Hypertension in Pregnancy: Executive Summary

Hypertension in Pregnancy
Report of the American College of Obstetricians and Gynecologists

Task Force on Hypertension in Pregnancy
Executive Summary
he American College of Obstetricians and Gynecologists (the College) convened a task force of
experts in the management of hypertension in
pregnancy to review available data and publish
evidence-based recommendations for clinical practice. The
Task Force on Hypertension in Pregnancy comprised 17
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force recommendations of each chapter in the report and is
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Hypertensive disorders of pregnancy remain a major
health issue for women and their infants in the United
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women for signs of preeclampsia and then delivery to termiQDWH WKH GLVRUGHU KDV UHGXFHG WKH QXPEHU DQG H[WHQW RI
SRRURXWFRPHVVHULRXVPDWHUQDOIHWDOPRUELGLW\DQGPRUtality still occur. Some of these adverse outcomes are avoidDEOH ZKHUHDV RWKHUV FDQ EH DPHOLRUDWHG $OVR DOWKRXJK
some of the problems that face neonates are related directly
WRSUHHFODPSVLDDODUJHSURSRUWLRQDUHVHFRQGDU\WRSUHPDturity that results from the appropriate induced delivery of
the fetuses of women who are ill. Optimal management
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optimal time for both maternal and fetal well-being. More
recent clinical evidence to guide this timing is now avail-
able. Chronic hypertension is associated with fetal morbidity in the form of growth restriction and maternal morbidity
manifested as severely increased blood pressure (BP). HowHYHU PDWHUQDO DQG IHWDO PRUELGLW\ LQFUHDVH GUDPDWLFDOO\
with the superimposition of preeclampsia. One of the major
challenges in the care of women with chronic hypertension
is deciphering whether chronic hypertension has worsened
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task force provides suggestions for the recognition and management of this challenging condition.
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in the understanding of preeclampsia as well as increased
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there remain areas on which evidence is scant. The evidence
is now clear that preeclampsia is associated with later-life
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needed to determine how best to use this information to
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management of preeclampsia that warrant special attenWLRQ)LUVWLVWKHIDLOXUHE\KHDOWKFDUHSURYLGHUVWRDSSUHFLate the multisystemic nature of preeclampsia. This is in part
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diagnosis such as mild preeclampsia (which is discouraged) applies only at the moment the diagnosis is estabOLVKHG EHFDXVH SUHHFODPSVLD E\ QDWXUH LV SURJUHVVLYH
DOWKRXJKDWGLHUHQWUDWHV$SSURSULDWHPDQDJHPHQWPDQdates frequent reevaluation for severe features that indicate the actions outlined in the recommendations (which
are listed after the chapter summaries). It has been known
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1122
VOL. 122, NO. 5, NOVEMBER 2013
OBSTETRICS & GYNECOLOGY
for many years that preeclampsia can worsen or present for

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provides guidelines to attempt to reduce maternal morbidity and mortality in the postpartum period.
The Approach
The task force used the evidence assessment and recommendation strategy developed by the Grading of RecomPHQGDWLRQV $VVHVVPHQW 'HYHORSPHQW DQG (YDOXDWLRQ
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KDVEHHQDGDSWHGZRUOGZLGHE\DODUJHQXPEHURIRUJDQL]DWLRQV:LWKWKH*5$'(:RUNLQJ*URXSDSSURDFKWKHIXQFtion of expert task forces and working groups is to evaluate
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the average health care provider to accomplish. The expert
group then makes recommendations based on the evidence
that are consistent with typical patient values and preferences. The task force evaluated the evidence for each recRPPHQGDWLRQ WKH LPSOLFDWLRQV DQG WKH FRQGHQFH LQ
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information was evaluated and recommendations were
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Recommendations are practices agreed to by the task
force as the most appropriate course of action; they are
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one that is so well supported that it would be the approach
appropriate for virtually all patients. It could be the basis for
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it might not be the optimal recommendation for some
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the health care provider and patient are encouraged to work
together to arrive at a decision based on the values and
judgment and underlying health condition of a particular
patient in a particular situation.
Classication of Hypertensive Disorders of

Pregnancy
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SUDFWLFDOFODVVLFDWLRQZDVXVHGZKLFKFRQVLGHUVK\SHUWHQsion during pregnancy in only four categories: 1) preHFODPSVLDHFODPSVLD FKURQLF K\SHUWHQVLRQ RI DQ\
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V\QGURPLFQDWXUHRISUHHFODPSVLDWKHWDVNIRUFHKDVHOLPLnated the dependence of the diagnosis on proteinuria. In
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hypertension in association with thrombocytopenia (plateOHW FRXQW OHVV WKDQ PLFUROLWHU LPSDLUHG OLYHU
function (elevated blood levels of liver transaminases to
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the absence of proteinuria or the aforementioned systemic
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pregnancy; and superimposed preeclampsia is chronic hypertension in association with preeclampsia.
Establishing the Diagnosis of

Preeclampsia or Eclampsia
The BP criteria are maintained from prior recommendations.
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for diagnostic use unless other approaches are not readily
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LV FRQVLGHUHG DV WKH FXWR IRU WKH GLDJQRVLV RI SURteinuria. In view of recent studies that indicate a minimal
relationship between the quantity of urinary protein and
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(greater than 5 g) has been eliminated from the considerDWLRQRISUHHFODPSVLDDVVHYHUH$OVREHFDXVHIHWDOJURZWK
restriction is managed similarly in pregnant women with
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Prediction of Preeclampsia
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pregnancy the later development of preeclampsia. Although
Executive Summary: Hypertension in Pregnancy
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BOX E-1.
Severe Features of Preeclampsia (Any of these ndings)
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ready for clinical use.
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suggested.*
TASK FORCE RECOMMENDATION
Quality of evidence: Moderate

Strength of recommendation: 4XDOLHG
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appropriate medical history to evaluate for risk factors is
not recommended.
Strength of recommendation: Strong
Prevention of Preeclampsia
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adverse outcomes from preeclampsia in unselected women
at high risk or low risk of preeclampsia. Calcium may be
useful to reduce the severity of preeclampsia in populations
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United States. The administration of low-dose aspirin (60
80 mg) to prevent preeclampsia has been examined in
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relevant to low-risk women but may be relevant to populations at very high risk in whom the number to treat to
achieve the desired outcome will be substantially less. There
is no evidence that bed rest or salt restriction reduces preeclampsia risk.
TASK FORCE RECOMMENDATIONS
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gestation or preeclampsia in more than one prior preg-
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of aspirin to prevent preeclampsia indicates a small reduction
in the incidence and morbidity of preeclampsia and reveals no
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be excluded. The number of women to treat to have a theraSHXWLFHHFWLVGHWHUPLQHGE\SUHYDOHQFH,QYLHZRIPDWHUQDO
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preeclampsia is not recommended.
Quality of evidence: High
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ing pregnancy for the prevention of preeclampsia.
Quality of evidence: /RZ
Strength of recommendation:4XDOLHG
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physical activity not be used for the primary prevention
of preeclampsia and its complications.
Management of Preeclampsia
and HELLP Syndrome
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TABLE E-1. Diagnostic Criteria for Preeclampsia
Blood pressure
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Proteinuria
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Thrombocytopenia
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Pulmonary edema
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several important questions remain unanswered. Reviews

of maternal mortality data reveal that deaths could be
avoided if health care providers remain alert to the likelihood that preeclampsia will progress. The same reviews
indicate that intervention in acutely ill women with multiple
organ dysfunction is sometimes delayed because of the
DEVHQFH RI SURWHLQXULD )XUWKHUPRUH DFFXPXODWLQJ LQIRUmation indicates that the amount of proteinuria does not
predict maternal or fetal outcome. It is for these reasons
that the task force has recommended that alternative sysWHPLFQGLQJVZLWKQHZRQVHWK\SHUWHQVLRQFDQIXOOOWKH
diagnosis of preeclampsia even in the absence of proteinuria.
Perhaps the biggest changes in preeclampsia management relate to the timing of delivery in women with preecODPSVLDZLWKRXWVHYHUHIHDWXUHVZKLFKEDVHGRQHYLGHQFHLV
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awareness of the importance of preeclampsia in the postpartum period. Health care providers are reminded of the conWULEXWLRQ RI QRQVWHURLGDO DQWLLQDPPDWRU\ DJHQWV WR
increased BP. It is suggested that these commonly used
postpartum pain relief agents be replaced by other analgesics in women with hypertension that persists for more than
1 day postpartum.
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serial assessment of maternal symptoms and fetal movement (daily byWKHZRPDQVHULDOPHDVXUHPHQWVRI%3
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BP at least once weekly with proteinuria assessment in
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rest not be prescribed.*
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*The task force acknowledged that there may be situations in
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may be indicated for individual women. The previous recommendations do not cover advice regarding overall physical acWLYLW\DQGPDQXDORURFHZRUN
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is resource intensive and should be considered as a priority for
research and future recommendations.
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use of ultrasonography to assess fetal growth and antenatal testing to assess fetal status is suggested.
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antenatal test is recommended.
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GHOLYHU\DWOHVVWKDQZHHNVRIJHVWDWLRQH[SHFtant management with maternal and fetal monitoring is
suggested.
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than 160 mm Hg and a diastolic BP less than 110 mm Hg
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maternal or fetal conditions irrespective of gestational
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0/7 weeks of gestation with stable maternal and fetal
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be undertaken only at facilities with adequate maternal and neonatal intensive care resources.
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administration of corticosteroids for fetal lung maturity
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during pregnancy (sustained systolic BP of at least 160
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antihypertensive therapy is recommended.
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delivery decision should not be based on the amount of
proteinuria or change in the amount of proteinuria.
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conditions remain stable for women with severe preeclampsia and a viable fetus at ZHHNVRUOHVVRI
gestation with any of the following:

preterm premature rupture of membranes

labor
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(twice or more the upper normal values)
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new-onset renal dysfunction or increasing renal dysfunction
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that delivery not be delayed after initial maternal stabili]DWLRQUHJDUGOHVVRIJHVWDWLRQDODJHIRUZRPHQZLWKVHvere preeclampsia that is complicated further with any of
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eclampsia
pulmonary edema
abruptio placentae
disseminated intravascular coagulation
evidence of nonreassuring fetal status
intrapartum fetal demise

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mode of delivery need not be cesarean delivery. The
mode of delivery should be determined by fetal gestaWLRQDODJHIHWDOSUHVHQWDWLRQFHUYLFDOVWDWXVDQGPDWHUnal and fetal conditions.
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of intrapartumpostpartum magnesium sulfate to prevent eclampsia is recommended.
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parenteral magnesium sulfate to prevent eclampsia is
recommended.
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to attempt to improve maternal and fetal condition. In these
VWXGLHVWKHUHZDVQRHYLGHQFHRIEHQHWWRLPSURYHRYHUDOOPDternal and fetal outcome (although this has been suggested in
REVHUYDWLRQDOVWXGLHV7KHUHLVHYLGHQFHLQWKHUDQGRPL]HGWULals of improvement of platelet counts with corticosteroid treatment. In clinical settings in which an improvement in platelet
FRXQWLVFRQVLGHUHGXVHIXOFRUWLFRVWHURLGVPD\EHMXVWLHG
)RUZRPHQZLWKSUHHFODPSVLDZKRUHTXLUHDQDOJHVLDIRU
labor or anesthesia for cesarean delivery and with a clinLFDO VLWXDWLRQ WKDW SHUPLWV VXFLHQW WLPH IRU HVWDEOLVKment of aneVWKHVLDWKHDGPLQLVWUDWLRQRIQHXUD[LDODQHVthesia (either spinal or epidural anesthesia) is recommended.
)RUZRPHQZLWKVHYHUHSUHHFODPSVLDLWLVVXJJHVWHGWKDW
invasive hemodynamic monitoring not be used routinely.
)RU ZRPHQ LQ ZKRP JHVWDWLRQDO K\SHUWHQVLRQ SUHHFODPSVLDRUVXSHULPSRVHGSUHHFODPSVLDLVGLDJQRVHGLWLV
suggested that BP be monitored in the hospital or that
equivalent outpatient surveillance be performed for at
OHDVW KRXUV SRVWSDUWXP DQG DJDLQ GD\V DIWHU
delivery or earlier in women with symptoms.
)RUDOOZRPHQLQWKHSRVWSDUWXPSHULRGQRWMXVWZRPHQ
ZLWK SUHHFODPSVLD LW LV VXJJHVWHG WKDW GLVFKDUJH LQstructions include information about the signs and symptoms of preeclampsia as well as the importance of
prompt reporting of this information to their health care
providers.
1127
)RUZRPHQLQWKHSRVWSDUWXPSHULRGZKRSUHVHQWZLWK
new-onset hypertension associated with headaches or
EOXUUHGYLVLRQRUSUHHFODPSVLDZLWKVHYHUHK\SHUWHQVLRQ
the parenteral administration of magnesium sulfate is
suggested.
)RUZRPHQZLWKSHUVLVWHQWSRVWSDUWXPK\SHUWHQVLRQ%3
RIPP+JV\VWROLFRUPP+JGLDVWROLFRUKLJKHU
RQDWOHDVWWZRRFFDVLRQVWKDWDUHDWOHDVWKRXUVDSDUW
antihypertensive therapy is suggested. Persistent BP of
160 mm Hg systolic or 110 mm Hg diastolic or higher
should be treated within 1 hour.
Management of Women With

Prior Preeclampsia
:RPHQ ZKR KDYH KDG SUHHFODPSVLD LQ D SULRU SUHJQDQF\
should receive counseling and assessments before their next
pregnancy. This can be initiated at the postpartum visit but
is ideally accomplished at a preconception visit before the
QH[WSODQQHGSUHJQDQF\'XULQJWKHSUHFRQFHSWLRQYLVLWWKH
previous pregnancy history should be reviewed and the
prognosis for the upcoming pregnancy should be discussed.
3RWHQWLDOO\PRGLDEOHOLIHVW\OHDFWLYLWLHVVXFKDVZHLJKWORVV
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including laboratory evaluation if appropriate. Medical
problems such as hypertension and diabetes should be
EURXJKWLQWRWKHEHVWFRQWUROSRVVLEOH7KHHHFWRIPHGLFDO
problems on the pregnancy should be discussed. MedicaWLRQVVKRXOGEHUHYLHZHGDQGWKHLUDGPLQLVWUDWLRQPRGLHG
for upcoming pregnancy. Folic acid supplementation should
be recommended. If a woman has given birth to a preterm
infant during a preeclamptic pregnancy or has had preecODPSVLD LQ PRUH WKDQ RQH SUHJQDQF\ WKH XVH RI ORZGRVH
aspirin in the upcoming pregnancy should be suggested.
:RPHQ ZLWK D PHGLFDO KLVWRU\ RI SUHHFODPSVLD VKRXOG EH
LQVWUXFWHGWRUHWXUQIRUFDUHHDUO\LQSUHJQDQF\'XULQJWKH
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WR GHWHUPLQH JHVWDWLRQDO DJH DQG DVVHVVPHQW DQG YLVLWV
VKRXOGEHWDLORUHGWRWKHSULRUSUHJQDQF\RXWFRPHZLWKIUHquent visits beginning earlier in women with prior preterm
preeclampsia. The woman should be educated about the
signs and symptoms of preeclampsia and instructed when
and how to contact her health care provider.
1128
)RUZRPHQZLWKSUHHFODPSVLDLQDSULRUSUHJQDQF\SUHconception counseling and assessment is suggested.

Strength of recommendation: 4XDOLHG
Chronic Hypertension and

Superimposed Preeclampsia
&KURQLFK\SHUWHQVLRQK\SHUWHQVLRQSUHGDWLQJSUHJQDQF\
presents special challenges to health care providers. Health
FDUH SURYLGHUV PXVW UVW FRQUP WKDW WKH %3 HOHYDWLRQ LV
QRWSUHHFODPSVLD2QFHWKLVLVHVWDEOLVKHGLIWKH%3HOHYDWLRQKDVQRWEHHQSUHYLRXVO\HYDOXDWHGDZRUNXSVKRXOGEH
SHUIRUPHG WR GRFXPHQW WKDW %3 LV WUXO\ HOHYDWHG LH QRW
white coat hypertension) and to check for secondary hypertension and end-organ damage. The choice of which
women to treat and how to treat them requires special conVLGHUDWLRQVGXULQJSUHJQDQF\HVSHFLDOO\LQOLJKWRIHPHUJing data that suggest lowering BP excessively might have
DGYHUVHIHWDOHHFWV
Perhaps the greatest challenge is the recognition of
SUHHFODPSVLDVXSHULPSRVHGRQFKURQLFK\SHUWHQVLRQDFRQdition that is commonly associated with adverse maternal
and fetal outcomes. Recommendations are provided to
guide health care providers in distinguishing women who
may have superimposed preeclampsia without severe features (only hypertension and proteinuria) and require only
observation from women who may have superimposed
preeclampsia with severe features (evidence of systemic
involvement beyond hypertension and proteinuria) and
require intervention.
)RUZRPHQZLWKIeatures suggestive of secondary hyperWHQVLRQUHIHUUDOWRDSK\VLFLDQZLWKH[SHUWLVHLQWUHDWLQJ

hypertension to direct the workup is suggested.
)RU SUHJQDQW ZRPHQ ZLWK FKURQLF K\SHUWHQVLRQ DQG
SRRUO\FRQWUROOHG%3WKHXVHRIKRPH%3PRQLWRULQJLV
suggested.
)RUZRPHQZLWKVXVSHFWHGZKLWHFRDWK\SHUWHQVLRQWKH
XVHRIDPEXODWRU\%3PRQLWRULQJWRFRQUPWKHGLDJQRsis before the initiation of antihypertensive therapy is
suggested.
,W LV VXJJHVWHG WKDW ZHLJKW ORVV DQG H[WUHPHO\ ORZ

VRGLXPGLHWVOHVVWKDQP(TGQRWEHXVHGIRUPDQaging chronic hypertension in pregnancy.
)RUZRPHQZLWKFKURQLFK\SHUWHQVLRQZKRDUHDFFXVWRPHGWRH[HUFLVLQJDQGLQZKRP%3LVZHOOFRQWUROOHG
it is recommended that moderate exercise be continued
during pregnancy.
)RU SUHJQDQW ZRPHQ ZLWK SHUVLVWHQW FKURQLF K\SHUWHQsion with systolic BP of 160 mm Hg or higher or diastolic
%3RIPP+JRUKLJKHUDQWLK\SHUWHQVLYHWKHUDS\LV
recommended.
)RUSUHJQDQWZomen with chronic hypertension and BP
less than 160 mm Hg systolic or 105 mm Hg diastolic and
QR HYLGHQFH RI HQGRUJDQ GDPDJH LW LV VXJJHVWHG WKDW
they not be treated with pharmacologic antihypertensive therapy.
Strength of recommendation: QualLHG
For pregnant women with chronic hypertension treated
ZLWKDQWLK\SHUWHQVLYHPHGLFDWLRQLWLVVXJJHVWHGWKDW
%3 OHYHOV EH PDLQWDLQHG EHWZHHQ PP +J V\VWROLF
and 80 mm Hg diastolic and 160 mm Hg systolic and 105
mm Hg diastolic.
)RUWKHLQLWLDOWUHDWPHQWRISUHJQDQWZRPHQZLWKFKURQLF
K\SHUWHQVLRQ ZKR UHTXLUH SKDUPDFRORJLF WKHUDS\ ODEHWDOROQLIHGLSLQHRUPHWK\OGRSDDUHUHFRPPHQGHGDERYH
all other antihypertensive drugs.
)RUZRPHQZLWKXQFRPSOLFDWHGFKURQLFK\SHUWHQVLRQLQ
SUHJQDQF\WKHXVHRIDQJLRWHQVLQFRQYHUWLQJHQ]\PHLQKLELWRUVDQJLRWHQVLQUHFHSWRUEORFNHUVUHQLQLQKLELWRUV
and mineralocorticoid receptor antagonists is not recommended.
)RU ZRPHQ RI UHSURGXFWLYH DJH ZLWK FKURQLF K\SHUWHQVLRQ WKH XVH RI DQJLRWHQVLQFRQYHUWLQJ HQ]\PH LQKLEL-
WRUVDQJLRWHQVLQUHFHSWRUEORFNHUVUHQLQLQKLELWRUVDQG
mineralocorticoid receptor antagonists is not recomPHQGHGXQOHVVWKHUHLVDFRPSHOOLQJUHDVRQVXFKDVWKH
presence of proteinuric renal disease.
)RU ZRPHQ ZLWK FKURQLF K\SHUWHQVLRQ ZKR DUH DW D
greatly increased risk of adverse pregnancy outcomes
(history of early-onset preeclampsia and preterm deOLYHU\DWOHVVWKDQZHHNVRIgestation or preecODPSVLDLQPRUHWKDQRQHSULRUSUHJQDQF\LQLWLDWLQJWKH
administration of daily low-dose aspirin (6080 mg) beJLQQLQJLQWKHODWHUVWWULPHVWHULVVXJJHVWHG
0HWDDQDO\VLVRIPRUHWKDQZRPHQLQUDQGRPL]HGWULDOV
of aspirin to prevent preeclampsia indicates a small reduction
in the incidence and morbidity of preeclampsia and reveals no
evidence of acuteULVNDOWKRXJKORQJWHUPIHWDOHHFWVFDQQRW
be excluded. The number of women to treat to have a theraSHXWLFHHFWLVGHWHUPLQHGE\SUHYDOHQFH,QYLHZRIPDWHUQDO
VDIHW\ D GLVFXVVLRQ RI WKH XVH RI DVSLULQ LQ OLJKW RI LQGLYLGXDO
ULVNLVMXVWLHG
)RUZRPHQZLWKFKURQLFK\SHUWHQVLRQWKHXVHRIXOWUDsonography to screen for fetal growth restriction is suggested.

,I HYLGHQFH RI IHWDO JURZWK UHVWULFWLRQ LV IRXQG LQ
ZRPHQZLWKFKURQLFK\SHUWHQVLRQIHWRSODFHQWDODVVHVVPHQWWRLQFOXGHXPELOLFDODUWHU\'RSSOHUYHORFLPHWU\DV
an adjunct antenatal test is recommended.
)RU ZRPHQ ZLWK FKURQLF K\SHUWHQVLRQ FRPSOLFDWHG E\
issues such as tKHQHHGIRUPHGLFDWLRQRWKHUXQGHUO\LQJ
PHGLFDO FRQGLWLRQV WKDW DHFW IHWDO RXWFRPH RU DQ\
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SUHHFODPSVLDDQWHQDWDOIHWDOWHVWLQJLVVXJJHVWHG
)RUZRPHQZLWKFKURQLFK\SHUWHQVLRQDQGQRDGGLWLRQDO
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weeks of gestation is not recommended.
)RUZRPHQZLWKVXSHULPSRVHGSUHHFODPSVLDZKRUHFHLYH
H[SHFWDQW PDQDJHPHQW DW OHVV WKDQ ZHHNV RI
1129
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OXQJPDWXULW\EHQHWLVUHFRPPHQGHG
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SUHHFODPSVLDZLWKVHYHUHIHDWXUHVWKHDGPLQLVWUDWLRQRI
intrapartumpostpartum parenteral magnesium sulfate
to prevent eclampsia is recommended.
)RUZRPHQZLWKVXSHULPSRVHGSUHHFODPSVLDZLWKRXWVHYHUH IHDWXUHV DQG VWDEOH PDWHUQDO DQG IHWDO FRQGLWLRQV
H[SHFWDQWPDQDJHPHQWXQWLOZHHNVRIJHVWDWLRQLV
suggested.
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LUUHVSHFWLYHRIJHVWDWLRQDODJHRUIXOOFRUWLFRVWHURLGEHQHW
for women with superimposed preeclampsia that is complicated further by any of the following:
uncontrollable severe hypertension

eclampsia
pulmonary edema
abruptio placentae
disseminated intravascular coagulation
nonreassuring fetal status

Strength of the recommendation: Strong
)RUZRPHQZLWKVXSHULPSRVHGSUHHFODPSVLDZLWKVHYHUH
IHDWXUHVDWOHVVWKDQZHHNVRIJHVWDWLRQZLWKVWDEOH PDWHUQDO DQG IHWDO FRQGLWLRQV LW LV UHFRPPHQGHG
that continued pregnancy should be undertaken only at
facilities with adequate maternal and neonatal intensive
care resources.
Strength of evidence: Strong
)RUZRPHQZLWKVXSHULPSRVHGSUHHFODPSVLDZLWKVHYHUH
IHDWXUHVH[SHFWDQWPDQDJHPHQWEH\RQGZHHNV
of gestation is not recommended.
Strength of the recommendation: Strong
is at an increased risk of later-life CV disease. This increase

ranges from a doubling of risk in all cases to an eightfold to
ninefold increase in women with preeclampsia who gave
ELUWKEHIRUHZHHNVRIJHVWDWLRQ7KLVKDVEHHQUHFRJQL]HGE\WKH$PHULFDQ+HDUW$VVRFLDWLRQZKLFKQRZUHFommends that a pregnancy history be part of the evaluation
of CV risk in women. It is the general belief that preeclampVLDGRHVQRWFDXVH&9GLVHDVHEXWUDWKHUSUHHFODPSVLDDQG
CV disease share common risk factors. Awareness that a
woman has had a preeclamptic pregnancy might allow for
WKH LGHQWLFDWLRQ RI ZRPHQ QRW SUHYLRXVO\ UHFRJQL]HG DV
at-risk for earlier assessment and potential intervention.
+RZHYHULWLVXQNQRZQLIWKLVZLOOEHDYDOXDEOHDGMXQFWWR
SUHYLRXVLQIRUPDWLRQ,IWKLVLVWKHFDVHZRXOGWKHFXUUHQW
recommendation of assessing risk factors for women by
PHGLFDO KLVWRU\ OLIHVW\OH HYDOXDWLRQ WHVWLQJ IRU PHWDEROLF
DEQRUPDOLWLHVDQGSRVVLEO\LQDPPDWRU\DFWLYDWLRQDWDJH
\HDUV SURYLGH DOO RI WKH LQIRUPDWLRQ WKDW ZRXOG EH
gained by knowing a woman had a past preeclamptic pregQDQF\":RXOGLWEe valuable to perform this assessment at
a younger age in women who had a past preeclamptic pregQDQF\",IWKHULVNZDVLGHQWLHGHDUOLHUZKDWLQWHUYHQWLRQ
RWKHU WKDQ OLIHVW\OH PRGLFDWLRQ ZRXOG SRWHQWLDOO\ EH
XVHIXODQGZRXOGLWPDNHDGLHUHQFH"$UHWKHUHULVNIDFtors that could be unmasked by pregnancy other than conventional risk factors? Further research is needed to
determine how to take advantage of this information relatLQJSUHHFODPSVLDWRODWHUOLIH&9GLVHDVH$WWKLVWLPHWKH
WDVN IRUFH FDXWLRXVO\ UHFRPPHQGV OLIHVW\OH PRGLFDWLRQ
PDLQWHQDQFHRIDKHDOWK\ZHLJKWLQFUHDVHGSK\VLFDODFWLYLW\DQGQRWVPRNLQJDQGVXJJHVWVHDUO\HYDOXDWLRQIRUWKH
most high-risk women.
)RUZRPHQZLWKDPHGLFDOKLVWRU\RISUHHFODPSVLDZKR
JDYHELUWKSUHWHUPOHVVWKDQZHHNVRIJHVWDWLRQ
RUZKRKDYHDPHGLFDOKLVWRU\RIUHFXUUHQWSUHHFODPSVLD
\HDUO\DVVHVVPHQWRI%3OLSLGVIDVWLQJEORRGJOXFRVHDQG
body mass index is suggested.*
*Although there is clear evidence of an association between
SUHHFODPSVLD DQG ODWHUOLIH &9 GLVHDVH WKH YDOXH DQG DSSURpriate timing of assessment is not yet established. Health care
providers and patients should make this decision based on their
judgment of the relative value of extra information versus expense and inconvenience.
Later-Life Cardiovascular Disease in Women

With Prior Preeclampsia
Patient Education
2YHUWKHSDVW\HDUVLQIRUPDWLRQKDVDFFXPXODWHGLQGLcating that a woman who has had a preeclamptic pregnancy
Patient and health care provider education is key to the

successful recognition and management of preeclampsia.
1130
Health care providers need to inform women during the

prenatal and postpartum periods of the signs and symptoms of preeclampsia and stress the importance of contacting health care providers if these are evident. The
recognition of the importance of patient education must be
complemented by the recognition and use of strategies that
facilitate the successful transfer of this information to
women with varying degrees of health literacy. Recommended strategies to facilitate this process include using
SODLQ QRQPHGLFDO ODQJXDJH WDNLQJ WLPH WR VSHDN VORZO\
reinforcing key issues in print using pictorially based inforPDWLRQDQGUHTXHVWLQJIHHGEDFNWRLQGLFDWHWKDWWKHSDWLHQW
XQGHUVWDQGVDQGZKHUHDSSOLFDEOHKHUSDUWQHU
,WLVVXJJHVWHGWKDWKHDOWKFDUHSURYLGHUVFRQYH\LQIRUmation about preeclampsia in the context of prenatal

care and postpartum care using proven health communication practices.
The State of the Science and

Research Recommendations
,QWKHSDVW\HDUVVWULNLQJLQFUHDVHVLQWKHXQGHUVWDQGLQJ
of the pathophysiology of preeclampsia have occurred. Clinical research advances also have emerged that have provided evidence to guide therapy. It is now understood that
SUHHFODPSVLDLVDPXOWLV\VWHPLFGLVHDVHWKDWDHFWVDOORUJDQ
systems and is far more than high BP and renal dysfunction.
The placenta is evident as the root cause of preeclampsia. It
is with the delivery of the placenta that preeclampsia begins
to resolve. The insult to the placenta is proposed as an
immunologically initiated alteration in trophoblast funcWLRQ DQG WKH UHGXFWLRQ LQ WURSKREODVW LQYDVLRQ OHDGV WR
failed vascular remodeling of the maternal spiral arteries
that perfuse the placenta. The resulting reduced perfusion
and increased velocity of blood perfusing the intervillous
space alter placental function. The altered placental function leads to maternal disease through putative primary
PHGLDWRUVLQFOXGLQJR[LGDWLYHDQGHQGRSODVPLFUHWLFXOXP
VWUHVV DQG LQDPPDWLRQ DQG VHFRQGDU\ PHGLDWRUV WKDW
LQFOXGHPRGLHUVRIHQGRWKHOLDOIXQFWLRQDQGDQJLRJHQHVLV
This understanding of preeclampsia pathophysiology has
not translated into predictors or preventers of preeclampsia or to improved clinical care. This has led to a reassessPHQW RI WKLV FRQFHSWXDO IUDPHZRUN ZLWK DWWHQWLRQ WR WKH
possibility that preeclampsia is not one disease but that the
syndrome may include subsets of pathophysiology.
Clinical research advances have shown approaches to
WKHUDS\WKDWZRUNHJGHOLYHU\IRUZRPHQZLWKJHVWDWLRQDO
hypertension and preeclampsia without severe features at
ZHHNVRIJHVWDWLRQRUGRQRWZRUNYLWDPLQ&DQG
YLWDPLQ(WRSUHYHQWSUHHFODPSVLD+RZHYHUWKHUHDUHIHZ
FOLQLFDOUHFRPPHQGDWLRQVWKDWFDQEHFODVVLHGDVVWURQJ
because there are huge gaps in the evidence base that guides
therapy. These knowledge gaps form the basis for research
recommendations to guide future therapy.
Conclusion
The task force provides evidence-based recommendations
for the management of patients with hypertension during
and after pregnancy. Recommendations are graded as strong
RU TXDOLHG EDVHG RQ HYLGHQFH RI HHFWLYHQHVV ZHLJKHG
DJDLQVWHYLGHQFHRISRWHQWLDOKDUP,QDOOLQVWDQFHVWKHQDO
decision is made by the health care provider and patient
after consideration of the strength of the recommendations
in relation to the values and judgments of the individual
patient.
The information in Hypertension in Pregnancy should not be viewed
as a body of rigid rules. The guidelines are general and intended to
EH DGDSWHG WR PDQ\ GLHUHQW VLWXDWLRQV WDNLQJ LQWR DFFRXQW WKH
QHHGVDQGUHVRXUFHVSDUWLFXODUWRWKHORFDOLW\WKHLQVWLWXWLRQRUWKH
type of practice. Variations and innovations that improve the quality
of patient care are to be encouraged rather than restricted. The
SXUSRVHRIWKHVHJXLGHOLQHVZLOOEHZHOOVHUYHGLIWKH\SURYLGHDUP
basis on which local norms may be built.
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publisher.
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1131

Hypertension in Pregnancy: Executive Summary

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Hypertension in Pregnancy: Executive Summary

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Hypertension in Pregnancy

Report of the American College of Obstetricians and Gynecologists

VOL. 122, NO. 5, NOVEMBER 2013

OBSTETRICS & GYNECOLOGY

for many years that preeclampsia can worsen or present for

Classication of Hypertensive Disorders of

VOL. 122, NO. 5, NOVEMBER 2013

Establishing the Diagnosis of

Executive Summary: Hypertension in Pregnancy

Severe Features of Preeclampsia (Any of these ndings)

QDQF\ LQLWLDWLQJ WKH DGPLQLVWUDWLRQ RI GDLO\ ORZGRVH

TASK FORCE RECOMMENDATION

Quality of evidence: Moderate

)RU ZRPHQ ZLWK D PHGLFDO KLVWRU\ RI HDUO\RQVHW SUHHFODPSVLDDQGSUHWHUPGHOLYHU\DWOHVVWKDQZHHNVRI

Executive Summary: Hypertension in Pregnancy

OBSTETRICS & GYNECOLOGY

TABLE E-1. Diagnostic Criteria for Preeclampsia

Impaired liver function

several important questions remain unanswered. Reviews

VOL. 122, NO. 5, NOVEMBER 2013

TASK FORCE RECOMMENDATIONS

7KHFORVHPRQLWRULQJRIZRPHQZLWKJHVWDWLRQDOK\SHUtension or preeclampsia ZLWKRXW VHYHUH IHDWXUHV ZLWK

Executive Summary: Hypertension in Pregnancy

)RU ZRPHQ ZLWK SUHHFODPSVLD ZLWKRXW VHYHUH IHDWXUHV

Executive Summary: Hypertension in Pregnancy

preterm premature rupture of membranes

OBSTETRICS & GYNECOLOGY

UHYHUVHG HQGGLDVWROLF RZ RQ XPELOLFDO DUWHU\

uncontrollable severe hypertension

Quality of evidence: Moderate

VOL. 122, NO. 5, NOVEMBER 2013

Quality of evidence: High

Executive Summary: Hypertension in Pregnancy

Management of Women With

Executive Summary: Hypertension in Pregnancy

TASK FORCE RECOMMENDATION

)RUZRPHQZLWKSUHHFODPSVLDLQDSULRUSUHJQDQF\SUHconception counseling and assessment is suggested.

Chronic Hypertension and

)RUZRPHQZLWKIeatures suggestive of secondary hyperWHQVLRQUHIHUUDOWRDSK\VLFLDQZLWKH[SHUWLVHLQWUHDWLQJ

OBSTETRICS & GYNECOLOGY

,W LV VXJJHVWHG WKDW ZHLJKW ORVV DQG H[WUHPHO\ ORZ

VOL. 122, NO. 5, NOVEMBER 2013

)RUZRPHQZLWKFKURQLFK\SHUWHQVLRQWKHXVHRIXOWUDsonography to screen for fetal growth restriction is suggested.

Executive Summary: Hypertension in Pregnancy

uncontrollable severe hypertension

Quality of evidence: Moderate

is at an increased risk of later-life CV disease. This increase

Later-Life Cardiovascular Disease in Women

2YHUWKHSDVW\HDUVLQIRUPDWLRQKDVDFFXPXODWHGLQGLcating that a woman who has had a preeclamptic pregnancy

Patient and health care provider education is key to the

Executive Summary: Hypertension in Pregnancy

OBSTETRICS & GYNECOLOGY

Health care providers need to inform women during the

,WLVVXJJHVWHGWKDWKHDOWKFDUHSURYLGHUVFRQYH\LQIRUmation about preeclampsia in the context of prenatal

The State of the Science and

VOL. 122, NO. 5, NOVEMBER 2013

Executive Summary: Hypertension in Pregnancy

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