Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

before delivery

1st line – monitoring ± hospital admission

Back
ACUTE
|
before delivery
1st line – 

monitoring ± hospital admission

Hypertension (systolic BP >140 mmHg and/or diastolic BP >90 mmHg) can generally be managed on an outpatient basis.[5][42]​​ Frequent fetal and maternal evaluation is recommended.

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.[1][5]​ 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]

Plus – decision regarding delivery

Back
ACUTE
|
before delivery
Plus – 

decision regarding delivery

Treatment recommended for ALL patients in selected patient group

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

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.

Consider – magnesium sulfate

Back
ACUTE
|
before delivery
Consider – 

magnesium sulfate

Treatment recommended for SOME patients in selected patient group

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

Primary options

magnesium sulfate: consult specialist for guidance on dose

More

Consider – corticosteroid

Back
ACUTE
|
before delivery
Consider – 

corticosteroid

Treatment recommended for SOME patients in selected patient group

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

Primary options

betamethasone sodium phosphate/betamethasone acetate: 12 mg intramuscularly every 24 hours for 2 doses

OR

dexamethasone sodium phosphate: 6 mg intramuscularly every 12 hours for 4 doses

Plus – lifestyle modifications ± antihypertensive therapy

Back
ACUTE
|
before delivery
|
with hypertension (systolic BP ≥140 mmHg and/or diastolic BP ≥90 mmHg)
Plus – 

lifestyle modifications ± antihypertensive therapy

Treatment recommended for ALL patients in selected patient group

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]

If lifestyle interventions fail to control the blood pressure (BP) and it remains above 140/90 mmHg, antihypertensive medication is recommended, with a target BP of 135/85 mmHg or less.[1][5][44][45][46] [ Cochrane Clinical Answers logo ] ​​​​

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]

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]

Primary options

labetalol: 100 mg orally twice daily initially, increase gradually according to response, usual dose 100-400 mg twice daily, maximum 2400 mg/day

Secondary options

nifedipine: 30-60 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 90-120 mg/day (depending on brand)

Tertiary options

methyldopa: 250 mg orally two to three times daily initially, increase gradually according to response, usual dose 250-1000 mg/day given in 2-4 divided doses, maximum 3000 mg/day

Plus – antihypertensive therapy

Back
ACUTE
|
before delivery
|
with severe hypertension (systolic BP ≥160 mmHg and/or diastolic BP ≥110 mmHg)
Plus – 

antihypertensive therapy

Treatment recommended for ALL patients in selected patient group

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. 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.

Primary options

labetalol: 10-20 mg intravenously initially, followed by 20-80 mg every 10-30 minutes according to response, maximum 300 mg/total dose; or 1-2 mg/minute intravenous infusion

OR

nifedipine: 10-20 mg orally (immediate-release) initially, repeat in 20 minutes if needed, followed by 10-20 mg every 2-6 hours according to response, maximum 180 mg/day

OR

hydralazine: 5 mg intravenously initially, followed by 5-10 mg every 20-40 minutes according to response, maximum 20 mg/total dose; or 0.5 to 10 mg/hour intravenous infusion

ONGOING

after delivery

1st line – antihypertensive therapy

Back
ONGOING
|
after delivery
1st line – 

antihypertensive therapy

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]

back arrow

Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer