1. Wisner, Kirsten MS, RNC-OB, CNS, C-EFM

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Hypertensive disorders of pregnancy continue to be a major contributor to maternal and perinatal morbidity and mortality. A summary of the American College of Obstetricians and Gynecologists (ACOG, 2019) updated guidelines for diagnosis and management of these disorders is presented.


Gestational hypertension is characterized by a new-onset systolic blood pressure (BP) >= 140 mmHg and/or a diastolic BP >= 90 mmHg on two occasions at least 4 hours apart, presenting after 20 weeks' gestation. It is further defined by absence of proteinuria or severe features (defined below) with a return to normotensive pressures postpartum. When gestational hypertension is in the severe range of >= 160 mmHg systolic and/or >= 110 mmHg diastolic, it is considered preeclampsia with severe features (ACOG, 2019).


Preeclampsia is defined as a new-onset systolic BP >= 140 mmHg and/or diastolic BP >= 90 mmHg on two occasions at least 4 hours apart, presenting after 20 weeks' gestation. When BPs are in the severe range (>= 160 mmHg systolic and/or >= 110 mmHg diastolic), they should be confirmed within minutes to facilitate prompt antihypertensive treatment. Preeclampsia is further defined by presence of proteinuria (defined as preeclampsia) or any of the following severe features (preeclampsia with severe features): thrombocytopenia, renal insufficiency, impaired hepatic function, pulmonary edema, or new-onset headache. See the ACOG Practice Bulletin for full details on these criteria. Note that BPs in the severe range are considered a severe feature (ACOG, 2019).


Initial evaluation of a woman presenting with a hypertensive disorder of pregnancy should include a full maternal and fetal evaluation including a complete blood cell count with platelets, serum creatinine, lactate dehydrogenase, aspartate aminotransferase, alanine aminotransferase, and an assessment of proteinuria. A uric acid test may be indicated when preeclampsia superimposed upon chronic hypertension is suspected. Fetal assessment should involve an ultrasound for fetal weight and amniotic fluid volume, and antepartum fetal testing (ACOG, 2019). See the table for an overview of management recommendations.


The guideline recommends low-dose aspirin (81 mg/day) beginning between 12 and 28 weeks of gestation (optimally before 16 weeks) for women with any high-risk factor for preeclampsia and one or more of the moderate-risk factors. High-risk factors include a history of preeclampsia, multiple gestation, renal or autoimmune disease, diabetes mellitus type 1 or 2, and chronic hypertension. Moderate-risk factors include a first pregnancy, maternal age >= 35, family history of preeclampsia, body mass index > 30, African American race, low socioeconomic status, a prior low birthweight or small for gestational age infant or adverse pregnancy outcome, and more than a 10-year pregnancy interval (ACOG, 2019).

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American College of Obstetricians and Gynecologists. (2019). Gestational hypertension and preeclampsia (Practice Bulletin No. 202). Obstetrics & Gynecology, 133(1), e1-e25. doi:10.1097/AOG.0000000000003018 [Context Link]