BJA Education, 20(12): 411e416 (2020)

doi: 10.1016/j.bjae.2020.07.007
Advance Access Publication Date: 12 October 2020

Matrix codes: 1A02,

2B06, 3B00

Update on hypertensive disorders in pregnancy

J. Goddard, M.Y.K. Wee* and L. Vinayakarao
Poole NHS Foundation Trust, Poole, Dorset, UK
*Corresponding author: michaelykwee@googlemail.com

Keywords: gestational hypertension; hypertensive emergencies; pre-eclampsia

Learning objectives Key points

By reading this article you should be able to:
The target blood pressure during pregnancy is

Describe the diagnostic criteria for hypertension <135/85 mmHg.
and pre-eclampsia.
New risk prediction models for pre-eclampsia can

Identify risk factors for developing pre- help guide decision making.
eclampsia.
Labetalol, hydralazine and immediate-release

Apply risk prediction models for pre-eclampsia in oral nifedipine are suitable treatment options
clinical practice. for hypertensive emergencies.

Formulate management plans for women pre-
Hypertensive disorders during pregnancy are
senting with hypertensive emergencies during associated with a long-term increased risk of
pregnancy. cardiovascular diseases so women should be
offered lifelong follow-up.

Introduction revealed that 2% were attributable to pre-eclampsia and

Hypertensive disorders during the peripartum period are
common and are accompanied by increased maternal and
fetal morbidity and mortality. They encompass chronic pre-
existing hypertension, gestational hypertension and pre-
eclampsia. The confidential enquiries into maternal deaths
Jennifer Goddard MBiol FRCA PgDip Edu is a specialty registrar in
Poole who has undertaken higher training in obstetric anaesthesia.
Michael Y. K. Wee BSc (Hons) FRCA is a consultant and visiting
professor at Bournemouth University. He is past Hon. Secretary of
the OAA; vice-president of the Association of Anaesthetists; exam-
iner of the Royal College of Anaesthetists and a contributor to
Standards in Obstetric Anaesthesia Services. Professor Wee had
published more than 40 peer-reviewed articles on obstetric
anaesthesia.
Latha Vinayakarao MRCOG MRCPI is a consultant obstetrician
with special interests in maternal and fetal medicine. She is the
clinical lead for obstetrics at her trust, quality improvement lead for
adoption of PlGF-based testing for the diagnosis of pre-eclampsia
and co-lead for the Wessex Intrapartum Care Network.
eclampsia.1 Untreated hypertension can lead to adverse
events for both mother and baby, including maternal cardio-
vascular morbidity and stroke, increased risk of preterm birth
and small for gestational age babies. Cardiovascular diseases
in later life are also more common in these women.
This article provides an update on the assessment and
management of hypertensive disorders in pregnancy of
particular relevance to the anaesthetist.
Hypertension
According to the American College of Obstetricians and Gy-
necologists (ACOG), hypertension in pregnancy is diagnosed if
the systolic blood pressure (SBP) is 140 mmHg, diastolic BP
(DBP) is 90 mmHg, or both, ideally confirmed on two occa-
sions or at least 4 h apart.2
Chronic hypertension is hypertension that presents before
20 weeks’ gestation. The majority of cases are attributable to
essential hypertension, which may be associated with obesity
or a family history of hypertension. Secondary causes are
much less common. This category also includes white coat
hypertension, which refers to a BP 140/90 mmHg within a
hospital setting but not at home. Ambulatory BP monitoring

Accepted: 20 July 2020

© 2020 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.
For Permissions, please email: permissions@elsevier.com

411

Descargado para Anonymous User (n/a) en University of Antioquia de ClinicalKey.es por Elsevier en noviembre 16, 2020.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos reservados.
Update on hypertensive disorders in pregnancy
Table 1 Severe features associated with pre-eclampsia.6 DBP, diastolic BP; SBP, systolic BP
Severe features
SBP 160 mmHg or DBP 110 mmHg
Thrombocytopaenia (platelet count 100,000 ml1)
Impaired liver function (aspartate transaminase or alanine transaminase levels elevated to twice the upper limit of normal and
severe persistent right upper quadrant or epigastric pain not accounted for by alternative diagnoses)
Renal insufficiency (doubling of the serum creatinine concentration in the absence of other renal disease)
Pulmonary oedema
New onset headache, unresponsive to medication and not accounted for by alternative diagnoses
Visual disturbance
over 24 h can confirm chronic hypertension. Up to half of
women with white coat hypertension develop gestational
hypertension or pre-eclampsia.
Gestational hypertension is new onset hypertension that
develops after 20 weeks’ gestation without any features of
pre-eclampsia. Transient gestational hypertension, particu-
larly if noted before 33 weeks’ gestation, is associated with up
to 40% risk of developing true gestational hypertension or pre-
eclampsia.3 Twenty-five percent of women with true gesta-
tional hypertension or chronic hypertension will develop pre-
eclampsia. Therefore, these women require additional moni-
toring throughout their pregnancy.
Pre-eclampsia
Definition and diagnosis
The International Society for the Study of Hypertension in
Pregnancy (ISSHP) defines pre-eclampsia as new onset hy-
pertension (SBP 140 mmHg, DBP 90 mmHg, or both)
accompanied by one or more of the following features at or
after 20 weeks’ gestation.4

Proteinuria
Proteinuria is considered positive if 1þ or more. The Na-
tional Institute for Health and Care Excellence (NICE) guide-
lines define significant proteinuria as a urine
protein:creatinine ratio (PCR) 30 mg mmol1, albu-
min:creatinine ratio (ACR) 8 mg mmol1, or both.5 Pre-
eclampsia can present without proteinuria.

Other maternal organ dysfunction, including:
 Acute kidney injury (increase in serum creatinine of
90 mmol L1)
 Liver involvement (elevated transaminases, increase in
alanine transaminase 70 IU L1, or twice upper limit of
normal range)
 Neurological complications (including eclamptic sei-
zures, severe headaches, persistent visual scotomata,
clonus, blindness, altered mental status or stroke)
 Haematological complications (thrombocytopaenia e
platelet count <150,000 ml1, disseminated intravascular
coagulation [DIC], haemolysis)

Uteroplacental dysfunction (e.g. abnormal umbilical artery
Doppler waveform analysis, restricted fetal growth or
stillbirth)
Pre-eclampsia represents a potentially progressive clinical
condition; therefore, the sub-categories ‘mild’ and ‘severe’
should no longer be used.4 The ACOG describe pre-eclampsia
as being with or without severe features (Table 1).6 The ISSHP
412 BJA Education - Volume 20, Number 12, 2020
Descargado para Anonymous User (n/a) en University of Antioquia de ClinicalKey.es por Elsevier en noviembre 16, 2020.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos reservados.
diagnostic criteria includes clonus but not hyperreflexia as
this is highly subjective and often present in otherwise
healthy women.
HELLP (haemolysis, elevated liver enzymes and low plate-
lets) syndrome is potentially life-threatening to both mother
and baby, and represents a severe form of pre-eclampsia.
Women may be critically unwell at presentation with
placental abruption or DIC.
Risk factors
Numerous strong and moderate risk factors have been iden-
tified for development of pre-eclampsia (Table 2).7 Risk pre-
diction tools that incorporate multiple features including
placental biomarkers, uterine artery Doppler measurements
and maternal risk factors, might aid earlier diagnosis and
improved outcomes. Placental growth factor (PlGF) is a
placental biomarker, with levels that peak between 26 and 30
weeks’ gestation and reduce towards term.8 PlGF is decreased
in pre-eclampsia, particularly in severe disease. A multicentre
study found that in women with possible pre-eclampsia pre-
senting before 35 weeks’ gestation, those with low PlGF
(<12 pg ml1) are likely to develop pre-eclampsia requiring
delivery within 14 days of testing.9 The PlGF test has a sensi-
tivity of 96% and a negative predictive value (NPV) of 98%.
Another placental biomarker, soluble fms-like tyrosine
kinase 1 (sFlt-1), is an antagonist of PlGF that causes vaso-
constriction and endothelial damage, and is increased in pre-
eclampsia. There is an increased risk of pre-eclampsia in
Table 2 Strong and moderate risk factors for development of
pre-eclampsia7
Strong risk factors Moderate risk factors
Prior pre-eclampsia Primiparity
Chronic hypertension Primipaternity e changed
paternity and inter-
pregnancy interval >5 yrs
Maternal BMI >30 Advanced maternal age 40
yrs
Pregestational diabetes Family history of pre-
mellitus eclampsia
Antiphospholipid syndrome/ Multiple gestation
systemic lupus
erythematosus (SLE)
Assisted reproductive Chronic kidney disease
therapies

Table 3 Severe features associated with pre-eclampsia that warrant consideration of planned early birth before 37 weeks’ gestation4,5
Severe features
Inability to control maternal BP despite using 3 or more classes of antihypertensives in appropriate doses
Progressive deterioration in liver function, renal function, haemolysis, or platelet count
Maternal pulse oximetry less than 90% on air
Ongoing neurological features, such as severe intractable headache, repeated visual scotomata or eclampsia
Placental abruption
Reversed end-diastolic flow in the umbilical artery Doppler velocimetry, a non-reassuring cardiotocograph or stillbirth
women with a high sFlt-1 to PlGF ratio.10 A short-term absence
of pre-eclampsia can be predicted by a sFlt-1/PlGF ratio of
38.11 The sFlt-1/PlGF ratio has a sensitivity of 80% and NPV of
99.3%. Overall, angiogenic biomarkers can help to rule out pre-
eclampsia and expedite diagnosis in women with pre-
eclampsia. NICE recommends the use of PlGF test and the
Elecsys immunoassay sFlt-1:PlGF ratio, in combination with
standard clinical assessment, to help exclude women with
pre-eclampsia between 20 weeks and before 35 weeks of
gestation.12
There is some evidence to support the use of new risk
prediction models for identifying risks of maternal adverse
outcomes from pre-eclampsia.
Both the PREP-S (Prediction model for Risks of complica-
tions in Early-onset Pre-eclampsia [survival analysis model ])
and fullPIERS (Pre-eclampsia Integrated Estimate of Risk) are
validated risk prediction models based on gestational age,
vital signs and biochemical observations.13,14 PREP-S can be
used up to 34 weeks’ gestation whereas fullPIERS can be used
at any time during pregnancy. Notably, neither of the models
can predict fetal outcomes. These risk prediction models are
recommended by NICE and can be used to help guide decision
making, particularly regarding the decision to admit a woman
to hospital.5
Prevention
General lifestyle advice about maintaining a healthy diet and
exercise should be given to all pregnant women. There is a
lower rate of hypertensive disorders and gestational diabetes
in women who take regular aerobic exercise during
pregnancy.15
Aspirin
The ASPRE (Aspirin for Evidence-Based Preeclampsia Preven-
tion) trial concluded there was a lower rate of preterm pre-
eclampsia in women taking aspirin 150 mg at night from
11e14 weeks’ to 36 weeks’ gestation compared with placebo
(1.6% vs 4.3%).16 NICE recommends that women at high risk of
developing pre-eclampsia be given aspirin 75e150 mg daily
from 12 weeks until the birth of the baby.5 Women with two or
more moderate risk factors should also be offered aspirin.
Calcium
Where calcium dietary intake is low, supplementation
(>1 g day1) may lower the chances of developing pre-
eclampsia.4
Descargado para Anonymous User (n/a) en University of Antioquia de ClinicalKey.es por Elsevier en noviembre 16, 2020.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos reservados.
Update on hypertensive disorders in pregnancy
Folic acid
The recently published folic acid supplementation in preg-
nancy on pre-eclampsia (FACT) trial found that in high-risk
women, high-dose folic acid supplementation (4 mg day1)
beyond the first trimester does not prevent pre-eclampsia.17
Management
Blood pressure
The threshold for initiating antihypertensive treatment for all
hypertensive disorders in pregnancy has been lowered. A
sustained BP 140/90 mmHg warrants treatment, targeting a
BP 135/85 mmHg.5 The main aim of controlling the maternal
BP is the prevention of intracerebral haemorrhage and stroke.
The rate of stroke during the peripartum period in women
with pre-eclampsia is 133 per 100,000, with haemorrhagic
stroke being more common than ischaemic stroke.18 NICE
recommends offering oral labetalol as initial therapy, fol-
lowed by nifedipine and then methyldopa as alternatives.5
Second- and third-line agents include hydralazine and pra-
zosin.4 Women with severe hypertension (SBP 160 mmHg,
DBP 110 mmHg, or both) should be admitted to hospital for
assessment and treatment in a monitored setting.
Labetalol is a non-selective beta blocker and the most
commonly used beta blocker in pregnancy. Other b1-selective
drugs such as bisoprolol and metoprolol can also be used but
atenolol should be avoided. Care should be taken in women
with asthma when using beta blockers.
Dihydropyridine calcium channel blockers, such as nifed-
ipine, are also used during pregnancy. Immediate-release oral
nifedipine can cause profound hypotension so its use should
be avoided concomitantly with magnesium sulphate, as the
potential synergistic action can result in fetal compromise.
Modified release nifedipine might be more suitable. Women
taking thiazide diuretics, angiotensin-converting enzyme
(ACE) inhibitors or angiotensin II receptor blockers (ARBs)
should have their medication reviewed, and a safer alterna-
tive offered when they become pregnant, owing to the risk of
congenital abnormalities.5
Timing of birth
Women should have BP monitoring, urinalysis and blood tests
performed with the frequency adjusted according to the
clinical picture.5 Foetal assessment with ultrasound should be
performed every 2e4 weeks as clinically indicated.5 A planned
birth before 37 weeks should be considered for women with
pre-eclampsia with severe features (Table 3). After 37 weeks’
gestation, birth should be initiated for women with pre-
eclampsia within 24e48 h.
BJA Education - Volume 20, Number 12, 2020 413
Update on hypertensive disorders in pregnancy

Table 4 Risk factors for hypertensive emergencies in pregnancy19

Risk factors

Pre-eclampsia
Chronic renal disease
Cardiac disease
Non-compliance with antihypertensive medication
Use of uterotonic drugs for prevention and treatment of postpartum haemorrhage (e.g. ergometrine)
Concomitant use of recreational drugs (e.g. cocaine, methamphetamine)
Low socioeconomic status
Non-Hispanic black population

Hypertensive emergencies of i.v. fluids and autotransfusion after uterotonic adminis-

tration. Therefore, in women with pre-eclampsia with severe
An ACOG committee defined severe hypertension as an acute
features, maintenance fluids should be restricted to 80 ml h1,
onset BP 160/110 mmHg persisting for 15 min.2 A hyper-
unless there are other ongoing fluid losses, and careful fluid
tensive emergency may present with end organ damage such
balance monitoring is required.5 The third stage should be
as myocardial infarction, pulmonary oedema, respiratory
managed with oxytocin and ergometrine should be avoided.
failure or stroke. Risk factors for hypertensive emergencies in
pregnancy are listed in Table 4.19
Initial investigations for suspected hypertensive emer- Eclampsia
gencies in pregnancy include blood tests (full blood count
Eclamptic seizures are usually self-limiting but may cause
[FBC], creatinine, electrolytes, lactate dehydrogenase [LDH],
maternal hypoxia and a risk of pulmonary aspiration
fibrinogen, haptoglobin); urine (PCR, ACR, microscopy); ECG
requiring airway protection. The risk of stroke in women with
and fundoscopy. Additional specific tests can be considered
eclampsia is approximately 10 times higher than women with
depending on the clinical picture, and these include echo-
pre-eclampsia.18 When a woman with pre-eclampsia presents
cardiography (ischaemia or heart failure); brain or chest im-
with persistent neurological symptoms or signs (severe
aging (stroke or aortic dissection); renal ultrasound (renal
intractable headache, signs of cerebral irritability, clonus or
parenchymal disease); urinary drug screen (suspected cocaine
visual disturbance) magnesium sulphate is the first-line
or methamphetamine use); and serum cardiac troponin (acute
treatment for prevention of eclamptic seizures. It is usually
myocardial ischaemia) or B-type natriuretic peptide (heart
given as an initial loading dose of 4e6 g i.v. over 20e30 min
failure). An assessment of fetal well-being should be per-
followed by a continuous infusion of 1e2 g h1 until delivery
formed and may include ultrasound examination for fetal
for 24 h.6 Further 2e4 g boluses can be given for recurrent
growth, Doppler flow studies and cardiotochography (CTG).
seizures. Magnesium sulphate can also be given i.m. into the
Treatment should be initiated urgently in a high de-
gluteal muscle with a loading dose of 10 g given as 5 g i.m. into
pendency setting, aiming for a stepped controlled reduction of
each buttock followed by further doses of 5 g every 4 h. Deep
blood pressure. Hypertensive emergencies can be treated with
tendon reflexes should be monitored throughout treatment as
intravenous labetalol, hydralazine and immediate-release
they are diminished with magnesium toxicity. Risk of mag-
oral nifedipine without the need for invasive cardiac moni-
nesium toxicity is increased in compromised renal function
toring.2 Labetalol 20 mg i.v. can be given over 2 min, and
and can lead to reduced ventilatory frequency, low oxygen
increased incrementally up to 80 mg i.v. If the BP remains
saturations and progressive muscle paralysis. The targeted
high, another antihypertensive agent such as hydralazine can
serum magnesium therapeutic range is 2e4 mmol L1. Mag-
be added. Hydralazine is a direct vasodilator and may cause
nesium toxicity is treated with calcium gluconate (10 ml of
adverse effects when used in large bolus doses without titra-
10% concentration given over 10 min i.v.). NICE does not
tion. These include maternal hypotension, increased risk of
recommend the use of benzodiazepines or other standard
emergency Caesarean section, placental abruption and fetal
anticonvulsants as an alternative to magnesium sulphate in
tachycardia. Judicious fluid administration is recommended
women with eclamptic seizures.5
for women with acute-onset severe hypertension but up to
500 ml crystalloid fluid i.v. may need to be administered with
i.v. hydralazine.5 An initial dose of hydralazine 5e10 mg i.v.
Considerations for anaesthesia
over 2 min can be followed by a further 10 mg i.v. after 20 min
if the BP remains high. Analgesia
A suggested initial dose of immediate-release oral nifedi- Women with pre-eclampsia with severe features would
pine is 10 mg, followed by a further 20 mg if the BP remains benefit from neuraxial analgesia during labour as this can
high after 20 min. help reduce the sympathetic response to pain and facilitate
An i.v. infusion of glycerol trinitrate (GTN), 5e100 mg min1 cardiovascular stability, and offers the facility to top up the
titrated to effect, can be used for acute pulmonary oedema epidural for operative delivery. Neuraxial techniques are
associated with severe hypertension and pre-eclampsia. Di- contraindicated in the presence of coagulopathy or throm-
uretics such as furosemide (20e60 mg i.v.) are also considered bocytopaenia because of the increased risk of epidural hae-
safe. The majority of cases of acute pulmonary oedema occur matoma. A recent platelet count and coagulation studies
after delivery and may be associated with excessive volumes should be obtained before performing a neuraxial block in
women with pre-eclampsia with severe features because of

414 BJA Education - Volume 20, Number 12, 2020

Descargado para Anonymous User (n/a) en University of Antioquia de ClinicalKey.es por Elsevier en noviembre 16, 2020.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos reservados.

the risk of thrombocytopaenia, and more rarely DIC, either of
which may present precipitously. The platelet count should be
obtained within 6 h of performing regional analgesia or more
recently in those with HELLP syndrome or DIC. The Associa-
tion of Anaesthetists provides guidance on the relative risks
related to neuraxial blockade in patients with pre-eclampsia,
depending on the platelet count and coagulation status.20
The risk of epidural haematoma is extremely low (<0.2%) in
the presence of a platelet count >70  109 L1.21 When regional
analgesia is contraindicated, inhalation and parenteral anal-
gesia may be used. Remifentanil patient-controlled analgesia
(PCA) is a good alternative to regional analgesia.22
Anaesthesia
When operative delivery is required, central neuraxial
anaesthesia is preferred over general anaesthesia for most
women with pre-eclampsia. Spinal, epidural or a combined
spinal/epidural anaesthesia can all be used with good effect.
General anaesthesia is associated with risks of airway prob-
lems and increased systemic and cerebral blood pressures
during laryngoscopy leading to cerebrovascular haemorrhage.
The hypertensive response to laryngoscopy must be actively
managed with i.v. opioids such as alfentanil 25 mg kg1 or
remifentanil 1 mg kg1, or other antihypertensive drugs such
as labetalol 0.25 mg kg1 or esmolol 500 mg kg1 bolus.23 Aim to
maintain BP at pre-induction values and prevent the increase
of mean arterial pressures above 110 mmHg. Any anaesthesia-
related hypotension can be treated with i.v. boluses or in-
fusions of an alpha agonist such as phenylephrine or meta-
raminol, titrated to effect.
It is important to continue magnesium sulphate infusions
to reduce the risk of seizures, and the rate may be increased
temporarily to reduce the hypertensive response to laryn-
goscopy. Magnesium sulphate potentiates the action of all
non-depolarising neuromuscular blocking agents, so smaller
doses are required. Alternatively, an intubating dose of
rocuronium 1.2 mg kg1 may be used and residual block
reversed using sugammadex. Magnesium does not affect the
action of suxamethonium or sugammadex.
Other risks associated with general anaesthesia are failed
intubation secondary to generalised airway and subglottic
oedema, mucosal bleeding and pulmonary aspiration. Mal-
lampati scores can deteriorate in labour and increase risks of
failed intubation, and the use of a videolarygoscope is rec-
ommended.24 A smaller-than-expected tracheal tube diam-
eter (e.g. 5.5e6.5 mm I.D.) may also be required if there is
subglottic oedema.
Monitoring
Women with pre-eclampsia should have regular monitoring
of oxygen saturations, ventilatory frequency, heart rate, and
noninvasive arterial pressure. Invasive arterial and central
venous pressure monitoring is not required routinely but
should be considered in high risk patients with resistant hy-
pertension and heart failure. As part of accurate fluid balance
assessment and to reduce the risk of pulmonary oedema,
urine output should be continuously monitored as acute
deterioration in renal function can occur. Women with pre-
eclampsia may be managed on a labour or postnatal ward,
high dependency unit, or ICU depending on the severity of
symptoms, and decisions should be made by a multidisci-
plinary team. Transfer to the ICU should be considered under
the following circumstances19:
Descargado para Anonymous User (n/a) en University of Antioquia de ClinicalKey.es por Elsevier en noviembre 16, 2020.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos reservados.
Update on hypertensive disorders in pregnancy

Need for respiratory support, including possible intubation

Tachypnoea >35 breaths min1

Heart rate <40 or >150 beats min1

Need for additional vasopressor or other cardiovascular
support

Need for more invasive monitoring

Abnormal ECG requiring further intervention (e.g.
cardioversion)

Need for additional i.v. antihypertensive medication

Acidebase or severe electrolyte abnormalities
Follow-up
Postpartum hypertension can persist for up to 6e8 weeks, so
all women should be offered follow-up 6e8 weeks after the
birth. Regardless of the type of hypertensive disorder during
pregnancy, all women postnatally have an increased risk of
cardiovascular disease, stroke, diabetes, chronic kidney dis-
ease and venous thromboembolism, compared with women
who have had normotensive pregnancies.4 Therefore, all of
these women should have lifelong follow-up with their gen-
eral practitioner arranged.
Summary
Hypertensive disorders during pregnancy continue to be a
considerable cause of morbidity and mortality to both mother
and fetus. Guidelines have been updated in recent years, and
there are new risk prediction tools that can be used to guide
decision making in women with pre-eclampsia. Anaesthetists
play an important role in the care of these women, providing
analgesia, anaesthesia and critical care during hypertensive
emergencies. Understanding these disorders and manage-
ment of their complications is vital for improving outcomes
for mothers and babies.
Declaration of interests
The authors declare that they have no conflicts of interest.
MCQs
The associated MCQs (to support CME/CPD activity) are
accessible at www.bjaed.org/cme/home by subscribers to BJA
Education.
References
1. Knight M, Bunch K, Tuffnell D et al. Saving lives, improving
mother’s care e lessons learned to inform maternity care from
the UK and Ireland confidential enquiries into maternal deaths
and morbidity 2015e17. 2019
2. ACOG committee Opinion No 767. Emergent therapy for
acute-onset, severe hypertension during pregnancy and
the postpartum period. Obstet Gynecol 2019; 133: 409e12
3. Hawkins TL-A, Brown MA, Mangos G, Davis G. Transient
gestational hypertension: not always a benign event.
Pregnancy Hypertens 2012; 2: 22e7
4. Brown MA, Magee LA, Kenny LC et al. Hypertensive dis-
orders of pregnancy: ISSHP classification, diagnosis, and
management recommendations for international prac-
tice. Hypertension 2018; 72: 24e43
5. NICE. Hypertension in pregnancy: diagnosis and man-
agement. Natl Inst Heal Care Excell 2019; 77: S1e22
BJA Education - Volume 20, Number 12, 2020 415
Update on hypertensive disorders in pregnancy
6. ACOG. ACOG practice bulletin no. 202: gestational hy-
pertension and preeclampsia. Obstet Gynecol 2019; 133:
e1e25
7. Bartsch E, Medcalf KE, Park AL et al. Clinical risk factors
for pre-eclampsia determined in early pregnancy: sys-
tematic review and meta-analysis of large cohort studies.
BMJ 2016; 353: i1753
8. Knudsen UB, Kronborg CS, von Dadelszen P et al. A single
rapid point-of-care placental growth factor determination
as an aid in the diagnosis of preeclampsia. Pregnancy
Hypertens 2012; 2: 8e15
9. Chappell LC, Duckworth S, Seed PT et al. Diagnostic ac-
curacy of placental growth factor in women with sus-
pected preeclampsia: a prospective multicenter study.
Circulation 2013; 128: 2121e31
10. Levine RJ, Maynard SE, Qian C et al. Circulating angiogenic
factors and the risk of preeclampsia. N Engl J Med 2004;
350: 672e83
11. Zeisler H, Llurba E, Chantraine F et al. Predictive value of
the sFlt-1:PlGF ratio in women with suspected pre-
eclampsia. N Engl J Med 2016; 374: 13e22
12. NICE e National Institute for Health and Care Excellence.
PlGF-based testing to help diagnose suspected pre-eclampsia
(Triage PlGF test, Elecsys immunoassay sFlt-1/PlGF ratio,
DELFIA Xpress PlGF 1-2-3 test, and BRAHMS sFlt-1 Kryptor/
BRAHMS PlGF plus Kryptor PE ratio). NICE Diagn Guid
2016;(May): 1e46. www.nice.org.uk/guidance/dg23
13. Thangaratinam S, Allotey J, Marlin N et al. Prediction of
complications in early-onset pre-eclampsia (PREP):
development and external multinational validation of
prognostic models. BMC Med 2017; 15: 1e11
14. Von Dadelszen P, Payne B, Li J et al. Prediction of adverse
maternal outcomes in preeclampsia: development and
validation of the fullPIERS model. Obstet Gynecol Surv 2011;
66: 267e8
15. Di Mascio D, Magro-Malosso ER, Saccone G, Marhefka GD,
Berghella V. Exercise during pregnancy in normal-weight
women and risk of preterm birth: a systematic review and
meta-analysis of randomized controlled trials. Am J Obstet
Gynecol 2016; 215: 561e71
416 BJA Education - Volume 20, Number 12, 2020
Descargado para Anonymous User (n/a) en University of Antioquia de ClinicalKey.es por Elsevier en noviembre 16, 2020.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos reservados.
16. Rolnik DL, Wright D, Poon LC et al. Aspirin versus placebo
in pregnancies at high risk for preterm preeclampsia.
N Engl J Med 2017; 377: 613e22
17. Wen SW, White RR, Rybak N et al. Effect of high dose
folic acid supplementation in pregnancy on pre-
eclampsia (FACT): double blind, phase III, randomised
controlled, international, multicentre trial. BMJ 2018;
362: 1e8
18. Liu S, Chan WS, Ray JG et al. Stroke and cerebrovascular
disease in pregnancy: incidence, temporal trends, and
risk factors. Stroke 2019; 50: 13e20
 R, Johnson MR, Kahan T et al. Peripartum man-
19. Cı́fkova
agement of hypertension: a position paper of the ESC
council on hypertension and the European society of
hypertension. Eur Hear J Cardiovasc Pharmacother 2020.
https://doi.org/10.1093/ehjcvp/pvz082
20. Association of Anaesthetists of Great Britain and Ireland;
Obstetric Anaesthetists’ Association; Regional Anaes-
thesia UK. Regional anaesthesia and patients with ab-
normalities of coagulation. Anaesthesia 2013; 68: 966e72
21. Lee LO, Bateman BT, Kheterpal S et al. Risk of epidural
hematoma after neuraxial techniques in thrombocyto-
penic parturients a report from the multicenter periop-
erative outcomes group. Anesthesiology 2017; 126:
1053e64
22. Van De Velde M, Carvalho B. Remifentanil for labor
analgesia: an evidence-based narrative review. Int J Obstet
Anesth 2016; 25: 66e74
23. Rasooli S, Moslemi F, Ari R, Shenas HV, Shokoohi M.
Comparison of hemodynamic changes due to endotra-
cheal intubation with labetalol and remifentanil in severe
preeclamptic patients undergoing cesarean delivery with
general anesthesia. Int J Women’s Heal Reprod Sci 2019; 7:
515e9
24. Kodali BS, Chandrasekhar S, Bulich LN, Topulos GP,
Datta S. Airway changes during labor and delivery. Obstet
Gynecol Surv 2008; 63: 423e4