importance of review before future pregnancies to ensure it will be safe to use.

The antihypertensive drugs that are safe in pregnancy are also safe in breastfeeding. However, given that methyldopa is associated with a 30% risk of depression, it is usually stopped postpartum. ACE inhibitors, particularly enalapril, have very low concentrations in breast milk and are often used during lactation. Angiotensin receptor blockers are not recommended due to a lack of available safety information.

Long-term implications

Gestational hypertension and pre-eclampsia are associated with a two- to fourfold increase in the future risk of cardiovascular disease. Women may develop hypertension, stroke, diabetes, venous thromboembolic disease or chronic kidney disease. Cardiovascular events such as stroke may occur in middle age. Given these risks, and the cumulative risks associated with several pregnancies complicated by severe pre-eclampsia, or preterm delivery, preconception counselling before future pregnancies is recommended.

Women with a history of hypertension in pregnancy require indefinite follow-up. They are recommended to have annual reviews of blood pressure, fasting lipids and blood glucose. Counselling on a healthy lifestyle and diet, maintenance of an optimal BMI, smoking cessation and regular exercise are essential for optimising long-term health outcomes. 12 - 14

Conflicts of interest: none declared

And That's a Wrap! ACC.24: An ACPC Perspective

Apr 29, 2024   |   Tarek Alsaied, MD, FACC ; Lasya Gaur, MD ; M. Regina Lantin-Hermoso, MD, FACC

Expert Analysis

Quick Takes

• ACC.24 provided opportunities for in-person collaboration and dissemination of cutting-edge research for the Adult Congenital and Pediatric Cardiology (ACPC) community.
• Diversity in the congenital cardiology workforce is critical in advancing our field.
• Changes in pediatric residency and the future congenital cardiology workforce are coming – are we prepared?

The American College of Cardiology Scientific Sessions 2024 (ACC.24), building on the successes and lessons of past gatherings, marked a significant return to in-person collaboration and learning for the Adult Congenital and Pediatric Cardiology (ACPC) community. As we continue to navigate the post-pandemic era, the sense of community and the eagerness for direct engagement were palpable, highlighting the invaluable benefits of face-to-face interactions for professional growth, networking, and exchange of ideas. This year's conference not only reflected the resilience of the ACPC community but also its commitment to advancing patient care through shared knowledge and experiences.

ACPC Community Day The ACC.24 Community Day, led by Dr. Ritu Sachdeva, featured discussions on pivotal changes in pediatric residency training (hint: less intensive care unit, more out-patient experience – how will this impact our current coverage?), the future of the pediatric cardiology workforce from the fellowship directors' perspective (hint: less medical student interest in pediatrics – how will this affect the pipeline of cardiology fellows?), and strategies to enhance the quality and number of trained professionals caring for adult congenital heart disease (ACHD) patients. These sessions, hosted by experts like Drs. Rebecca Sanders, Lowell Frank, and Ali Zaidi, spotlighted crucial developments in training and workforce management, setting a tone for our field's future.

Scientific Sessions The ACC.24 Scientific Sessions showcased a myriad of topics, from the importance of diversity in the cardiology workforce to groundbreaking surgical techniques in congenital heart disease (CHD). Interactive sessions, discussion panels on the challenges of managing pregnancy in CHD, debates on perinatal management, and conundrums in ACHD were highlights of this year's meeting. Workshops for young professionals emphasized career development, while sessions on non-clinical skills addressed broader aspects of cardiology practice and wellness in the CHD physician. All these reflect the ongoing commitment to innovation, inclusivity, and education in our field.

The session on "Valvular Heart Surgery in Complex CHD" 1 delved into the nuances of managing Ebstein anomaly and repairing the mitral and aortic valves as well as the enduring role of surgical pulmonary valve replacement despite the mainstream availability of transcatheter techniques.

The "Game of Shones" session, 2 led by a panel of experts acting as co-chairs, case presenters, contestants, and judges, featured fun, lively competitive discussions regarding the diagnosis, "un"natural history, and management of this complex disease from the neonatal period to adulthood. Not only did this session facilitate learning through competition, but it also underscored the importance of collaboration in the challenges of managing CHD.

Dr. Anne Marie Valente gave an excellent summary of the past year's advancements in congenital cardiology in her inspiring "Year in Review" presentation. 3 This was followed by "Highlighted Original Research" of this year's top five submitted abstracts: a multicenter experience with sodium-glucose co-transporter-2 inhibitors for heart failure in ACHD; a scoring system to predict sudden death in hypertrophic cardiomyopathy utilizing clinical and imaging variables; a multi-institutional study looking at clinical and demographic variables to predict neurocognitive decline in ACHD; a study exploring the utility of artificial intelligence (AI) in electrocardiogram analysis to predict mortality in tetralogy of Fallot; and a study utilizing statistical modeling for risk stratification in patients with anomalous origin of the right coronary artery. Congratulations to all these innovative researchers for their cutting-edge work!

The session "Pregnancy in Congenital Heart Disease: High Risk, High Reward!" 4 moderated by Dr. Candice Silversides, editor of JACC Advances , provided valuable insights into the heightened risks associated with pregnancy in CHD while offering management strategies.

There were multiple poster sessions from basic and translational science to clinical and population studies, many contributed by our fellows-in-training. Especially engaging were the moderated poster sessions on "advances in single ventricle care", "unique investigations in congenital heart anatomy and function", and AI.

McNamara Lecture The Dan G. McNamara keynote 5 at ACC.24 was given by Dr. Josephine Isabel-Jones, who played a pivotal role in promoting diversity, equity, and inclusion within the ACPC workforce with her enduring legacy. She emphasized the critical importance of diversity in advancing our field, now one of the pillars of the ACC strategic plan.

ACPC Section Meeting Also well attended was the ACPC Member Section meeting which celebrated the past year's achievements of the section work groups: Cardiology Chiefs, Fellowship Training Directors, Education, Advocacy, AI, Quality, Women in Cardiology, and Publication/Communication. We are grateful for the leadership of Dr. Ritu Sachdeva, our Section Chair. The ACPC Member Section aims to be your professional ACC home, and there truly are multiple ways to be involved.

We look forward to ACC.25 with Drs. Anna Kamp and Ali Zaidi leading the ACPC sessions and are hoping for continued member engagement and involvement. See you in Chicago in 2025!

PS: If you were unable to make it to Atlanta, check out "ACC Anywhere" and don't forget to claim your ABP MOC Part 4 credit for the sessions you've attended!

• From the Surgeon Lens: Valvular Heart Surgery in Complex CHD. Presented at the American College of Cardiology Annual Scientific Session (ACC.24), April 6, 2024.
• April Adventure – Game of Shones. Presented at the American College of Cardiology Annual Scientific Session (ACC.24), April 6, 2024.
• Year in Review: Pediatric and Congenital Heart Disease. Presented by Dr. Anne Marie Valente at the American College of Cardiology Annual Scientific Session (ACC.24), April 7, 2024.
• Pregnancy in Congenital Heart Disease: High Risk, High Reward! Presented at the American College of Cardiology Annual Scientific Session (ACC.24), April 7, 2024.
• Dan G. McNamara Keynote Lecture: From Civil Rights to Patient Equity – A Legacy of Strength. Presented by Dr. Josephine B. Isabel-Jones at the American College of Cardiology Annual Scientific Session (ACC.24), April 6, 2024.

Clinical Topics: Congenital Heart Disease and Pediatric Cardiology, Congenital Heart Disease

Keywords: ACC Annual Scientific Session, ACC24, Heart Defects, Congenital, Pediatrics

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