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Gestational Hypertension - Guidelines & Management
Definition
Gestational hypertension (GH) is defined as new-onset hypertension (SBP ≥140 mmHg or DBP ≥90 mmHg) after 20 weeks of gestation, in the absence of proteinuria or other features of end-organ dysfunction, that resolves within 3 months of delivery.
- It is a provisional diagnosis - it includes women who will later develop preeclampsia but have not yet shown proteinuria.
- If BP does not normalize by 6-12 weeks postpartum, the diagnosis is revised to chronic hypertension.
- Incidence: ~6-7% of pregnancies.
(Creasy & Resnik's Maternal-Fetal Medicine; Fuster and Hurst's The Heart, 15e)
Classification of Hypertensive Disorders of Pregnancy
| Condition | Definition |
|---|---|
| Chronic hypertension | BP ≥140/90 before 20 weeks OR pre-existing hypertension |
| Gestational hypertension | New BP ≥140/90 after 20 weeks, no proteinuria or end-organ damage |
| Preeclampsia | New BP ≥140/90 after 20 weeks + proteinuria ≥300 mg/24h OR end-organ findings |
| Preeclampsia with severe features | BP ≥160/110 OR cerebral/visual symptoms, pulmonary edema, elevated LFTs ×2, thrombocytopenia <100,000, Cr >1.1 |
| Eclampsia | Generalized seizures in a woman with preeclampsia |
| Superimposed preeclampsia | New proteinuria or worsening BP in a woman with chronic hypertension |
Note: ACOG has eliminated "mild preeclampsia" - it is now "preeclampsia without severe features."
Key Diagnostic Points
- No longer used: Incremental BP rise of 30/15 mmHg - this was part of older criteria and is not included in current diagnostic criteria (no evidence of increased adverse outcomes in this group).
- Proteinuria definitions: ≥300 mg/24h urine, or protein:creatinine ratio ≥0.3; dipstick 2+ is only acceptable if quantitative methods unavailable.
- GH and preeclampsia are likely a spectrum - 15-25% of patients with GH will develop overt preeclampsia.
(Creasy & Resnik's Maternal-Fetal Medicine; Harrison's 22e)
Monitoring / Surveillance
Women with GH should be monitored closely for progression to preeclampsia:
- Frequent BP checks
- Watch for new proteinuria, visual changes, headache, RUQ pain, lab abnormalities (LFTs, platelets, creatinine)
- Fetal surveillance (NST, BPP, fetal growth assessment) given increased risk of IUGR and preterm delivery
Antihypertensive Therapy
The BP threshold for initiating antihypertensive treatment differs slightly across guidelines, but treatment is clearly indicated for severe-range BP (≥160/110 mmHg) to reduce risk of stroke and maternal morbidity.
Oral Antihypertensives (First-Line)
| Drug | Starting Dose | Max Daily Dose | Key Side Effects |
|---|---|---|---|
| Labetalol | 200 mg twice daily | 1200 mg | Bronchospasm, fatigue |
| Long-acting nifedipine | 30 mg daily | 120 mg | Edema, headache |
| Methyldopa | 250 mg twice daily | 2000 mg | Sedation, fatigue, hemolytic anemia (rare) |
| Hydralazine | 50 mg three times daily | 300 mg | Reflex tachycardia |
- Second-line oral: Other beta-blockers (excluding atenolol), calcium channel blockers
- Contraindicated in pregnancy: ACE inhibitors, ARBs, atenolol
IV Therapy (for Acute Severe HTN)
Indicated when SBP ≥160 or DBP ≥110:
- IV Labetalol (first-line)
- IV Hydralazine
- IV Sodium nitroprusside or nitroglycerin (for acute decompensation)
(NKF Primer on Kidney Diseases, 8e; Fuster and Hurst's The Heart, 15e)
BP Targets
- Avoid reducing BP below 120/80 mmHg (risk of fetoplacental hypoperfusion).
- Upper goal: <160/105-110 mmHg in uncomplicated cases.
- The CHIPS trial (tight control - target diastolic 85 mmHg vs less-tight - target diastolic 100 mmHg) found no significant difference in the composite of pregnancy loss or need for high-level neonatal care, though severe maternal hypertension was less frequent with tight control (27.5% vs 40.6%).
Delivery
- GH/preeclampsia without severe features: Expectant management acceptable; deliver at 37 weeks.
- GH/preeclampsia with severe features: Deliver unless <34 weeks (consider expectant in tertiary center).
- Indications for delivery before 34 weeks: unrelenting symptoms, lab abnormalities, or BP refractory to medical management.
- Definitive treatment is delivery of the fetus and placenta.
(Barash Clinical Anesthesia, 9e; Harrison's 22e)
Prevention
- Low-dose aspirin (60-150 mg/day) initiated at 12-14 weeks of gestation is recommended for women at high risk of preeclampsia (including those with chronic or prior gestational hypertension, to reduce preeclampsia risk).
Postpartum Follow-up
- BP often improves in the first 48 hours postpartum, then may worsen again at 3-6 days.
- Blood pressure check recommended 7-10 days after delivery (or earlier if symptomatic).
- Women with GH carry increased long-term risk for hypertension, cardiovascular disease, chronic kidney disease, and diabetes mellitus.
(Creasy & Resnik's Maternal-Fetal Medicine, pp. 1055-1140; Harrison's Principles of Internal Medicine 22e)
Summary of ACOG Key Changes (vs Older Guidelines)
- The term "mild preeclampsia" is abandoned - now "preeclampsia without severe features."
- Incremental BP rise criteria (30/15 mmHg) removed.
- Proteinuria is not required for preeclampsia diagnosis if end-organ involvement is present.
- Gestational hypertension with severe features is best classified as preeclampsia.
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