Hypertension in Pregnancy
Report of the American College of Obstetricians and Gynecologists’
Task Force on Hypertension in Pregnancy
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Executive Summary
T
he American College of Obstetricians and Gyne-
cologists (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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utive summary includes a synopsis of the content and task
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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able. Chronic hypertension is associated with fetal morbid-
ity in the form of growth restriction and maternal morbidity
manifested as severely increased blood pressure (BP). How-
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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 man-
agement 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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women for signs of preeclampsia and then delivery to termi-
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tality still occur. Some of these adverse outcomes are avoid-
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some of the problems that face neonates are related directly
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turity 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-
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needed to determine how best to use this information to
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management of preeclampsia that warrant special atten-
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ate the multisystemic nature of preeclampsia. This is in part
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diagnosis such as “mild preeclampsia” (which is discour-
aged) applies only at the moment the diagnosis is estab-
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dates frequent reevaluation for severe features that indi-
cate 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

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provides guidelines to attempt to reduce maternal morbid- sion during pregnancy in only four categories: 1) pre-
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The Approach
The task force used the evidence assessment and recom-
mendation strategy developed by the Grading of Recom-
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nated the dependence of the diagnosis on proteinuria. In
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*5$'(:RUNLQJ*URXSDYDLODEOHDWZZZJUDGHZRUNLQJ hypertension in association with thrombocytopenia (plate-
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tion of expert task forces and working groups is to evaluate UHQDOLQVXűFLHQF\HOHYDWHGVHUXPFUHDWLQLQHJUHDWHUWKDQ
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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 prefer-
ences. The task force evaluated the evidence for each rec-
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information was evaluated and recommendations were
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the absence of proteinuria or the aforementioned systemic
ÀQGLQJVFhronic hypertension is hypertension that predates
pregnancy; and superimposed preeclampsia is chronic hyper-
tension in association with preeclampsia.
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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
Establishing the Diagnosis of
Preeclampsia or Eclampsia
The BP criteria are maintained from prior recommendations.
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it might not be the optimal recommendation for some for diagnostic use unless other approaches are not readily
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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.
Classification of Hypertensive Disorders of
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teinuria. 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 consider-
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restriction is managed similarly in pregnant women with
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Pregnancy
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VOL. 122, NO. 5, NOVEMBER 2013
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Prediction of Preeclampsia
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pregnancy the later development of preeclampsia. Although
Executive Summary: Hypertension in Pregnancy 1123
 BOX E-1. Severe Features of Preeclampsia (Any of these findings)

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ready for clinical use.
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appropriate medical history to evaluate for risk factors is
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not recommended.
Quality of evidence: Moderate
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 popula-
tions 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 preec-
lampsia risk.
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gestation or preeclampsia in more than one prior preg-
1124 Executive Summary: Hypertension in Pregnancy
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suggested.*
Quality of evidence: Moderate
Strength of recommendation: 4XDOLÀHG
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 thera-
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preeclampsia is not recommended.
Quality of evidence: High
Strength of recommendation: Strong
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ing pregnancy for the prevention of preeclampsia.
Quality of evidence: /RZ
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physical activity not be used for the primary prevention
of preeclampsia and its complications.
Quality of evidence: /RZ
Strength of recommendation:4XDOLÀHG
Management of Preeclampsia
and HELLP Syndrome
Clinical trials have provided an evidence base to guide man-
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OBSTETRICS & GYNECOLOGY
 TABLE E-1. Diagnostic Criteria for Preeclampsia

Blood pressureÊ ÊUÊ Ài>ÌiÀÊ̅>˜ÊœÀÊiµÕ>Ê̜ʣ{äʓ“Ê}ÊÃÞÃ̜ˆVʜÀÊ}Ài>ÌiÀÊ̅>˜ÊœÀÊiµÕ>Ê̜ʙäʓ“Ê}Ê

ÊÊÊÊ`ˆ>Ã̜ˆVʜ˜ÊÌܜʜVV>Ȝ˜ÃÊ>Ìʏi>ÃÌÊ{ʅœÕÀÃÊ>«>ÀÌÊ>vÌiÀÊÓäÊÜiiŽÃʜvÊ}iÃÌ>̈œ˜Êˆ˜Ê>Ê
ÊÊÊÊܜ“>˜Ê܈̅Ê>Ê«ÀiۈœÕÏÞʘœÀ“>ÊLœœ`Ê«ÀiÃÃÕÀiÊ
Ê ÊUÊ Ài>ÌiÀÊ̅>˜ÊœÀÊiµÕ>Ê̜ʣÈäʓ“Ê}ÊÃÞÃ̜ˆVʜÀÊ}Ài>ÌiÀÊ̅>˜ÊœÀÊiµÕ>Ê̜ʣ£äʓ“Ê}Ê
ÊÊÊ `ˆ>Ã̜ˆV]ʅޫiÀÌi˜Ãˆœ˜ÊV>˜ÊLiÊVœ˜wÀ“i`Ê܈̅ˆ˜Ê>ÊŜÀÌʈ˜ÌiÀÛ>Ê­“ˆ˜ÕÌiîÊ̜Êv>VˆˆÌ>ÌiÊÊ
ÊÊÊÊ̈“iÞÊ>˜Ìˆ…Þ«iÀÌi˜ÃˆÛiÊ̅iÀ>«Þ
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ProteinuriaÊ UÊ Ê Ài>ÌiÀÊ̅>˜ÊœÀÊiµÕ>Ê̜ÊÎääʓ}Ê«iÀÊÓ{‡…œÕÀÊÕÀˆ˜iÊVœiV̈œ˜Ê­œÀÊ̅ˆÃÊ>“œÕ˜ÌÊÊ
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Ê Ê ÊœÀ
Ê UÊ *ÀœÌiˆ˜ÉVÀi>̈˜ˆ˜iÊÀ>̈œÊ}Ài>ÌiÀÊ̅>˜ÊœÀÊiµÕ>Ê̜Êä°ÎI
Ê UÊ ˆ«Ã̈VŽÊÀi>`ˆ˜}ʜvÊ£³Ê­ÕÃi`ʜ˜Þʈvʜ̅iÀʵÕ>˜ÌˆÌ>̈Ûiʓi̅œ`ÃʘœÌÊ>Û>ˆ>Li®
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ThrombocytopeniaÊ ÊUÊ *>ÌiiÌÊVœÕ˜ÌʏiÃÃÊ̅>˜Ê£ää]äääɓˆVÀœˆÌiÀ
Renal insufficiency Ê UÊ Ê-iÀՓÊVÀi>̈˜ˆ˜iÊVœ˜Vi˜ÌÀ>̈œ˜ÃÊ}Ài>ÌiÀÊ̅>˜Ê£°£Ê“}É`ʜÀÊ>Ê`œÕLˆ˜}ʜvÊ̅iÊÃiÀՓÊ
VÀi>̈˜ˆ˜iÊVœ˜Vi˜ÌÀ>̈œ˜Êˆ˜Ê̅iÊ>LÃi˜Viʜvʜ̅iÀÊÀi˜>Ê`ˆÃi>Ãi
Impaired liver functionÊ UÊ iÛ>Ìi`ÊLœœ`ÊVœ˜Vi˜ÌÀ>̈œ˜ÃʜvʏˆÛiÀÊÌÀ>˜Ã>“ˆ˜>ÃiÃÊ̜ÊÌ܈ViʘœÀ“>ÊVœ˜Vi˜ÌÀ>̈œ˜
Pulmonary edema
Cerebral or visual
symptoms

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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 likeli-
hood that preeclampsia will progress. The same reviews
indicate that intervention in acutely ill women with multiple
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serial assessment of maternal symptoms and fetal move-
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mation 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 sys-
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diagnosis of preeclampsia even in the absence of pro-
teinuria.
Perhaps the biggest changes in preeclampsia manage-
ment relate to the timing of delivery in women with preec-
ODPSVLDZLWKRXWVHYHUHIHDWXUHVZKLFKEDVHGRQHYLGHQFHLV
VXJJHVWHGDWZHHNVRIJHVWDWLRQDQGDQLQFUHDVLQJ
awareness of the importance of preeclampsia in the postpar-
tum period. Health care providers are reminded of the con-
WULEXWLRQ RI QRQVWHURLGDO DQWLLQÁDPPDWRU\ DJHQWV WR
increased BP. It is suggested that these commonly used
postpartum pain relief agents be replaced by other analge-
sics in women with hypertension that persists for more than
1 day postpartum.
VOL. 122, NO. 5, NOVEMBER 2013
OLYHUHQ]\PHVZHHNO\LVVXJJHVWHG
Quality of evidence: Moderate
Strength of recommendation:4XDOLÀHG
‡ )RU ZRPHQ ZLWK JHVWDWLRQDO K\SHUWHQVLRQ PRQLWRULQJ
BP at least once weekly with proteinuria assessment in
WKHRűFHDQGZLWKDQDGGLWLRQDOZHHNO\PHDVXUHPHQWRI
%3DWKRPHRULQWKHRűFHLVVXJJHVWHG
Quality of evidence: Moderate
Strength of recommendation:4XDOLÀHG
‡ )RUZRPHQZLWKPLOGJHVWDWLRQDOK\SHUWHQVLRQRUSUHHF-
lampsia with a persistent BP of less than 160 mm Hg
V\VWROLFRUPP+JGLDVWROLFLWLVVXJJHVWHGWKDWDQWL-
hypertensive medications not be administered.
Quality of evidence: Moderate
Strength of recommendation:4XDOLÀHG
Executive Summary: Hypertension in Pregnancy 1125
‡ )RUZRPHQZLWKJHVWDWLRQDOK\SHUWHQVLRQRUSUHHFODPS- DJHGHOLYHU\VRRQDIWHUPDWHUQDOVWDELOL]DWLRQLVUHFRP-
VLDZLWKRXWVHYHUHIHDWXUHVLWLVVXJJHVWHGWKDWVWULFWEHG mended.
rest not be prescribed.* † Quality of evidence: Moderate
Quality of evidence:/RZ Strength of recommendation: Strong
Strength of recommendation:4XDOLÀHG
‡ )RU ZRPHQ ZLWK VHYHUH SUHHFODPSVLD DW OHVV WKDQ 
*The task force acknowledged that there may be situations in
0/7 weeks of gestation with stable maternal and fetal
ZKLFKGLŲHUHQWOHYHOVRIUHVWHLWKHUDWKRPHRULQWKHKRVSLWDO
may be indicated for individual women. The previous recom- FRQGLWLRQVLWLVUHFRPPHQGHGWKDWFRQWLQXHGSUHJQDQF\
mendations do not cover advice regarding overall physical ac- be undertaken only at facilities with adequate mater-
WLYLW\DQGPDQXDORURűFHZRUN nal and neonatal intensive care resources.
†
:RPHQPD\QHHGWREHKRVSLWDOL]HGIRUUHDVRQVRWKHUWKDQEHG
Quality of evidence: Moderate
UHVWVXFKDVIRUPDWHUQDODQGIHWDOVXUYHLOODQFH7KHWDVNIRUFH
DJUHHGWKDWKRVSLWDOL]DWLRQIRUPDWHUQDODQGIHWDOVXUYHLOODQFH Strength of recommendation: Strong
is resource intensive and should be considered as a priority for
‡ )RUZRPHQZLWKVHYHUHSUHHFODPSVLDUHFHLYLQJH[SHFWDQW
research and future recommendations.
PDQDJHPHQW DW   ZHHNV RU OHVV RI JHVWDWLRQ WKH
‡ )RU ZRPHQ ZLWK SUHHFODPSVLD ZLWKRXW VHYHUH IHDWXUHV administration of corticosteroids for fetal lung maturity
use of ultrasonography to assess fetal growth and antena- EHQHÀWLVUHFRPPHQGHG
tal testing to assess fetal status is suggested.
Quality of evidence: High
Quality of evidence: Moderate Strength of recommendation: Strong
Strength of recommendation:4XDOLÀHG
‡ )RUZRPHQZLWKSUHHFODPSVLDZLWKVHYHUHK\SHUWHQVLRQ
‡ ,IHYLGHQFHRIIHWDOJURZWKUHVWULFWLRQLVIRXQGLQZRPHQ during pregnancy (sustained systolic BP of at least 160
ZLWK SUHHFODPSVLD IHWRSODFHQWDO DVVHVVPHQW WKDW LQ-
FOXGHVXPELOLFDODUWHU\'RSSOHUYHORFLPHWU\DVDQDGMXQFW
antenatal test is recommended.
Quality of evidence: Moderate
Strength of recommendation: Strong
‡ )RUZRPHQZLWKPLOGJHVWDWLRQDOK\SHUWHQVLRQRUSUHHF-
lampsia without severe features and no indication for
GHOLYHU\DWOHVVWKDQZHHNVRIJHVWDWLRQH[SHF-
tant management with maternal and fetal monitoring is
suggested.
Quality of evidence:/RZ
Strength of recommendation:4XDOLÀHG
‡ )RUZRPHQZLWKPLOGJHVWDWLRQDOK\SHUWHQVLRQRUSUHHF-
ODPSVLD ZLWKRXW VHYHUH IHDWXUHV DW RU EH\RQG 
ZHHNVRIJHVWDWLRQGHOLYHU\UDWKHUWKDQFRQWLQXHGREVHU-
vation is suggested.
Quality of evidence: Moderate
Strength of recommendation:4XDOLÀHG
‡ )RU ZRPHQ ZLWK SUHHFODPSVLD ZLWK V\VWROLF %3 RI OHVV
than 160 mm Hg and a diastolic BP less than 110 mm Hg
DQGQRPDWHUQDOV\PSWRPVLWLVVXJJHVWHGWKDWPDJQH-
sium sulfate not be administered universally for the pre-
vention of eclampsia.
PP+JRUGLDVWROLF%3RIDWOHDVWPP+JWKHXVHRI
antihypertensive therapy is recommended.
Quality of evidence: Moderate
Strength of recommendation: Strong
‡ )RU ZRPHQ ZLWK SUHHFODPSVLD LW LV VXJJHVWHG WKDW D
delivery decision should not be based on the amount of
proteinuria or change in the amount of proteinuria.
Quality of evidence: Moderate
Strength of recommendation: Strong
‡ )RU ZRPHQ ZLWK VHYHUH SUHHFODPSVLD DQG EHIRUH IHWDO
YLDELOLW\ GHOLYHU\ DIWHU PDWHUQDO VWDELOL]DWLRQ LV UHFRP-
PHQGHG([SHFWDQWPDQDJHPHQWLVQRWUHFRPPHQGHG
Quality of evidence: Moderate
Strength of recommendation: Strong
‡ ,WLVVXJJHVWHGWKDWFRUWLFRVWHURLGVEHDGPLQLVWHUHGDQG
GHOLYHU\ GHIHUUHG IRU  KRXUV LI PDWHUQDO DQG IHWDO
conditions remain stable for women with severe pre-
eclampsia and a viable fetus at ZHHNVRUOHVVRI
gestation with any of the following:
– preterm premature rupture of membranes
– labor
² ORZSODWHOHWFRXQWOHVVWKDQPLFUROLWHU
Quality of evidence:/RZ
² SHUVLVWHQWO\DEQRUPDOKHSDWLFHQ]\PHFRQFHQWUDWLRQV
Strength of recommendation:4XDOLÀHG (twice or more the upper normal values)
‡ )RU ZRPHQ ZLWK VHYHUH SUHHFODPSVLD DW RU EH\RQG  ² IHWDOJURZWKUHVWULFWLRQOHVVWKDQWKHÀIWKSHUFHQWLOH
 ZHHNV RI JHVWDWLRQ DQG LQ WKRVH ZLWK XQVWDEOH ² VHYHUH ROLJRK\GUDPQLRV DPQLRWLF ÁXLG LQGH[ OHVV
maternal or fetal conditions irrespective of gestational than 5 cm)

1126 Executive Summary: Hypertension in Pregnancy OBSTETRICS & GYNECOLOGY

 ² UHYHUVHG HQGGLDVWROLF ÁRZ RQ XPELOLFDO DUWHU\ Quality of evidence: High
'RSSOHUVWXGLHV Strength of recommendation: Strong
– new-onset renal dysfunction or increasing renal dys-
‡ )RU ZRPHQ ZLWK +(//3 V\QGURPH DW  ZHHNV RU
function
PRUH RI JHVWDWLRQ LW LV UHFRPPHQGHG WKDW GHOLYHU\ EH
Quality of evidence: Moderate XQGHUWDNHQVRRQDIWHULQLWLDOPDWHUQDOVWDELOL]DWLRQ
Strength of recommendation:4XDOLÀHG
Quality of evidence: Moderate
‡ ,WLVUHFRPPHQGHGWKDWFRUWLFRVWHURLGVEHJLYHQLIWKHIH- Strength of recommendation: Strong
WXVLVYLDEOHDQGDWZHHNVRUOHVVRIJHVWDWLRQEXW
‡ )RUZRPHQZLWK+(//3V\QGURPHIURPWKHJHVWDWLRQDO
that delivery not be delayed after initial maternal stabili-
DJH RI IHWDO YLDELOLW\ WR  ZHHNV RI JHVWDWLRQ LW LV
]DWLRQUHJDUGOHVVRIJHVWDWLRQDODJHIRUZRPHQZLWKVH-
VXJJHVWHGWKDWGHOLYHU\EHGHOD\HGIRU²KRXUVLIPD-
vere preeclampsia that is complicated further with any of
the following: ternal and fetal condition remains stable to complete a
FRXUVHRIFRUWLFRVWHURLGVIRUIHWDOEHQHÀW

– uncontrollable severe hypertension
– eclampsia Quality of evidence:/RZ
– pulmonary edema Strength of recommendation:4XDOLÀHG
– abruptio placentae
&RUWLFRVWHURLGVKDYHEHHQXVHGLQUDQGRPL]HGFRQWUROOHGWULDOV
– disseminated intravascular coagulation to attempt to improve maternal and fetal condition. In these
– evidence of nonreassuring fetal status VWXGLHVWKHUHZDVQRHYLGHQFHRIEHQHÀWWRLPSURYHRYHUDOOPD-
ternal and fetal outcome (although this has been suggested in
– intrapartum fetal demise
Quality of evidence: Moderate
Strength of recommendation: Strong
‡ )RU ZRPHQ ZLWK SUHHFODPSVLD LW LV VXJJHVWHG WKDW WKH
mode of delivery need not be cesarean delivery. The
mode of delivery should be determined by fetal gesta-
WLRQDODJHIHWDOSUHVHQWDWLRQFHUYLFDOVWDWXVDQGPDWHU-
nal and fetal conditions.
Quality of evidence: Moderate
Strength of recommendation:4XDOLÀHG
‡ )RUZRPHQZLWKHFODPSVLDWKHDGPLQLVWUDWLRQRISDUHQ-
teral magnesium sulfate is recommended.
Quality of evidence: High
Strength of recommendation: Strong
‡ )RUZRPHQZLWKVHYHUHSUHHFODPSVLDWKHDGPLQLVWUDWLRQ
of intrapartum–postpartum magnesium sulfate to pre-
vent eclampsia is recommended.
Quality of evidence: High
Strength of recommendation: Strong
‡ )RU ZRPHQ ZLWK SUHHFODPSVLD XQGHUJRLQJ FHVDUHDQ
GHOLYHU\WKHFRQWLQXHGLQWUDRSHUDWLYHDGPLQLVWUDWLRQRI
parenteral magnesium sulfate to prevent eclampsia is
recommended.
Quality of evidence: Moderate
Strength of recommendation: Strong
REVHUYDWLRQDOVWXGLHV7KHUHLVHYLGHQFHLQWKHUDQGRPL]HGWUL-
als of improvement of platelet counts with corticosteroid treat-
ment. In clinical settings in which an improvement in platelet
FRXQWLVFRQVLGHUHGXVHIXOFRUWLFRVWHURLGVPD\EHMXVWLÀHG
‡ )RUZRPHQZLWKSUHHFODPSVLDZKRUHTXLUHDQDOJHVLDIRU
labor or anesthesia for cesarean delivery and with a clin-
LFDO VLWXDWLRQ WKDW SHUPLWV VXűFLHQW WLPH IRU HVWDEOLVK-
ment of aneVWKHVLDWKHDGPLQLVWUDWLRQRIQHXUD[LDODQHV-
thesia (either spinal or epidural anesthesia) is recom-
mended.
Quality of evidence: Moderate
Strength of recommendation: Strong
‡ )RUZRPHQZLWKVHYHUHSUHHFODPSVLDLWLVVXJJHVWHGWKDW
invasive hemodynamic monitoring not be used routinely.
Quality of evidence:/RZ
Strength of recommendation:4XDOLÀHG
‡ )RU ZRPHQ LQ ZKRP JHVWDWLRQDO K\SHUWHQVLRQ SUHHF-
ODPSVLDRUVXSHULPSRVHGSUHHFODPSVLDLVGLDJQRVHGLWLV
suggested that BP be monitored in the hospital or that
equivalent outpatient surveillance be performed for at
OHDVW  KRXUV SRVWSDUWXP DQG DJDLQ ² GD\V DIWHU
delivery or earlier in women with symptoms.
Quality of evidence: Moderate
Strength of recommendation:4XDOLÀHG
‡ )RUDOOZRPHQLQWKHSRVWSDUWXPSHULRGQRWMXVWZRPHQ
‡ )RUZRPHQZLWK+(//3V\Qdrome and before the gesta-
WLRQDODJHRIIHWDOYLDELOLW\LWLVUHFRPPHQGHGWKDWGHOLY-
ery be undertaken shortly after initial maternal stabili-
]DWLRQ
VOL. 122, NO. 5, NOVEMBER 2013
ZLWK SUHHFODPSVLD LW LV VXJJHVWHG WKDW GLVFKDUJH LQ-
structions include information about the signs and symp-
toms of preeclampsia as well as the importance of
prompt reporting of this information to their health care
providers.
Executive Summary: Hypertension in Pregnancy 1127
 Quality of evidence:/RZ
TASK FORCE RECOMMENDATION
Strength of recommendation:4XDOLÀHG
‡ )RUZRPHQZLWKSUHHFODPSVLDLQDSULRUSUHJQDQF\SUH-
‡ )RUZRPHQLQWKHSRVWSDUWXPSHULRGZKRSUHVHQWZLWK conception counseling and assessment is suggested.
new-onset hypertension associated with headaches or
Quality of evidence:/RZ
EOXUUHGYLVLRQRUSUHHFODPSVLDZLWKVHYHUHK\SHUWHQVLRQ
Strength of recommendation: 4XDOLÀHG
the parenteral administration of magnesium sulfate is
suggested.
Chronic Hypertension and
Quality of evidence:/RZ
Superimposed Preeclampsia
Strength of recommendation:4XDOLÀHG
‡ )RUZRPHQZLWKSHUVLVWHQWSRVWSDUWXPK\SHUWHQVLRQ%3
RIPP+JV\VWROLFRUPP+JGLDVWROLFRUKLJKHU
RQDWOHDVWWZRRFFDVLRQVWKDWDUHDWOHDVW²KRXUVDSDUW
antihypertensive therapy is suggested. Persistent BP of
160 mm Hg systolic or 110 mm Hg diastolic or higher
should be treated within 1 hour.
Quality of evidence:/RZ
Strength of recommendation:4XDOLÀHG
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\PRGLÀDEOHOLIHVW\OHDFWLYLWLHVVXFKDVZHLJKWORVV
DQGLQFUHDVHGSK\VLFDODFWLYLW\VKRXOGEHHQFRXUDJHG7KH
FXUUHQW VWDWXV RI PHGLFDO SUREOHPV VKRXOG EH DVVHVVHG
including laboratory evaluation if appropriate. Medical
problems such as hypertension and diabetes should be
EURXJKWLQWRWKHEHVWFRQWUROSRVVLEOH7KHHŲHFWRIPHGLFDO
problems on the pregnancy should be discussed. Medica-
WLRQVVKRXOGEHUHYLHZHGDQGWKHLUDGPLQLVWUDWLRQPRGLÀHG
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 preec-
ODPSVLD 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
QH[WSUHJQDQF\HDUO\XOWUDVRQRJUDSK\VKRXOGEHSHUIRUPHG
WR GHWHUPLQH JHVWDWLRQDO DJH DQG DVVHVVPHQW DQG YLVLWV
VKRXOGEHWDLORUHGWRWKHSULRUSUHJQDQF\RXWFRPHZLWKIUH-
quent 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 Executive Summary: Hypertension in Pregnancy
&KURQLFK\SHUWHQVLRQK\SHUWHQVLRQSUHGDWLQJSUHJQDQF\
presents special challenges to health care providers. Health
FDUH SURYLGHUV PXVW ÀUVW FRQÀUP WKDW WKH %3 HOHYDWLRQ LV
QRWSUHHFODPSVLD2QFHWKLVLVHVWDEOLVKHGLIWKH%3HOHYD-
WLRQKDVQRWEHHQSUHYLRXVO\HYDOXDWHGDZRUNXSVKRXOGEH
SHUIRUPHG WR GRFXPHQW WKDW %3 LV WUXO\ HOHYDWHG LH QRW
white coat hypertension) and to check for secondary hyper-
tension and end-organ damage. The choice of which
women to treat and how to treat them requires special con-
VLGHUDWLRQVGXULQJSUHJQDQF\HVSHFLDOO\LQOLJKWRIHPHUJ-
ing data that suggest lowering BP excessively might have
DGYHUVHIHWDOHŲHFWV
Perhaps the greatest challenge is the recognition of
SUHHFODPSVLDVXSHULPSRVHGRQFKURQLFK\SHUWHQVLRQDFRQ-
dition 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 fea-
tures (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.
TASK FORCE RECOMMENDATIONS
‡ )RUZRPHQZLWKIeatures suggestive of secondary hyper-
WHQVLRQUHIHUUDOWRDSK\VLFLDQZLWKH[SHUWLVHLQWUHDWLQJ
hypertension to direct the workup is suggested.
Quality of evidence:/RZ
Strength of recommendation:4XDOLÀHG
‡ )RU SUHJQDQW ZRPHQ ZLWK FKURQLF K\SHUWHQVLRQ DQG
SRRUO\FRQWUROOHG%3WKHXVHRIKRPH%3PRQLWRULQJLV
suggested.
Quality of evidence: Moderate
Strength of recommendation:4XDOLÀHG
‡ )RUZRPHQZLWKVXVSHFWHGZKLWHFRDWK\SHUWHQVLRQWKH
XVHRIDPEXODWRU\%3PRQLWRULQJWRFRQÀUPWKHGLDJQR-
sis before the initiation of antihypertensive therapy is
suggested.
Quality of evidence:/RZ
Strength of recommendation:4XDOLÀHG
OBSTETRICS & GYNECOLOGY
‡ ,W LV VXJJHVWHG WKDW ZHLJKW ORVV DQG H[WUHPHO\ ORZ WRUVDQJLRWHQVLQUHFHSWRUEORFNHUVUHQLQLQKLELWRUVDQG
VRGLXPGLHWVOHVVWKDQP(TGQRWEHXVHGIRUPDQ-
aging chronic hypertension in pregnancy.
Quality of evidence:/RZ
Strength of recommendation:4XDOLÀHG
‡ )RUZRPHQZLWKFKURQLFK\SHUWHQVLRQZKRDUHDFFXV-
WRPHGWRH[HUFLVLQJDQGLQZKRP%3LVZHOOFRQWUROOHG
it is recommended that moderate exercise be continued
during pregnancy.
Quality of evidence:/RZ
mineralocorticoid receptor antagonists is not recom-
PHQGHGXQOHVVWKHUHLVDFRPSHOOLQJUHDVRQVXFKDVWKH
presence of proteinuric renal disease.
Quality of evidence:/RZ
Strength of recommendation:4XDOLÀHG
‡ )RU ZRPHQ ZLWK FKURQLF K\SHUWHQVLRQ ZKR DUH DW D
greatly increased risk of adverse pregnancy outcomes
(history of early-onset preeclampsia and preterm de-
OLYHU\DWOHVVWKDQZHHNVRIgestation or preec-
Strength of recommendation:4XDOLÀHG
‡ )RU SUHJQDQW ZRPHQ ZLWK SHUVLVWHQW FKURQLF K\SHUWHQ-
sion with systolic BP of 160 mm Hg or higher or diastolic
%3RIPP+JRUKLJKHUDQWLK\SHUWHQVLYHWKHUDS\LV
recommended.
0HWDDQDO\VLVRIPRUHWKDQZRPHQLQUDQGRPL]HGWULDOV
Quality of evidence: Moderate
Strength of recommendation: Strong
‡ )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 antihyperten-
sive therapy.
Quality of evidence:/RZ
Strength of recommendation: QualLÀHG
‡ 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.
Quality of evidence:/RZ
Strength of recommendation:4XDOLÀHG
‡ )RUWKHLQLWLDOWUHDWPHQWRISUHJQDQWZRPHQZLWKFKURQLF
K\SHUWHQVLRQ ZKR UHTXLUH SKDUPDFRORJLF WKHUDS\ ODEH-
WDOROQLIHGLSLQHRUPHWK\OGRSDDUHUHFRPPHQGHGDERYH
all other antihypertensive drugs.
Quality of evidence: Moderate
Strength of recommendation: Strong
‡ )RUZRPHQZLWKXQFRPSOLFDWHGFKURQLFK\SHUWHQVLRQLQ
SUHJQDQF\WKHXVHRIDQJLRWHQVLQFRQYHUWLQJHQ]\PHLQ-
KLELWRUVDQJLRWHQVLQUHFHSWRUEORFNHUVUHQLQLQKLELWRUV
and mineralocorticoid receptor antagonists is not rec-
ommended.
Quality of evidence: Moderate
Strength of recommendation: Strong
‡ )RU ZRPHQ RI UHSURGXFWLYH DJH ZLWK FKURQLF K\SHUWHQ-
VLRQ WKH XVH RI DQJLRWHQVLQFRQYHUWLQJ HQ]\PH LQKLEL-
VOL. 122, NO. 5, NOVEMBER 2013
ODPSVLDLQPRUHWKDQRQHSULRUSUHJQDQF\LQLWLDWLQJWKH
administration of daily low-dose aspirin (60–80 mg) be-
JLQQLQJLQWKHODWHÀUVWWULPHVWHULVVXJJHVWHG
Quality of evidence: Moderate
Strength of recommendation:4XDOLÀHG
of aspirin to prevent preeclampsia indicates a small reduction
in the incidence and morbidity of preeclampsia and reveals no
evidence of acuteULVNDOWKRXJKORQJWHUPIHWDOHŲHFWVFDQQRW
be excluded. The number of women to treat to have a thera-
SHXWLFHŲHFWLVGHWHUPLQHGE\SUHYDOHQFH,QYLHZRIPDWHUQDO
VDIHW\ D GLVFXVVLRQ RI WKH XVH RI DVSLULQ LQ OLJKW RI LQGLYLGXDO
ULVNLVMXVWLÀHG
‡ )RUZRPHQZLWKFKURQLFK\SHUWHQVLRQWKHXVHRIXOWUD-
sonography to screen for fetal growth restriction is sug-
gested.
Quality of evidence:/RZ
Strength of recommendation:4XDOLÀHG
‡ ,I HYLGHQFH RI IHWDO JURZWK UHVWULFWLRQ LV IRXQG LQ
ZRPHQZLWKFKURQLFK\SHUWHQVLRQIHWRSODFHQWDODVVHVV-
PHQWWRLQFOXGHXPELOLFDODUWHU\'RSSOHUYHORFLPHWU\DV
an adjunct antenatal test is recommended.
Quality of evidence: Moderate
Strength of recommendation: Strong
‡ )RU ZRPHQ ZLWK FKURQLF K\SHUWHQVLRQ FRPSOLFDWHG E\
issues such as tKHQHHGIRUPHGLFDWLRQRWKHUXQGHUO\LQJ
PHGLFDO FRQGLWLRQV WKDW DŲHFW IHWDO RXWFRPH RU DQ\
HYLGHQFHRIIHWDOJURZWKUHVWULFWLRQDQGVXSHULPSRVHG
SUHHFODPSVLDDQWHQDWDOIHWDOWHVWLQJLVVXJJHVWHG
Quality of evidence:/RZ
Strength of recommendation:4XDOLÀHG
‡ )RUZRPHQZLWKFKURQLFK\SHUWHQVLRQDQGQRDGGLWLRQDO
PDWHUQDORUIHWDOFRPSOLFDWLRQVGHOLYHU\EHIRUH
weeks of gestation is not recommended.
Quality of evidence: Moderate
Strength of recommendation: Strong
‡ )RUZRPHQZLWKVXSHULPSRVHGSUHHFODPSVLDZKRUHFHLYH
H[SHFWDQW PDQDJHPHQW DW OHVV WKDQ   ZHHNV RI
Executive Summary: Hypertension in Pregnancy 1129
 JHVWDWLRQWKHDGPLQLVWUDWLRQRIFRUWLFRVWHURLGVIRUIHWDO
OXQJPDWXULW\EHQHÀWLVUHFRPPHQGHG
Quality of evidence: High
Strength of recommendation: Strong
‡ )RUZRPHQZLWKFKURQLFK\SHUWHQVLRQDQGVXSHULPSRVHG
SUHHFODPSVLDZLWKVHYHUHIHDWXUHVWKHDGPLQLVWUDWLRQRI
intrapartum–postpartum parenteral magnesium sulfate
to prevent eclampsia is recommended.
Quality of evidence: Moderate
Strength of recommendation: Strong
‡ )RUZRPHQZLWKVXSHULPSRVHGSUHHFODPSVLDZLWKRXWVH-
YHUH IHDWXUHV DQG VWDEOH PDWHUQDO DQG IHWDO FRQGLWLRQV
H[SHFWDQWPDQDJHPHQWXQWLOZHHNVRIJHVWDWLRQLV
suggested.
Quality of evidence:/RZ
Strength of recommendation:4XDOLÀHG
‡ 'HOLYHU\VRRQDIWHUPDWHUQDOVWDELOL]DWLRQLVUHFRPPHQGHG
LUUHVSHFWLYHRIJHVWDWLRQDODJHRUIXOOFRUWLFRVWHURLGEHQHÀW
for women with superimposed preeclampsia that is com-
plicated further by any of the following:
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
ELUWKEHIRUHZHHNVRIJHVWDWLRQ7KLVKDVEHHQUHF-
RJQL]HGE\WKH$PHULFDQ+HDUW$VVRFLDWLRQZKLFKQRZUHF-
ommends that a pregnancy history be part of the evaluation
of CV risk in women. It is the general belief that preeclamp-
VLDGRHVQRWFDXVH&9GLVHDVHEXWUDWKHUSUHHFODPSVLDDQG
CV disease share common risk factors. Awareness that a
woman has had a preeclamptic pregnancy might allow for
WKH LGHQWLÀFDWLRQ 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
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gained by knowing a woman had a past preeclamptic preg-
QDQF\":RXOGLWEe valuable to perform this assessment at
a younger age in women who had a past preeclamptic preg-
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– uncontrollable severe hypertension XVHIXODQGZRXOGLWPDNHDGLŲHUHQFH"$UHWKHUHULVNIDF-
– eclampsia tors that could be unmasked by pregnancy other than con-
– pulmonary edema ventional risk factors? Further research is needed to
– abruptio placentae determine how to take advantage of this information relat-
– disseminated intravascular coagulation LQJSUHHFODPSVLDWRODWHUOLIH&9GLVHDVH$WWKLVWLPHWKH
– nonreassuring fetal status WDVN IRUFH FDXWLRXVO\ UHFRPPHQGV OLIHVW\OH PRGLÀFDWLRQ
Quality of evidence: Moderate PDLQWHQDQFHRIDKHDOWK\ZHLJKWLQFUHDVHGSK\VLFDODFWLY-
Strength of the recommendation: Strong LW\DQGQRWVPRNLQJDQGVXJJHVWVHDUO\HYDOXDWLRQIRUWKH
most high-risk women.
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TASK FORCE RECOMMENDATION
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that continued pregnancy should be undertaken only at ‡ )RUZRPHQZLWKDPHGLFDOKLVWRU\RISUHHFODPSVLDZKR
facilities with adequate maternal and neonatal intensive
care resources.
Quality of evidence: Moderate
Strength of evidence: Strong
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of gestation is not recommended.
Quality of evidence: Moderate
Strength of the recommendation: Strong
Later-Life Cardiovascular Disease in Women
With Prior Preeclampsia
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cating that a woman who has had a preeclamptic pregnancy
1130 Executive Summary: Hypertension in Pregnancy
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body mass index is suggested.*
Quality of evidence:/RZ
Strength of recommendation:4XDOLÀHG
*Although there is clear evidence of an association between
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priate 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 ex-
pense and inconvenience.
Patient Education
Patient and health care provider education is key to the
successful recognition and management of preeclampsia.
OBSTETRICS & GYNECOLOGY
Health care providers need to inform women during the
prenatal and postpartum periods of the signs and symp-
toms of preeclampsia and stress the importance of contact-
ing 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. Recom-
mended strategies to facilitate this process include using
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This understanding of preeclampsia pathophysiology has
not translated into predictors or preventers of preeclamp-
sia or to improved clinical care. This has led to a reassess-
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possibility that preeclampsia is not one disease but that the
syndrome may include subsets of pathophysiology.
Clinical research advances have shown approaches to
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hypertension and preeclampsia without severe features at
reinforcing key issues in print using pictorially based infor- ZHHNVRIJHVWDWLRQRUGRQRWZRUNYLWDPLQ&DQG
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TASK FORCE RECOMMENDATION
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mation about preeclampsia in the context of prenatal
care and postpartum care using proven health communi-
cation practices.
Quality of evidence: /RZ
Strength of recommendation:4XDOLÀHG
The State of the Science and
Research Recommendations
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of the pathophysiology of preeclampsia have occurred. Clin-
ical research advances also have emerged that have pro-
vided evidence to guide therapy. It is now understood that
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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 func-
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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 func-
tion leads to maternal disease through putative primary
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VOL. 122, NO. 5, NOVEMBER 2013
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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
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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
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type of practice. Variations and innovations that improve the quality
of patient care are to be encouraged rather than restricted. The
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basis on which local norms may be built.
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publisher.
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Executive Summary: Hypertension in Pregnancy 1131