A C TA Obstetricia et Gynecologica

AOGS M A I N R E SE A RC H A R TI C LE

Differentiating between gestational and chronic hyper-

tension; an explorative study
JOSIEN A. TERWISSCHA VAN SCHELTINGA, INEKE KRABBENDAM & MARC E.A. SPAANDERMAN
Department of Obstetrics and Gynecology, Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands

Key words Abstract

Chronic hypertension, gestational
hypertension, HELLP syndrome, intra-uterine
growth restriction, pre-eclampsia
Correspondence
Josien A. Terwisscha van Scheltinga, Radboud
University Nijmegen Medical Center,
Department of Obstetrics & Gynecology
(791), PO Box 9101, Nijmegen 6500HB, the
Netherlands. E-mail:
j.terwisschavanscheltinga@obgyn.umcn.nl
Conflict of interest
The authors have stated explicitly that there
are no conflicts of interest in connection with
this article.
Please cite this article as: Terwisscha van
Scheltinga JA, Krabbendam I, Spaanderman
MEA. Differentiating between gestational and
chronic hypertension; an explorative study.
Acta Obstet Gynecol Scand 2013;
92:312–317.
Received: 15 April 2012
Accepted: 23 November 2012
Objective. Guidelines define hypertension diagnosed before 20 weeks’ gestation
as chronic hypertension (CH) and thereafter as gestational hypertension (GH).
We tested whether hypertension diagnosed before 20 weeks is preceded by CH
and whether pregnancy outcome depends on the time of onset of hypertension.
Design. Retrospective cohort study. Setting. Tertiary obstetric center. Popula-
tion. Women with a history of obstetric vascular complications. Methods. Blood
pressure data prior to and during pregnancy and subsequent maternal and neo-
natal outcome were reviewed in 148 women. Women were grouped according to
the onset of hypertension; pre-pregnancy (CH), before 20 weeks’ (early GH),
after 20 weeks’ gestation (late GH) and normotensive. Main outcome measures.
Onset of hypertension, obstetric complications (pre-eclampsia, HELLP (hemoly-
sis, elevated liver enzymes and low platelets) syndrome, intra-uterine growth
restriction). Results. Twenty-nine women had CH. Early GH occurred in 46
women and another 32 developed late GH. Of 75 women with hypertension in
the first half of pregnancy, 29 (39%) had CH and 46 (61%) early GH. Obstetric
complications occurred more often in all hypertensive women, but no differences
between the CH and GH groups could be detected. Conclusions. Hypertension
detected in the first half of pregnancy does not necessarily indicate chronic hyper-
tension. Hypertension in general is related to hypertensive maternal complica-
tions and fetal growth restriction. Differentiating between chronic or gestational
hypertension does not seem to help in establishing the risk for later hypertensive
sequelae or intra-uterine growth restriction.

DOI: 10.1111/aogs.12061 CH, chronic hypertension; GH, gestational hypertension;

Abbreviations:
HELLP, hemolysis, elevated liver enzymes, and low platelets; PE, pre-eclampsia.
Introduction
Hypertensive disorders complicate about 10–15% of all
pregnancies (1,2). Gestational hypertensive diseases
increase the risk of maternal and neonatal morbidity and
mortality (3). To estimate these risks, clinicians often
distinguish between chronic hypertension (CH), gesta-
tional hypertension (GH) and in combination with pro-
teinuria, pre-eclampsia (PE) and PE superimposed on
chronic hypertension. The definitions of these disorders
have undergone slight changes over time and depend on
the guidelines used (1,4–7). Most recent guidelines define
hypertension diagnosed before 20 weeks’ gestation as CH
and hypertension occurring after 20 weeks’ gestation as
GH (1). The difference between CH and GH might be
important for their associated different risks of obstetric
complications. In women with CH the risk of developing
superimposed PE is 10–40% (7–9) but increases with
Key Message
Gestational hypertension can arise in the first
20 weeks of pregnancy and therefore does not neces-
sarily indicate chronic hypertension. Distinguishing
these conditions does not seem to help in establishing
the risk for later obstetric complications.

ª 2012 The Authors

312 Acta Obstetricia et Gynecologica Scandinavica ª 2012 Nordic Federation of Societies of Obstetrics and Gynecology 92 (2013) 312–317
J.A. Terwisscha van Scheltinga et al.
hypertension that is present for longer or is more severe
(10). In these women the risk of neonatal morbidity and
preterm birth is three times higher than among those
with normal blood pressure (11). GH is supposed to be
less threatening, although the reported risk of PE largely
overlaps with that of CH and varies between 15 and 50%
(12,13). In general, if GH evolves to PE, the risk for pre-
term birth rises four- to fivefold and the risk for intra-uterine
growth restriction twofold compared with GH alone.
In most women, pre-pregnancy blood pressure is not
known. In clinical practice CH is assumed when hyper-
tension is detected before 20 weeks’ gestation (14).
However, to our knowledge, data to substantiate this
assumption are lacking. The objective of this study was to
test whether hypertension in the first half of pregnancy is
indeed preceded by chronic hypertension. In addition we
investigated whether hypertensive sequelae and pregnancy
outcome differ between CH, GH established early in
pregnancy, and GH established late in pregnancy.
Material and methods
We retrospectively recorded information on 246 pregnan-
cies in women who had preconception screening between
January 2004 and December 2008 because of a history of
obstetric (vascular) complications and who had a subse-
quent pregnancy. Possible reasons for the screening
included a combination of PE, hemolysis, HELLP (hemo-
lysis, elevated liver enzymes and low platelets) syndrome,
placental abruption or stillbirth in a previous pregnancy.
We have chosen to include stillbirth in accordance with
recommendations from Ray et al. (15), who introduced a
few years ago the term maternal and fetal placental syn-
drome. All stillbirths may originate from some kind of
maternal vascular dysfunction and are therefore most
likely related to remote cardiovascular complications.
Stillbirth may be considered a fetal placental syndrome.
Therefore, we include these women in a comparable eval-
uation program as formerly pre-eclamptic women.
We excluded 98 women due to subsequent twin preg-
nancy (n = 8), incomplete subsequent pregnancy data
(n = 43), mostly as a consequence of obstetric check-ups in
other hospitals, or underlying illness (n = 47), such as dia-
betes mellitus, thromboembolic disease or kidney disease,
as these abnormalities relate to hypertension but also
require additional treatment. The study was approved by
the hospital medical ethical committee (2007/252).
Blood pressure data prior to and during the subsequent
pregnancy were recorded by sphygmomanometrically
measured systolic and diastolic blood pressure. The mean
arterial pressure (mmHg) was calculated as 29 diastolic
blood pressure + 19 systolic blood pressure/3. Diastolic
blood pressure was based on Korotkoff V and an appropri-
ª 2012 The Authors
Acta Obstetricia et Gynecologica Scandinavica ª 2012 Nordic Federation of Societies of Obstetrics and Gynecology 92 (2013) 312–317
Gestational and chronic hypertension
ate cuff size was used. Blood pressure was measured in
the sitting position. Blood pressure data were recorded
prior to pregnancy and again at 11 different gestational age
points in the subsequent pregnancy: before 8 weeks’ gesta-
tion, 9–12, 13–16, 17–20, 21–25, 26–30, 31–34, 35–36, 37–
38, 39–40 and 41–42 weeks’ gestation. If in these intervals
blood pressure measurements were performed repeatedly,
the median of these measurements was used.
Women were considered hypertensive when systolic
blood pressure exceeded 140 mmHg and/or diastolic
blood pressure exceeded 90 mmHg and/or when they were
using anti-hypertensive medication. Women commenced
anti-hypertensive medication according to the local proto-
col. In general, anti-hypertensive medication during preg-
nancy was started when blood pressure exceeded 140/
90 mmHg. First choice antihypertensive agents were sym-
paticolytic methyldopa and labetalol. Second line medica-
tion was nifedipine. Data of all women, including those
who use antihypertensive medication, are included in the
figures and analysis.
We also evaluated pregnancy outcome and obstetric vas-
cular complications. We recorded the incidence of PE,
eclampsia (PE along with concurrent epileptic seizures),
HELLP syndrome, placental abruption, intra-uterine
growth restriction (neonatal weight <10th centile) (16),
stillbirth (fetal demise >20 weeks’ gestation) and gesta-
tional age at delivery (weeks).
The statistical software package SPSS 16.0 (SPSS Inc.,
Chicago, IL, USA) was used for all data analyses. Differ-
ences between the groups were assessed non-parametri-
cally with Mann-Whitney’s U or Pearson’s chi-squared
tests where applicable. Bonferroni correction for multiple
testing was used. Data are presented as median (inter-
quartile range). The CH group served as reference. A
p-value of less than 0.05 was considered significant. If we
considered a 35% difference in the development of vascu-
lar complications between CH (assuming a complication
rate 45%) on the one hand and early GH and late GH
(assuming a complication rate 10%) on the other to be
clinically important, using a 0.05 and 90% power, at least
28 women per group were needed. Assuming a 60%
(10%) occurrence of gestational hypertension in the ini-
tially normotensive (high risk) women equally distributed
between the first and second half of pregnancy, at least 93
(80–112) initially normotensive women were needed to
be included in the final analysis. We therefore decided to
include at least 112 initially normotensive women.
Results
Of 148 included women with a history of obstetric vascular
complications, 119 were normotensive prior to pregnancy
(80%) and 29 (20%) had chronic hypertension. Of 119
313
Gestational and chronic hypertension
initially normotensive women, 34% (n = 41) remained
normotensive throughout pregnancy. The remainder of the
women developed hypertension. The gestational age at
which the hypertension developed is detailed in Figure 1.
Only 32 (41%) women with gestational hypertension devel-
oped it after 20 weeks’ gestation, which is the current defi-
nition of gestational hypertension. The majority of pre-
pregnancy normotensive women (n = 46, 59%) developed
hypertension before 20 weeks’ gestation and would have
been diagnosed chronically hypertensive in the case of
unknown pre-pregnancy blood pressure.
To explore whether the onset of hypertension affects
pregnancy outcome, women were grouped by the onset of
hypertension into pre-pregnancy chronic hypertension
(CH), before 20 weeks’ gestation (early GH), after
20 weeks’ gestation (late GH), and those remaining nor-
motensive. Patient characteristics are listed in Table 1.
These did not differ with respect to age, parity, daily smok-
ing, daily coffee consumption, and the interval between
pre-pregnancy evaluation and conception. The pre-preg-
nancy body mass index was lower in the normotensive
group than in the CH group. The obstetric history showed
no significant differences in birth centile or in the incidence
of PE, eclampsia, HELLP syndrome, placental abruption,
or stillbirth between groups. Patients could have a combi-
nation of diagnoses. The gestational age at delivery in the
previous pregnancy was higher in the late GH group than
in the CH group. Obviously, pre-pregnancy blood pressure
was highest in the CH group. Although normotensive,
blood pressure in the early GH group was slightly higher
than in the normotensive or late GH group.
In the subsequent pregnancy, the normotensive women
had the least maternal obstetric complications and the
highest gestational age at delivery. Despite this, there were
no differences in birthweight, intra-uterine growth restric-
Figure 1. Gestational age at onset of hypertension.
314 Acta Obstetricia et Gynecologica Scandinavica ª 2012 Nordic Federation of Societies of Obstetrics and Gynecology 92 (2013) 312–317
J.A. Terwisscha van Scheltinga et al.
tion or birthweight centile between the hypertensive
groups (Table 2). In all hypertensive groups, we observed
comparable incidences of PE (7–16%) and HELLP syn-
drome (0–3%). Three women with PE delivered before
34 weeks’ gestation. All women with PE also had PE in
the previous pregnancy. The only case of HELLP syn-
drome was a recurrence as well. Since 101 of included
women had PE in their previous pregnancy, the recur-
rence risk in this study was 10%; for HELLP syndrome,
the risk was 1.3%.
The percentage of patients using antihypertensive and
prophylactic medication, at that time supposed to reduce
the risk of recurrent PE, is shown in Table 3. The risk-
lowering medication included vitamin C and E, piridoxine
(in case of mildly elevated pre-pregnancy homocysteine
levels), acetylsalicylic acid and calcium. The decision to
use these medications was based on the medical history
and findings at the preconception screening. Acetylsali-
cylic acid was used by 72% of the women with a history
of PE. All of the risk-lowering medications were used
least in the normotensive group. There was no difference
in the use of these medications in the different hyperten-
sive groups.
Discussion
Currently, chronic hypertension is assumed when blood
pressure exceeds 140/90 mmHg before 20 weeks’ gesta-
tion. In this study we observed among women at high
risk for hypertensive complications that more than half
who had hypertension before 20 weeks’ gestation did not
have pre-pregnancy chronic hypertension. Moreover, the
distinction between chronic hypertension and gestational
hypertension was correlated neither with maternal hyper-
tensive complications or with fetal growth restriction.
In this explorative study we were able to use pre-preg-
nancy blood pressure data. Most published studies on this
topic did not have such information available but used
the postpartum value instead (17–19), mostly 6–12 weeks
after delivery. Although gestational hypertension usually
resolves quickly after delivery [within 2 (GH) to 3 (PE)
weeks (20)], full blood pressure recovery can take up to
two years (21). Although one old study reported blood
pressure readings both prior to and during pregnancy,
there was no possibility of interpreting the prevalence of
the de novo hypertension prior to 20 weeks’ gestation, as
all women who became hypertensive were excluded, with-
out specifying the number of women and gestational age
at exclusion of these patients (22). In addition, as most
reported gestational blood pressure data begin at 17–
20 weeks, first trimester changes may have been missed
(23). Therefore, comparison of earlier findings with our
data hardly seem to be possible.
ª 2012 The Authors
J.A. Terwisscha van Scheltinga et al. Gestational and chronic hypertension

Table 1. Patient characteristics.

CH Early GH Late GH Normotensive

Characteristic n = 29 n = 46 n = 32 n = 41

Age, years 33 [31–36] 32 [29–35] 34 [31–36] 32 [30–36]

Parity 1 [1–1] 1 [1–1] 1 [1–1] 1 [1–1]
Body mass index, kg/m2 25 [22–30] 25 [22–29] 23 [21–27] 23 [21–25]*
Daily smoking, n (%) 3 (10) 4 (9) 4 (12) 5 (12)
Daily use of coffee, n (%) 15 (52) 29 (63) 16 (50) 23 (56)
Pre-pregnancy blood pressure, 132 [122–142]/ 119 [113–125]*/ 113 [108–125]*/ 113 [107–119]*/
mmHg: systolic/diastolic 80 [70–87] 70 [66–76]* 65 [59–74]* 68 [65–71]*
Interval between pre-conception 5 [2–13] 10 [4–15] 10 [3–19] 10 [3–25]
screening and conception, months
Obstetric history
Gestational age at delivery, weeks 29+4 [26+1–35+1] 31+2 [28+6–35+1] 34+0 [30+2–37+6]* 33+1 [29+5–38+1]*
Birthweight centile 7 [2–26] 12 [5–41] 10 [5–40] 15 [4–50]
Preeclampsia, % 79 70 66 61
HELLP syndrome, % 69 48 53 49
Eclampsia, % 0 7 6 2
Placental abruption, % 7 7 6 5
Stillbirth, % 34 22 19 20

Data are presented as median and [interquartile range] or percentage (%).

*Significantly different compared with CH (p < 0.050).
CH, chronic hypertension; GH, gestational hypertension; HELLP, hemolysis, elevated liver enzymes, and low platelets.

Table 2. Pregnancy outcome in subsequent pregnancy.

CH Early GH Late GH Normotensive

Outcome n = 29 n=4 n = 32 n = 41

Obstetric complications 10 (35) 13 (28) 10 (31) 5 (12)*

Preeclampsia 2 (7) 3 (7) 5 (16) 0
HELLP 0 0 1 (3) 0
Abruption 0 1 (26) 0 0
IUGR 9 (31) 10 (22) 7 (22) 5 (12)
Gestational age at delivery, weeks 38+2 [37+2–39+2] 38+5 [37+4–40+1] 38+5 [37+5–40+0] 39+1* [38+1–40+3]
Birthweight, g 3060 [2445–3703] 3155 [2618–3739] 2925 [2550–3425] 3295 [2073–3780]
Birthweight centile 27 [7–79] 34 [14–68] 26 [11–64] 45 [20–80]

Data are presented as median and [interquartile range] or number of women and percentage (%).
*Significantly different compared with CH (p < 0.050).
CH, chronic hypertension; GH, gestational hypertension; HELLP, hemolysis, elevated liver enzymes, and low platelets; IUGR, intra-uterine growth
restriction.

Clinically, we did not find any difference in preg-
nancy outcome between early GH, late GH or CH. In
supposed chronic hypertension, the risk of PE is
reported to be between 15 and 50%. In all hypertensive
subgroups we observed lower PE incidences (7–16%)
than reported elsewhere (8,12,13,24). The use of acetyl-
salicylic acid in 72% of women might have influenced
the incidence of PE to some degree. In line with
reported meta-analytical data, it may be that both the
tight antihypertensive control and low threshold to
start antihypertensive medication with sympaticolytic
agents, especially labetalol [which was shown to reduce
the risk for preeclampsia by 27% (95% confidence
interval 6–43%)] and the use of preventive medica-
tion, affected our low hypertensive complication rates
(25).
We are aware that there is a selection bias since we
only included women with an elevated risk for hyperten-
sive complications. It may be that this group responds
hemodynamically differently to pregnancy compared with
primigravid women. Therefore we cannot directly trans-
late our findings to primigravid women. Nonetheless, as
we observed no difference in obstetric outcome between
chronic hypertension and all forms of gestational hyper-
tension, we suggest that any kind of hypertension in
pregnancy be considered high risk.

ª 2012 The Authors

Acta Obstetricia et Gynecologica Scandinavica ª 2012 Nordic Federation of Societies of Obstetrics and Gynecology 92 (2013) 312–317 315
Gestational and chronic hypertension J.A. Terwisscha van Scheltinga et al.

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