H T TOPICS IN
Gestational Hypertension and Preeclampsia
Kirsten Wisner, MS, RNC-OB, CNS, C-EFM
H
ypertensive disorders of preg-
nancy continue to be a major
contributor to maternal and
perinatal morbidity and mortality. A
summary of the American College of
Obstetricians and Gynecologists
(ACOG, 2019) updated guidelines
for diagnosis and management of
these disorders is presented.
Gestational hypertension is charac-
terized by a new-onset systolic blood
pressure (BP) ≥ 140 mmHg and/or a
diastolic BP ≥ 90 mmHg on two occa-
sions at least 4 hours apart, presenting
after 20 weeks’ gestation. It is further
defined by absence of proteinuria or
severe features (defined below) with
a return to normotensive pressures
postpartum. When gestational hyper-
tension is in the severe range of ≥ 160
mmHg systolic and/or ≥ 110 mmHg
diastolic, it is considered preeclampsia
with severe features (ACOG, 2019).
Preeclampsia is defined as a new-
onset systolic BP ≥ 140 mmHg and/
or diastolic BP ≥ 90 mmHg on two
occasions at least 4 hours apart, pre-
senting after 20 weeks’ gestation.
When BPs are in the severe range
(≥ 160 mmHg systolic and/or ≥ 110
mmHg diastolic), they should be
confirmed within minutes to facili-
tate prompt antihypertensive treat-
ment. Preeclampsia is further defined
by presence of proteinuria (defined
as preeclampsia) or any of the fol-
lowing severe features (preeclampsia
with severe features): thrombocyto-
penia, renal insufficiency, impaired
hepatic function, pulmonary edema,
or new-onset headache. See the
ACOG Practice Bulletin for full
details on these criteria. Note that
BPs in the severe range are consid-
ered a severe feature (ACOG, 2019).
Initial evaluation of a woman pre-
senting with a hypertensive disorder
of pregnancy should include a full
maternal and fetal evaluation includ-
ing a complete blood cell count with
170 volume 44 | number 3
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Overview of Management Recommendations
Diagnosis Management Recommendations
Gestational • Antenatal testing 1–2 times weekly with weekly amni-
hypertension otic fluid volume assessment
• Fetal growth assessment via ultrasound every 3–4 weeks
Preeclampsia
• Birth at 37 0/7 weeks
without severe
features • Close monitoring of BPs
• Weekly laboratory tests (may be modified per findings)
Preeclampsia • Antihypertensive therapy as soon as detected (minimally
with severe within 30–60 minutes)
features • Intravenous magnesium sulfate for seizure prophylaxis
• Birth at 34 0/7 weeks (after stabilization)
° Should not be delayed for the administration of
antenatal steroids
• Close monitoring of BPs and laboratory values
Eclampsia • Lateral decubitus position
• Prevention of maternal injury and aspiration
• Administration of oxygen
• Magnesium sulfate for subsequent seizure prophylaxis
• Timing of birth should be based on gestational age,
fetal presentation, and maternal and fetal condition
platelets, serum creatinine, lactate family history of preeclampsia, body
dehydrogenase, aspartate amino- mass index > 30, African American
transferase, alanine aminotransfer- race, low socioeconomic status, a
ase, and an assessment of proteinuria. prior low birthweight or small for
A uric acid test may be indicated gestational age infant or adverse
when preeclampsia superimposed pregnancy outcome, and more than a
upon chronic hypertension is sus- 10-year pregnancy interval (ACOG,
pected. Fetal assessment should 2019). ✜
involve an ultrasound for fetal weight
and amniotic fluid volume, and ante- Kirsten Wisner is the Magnet Pro-
partum fetal testing (ACOG, 2019). gram Director at Salinas Valley Me-
See the table for an overview of man- morial Healthcare System, Salinas,
agement recommendations. CA. Ms. Wisner can be reached via
The guideline recommends low- e-mail at klwisner@gmail.com
dose aspirin (81 mg/day) beginning The author declares no conflicts of
between 12 and 28 weeks of gesta- interest.
tion (optimally before 16 weeks) for
women with any high-risk factor for Copyright © 2019 Wolters Kluwer
preeclampsia and one or more of the Health, Inc. All rights reserved.
moderate-risk factors. High-risk fac-
DOI:10.1097/NMC.0000000000000523
tors include a history of preeclamp-
sia, multiple gestation, renal or Reference
autoimmune disease, diabetes melli- American College of Obstetricians and Gyne-
tus type 1 or 2, and chronic hyperten- cologists. (2019). Gestational hypertension
and preeclampsia (Practice Bulletin No.
sion. Moderate-risk factors include a 202). Obstetrics & Gynecology, 133(1),
first pregnancy, maternal age ≥ 35, e1-e25. doi:10.1097/AOG.0000000000003018
May/June 2019