Approach

Early detection and optimal outpatient management is associated with low rates of hospital admission and low perinatal and maternal mortality.

Plan for delivery

Less than 37 weeks' gestation

Planned early delivery (before 37 weeks' gestation) should not be offered to women with gestational hypertension whose blood pressure (BP) is lower than 160/110 mmHg, unless there are other indications.[1][5]

Indications for planned early delivery include the following:

  • Preterm labor or premature rupture of membranes

  • Vaginal bleeding

  • Abnormal fetal testing

  • Intrauterine growth restriction

  • Development of preeclampsia (depending on the gestational age and severity) or eclampsia

  • Evidence of end-organ damage (e.g., neurologic, hepatic, or renal dysfunction).

Routine induction of labor in women with hypertensive disorders at 34-37 weeks' gestation significantly increases the risk of neonatal respiratory distress syndrome.[36] [ Cochrane Clinical Answers logo ] ​​ However, there is evidence to suggest that planned early delivery after 34 weeks' gestation is associated with a reduction in maternal morbidity and mortality.[37]

If planned early delivery before 34 weeks' gestation is necessary, offer prenatal magnesium sulfate for neuroprotection of the baby, as indicated.[38][39]

If planned early delivery before 37 weeks' gestation is necessary, offer prenatal corticosteroids to mature fetal lungs, as indicated.[38][40]​​

37 weeks' gestation and over

Women diagnosed with gestational hypertension at or beyond 37 weeks' gestation are generally best managed by delivering the baby by induction within 24-48 hours, after maternal stabilization, rather than expectant management.[41] [ Cochrane Clinical Answers logo ] ​ However, timing of birth and maternal and fetal indications for birth for women whose BP is <160/110 mmHg after 37 weeks' gestation should be agreed between the mother and the senior obstetrician.[5]

If the woman does not respond to medical induction, cesarean delivery is necessary.

Management of hypertension

Systolic BP levels ≥140 mmHg and/or diastolic BP levels ≥90 mmHg to systolic BP levels ≤159 mmHg and/or diastolic BP levels ≤109 mmHg (hypertension)

Hypertension can generally be managed on an outpatient basis.[5][42]​​​​[Evidence C]​​​ Treatment should begin with lifestyle modifications such as changes in diet (through consultation with a dietitian), but salt restriction should not be recommended only to prevent gestational hypertension or preeclampsia.[5] Note that significant weight loss is not recommended for obese mothers, because this may affect the growth of the fetus; however, limited or no weight gain in obese pregnant women has favorable pregnancy outcomes.[43]

If lifestyle interventions fail to control the BP and it remains above 140/90 mmHg, antihypertensive medication is recommended, with a target BP of 135/85 mmHg or less.[1][5]​​​ Evidence supports initiating or titrating medical therapy for pregnant women with chronic hypertension whose BP is ≥140/90 mmHg; this is associated with better fetal and maternal outcomes, compared with initiating or titrating medical therapy for severe hypertension only.[44][45][46] [ Cochrane Clinical Answers logo ] ​​​​ Frequent fetal and maternal evaluation is recommended. 

Labetalol is usually considered the antihypertensive of choice and is effective as monotherapy in 80% of women.[1][5]​​​​​[47]​​​​ It seems safe and effective for the management of hypertensive disorders of pregnancy; however, it should be avoided in women with asthma or any other contraindications to its use.[1][Evidence C]

Oral nifedipine may be as effective as intravenous labetalol, and can be considered in cases of deteriorating hypertension previously controlled with oral labetalol.[48]

Oral monotherapy with labetalol or nifedipine is effective in most cases, although some women may require combination therapy.[1]

Methyldopa is widely used in lower- and middle-income countries and remains an acceptable alternative if labetalol or nifedipine is not suitable.​[2]​​​[5] Methyldopa should be avoided in the postpartum period due to its association with depression; women already taking methyldopa should change to an alternative antihypertensive treatment within 2 days of delivery.​[5][49]

The choice of antihypertensive agent for women with gestational hypertension should be based on adverse effect profiles, risk (including fetal effects), and the woman's preferences.[5]

Systolic BP levels ≥160 mmHg and/or diastolic BP levels ≥110 mmHg (severe hypertension)

All women with persistent severe hypertension (systolic BP >160 mmHg and/or diastolic BP >110 mmHg for >15 minutes) should be admitted to the hospital and started on antihypertensive medication, with a target BP of 135/85 mmHg or less.[1][5]​ For the management of acute-onset, severe hypertension in a critical care setting, labetalol (oral or intravenous), oral nifedipine, or intravenous hydralazine is recommended as a first-line option.[1] Parenteral therapy may be needed initially for acute control of BP, but oral medications can then be used. Second-line options (e.g., combination therapy, alternative drugs) can be discussed with a specialist if the woman does not respond to first-line therapies.[1][5]​​​​​ Hydralazine is widely used to manage severe hypertension in pregnancy; however, it can produce an acute fall in BP and should be used along with plasma expansion.[5]​​​​ Smaller, more frequent doses of hydralazine may be used.

The woman's BP should be measured every 15-30 minutes until it is less than 160/110 mmHg; once BP falls below 160/110 mmHg, manage as for hypertension.[1][5]

Postpartum management

After delivery of the baby, continue monitoring the mother's BP and adjust her antihypertensive medication if required. For women with gestational hypertension who required antihypertensive therapy before delivery, reduce their antihypertensive treatment if their BP falls below 130/80 mmHg. For women with gestational hypertension who did not require antihypertensive therapy before delivery, start antihypertensive treatment if their BP is 150/100 mmHg or higher. All women who had gestational hypertension should undergo a medical review 6-8 weeks after the birth.[5]

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