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Here is a comprehensive summary of the 2025 AHA/ACC Hypertensive Disorders of Pregnancy (HDP) Guidelines — the most significant update since 2017, published September 16, 2025 in Circulation (PMID 40811497).
2025 AHA/ACC Guidelines: Hypertensive Disorders of Pregnancy
What's New
For the first time, the AHA/ACC guideline formally incorporates a dedicated section (Section 5.5) on hypertension in pregnancy — recommendations previously left to ACOG alone.
Classification of HDP (Table 20 of guideline)
| Condition | Definition |
|---|---|
| Chronic hypertension | Diagnosed before pregnancy or before 20 weeks' gestation |
| Gestational hypertension | De novo hypertension ≥20 weeks' gestation, no proteinuria or end-organ signs |
| Preeclampsia | Gestational hypertension + proteinuria or end-organ dysfunction (neurologic, pulmonary edema, hematologic, AKI, hepatic) |
| Preeclampsia superimposed on chronic hypertension | Preeclampsia in a woman with pre-existing hypertension |
| Postpartum chronic HTN | Persistent BP elevation beyond ~12 weeks postpartum in those with gestational HTN or preeclampsia |
Note: ACOG defines hypertension at ≥140/90 mmHg. The AHA/ACC general adult threshold of ≥130/80 mmHg does not apply in pregnancy.
BP Targets
| Situation | Target |
|---|---|
| Chronic hypertension in pregnancy | <140/90 mmHg (COR 1 / LOE B-R) |
| Planning pregnancy (pre-conception) | <140/90 mmHg (reasonable; insufficient data to support <130/80) |
| Severe-range hypertension (≥160/110) | Requires urgent treatment to prevent stroke/eclampsia |
Evidence base: The CHAP Trial (NEJM 2022) showed that targeting BP <140/90 mmHg in mild chronic hypertension improved perinatal outcomes without impairing fetal growth, compared to the prior threshold of <160/105 mmHg.
Preferred Antihypertensives in Pregnancy
First-line agents (no preference between them — insufficient head-to-head data):
- Labetalol
- Extended-release nifedipine
Methyldopa, previously the go-to agent, has been stepped down. A Cochrane review (Abalos et al., 2018) supported this shift.
For acute severe-range hypertension (≥160/110 mmHg):
- IV labetalol, IV hydralazine
- Immediate-release oral nifedipine (meta-analysis showed faster time to target BP specifically in pregnancy — acceptable here, unlike other hypertension contexts)
Medications to AVOID (COR 3: Harm)
| Drug Class | Reason |
|---|---|
| ACE inhibitors | Fetal renal toxicity, oligohydramnios |
| ARBs | Same as ACEi |
| Direct renin inhibitors | Fetal harm |
| Nitroprusside | ⬅ Newly added — cyanide toxicity risk to fetus |
| Mineralocorticoid receptor antagonists (MRAs) | ⬅ Newly added — anti-androgenic fetal effects |
| Atenolol | Fetal growth restriction |
Aspirin for Preeclampsia Prevention
- COR 1 / LOE B-R: All individuals with hypertension planning pregnancy or who become pregnant should be counseled about low-dose aspirin (81 mg/day) to reduce preeclampsia risk.
- Start between 12–28 weeks' gestation (not at the start of pregnancy).
Postpartum Considerations
- Women with gestational hypertension or preeclampsia should have BP checked 3–10 days after delivery (new recommendation).
- Persistent BP elevation beyond ~12 weeks postpartum → reclassified as new chronic hypertension.
- HDP is an established long-term cardiovascular risk factor: 2× higher risk of future HTN and CVD; up to 8× risk for early-onset preeclampsia.
- Affects 36.5% of women who had HDP in their first pregnancy vs. 17% with uncomplicated pregnancies by 2–7 years postpartum (Creasy & Resnik's Maternal-Fetal Medicine).
Monitoring
- Use BP monitors validated specifically for pregnancy (see validatebp.org) — standard monitors may be inaccurate due to hemodynamic changes in pregnancy.
- Physiological BP nadir occurs in the second trimester (~10% below baseline), returning to baseline by the third trimester — this affects classification timing.
Key Takeaways (What Changed from 2017)
| Domain | 2017 | 2025 |
|---|---|---|
| Pregnancy section | Not included | Formally added (Section 5.5) |
| BP target in chronic HTN in pregnancy | Not specified | <140/90 mmHg (COR 1) |
| First-line drug | Methyldopa (ACOG default) | Labetalol or ER nifedipine |
| Drugs to avoid | ACEi, DRI | + ARBs, nitroprusside, MRAs, atenolol |
| Aspirin guidance | Not in AHA/ACC | COR 1 recommendation, 12–28 wks |
| Postpartum BP check | Not specified | 3–10 days after delivery (new) |
| Terminology | "Hypertensive urgency" | Replaced by "severe hypertension without acute target-organ damage" |
Source: Jones DW et al. 2025 AHA/ACC/Multispecialty Guideline for Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. Circulation. 2025;152:e114–e218. PMID 40811497
Any new guideline in 2026 by fogsi,gestosis and icog on hdp?
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FOGSI GESTOSIS ICOG 2026 HDP guideline eclampsia management postpartum screening antihypertensives delivery
Yes — the FOGSI-GESTOSIS-ICOG HDP Good Clinical Practice Recommendations, 3rd Edition 2026 was released in January 2026. Here is a detailed summary:
FOGSI-GESTOSIS-ICOG HDP GCPR — 3rd Edition 2026
Published by:
- President, FOGSI: Dr Bhaskar Pal
- President, Gestosis India: Dr Alpesh Gandhi
- Chairperson, ICOG: Dr Sheela Mane
Editions: 1st – 2014 | 2nd – 2019 | 3rd – 2026
Full PDF: fogsi.org
Classification of HDP (Section 3)
| Category | Definition |
|---|---|
| Gestational hypertension | BP ≥140/90 mmHg on 2 occasions ≥4 hours apart, after 20 weeks, returning to normal within 6 weeks postpartum, without other preeclampsia features |
| Preeclampsia without severe features | BP ≥140/90 and ≤160/110 mmHg; no premonitory symptoms; normal labs |
| Preeclampsia with severe features | BP ≥160/110 mmHg, with or without premonitory symptoms |
| Chronic hypertension | Hypertension before pregnancy or before 20 weeks, persisting beyond 6 weeks postpartum (essential or secondary) |
| Superimposed preeclampsia | Preeclampsia occurring in a woman with chronic hypertension |
| White coat hypertension | BP ≥140/90 in clinic, but <135/85 at home/ABPM |
| Masked hypertension | BP <140/90 in clinic, but ≥135/85 at home/ABPM |
| Postpartum hypertension | BP ≥140/90 after delivery (de novo or continuation of pre-existing HDP) |
Screening for Preeclampsia (Section 4)
Two approaches are endorsed:
4.1 HDP Gestosis Score (History-Based)
- A risk stratification tool using clinical risk factors
- Score ≥3 → initiate low-dose aspirin
- Risk factors include: prior preeclampsia, diabetes, chronic hypertension, renal disease, autoimmune disease, multiple pregnancy, nulliparity, obesity, etc.
4.2 Multimodal Screening (11–14 weeks)
Combines:
- Maternal characteristics
- Mean Arterial Pressure (MAP)
- Uterine artery Doppler mean pulsatility index (PI)
- Serum Placental Growth Factor (PlGF)
Either approach may be used depending on available resources, but preeclampsia screening must be integrated into routine antenatal care.
Prevention of Preeclampsia (Section 5)
Aspirin (Section 5.1)
| Parameter | Recommendation |
|---|---|
| Dose — Gestosis score positive | 75 mg/day |
| Dose — Multimodal screening positive | 150 mg/day |
| Timing | Start as early as possible; optimally before 16 weeks |
| Latest start | Up to 20 weeks (still offers some benefit) |
| Compliance | >90% required for significant risk reduction |
Medical Management (Section 8)
- All forms of HDP (chronic HTN, gestational HTN, preeclampsia) should be treated with antihypertensives when BP ≥140/90 mmHg (consistent with ISSHP/WOG recommendations)
- Target BP: ≤140/90 mmHg — lower promptly but gradually
- Intrapartum: Hourly BP recording in labour; if BP ≥160/110 mmHg, repeat every 15–30 minutes until controlled
Acute Severe Hypertension (≥160/110 mmHg)
- IV labetalol (see Annexure 4 for preparation protocol)
- IV hydralazine
- Immediate-release oral nifedipine
- Nicardipine IV: Starting 1.5 mg/h, up to 6 mg/h — highlighted as an easily titratable IV calcium channel blocker (100× more water-soluble than nifedipine)
MgSO₄ (Seizure Prophylaxis & Treatment)
- Loading dose recommended for ALL cases of severe preeclampsia, followed by maintenance for 24 hours
- Also provides neuroprotection for pregnancies between 26–32 weeks
Antenatal Corticosteroids (Section 8.6)
Indicated in:
- Established preterm labour
- PPROM
- When delivery is expected prematurely due to HDP severity
Fetal Monitoring (Section 7/Biophysical)
| Scenario | Monitoring |
|---|---|
| Chronic HTN or prior severe PE/abruption/IUFD | Growth scan + Dopplers every 4 weeks from 28 weeks |
| Gestational HTN without severe features | Growth scan + Dopplers from diagnosis; 4-weekly if normal |
| Preeclampsia with severe features | Inpatient; CTG on admission then as clinically indicated; BPP |
| FGR with absent/reversed end-diastolic flow, abnormal DV before 32 weeks or abnormal MCA/CPR <5th centile after 32 weeks | Daily CTG; consider inpatient management |
Delivery Decisions (Section 9)
| Condition | Timing |
|---|---|
| Gestational HTN, occasional mild BP rise, not on antihypertensives | 38 completed weeks |
| Gestational HTN with comorbidities (DM, obesity, frequent BP elevation) | 37 completed weeks |
| Chronic hypertension on medication | 37–38 completed weeks |
| Preeclampsia without severe features | 37 completed weeks |
| Preeclampsia with complications | 34–37 weeks (individualized) |
| Severe preeclampsia with worsening trend | Earlier, based on clinical features |
Postpartum Hypertension (Section 11)
- Defined as BP ≥140/90 mmHg after delivery (de novo or continuing)
- Requires close monitoring and vigilant management to prevent adverse maternal outcomes
- Long-term cardiovascular follow-up is standardized for all women with prior HDP
Long-Term Prognosis (Section 12)
- Women with prior HDP have substantially increased lifetime CVD risk
- Guideline explicitly recommends standardized long-term cardiovascular follow-up for all affected women
Summary of Key New Features vs. 2019 Edition
| Feature | Update |
|---|---|
| Gestosis Score | Formalized as dual-tier screening (score ≥3 → aspirin 75 mg; multimodal positive → 150 mg) |
| Masked & White Coat HTN | Formally classified using ABPM/home BP criteria |
| Nicardipine IV | Added as an option for acute severe HTN |
| Postpartum HTN | Explicitly defined and given dedicated management section |
| Long-term CV follow-up | Standardized recommendation added |
| Fetal monitoring Doppler criteria | Detailed decision tree for absent/reversed EDF and abnormal DV Dopplers |
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