Practice Guidelines

Gestational Hypertension and Preeclampsia:​

A Practice Bulletin from ACOG
twice on measurements taken four or more hours apart.
Key Points for Practice Hypertension is considered severe when blood pressure is
• Low-dose aspirin therapy should be started between at least 160 mm Hg systolic or at least 110 mm Hg diastolic.
12 and 28 weeks’ gestation for patients with one high risk
Severe blood pressure values should be confirmed within a
factor or two moderate risk factors for preeclampsia.
few minutes to facilitate timely intervention.
• Any patient with preeclampsia or gestational hyperten-
sion at 37 weeks’ gestation or greater should proceed to
To diagnose preeclampsia, women with hypertension also
delivery. will have proteinuria, defined as at least 300 mg per 24-hour
• Patients with preeclampsia or gestational hypertension urine collection, a protein-to-creatinine ratio of at least
with severe features at 34 weeks’ gestation or greater 0.3 mg per dL, or urine dipstick test result of 2+. If patients
should proceed to delivery, whereas expectant manage- do not have proteinuria, preeclampsia can still be diagnosed
ment can be considered at less than 34 weeks’ gestation. if they also have new-onset thrombocytopenia;​renal insuf-
From the AFP Editors ficiency;​impaired liver function combined with right upper
quadrant or epigastric pain unresponsive to medication and
Preeclampsia, a disorder of pregnancy associated with not attributed to other etiologies;​pulmonary edema;​head-
new-onset hypertension, occurs in up to 8% of pregnancies ache not amenable to treatment or that cannot be attributed
globally, with an incidence that increased by 25% from 1987 to another etiology; or vision problems. Eclampsia, which
to 2004 in the United States. Globally, hypertensive disor- is new-onset seizures not attributed to other etiologies (e.g.,
ders of pregnancy are one of the main causes of maternal epilepsy), is one of the more severe manifestations of hyper-
death. The American College of Obstetricians and Gyne- tensive disorders of pregnancy and also a main contributor
cologists (ACOG) has released a practice bulletin to out- to maternal death.
line diagnosis and treatment recommendations for these Gestational hypertension is diagnosed in patients with
conditions. the hypertension criteria for preeclampsia without the pro-
teinuria or severe features. Up to 50% of women diagnosed
Preeclampsia with gestational hypertension will develop preeclampsia.
Preeclampsia most commonly occurs in healthy women Gestational hypertension with severe range blood pressures
without risk factors or previous delivery; it typically pre- should be managed in the same way as preeclampsia with
sents after 20 weeks’ gestation, usually near term. Risk is severe features because of similar risk.
increased in patients with the factors noted in Table 1.
The presence of hypertension and proteinuria is most Recommendations
commonly used to diagnose preeclampsia. In a woman GOOD EVIDENCE
at 20 weeks’ gestation or more whose blood pressure was Low-dose aspirin has been shown to reduce the incidence
previously in the healthy range, hypertension is defined as of preeclampsia in high-risk women. Women with one high
at least 140 mm Hg systolic or at least 90 mm Hg diastolic risk factor or those with at least two moderate risk factors
from Table 1 should take 81 mg of aspirin daily, starting at
12 to 28 weeks’ gestation, preferably by 16 weeks, until the
Coverage of guidelines from other organizations does not infant is delivered.
imply endorsement by AFP or the AAFP.
Women with gestational hypertension or preeclampsia
This series is coordinated by Sumi Sexton, MD,
with severe features or eclampsia should receive magnesium
editor-in-chief.
sulfate to help prevent and manage seizures during stabili-
A collection of Practice Guidelines published in AFP is avail-
able at https://​w ww.aafp.org/afp/practguide.
zation and until 24 hours after delivery. However, there is
CME This clinical content conforms to AAFP criteria for
debate surrounding the use of magnesium sulfate in women
continuing medical education (CME). See CME Quiz on with nonsevere gestational hypertension or preeclampsia
page 607. due to lower risk of eclampsia;​decisions about its use in this
Author disclosure:​ No relevant financial affiliations. patient population should be based on physician and patient
preferences, as well as the associated benefits and harms. In

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 PRACTICE GUIDELINES

with severe features, noting that the mother’s con-

TABLE 1 dition should be stabilized first. Physicians should
not delay delivery to complete steroid administra-
Clinical Risk Factors for Preeclampsia tion. In a patient who has preeclampsia with severe
Risk level Risk factors features before 34 weeks’ gestation, expectant
management can be considered based on shared
High Autoimmune disease (e.g., systemic lupus
decision making and local capabilities. If the
erythematosus, antiphospholipid syndrome)
mother’s or infant’s condition worsens, expect-
Chronic hypertension
ant management should be stopped and delivery
Diabetes mellitus – type 1 or type 2
performed. If the infant is not expected to survive,
History of preeclampsia expectant management is not appropriate because
Multifetal gestation increased maternal risks are not offset by any ben-
Renal disease efit to the infant.
Moderate Age 35 years or older
When a woman presents with severe hyperten-
sion lasting at least 15 minutes, antihypertensive
Black race or low socioeconomic status
treatment, typically with oral nifedipine or intra-
Family history of preeclampsia (mother or
sister)
venous hydralazine or labetalol, should be started
as soon as possible and within 60 minutes of pre-
History of low-birth-weight infant, adverse
pregnancy outcome, or more than 10 years sentation to avoid such adverse outcomes as con-
between pregnancies gestive heart failure, myocardial ischemia, renal
Obesity (body mass index > 30 kg per m2) failure, and stroke.
Nulliparity
CONSENSUS AND EXPERT OPINION
Epidural and spinal anesthesia are appropriate
any patient receiving magnesium sulfate, urine options during delivery for women who have a
output, respiration, and tendon reflexes should stable platelet count of at least 70 × 103 per μL
be monitored. Despite interactions with some (70 × 109 per L), without coagulopathy, platelet
muscle relaxants used in general anesthesia, the function abnormalities, or active anticoagulant
magnesium sulfate infusion should be given to or antiplatelet therapy. The risk of hematoma
women with preeclampsia undergoing cesarean associated with epidural anesthesia is low.
delivery. Delivery is recommended in women Guideline source:​ American College of Obstetricians
who are diagnosed with gestational hypertension and Gynecologists
or preeclampsia of any severity at 37 weeks’ ges-
Evidence rating system used? Yes
tation or later.
Systematic literature search described? Yes
Nonsteroidal anti-inflammatory drugs (NSAID)
are preferred over opioids for treating pain after Guideline developed by participants without
relevant financial ties to industry? Not reported
delivery, with their safety supported by evidence.
Studies of postpartum women receiving magne- Recommendations based on patient-oriented
outcomes? Yes
sium prophylaxis after delivery showed no adverse
effects from NSAID use. Published source:​ Obstet Gynecol. January 2019;​
133(1):​211-214
LIMITED OR INCONSISTENT EVIDENCE Available at:​ https://​journals.lww.com/greenjournal/
Because of the likelihood of harm to the infant fulltext/2019/01000/ACOG_Practice_Bulletin_
No__202_Summary_.42.aspx
and mother, delivery is recommended in women
at 34 weeks’ gestation or later who are diagnosed Lisa Croke
with preeclampsia or gestational hypertension AFP Senior Associate Editor ■

650  American Family Physician www.aafp.org/afp Volume 100, Number 10 ◆ November 15, 2019