Gestational hypertension is a form of high blood pressure in pregnancy. It occurs in about 6 percent of all pregnancies. Another type of high blood pressure is chronic hypertension--high blood pressure that is present before pregnancy begins. Show
Gestational hypertension can develop into preeclampsia. This condition occurs often in young women with a first pregnancy. It is more common in twin pregnancies, in women over the age of 35, in women with chronic hypertension or who had hypertension in a previous pregnancy, in African-American women, and in women with diabetes. Gestational hypertension is diagnosed when blood pressure readings are higher than 140/90 mm Hg in a woman who had normal blood pressure prior to 20 weeks and has no proteinuria (excess protein in the urine). Preeclampsia is diagnosed when a woman with gestational hypertension also has increased protein in her urine. Eclampsia is a severe form of preeclampsia. Women with eclampsia have seizures resulting from the condition. Eclampsia occurs in about one in 1,600 pregnancies and develops near the end of pregnancy, in most cases. HELLP syndrome is a complication of severe preeclampsia or eclampsia. HELLP syndrome is a group of physical changes including the breakdown of red blood cells, changes in the liver, and low platelets (cells found in the blood that are needed to help the blood to clot in order to control bleeding).
The cause of gestational hypertension is unknown. Some conditions may increase the risk of developing the condition, including the following:
With high blood pressure, there is an increase in the resistance of blood vessels. This may hinder blood flow in many different organ systems in the expectant mother including the liver, kidneys, brain, uterus, and placenta. There are other problems that may develop as a result of severe gestational hypertension (blood pressure readings that are higher than 160/110 mm Hg). Placental abruption (premature detachment of the placenta from the uterus) may occur in some pregnancies. Gestational hypertension can also lead to fetal problems including intrauterine growth restriction (poor fetal growth) and stillbirth. If untreated, severe gestational hypertension may cause dangerous seizures (eclampsia) and even death in the mother and fetus. Because of these risks, it may be necessary for the baby to be delivered early, before 37 weeks gestation.
The following are the most common symptoms of high blood pressure in pregnancy. However, each woman may experience symptoms differently, and a patient with gestational hypertension may be completely asymptomatic. Symptoms may include:
Diagnosis is often based on the increase in blood pressure levels, but other symptoms may help establish gestational hypertension as the diagnosis. Tests for gestational hypertension may include the following:
Specific treatment for gestational hypertension will be determined by your doctor based on:
The goal of treatment is to prevent the condition from becoming worse and to prevent it from causing other complications. Treatment for gestational hypertension may include:
Early identification of women at risk for gestational hypertension may help prevent some complications of the disease. Education about the warning symptoms is also important because early recognition may help women receive treatment and prevent worsening of the disease.
and on behalf of the International Society for the Study of Hypertension in Pregnancy (ISSHP) These recommendations from the International Society for the Study of Hypertension in Pregnancy (ISSHP) are based on available literature and expert opinion. It is intended that this be a living document, to be updated when needed as more research becomes available to influence good clinical practice. Unfortunately, there is a relative lack of high-quality randomized trials in the field of hypertension in pregnancy compared with studies in essential hypertension outside of pregnancy, and ISSHP encourages greater funding and uptake of collaborative research in this field. Accordingly, the quality of evidence for the recommendations in this document has not been graded although relevant references and explanations are provided for each recommendation. The document will be a living guideline, and we hope to be able to grade recommendations in the future. Guidelines and recommendations for management of hypertension in pregnancy are typically written for implementation in an ideal setting. It is acknowledged that in many parts of the world, it will not be possible to adopt all of these recommendations; for this reason, options for management in less-resourced settings are discussed separately in relation to diagnosis, evaluation, and treatment. This document has been endorsed by the International Society of Obstetric Medicine and the Japanese Society for the Study of Hypertension in Pregnancy. Key PointsAll units managing hypertensive pregnant women should maintain and review uniform departmental management protocols and conduct regular audits of maternal and fetal outcomes. The cause(s) of preeclampsia and the optimal clinical management of the hypertensive disorders of pregnancy remain uncertain; therefore, we recommend that every hypertensive pregnant woman be offered an opportunity to participate in research, clinical trials, and follow-up studies. Classification
Diagnosis of Hypertension and Proteinuria
Prediction and Prevention of Preeclampsia and Associated Complications
Management
Postpartum Care
IntroductionWorldwide there is disagreement about many aspects of the classification, diagnosis, and management of the hypertensive disorders of pregnancy. This lack of consensus hampers our ability to study not only the immediate rates of adverse maternal and fetal outcomes for the various hypertensive disorders in pregnancy, particularly preeclampsia, but also the long-term health outcomes of women and babies who survive this condition. It also impacts on research into the pathophysiology of this condition and has almost certainly delayed the development of effective screening tests and treatments, leading to poorer pregnancy outcomes. One scholarly review of available guidelines has shown broad agreement in the following areas1:
However, in this analysis, there was little or no agreement on
After the 2016 World Congress of the ISSHP, it was agreed that a single up-to-date guideline should be available that reflects current evidence, and both the collective expertise of the ISSHP membership and the leadership role that ISSHP would like to take in improving hypertension-related outcomes in pregnancy. After the Congress, ISSHP charged a small group of clinician researchers to update the last statements from ISSHP 2013 and 2014.2,3 This set of recommendations provides practical advice on classification, diagnostic criteria, and management for all clinicians, everywhere, who are involved in the management of women with hypertension in pregnancy. Section 1. Classification of the Hypertensive Disorders of PregnancyThe recommended classification for hypertensive disorders of pregnancy is as follows:
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Section 2. Diagnosis of the Hypertensive Disorders of PregnancyWhat Constitutes Hypertension in Pregnancy?
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What Constitutes Abnormal Proteinuria in Pregnancy?
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It is, therefore, recommended to monitor these women more frequently than usual for the remainder of their pregnancy, as well as to assess proteinuria at 3 months postpartum.
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ISSHP recommends that all women with chronic hypertension in pregnancy have the following tests performed at first diagnosis. This will provide a baseline reference should suspicion arise later in pregnancy of superimposed preeclampsia (which will complicate up to 25% of these pregnancies).
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Hemolysis, elevated liver enzymes, low platelets: The combination of all or some of hemolysis, elevated liver enzymes and thrombocytopenia is often referred to as the HELLP syndrome. For clinicians familiar with the management of preeclampsia, this constellation of abnormalities signifies a more serious part of the spectrum of this disorder. However, it is still considered part of preeclampsia and not a separate disorder. ISSHP endorses this approach to reduce confusion among those less familiar with the multisystem complications that might occur in preeclampsia. In other words, women with features of HELLP syndrome should be considered to have preeclampsia so that all other features of preeclampsia will be sought and addressed.
Section 3. Prediction and Prevention of PreeclampsiaPredicting the Development of Preeclampsia
NotesMany clinical, ultrasonographic, and laboratory parameters have been explored during early pregnancy as tools for predicting who will later develop preeclampsia. These include, among others:
Maternal characteristics that are most strongly associated with an increased likelihood of preeclampsia include those listed above, as well as underlying renal disease or multiple pregnancies. Other factors less strongly associated with preeclampsia include, but are not limited to:
Tests to Rule Out Preeclampsia
NotesIn May 2016, the NICE group published NICE Diagnostics guidance (DG23; (https://www.nice.org.uk/guidance/dg23) recommending that the Elecsys immunoassay for the sFlt-1/PlGF ratio, or the Triage PlGF test, be used with standard clinical assessment to help rule out proteinuric preeclampsia or preeclampsia requiring delivery within the next 7 (for the sFlt-1/PlGF ratio) or 14 days (for Triage PlGF) in women with suspected preeclampsia between 20 and 34+6 weeks’ gestation. This recommendation was based primarily on 2 multicenter studies of women with a broad definition of suspected preeclampsia at <34+6 weeks’ gestation. The PROGNOSIS study (Prediction of Short-Term Outcome in Pregnant Women With Suspected Preeclampsia Study)54 found that a sFlt1/PlGF ratio <38 could reliably rule out development of preeclampsia for the next 7 days in women with a wide range of inclusion criteria; this finding may not be of any clinical advantage in centers already established for regular antenatal follow-up but may become of use in remote or low- and middle-income countries (LMIC) areas once further research is conducted. The PELICAN study (Plasma Placental Growth Factor [PlGF] in the Diagnosis of Women With Pre-eclampsia Requiring Delivery Within 14 Days)55 found that a Triage PlGF value of ≤100 pg/mL or the fifth centile of PlGF concentration for gestational age gave high sensitivity with good precision for identifying women likely to develop preeclampsia needing delivery within 14 days of testing, when presenting with suspected preeclampsia before 35 weeks’ gestation. PlGF, alone or in combination with sFlt-1, was not recommended to rule-in preeclampsia. Predicting the Course of Established PreeclampsiaThere are recent studies aiming to predict clinical outcomes for women when they initially present with early features of preeclampsia. Measurement of angiogenic factors may play a role in this regard in the future but is still at a research stage.56
NotesThe PREP Collaborative Network (Prediction of Complications in Early-Onset Preeclampsia) published prognostic models that assist predicting the overall risk of women with established preeclampsia to experience a complication using logistic regression (PREP-L) and for predicting the time to adverse maternal outcome using a survival model (PREP-S).59 The PREP-S model included maternal age, gestation, medical history, systolic BP, deep tendon reflexes, urine protein creatinine ratio, platelets, serum alanine amino transaminase, urea, creatinine, oxygen saturation, and treatment with antihypertensives or MgSO4. The PREP-L model included the above except deep tendon reflexes, serum alanine amino transaminase, and creatinine (available at http://stg.pocketapp.co.uk/qmul/#home). Prevention
Fetal Monitoring and Management for the Hypertensive Disorders of Pregnancy
NotesPreeclampsia is, at least in part, a disease of placentation/placental dysfunction and the fetus is potentially vulnerable to the effects of uteroplacental insufficiency, particularly fetal growth restriction and placental abruption.
Section 4. Management Principles for the Hypertensive Disorders of PregnancyChronic Essential Hypertension
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Chronic Hypertension Because of Renal Disease
White-Coat Hypertension
Gestational Hypertension
Figure 1. Clinical application of ambulatory blood pressure monitoring (ABPM) in early pregnancy to diagnose and manage white-coat hypertension. Hypertension is diagnosed if either systolic or diastolic blood pressure (BP) is elevated, awake or sleep. GH indicates gestational hypertension; HBPM, home blood pressure monitoring; and PE, preeclampsia (from reference 83). Notes
PreeclampsiaAntenatalISSHP endorses the following key management points:
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Intrapartum
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Postpartum
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Short-Term Follow-Up
Long-Term Follow-Up
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Section 5. Application of These ISSHP Recommendations to Low Resource CountriesGeneral Recommendations
Antenatal CareThe 2016 World Health Organization guidelines on routine antenatal care (ANC) (http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/anc-positive-pregnancy-experience/en/) recommends several health systems interventions to increase use of antenatal services and improve the quality of care delivered. Recommendations include
Prevention of Hypertensive Disorders in Pregnancy
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Early Detection and Diagnosis
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Fetal MonitoringIn some LMICs in tertiary facilities, first and midtrimester ultrasound, fetal biometry, amniotic fluid volume, and fetal Doppler studies take place. Fundal height measurements may also take place every 2 weeks. However, the recent World Health Organization ANC guidelines suggest that the following should not be continued because of insufficient evidence:
Management of Hypertensive Disorders of Pregnancy
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Figure 2. Management of severe hypertension with oral nifedipine and intravenous hydralazine. BP indicates blood pressure; CTG, cardiotocograph; DBP, diastolic BP; and SBP, systolic BP. Figure 3. One protocol for use of magnesium sulfate (MgSO4) for eclampsia treatment or prophylaxis. Check the concentration of Mg carefully to ensure a match with the doses below. Different countries may have different strength Mg concentrations. BP indicates blood pressure; and CTG, cardiotocograph. Chronic Hypertension in Pregnancy
Postnatal Care
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What Do Other Guidelines Say?ISSHP acknowledges the expertise and rigorous approach that has been undertaken in the development of several key guidelines including:
The key areas in which these guidelines differ are as follows:
Other guidelines include those of World Health Organization 2011115 and the Integrated Management of Pregnancy and Childbirth 2017.116 Adopting the management recommendations of any of these guidelines is entirely justified although one aim of the ISSHP is to see a single set of flexible and regularly updated guidelines throughout the world so as to reduce confusion around diagnosis and management of women with hypertension in pregnancy. Importantly, ISSHP recommends that each unit has a specific policy as to management guidelines that are to be followed so that there is uniform practice within each unit. In addition, each unit should strive to record and evaluate their maternal and fetal outcomes to ensure that their policies and guidelines remain appropriate at all times. Guideline ProcessThe first author drafted the initial document and sought further input from all coauthors; these authors were chosen as being expert members of the ISSHP executive (authors 1–7) with additional authors who had expertise and experience in the management of preeclampsia in low resource countries (authors 7–10). Relevant literature up to April 2017 was included with an emphasis on more recent publications; the document was revised again after the publication of the ASPRE trial in August 2017. The first version was circulated by email to all members in March 2017 and 8 subsequent versions emanated following email discussions to achieve consensus among the group. The document was then sent to all members of ISSHP Council for further comment and those who responded are listed in the acknowledgments below. The final version was concluded on December 28, 2017 and then amended after reviewers’ comments by March 1, 2018. AcknowledgmentsWe thank Prof Peter von Dadelszen and the following International Society for the Study of Hypertension in Pregnancy (ISSHP) Council members for their assistance and comments on these recommendations: Prof Nelson Sass, Brazil; Prof Marijke Faas, Netherlands; Dr Sebastian Illanes, Chile; Prof Annetine Staff, Norway; Prof Markus Mohaupt, Switzerland; Prof Lucy Chappell, United Kingdom; Prof Thomas Easterling, USA; Dr Hannele Laivouri, Finland; Prof Janos Rigo, Hungary; Dr Helena Strevens, Sweden. S.A. Karumanchi received patents on biomarkers held by Harvard hospitals and is a consultant to Thermofisher Scientific, Roche, and Aggamin LLC. The other authors report no conflicts. FootnotesReferences
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