Top Things to Know: Hypertension in Pregnancy: Diagnosis, Blood Pressure Goals, and Pharmacotherapy
Published: December 15, 2021
Prepared by Anne Leonard MPH, RN, FAHA , Senior Science and Medicine Advisor, Lead
- Hypertensive disorders of pregnancy (HDP) include chronic hypertension, gestational hypertension, preeclampsia/eclampsia and preeclampsia in chronic hypertension.
- Most guidelines around the world are in alignment in defining HDP as blood pressure (BP) >140/90 mmHg. There is variability regarding the threshold for initiating antihypertensive treatment due to uncertainty about the maternal benefits of lowering BP and potential fetal risks from medication induced reductions in utero-placental circulation and in utero exposure to antihypertensive medications.
- Some guidelines recommend withholding antihypertensive therapy for patients with preeclampsia unless BP approaches 160/110 mm Hg. It is also recommended urgent delivery for women with severe features of preeclampsia, which include uncontrollable HTN with BP ≥160/ 110 mm Hg, even for pregnancies < 34 gestational weeks, unless high level care is available in facilities with adequate maternal and neonatal intensive care resources.
- Lowering thresholds for treatment of hypertension may allow for timely blood pressure control and avoidance of a rushed delivery that commonly leads to neonatal prematurity and related complications.
- Diagnostic and treatment thresholds for the general population have evolved over the years with the ACC/AHA Guidelines for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults threshold of Stage 1 hypertension lowered to 130/80 mmHg from 140/90 mmHg with evidence of reduced cardiovascular events with treatment to lower levels.
- This scientific statement presents a synthesis of the scientific evidence that is relevant to the current controversies regarding HDP diagnostic and treatment strategies. This statement also calls out the long-term maternal and off-spring complications of HDP.
- Table 6 of this statement points out the key differences between published guidelines for the diagnosis and treatment of HDP across several different societies.
- Primary and secondary causes of hypertension in pregnancy among young women is discussed in this statement as well as postpartum hypertension and postpartum preeclampsia.
- This statement submits the evidence that antihypertensive therapy for pregnancy hypertension of any type reduces by about half the incidence of severe hypertension. This may be especially important for under-resourced communities with less experience and lower capacity to respond to hypertensive urgencies/emergencies.
- Based on existing data physicians are encouraged to individualize treatment decisions, taking all risk factors into account including women with pre-existing heart or kidney disease, obesity and Black race. This statement highly recommends the need for future research aimed at recognizing and appropriately treating HDP.
- HDP are a major health problem for pregnant women. Currently each woman should be evaluated on an individual basis and her hypertension treated to her individual risks to reduce the maternal morbidity and mortality associated with HDP.
Citation
Garovic VD, Dechend R, Easterling T, Karumanchi SA, McMurtry Baird S, Magee LA, Rana S, Vermunt JV, August P; on behalf of the American Heart Association Council on Hypertension; Council on the Kidney in Cardiovascular Disease, Kidney in Heart Disease Science Committee; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Lifestyle and Cardiometabolic Health; Council on Peripheral Vascular Disease; and Stroke Council. Hypertension in pregnancy: diagnosis, blood pressure goals, and pharmacotherapy: a scientific statement from the American Heart Association [published online ahead of print December 15, 2021]. Hypertension. doi: 10.1161/HYP.0000000000000208