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1122 VOL. 122, NO.

5, NOVEMBER 2013 OBSTETRICS & GYNECOLOGY


Hypertension in Pregnancy
Report of the American College of Obstetricians and Gynecologists
Task Force on Hypertension in Pregnancy
Executive Summary
T
he American College of Obstetricians and Gyne-
cologists (the College) convened a task force of
experts in the management of hypertension in
pregnancy to review available data and publish
evidence-based recommendations for clinical practice. The
Task Force on Hypertension in Pregnancy comprised 17
cliniciunscientists liom tle elds ol obstetiics, muteinul
letul medicine, lypeitension, inteinul medicine, nepliology,
unestlesiology, plysiology, und putient udvocucy. Tlis exec-
utive summary includes a synopsis of the content and task
force recommendations of each chapter in the report and is
intended to complement, not substitute, tle iepoit.
Hypertensive disorders of pregnancy remain a major
health issue for women and their infants in the United
Stutes. Pieeclumpsiu, eitlei ulone oi supeiimposed on pie-
existing (clionic) lypeitension, piesents tle mujoi iisk.
Altlougl uppiopiiute pienutul cuie, witl obseivution ol
women for signs of preeclampsia and then delivery to termi-
nute tle disoidei, lus ieduced tle numbei und extent ol
pooi outcomes, seiious muteinulletul moibidity und moi-
tality still occur. Some of these adverse outcomes are avoid-
uble, wleieus otleis cun be umelioiuted. Also, ultlougl
some of the problems that face neonates are related directly
to pieeclumpsiu, u luige piopoition uie seconduiy to piemu-
turity that results from the appropriate induced delivery of
the fetuses of women who are ill. Optimal management
iequiies close obseivution loi signs und piemonitoiy nd-
ings und, ultei estublisling tle diugnosis, deliveiy ut tle
optimal time for both maternal and fetal well-being. More
recent clinical evidence to guide this timing is now avail-
able. Chronic hypertension is associated with fetal morbid-
ity in the form of growth restriction and maternal morbidity
manifested as severely increased blood pressure (BP). How-
evei, muteinul und letul moibidity incieuse diumuticully
with the superimposition of preeclampsia. One of the major
challenges in the care of women with chronic hypertension
is deciphering whether chronic hypertension has worsened
oi wletlei pieeclumpsiu lus developed. In tlis iepoit, tle
task force provides suggestions for the recognition and man-
agement of this challenging condition.
In tle pust 10 yeuis, tleie luve been substuntiul udvunces
in the understanding of preeclampsia as well as increased
eoits to obtuin evidence to guide tleiupy. Nonetleless,
there remain areas on which evidence is scant. The evidence
is now clear that preeclampsia is associated with later-life
cuidiovuscului (CV) diseuse; lowevei, luitlei ieseuicl is
needed to determine how best to use this information to
lelp putients. Tle tusk loice ulso lus identied issues in tle
management of preeclampsia that warrant special atten-
tion. Fiist, is tle luiluie by leultl cuie piovideis to uppieci-
ate the multisystemic nature of preeclampsia. This is in part
due to uttempts ut iigid diugnosis, wlicl is uddiessed in tle
iepoit. Second, pieeclumpsiu is u dynumic piocess, und u
diagnosis such as mild preeclampsia (which is discour-
aged) applies only at the moment the diagnosis is estab-
lisled becuuse pieeclumpsiu by nutuie is piogiessive,
ultlougl ut dieient iutes. Appiopiiute munugement mun-
dates frequent reevaluation for severe features that indi-
cate the actions outlined in the recommendations (which
are listed after the chapter summaries). It has been known
Hypertension in Pregnancy wus developed by tle Tusk Foice on Hypeitension in Piegnuncy: Jumes M. Robeits, MD, Cluii; Plyllis A. August,
MD, MPH; Geoige Bukiis, MD; Joln R. Buiton, MD; Iiu M. Beinstein, MD; Muuiice Diuzin, MD; Robeit R. Guisei, MD; Joey P. Giungei, PlD;
Aiun Jeyubulun, MD, MS; Donnu D. Jolnson, MD; S. Anuntl Kuiumuncli, MD; Muislull Lindleimei, MD; Miclelle Y. Owens, MD, MS;
Geoige R. Suude, MD; Bulu M. Sibui, MD; Cutleiine Y. Spong, MD; Eleni Tsigus; und tle Ameiicun College ol Obstetiiciuns und Gynecolo-
gists' stu: Geiuld F. Josepl, MD; Nuncy O'Reilly, MHS; Alyssu Politzei; Suiul Son, MPH; und Kuiinu Nguizu.
VOL. 122, NO. 5, NOVEMBER 2013 Executive Summary: Hypertension in Pregnancy 1123
for many years that preeclampsia can worsen or present for
tle ist time ultei deliveiy, wlicl cun be u mujoi scenuiio
loi udveise muteinul events. In tlis iepoit, tle tusk loice
provides guidelines to attempt to reduce maternal morbid-
ity and mortality in the postpartum period.
The Approach
The task force used the evidence assessment and recom-
mendation strategy developed by the Grading of Recom-
mendutions Assessment, Development und Evuluution
(GRADE) Woiking Gioup (uvuiluble ut www.giudewoiking
gioup.oig/index.ltm). Becuuse ol its utility, tlis stiutegy
lus been udupted woildwide by u luige numbei ol oigunizu-
tions. Witl tle GRADE Woiking Gioup uppioucl, tle lunc-
tion of expert task forces and working groups is to evaluate
tle uvuiluble evidence ieguiding u clinicul decision tlut,
becuuse ol limited time und iesouices, would be dimcult loi
the average health care provider to accomplish. The expert
group then makes recommendations based on the evidence
that are consistent with typical patient values and prefer-
ences. The task force evaluated the evidence for each rec-
ommendution, tle implicutions, und tle condence in
estimutes ol eect. Witl tlis combinution, tle uvuiluble
information was evaluated and recommendations were
mude. In tlis iepoit, tle condence in estimutes ol eect
(quulity) ol tle uvuiluble evidence is judged us veiy low, low,
modeiute, oi ligl.
Recommendations are practices agreed to by the task
force as the most appropriate course of action; they are
giuded us stiong oi quulied. A stiong iecommendution is
one that is so well supported that it would be the approach
appropriate for virtually all patients. It could be the basis for
leultl cuie policy. A quulied iecommendution is ulso one
tlut would be judged us uppiopiiute loi most putients, but
it might not be the optimal recommendation for some
putients (wlose vulues und pieleiences diei, oi wlo luve
dieient uttitudes towuid unceituinty in estimutes ol eect).
Wlen tle tusk loice lus mude u quulied iecommendution,
the health care provider and patient are encouraged to work
together to arrive at a decision based on the values and
judgment and underlying health condition of a particular
patient in a particular situation.
Classication of Hypertensive Disorders of
Pregnancy
Tle tusk loice close to continue using tle clussicution
sclemu ist intioduced in 1972 by tle College und modi-
ed in tle 1990 und 2000 iepoits ol tle Woiking Gioup
ol tle Nutionul Higl Blood Piessuie Educution Piogium.
Similui clussicutions cun be lound in tle Ameiicun Soci-
ety ol Hypeitension guidelines, us well us College Piuctice
Bulletins. Altlougl tle tusk loice lus modied some ol tle
components ol tle clussicution, tlis busic, piecise, und
piucticul clussicution wus used, wlicl consideis lypeiten-
sion during pregnancy in only four categories: 1) pre-
eclumpsiueclumpsiu, 2) clionic lypeitension (ol uny
cuuse), 3) clionic lypeitension witl supeiimposed pieec-
lumpsiu, und 4) gestutionul lypeitension. Impoituntly, tle
lollowing components weie modied. In iecognition ol tle
syndiomic nutuie ol pieeclumpsiu, tle tusk loice lus elimi-
nated the dependence of the diagnosis on proteinuria. In
tle ubsence ol pioteinuiiu, pieeclumpsiu is diugnosed us
hypertension in association with thrombocytopenia (plate-
let count less tlun 100,000/miciolitei), impuiied livei
function (elevated blood levels of liver transaminases to
twice tle noimul concentiution), tle new development ol
ienul insumciency (elevuted seium cieutinine gieutei tlun
1.1 mg/dL oi u doubling ol seium cieutinine in tle ubsence
ol otlei ienul diseuse), pulmonuiy edemu, oi new-onset
ceiebiul oi visuul distuibunces (see Box E-1). Gestational
hypertension is BP elevution ultei 20 weeks ol gestution in
the absence of proteinuria or the aforementioned systemic
ndings; chronic hypertension is hypertension that predates
pregnancy; and superimposed preeclampsia is chronic hyper-
tension in association with preeclampsia.
Establishing the Diagnosis of
Preeclampsia or Eclampsia
The BP criteria are maintained from prior recommendations.
Proteinuria is dened us tle excietion ol 300 mg oi moie ol
piotein in u 24-loui uiine collection. Alteinutively, u timed
excietion tlut is extiupoluted to tlis 24-loui uiine vulue oi
u piotein/cieutinine iutio ol ut leust 0.3 (eucl meusuied us
mg/dL) is used. Becuuse ol tle vuiiubility ol quulitutive
deteiminutions (dipstick test), tlis metlod is discouiuged
for diagnostic use unless other approaches are not readily
uvuiluble. Il tlis uppioucl must be used, u deteiminution ol
1+ is consideied us tle cuto loi tle diugnosis ol pio-
teinuria. In view of recent studies that indicate a minimal
relationship between the quantity of urinary protein and
piegnuncy outcome in pieeclumpsiu, mussive pioteinuiiu
(greater than 5 g) has been eliminated from the consider-
ution ol pieeclumpsiu us seveie. Also, becuuse letul giowtl
restriction is managed similarly in pregnant women with
und witlout pieeclumpsiu, it lus been iemoved us u nding
indicutive ol seveie pieeclumpsiu (Tuble E-1).
Prediction of Preeclampsia
A gieut deul ol eoit lus been diiected ut tle identicution
ol demogiuplic luctois, bioclemicul unulytes, oi bioplysi-
cul ndings, ulone oi in combinution, to piedict euily in
pregnancy the later development of preeclampsia. Although
1124 Executive Summary: Hypertension in Pregnancy OBSTETRICS & GYNECOLOGY
BOX E-1. Severe Features of Preeclampsia (Any of these ndings)
Sysrolic 6lood pressure ol 10 mm Hg or |ig|er, or diosrolic 6lood pressure ol 110 mm Hg or |ig|er
on rwo occosions or leosr 4 |ours oporr w|ile r|e porienr is on 6ed resr (unless onri|yperrensive
r|eropy is iniriored 6elore r|is rime)
T|rom6ocyropenio (ploreler counr less r|on 100,000/microlirer)
mpoired liver luncrion os indicored 6y o6normolly elevored 6lood concenrrorions ol liver enzymes
(ro rwice normol concenrrorion), severe persisrenr rig|r upper quodronr or epigosrric poin unrespon-
sive ro medicorion ond nor occounred lor 6y olrernorive diognoses, or 6or|
Frogressive renol insullciency (serum creorinine concenrrorion greorer r|on 1.1 mg/dL or o dou6ling
ol r|e serum creorinine concenrrorion in r|e o6sence ol or|er renol diseose)
Fulmonory edemo
New-onser cere6rol or visuol disrur6onces
tleie uie some encouiuging ndings, tlese tests uie not yet
ready for clinical use.
TASK FORCE RECOMMENDATION
Scieening to piedict pieeclumpsiu beyond obtuining un
appropriate medical history to evaluate for risk factors is
not recommended.
Quality of evidence: Moderate
Strength of recommendation: Strong
Prevention of Preeclampsia
It is cleui tlut tle untioxidunts vitumin C und vitumin E uie
not eective inteiventions to pievent pieeclumpsiu oi
adverse outcomes from preeclampsia in unselected women
at high risk or low risk of preeclampsia. Calcium may be
useful to reduce the severity of preeclampsia in populations
witl low culcium intuke, but tlis nding is not ielevunt to u
populution witl udequute culcium intuke, sucl us in tle
United States. The administration of low-dose aspirin (60
80 mg) to prevent preeclampsia has been examined in
metu-unulyses ol moie tlun 30,000 women, und it uppeuis
tlut tleie is u sliglt eect to ieduce pieeclumpsiu und
udveise peiinutul outcomes. Tlese ndings uie not clinicully
relevant to low-risk women but may be relevant to popula-
tions at very high risk in whom the number to treat to
achieve the desired outcome will be substantially less. There
is no evidence that bed rest or salt restriction reduces preec-
lampsia risk.
TASK FORCE RECOMMENDATIONS
Foi women witl u medicul listoiy ol euily-onset pieec-
lumpsiu und pieteim deliveiy ut less tlun 34 0/7 weeks ol
gestation or preeclampsia in more than one prior preg-
nuncy, initiuting tle udministiution ol duily low-dose
(6080 mg) uspiiin beginning in tle lute ist tiimestei is
suggested.*
Quality of evidence: Moderate
Strength of recommendation: Quulied
Metu-unulysis ol moie tlun 30,000 women in iundomized tiiuls
of aspirin to prevent preeclampsia indicates a small reduction
in the incidence and morbidity of preeclampsia and reveals no
evidence ol ucute iisk, ultlougl long-teim letul eects cunnot
be excluded. The number of women to treat to have a thera-
peutic eect is deteimined by pievulence. In view ol muteinul
sulety, u discussion ol tle use ol uspiiin in liglt ol individuul
iisk is justied.
Tle udministiution ol vitumin C oi vitumin E to pievent
preeclampsia is not recommended.
Quality of evidence: High
Strength of recommendation: Strong
It is suggested tlut dietuiy sult not be iestiicted dui-
ing pregnancy for the prevention of preeclampsia.
Quality of evidence: Low
Strength of recommendation: Quulied
It is suggested tlut bed iest oi tle iestiiction ol otlei
physical activity not be used for the primary prevention
of preeclampsia and its complications.
Quality of evidence: Low
Strength of recommendation: Quulied
Management of Preeclampsia
and HELLP Syndrome
Clinical trials have provided an evidence base to guide man-
ugement ol seveiul uspects ol pieeclumpsiu. Nonetleless,
VOL. 122, NO. 5, NOVEMBER 2013 Executive Summary: Hypertension in Pregnancy 1125
several important questions remain unanswered. Reviews
of maternal mortality data reveal that deaths could be
avoided if health care providers remain alert to the likeli-
hood that preeclampsia will progress. The same reviews
indicate that intervention in acutely ill women with multiple
organ dysfunction is sometimes delayed because of the
ubsence ol pioteinuiiu. Fuitleimoie, uccumuluting inloi-
mation indicates that the amount of proteinuria does not
predict maternal or fetal outcome. It is for these reasons
that the task force has recommended that alternative sys-
temic ndings witl new-onset lypeitension cun lulll tle
diagnosis of preeclampsia even in the absence of pro-
teinuria.
Perhaps the biggest changes in preeclampsia manage-
ment relate to the timing of delivery in women with preec-
lumpsiu witlout seveie leutuies, wlicl bused on evidence is
suggested ut 37 0/7 weeks ol gestution, und un incieusing
awareness of the importance of preeclampsia in the postpar-
tum period. Health care providers are reminded of the con-
tiibution ol nonsteioidul untiinummutoiy ugents to
increased BP. It is suggested that these commonly used
postpartum pain relief agents be replaced by other analge-
sics in women with hypertension that persists for more than
1 day postpartum.
TASK FORCE RECOMMENDATIONS
Tle close monitoiing ol women witl gestutionul lypei-
tension or preeclampsia witlout seveie leutuies, witl
serial assessment of maternal symptoms and fetal move-
ment (daily by tle womun), seiiul meusuiements ol BP
(twice weekly), und ussessment ol plutelet counts und
livei enzymes (weekly) is suggested.
Quality of evidence: Moderate
Strength of recommendation: Quulied
Foi women witl gestutionul lypeitension, monitoiing
BP at least once weekly with proteinuria assessment in
tle omce und witl un udditionul weekly meusuiement ol
BP ut lome oi in tle omce is suggested.
Quality of evidence: Moderate
Strength of recommendation: Quulied
Foi women witl mild gestutionul lypeitension oi pieec-
lampsia with a persistent BP of less than 160 mm Hg
systolic oi 110 mm Hg diustolic, it is suggested tlut unti-
hypertensive medications not be administered.
Quality of evidence: Moderate
Strength of recommendation: Quulied
TABLE E-1. Diagnostic Criteria for Preeclampsia
Blood pressure Creorer r|on or equol ro 140 mm Hg sysrolic or greorer r|on or equol ro 0 mm Hg
diosrolic on rwo occosions or leosr 4 |ours oporr olrer 20 wee|s ol gesrorion in o
womon wir| o previously normol 6lood pressure
Creorer r|on or equol ro 10 mm Hg sysrolic or greorer r|on or equol ro 110 mm Hg
diosrolic, |yperrension con 6e conlrmed wir|in o s|orr inrervol (minures) ro locilirore
rimely onri|yperrensive r|eropy
ond
Proteinuria Creorer r|on or equol ro 300 mg per 24-|our urine collecrion (or r|is omounr
exrropolored lrom o rimed collecrion)
or
Frorein/creorinine rorio greorer r|on or equol ro 0.3*
Dipsric| reoding ol 1- (used only il or|er quonrirorive mer|ods nor ovoilo6le)
r in r|e o6sence ol proreinurio, new-onser |yperrension wir| r|e new onser ol ony ol r|e lollowing:
Thrombocytopenia Floreler counr less r|on 100,000/microlirer
Renal insufciency Serum creorinine concenrrorions greorer r|on 1.1 mg/dL or o dou6ling ol r|e serum
creorinine concenrrorion in r|e o6sence ol or|er renol diseose
Impaired liver function Elevored 6lood concenrrorions ol liver rronsominoses ro rwice normol concenrrorion
Pulmonary edema
Cerebral or visual
symptoms
*Eoc| meosured os mg/dL.
1126 Executive Summary: Hypertension in Pregnancy OBSTETRICS & GYNECOLOGY
Foi women witl gestutionul lypeitension oi pieeclump-
siu witlout seveie leutuies, it is suggested tlut stiict bed
rest not be prescribed.
*
Quality of evidence: Low
Strength of recommendation: Quulied
*The task force acknowledged that there may be situations in
wlicl dieient levels ol iest, eitlei ut lome oi in tle lospitul,
may be indicated for individual women. The previous recom-
mendations do not cover advice regarding overall physical ac-
tivity und munuul oi omce woik.

Women muy need to be lospitulized loi ieusons otlei tlun bed


iest, sucl us loi muteinul und letul suiveillunce. Tle tusk loice
ugieed tlut lospitulizution loi muteinul und letul suiveillunce
is resource intensive and should be considered as a priority for
research and future recommendations.
Foi women witl pieeclumpsiu witlout seveie leutuies,
use of ultrasonography to assess fetal growth and antena-
tal testing to assess fetal status is suggested.
Quality of evidence: Moderate
Strength of recommendation: Quulied
Il evidence ol letul giowtl iestiiction is lound in women
witl pieeclumpsiu, letoplucentul ussessment tlut in-
cludes umbilicul uiteiy Dopplei velocimetiy us un udjunct
antenatal test is recommended.
Quality of evidence: Moderate
Strength of recommendation: Strong
Foi women witl mild gestutionul lypeitension oi pieec-
lampsia without severe features and no indication for
deliveiy ut less tlun 37 0/7 weeks ol gestution, expec-
tant management with maternal and fetal monitoring is
suggested.
Quality of evidence: Low
Strength of recommendation: Quulied
Foi women witl mild gestutionul lypeitension oi pieec-
lumpsiu witlout seveie leutuies ut oi beyond 37 0/7
weeks ol gestution, deliveiy iutlei tlun continued obsei-
vation is suggested.
Quality of evidence: Moderate
Strength of recommendation: Quulied
Foi women witl pieeclumpsiu witl systolic BP ol less
than 160 mm Hg and a diastolic BP less than 110 mm Hg
und no muteinul symptoms, it is suggested tlut mugne-
sium sulfate not be administered universally for the pre-
vention of eclampsia.
Quality of evidence: Low
Strength of recommendation: Quulied
Foi women witl seveie pieeclumpsiu ut oi beyond 34
0/7 weeks ol gestution, und in tlose witl unstuble
maternal or fetal conditions irrespective of gestational
uge, deliveiy soon ultei muteinul stubilizution is iecom-
mended.
Quality of evidence: Moderate
Strength of recommendation: Strong
Foi women witl seveie pieeclumpsiu ut less tlun 34
0/7 weeks of gestation with stable maternal and fetal
conditions, it is iecommended tlut continued piegnuncy
be undertaken only at facilities with adequate mater-
nal and neonatal intensive care resources.
Quality of evidence: Moderate
Strength of recommendation: Strong
Foi women witl seveie pieeclumpsiu ieceiving expectunt
munugement ut 34 0/7 weeks oi less ol gestution, tle
administration of corticosteroids for fetal lung maturity
benet is iecommended.
Quality of evidence: High
Strength of recommendation: Strong
Foi women witl pieeclumpsiu witl seveie lypeitension
during pregnancy (sustained systolic BP of at least 160
mm Hg oi diustolic BP ol ut leust 110 mm Hg), tle use ol
antihypertensive therapy is recommended.
Quality of evidence: Moderate
Strength of recommendation: Strong
Foi women witl pieeclumpsiu, it is suggested tlut u
delivery decision should not be based on the amount of
proteinuria or change in the amount of proteinuria.
Quality of evidence: Moderate
Strength of recommendation: Strong
Foi women witl seveie pieeclumpsiu und beloie letul
viubility, deliveiy ultei muteinul stubilizution is iecom-
mended. Expectunt munugement is not iecommended.
Quality of evidence: Moderate
Strength of recommendation: Strong
It is suggested tlut coiticosteioids be udministeied und
deliveiy deleiied loi 48 louis il muteinul und letul
conditions remain stable for women with severe pre-
eclampsia and a viable fetus at 33 6/7 weeks oi less ol
gestation with any of the following:
preterm premature rupture of membranes
labor
low plutelet count (less tlun 100,000/miciolitei)
peisistently ubnoimul leputic enzyme concentiutions
(twice or more the upper normal values)
letul giowtl iestiiction (less tlun tle ltl peicentile)
seveie oligolydiumnios (umniotic uid index less
than 5 cm)
VOL. 122, NO. 5, NOVEMBER 2013 Executive Summary: Hypertension in Pregnancy 1127
ieveised end-diustolic ow on umbilicul uiteiy
Dopplei studies
new-onset renal dysfunction or increasing renal dys-
function
Quality of evidence: Moderate
Strength of recommendation: Quulied
It is iecommended tlut coiticosteioids be given il tle le-
tus is viuble und ut 33 6/7 weeks oi less ol gestution, but
that delivery not be delayed after initial maternal stabili-
zution ieguidless ol gestutionul uge loi women witl se-
vere preeclampsia that is complicated further with any of
the following:
uncontrollable severe hypertension
eclampsia
pulmonary edema
abruptio placentae
disseminated intravascular coagulation
evidence of nonreassuring fetal status
intrapartum fetal demise
Quality of evidence: Moderate
Strength of recommendation: Strong
Foi women witl pieeclumpsiu, it is suggested tlut tle
mode of delivery need not be cesarean delivery. The
mode of delivery should be determined by fetal gesta-
tionul uge, letul piesentution, ceivicul stutus, und mutei-
nal and fetal conditions.
Quality of evidence: Moderate
Strength of recommendation: Quulied
Foi women witl eclumpsiu, tle udministiution ol puien-
teral magnesium sulfate is recommended.
Quality of evidence: High
Strength of recommendation: Strong
Foi women witl seveie pieeclumpsiu, tle udministiution
of intrapartumpostpartum magnesium sulfate to pre-
vent eclampsia is recommended.
Quality of evidence: High
Strength of recommendation: Strong
Foi women witl pieeclumpsiu undeigoing cesuieun
deliveiy, tle continued intiuopeiutive udministiution ol
parenteral magnesium sulfate to prevent eclampsia is
recommended.
Quality of evidence: Moderate
Strength of recommendation: Strong
Foi women witl HELLP syndrome and before the gesta-
tionul uge ol letul viubility, it is iecommended tlut deliv-
ery be undertaken shortly after initial maternal stabili-
zution.
Quality of evidence: High
Strength of recommendation: Strong
Foi women witl HELLP syndiome ut 34 0/7 weeks oi
moie ol gestution, it is iecommended tlut deliveiy be
undeituken soon ultei initiul muteinul stubilizution.
Quality of evidence: Moderate
Strength of recommendation: Strong
Foi women witl HELLP syndiome liom tle gestutionul
uge ol letul viubility to 33 6/7 weeks ol gestution, it is
suggested tlut deliveiy be deluyed loi 24 48 louis il mu-
ternal and fetal condition remains stable to complete a
couise ol coiticosteioids loi letul benet.
Quality of evidence: Low
Strength of recommendation: Quulied
Coiticosteioids luve been used in iundomized contiolled tiiuls
to attempt to improve maternal and fetal condition. In these
studies, tleie wus no evidence ol benet to impiove oveiull mu-
ternal and fetal outcome (although this has been suggested in
obseivutionul studies). Tleie is evidence in tle iundomized tii-
als of improvement of platelet counts with corticosteroid treat-
ment. In clinical settings in which an improvement in platelet
count is consideied uselul, coiticosteioids muy be justied.
Foi women witl pieeclumpsiu wlo iequiie unulgesiu loi
labor or anesthesia for cesarean delivery and with a clin-
icul situution tlut peimits sumcient time loi estublisl-
ment of anestlesiu, tle udministiution ol neuiuxiul unes-
thesia (either spinal or epidural anesthesia) is recom-
mended.
Quality of evidence: Moderate
Strength of recommendation: Strong
Foi women witl seveie pieeclumpsiu, it is suggested tlut
invasive hemodynamic monitoring not be used routinely.
Quality of evidence: Low
Strength of recommendation: Quulied
Foi women in wlom gestutionul lypeitension, pieec-
lumpsiu, oi supeiimposed pieeclumpsiu is diugnosed, it is
suggested that BP be monitored in the hospital or that
equivalent outpatient surveillance be performed for at
leust 72 louis postpuitum und uguin 710 duys ultei
delivery or earlier in women with symptoms.
Quality of evidence: Moderate
Strength of recommendation: Quulied
Foi ull women in tle postpuitum peiiod (not just women
witl pieeclumpsiu), it is suggested tlut discluige in-
structions include information about the signs and symp-
toms of preeclampsia as well as the importance of
prompt reporting of this information to their health care
providers.
1128 Executive Summary: Hypertension in Pregnancy OBSTETRICS & GYNECOLOGY
Quality of evidence: Low
Strength of recommendation: Quulied
Foi women in tle postpuitum peiiod wlo piesent witl
new-onset hypertension associated with headaches or
bluiied vision oi pieeclumpsiu witl seveie lypeitension,
the parenteral administration of magnesium sulfate is
suggested.
Quality of evidence: Low
Strength of recommendation: Quulied
Foi women witl peisistent postpuitum lypeitension, BP
ol 1S0 mm Hg systolic oi 100 mm Hg diustolic oi liglei,
on ut leust two occusions tlut uie ut leust 46 louis upuit,
antihypertensive therapy is suggested. Persistent BP of
160 mm Hg systolic or 110 mm Hg diastolic or higher
should be treated within 1 hour.
Quality of evidence: Low
Strength of recommendation: Quulied
Management of Women With
Prior Preeclampsia
Women wlo luve lud pieeclumpsiu in u piioi piegnuncy
should receive counseling and assessments before their next
pregnancy. This can be initiated at the postpartum visit but
is ideally accomplished at a preconception visit before the
next plunned piegnuncy. Duiing tle pieconception visit, tle
previous pregnancy history should be reviewed and the
prognosis for the upcoming pregnancy should be discussed.
Potentiully modiuble lilestyle uctivities, sucl us weiglt loss
und incieused plysicul uctivity, slould be encouiuged. Tle
cuiient stutus ol medicul pioblems slould be ussessed,
including laboratory evaluation if appropriate. Medical
problems such as hypertension and diabetes should be
biouglt into tle best contiol possible. Tle eect ol medicul
problems on the pregnancy should be discussed. Medica-
tions slould be ieviewed und tleii udministiution modied
for upcoming pregnancy. Folic acid supplementation should
be recommended. If a woman has given birth to a preterm
infant during a preeclamptic pregnancy or has had preec-
lumpsiu in moie tlun one piegnuncy, tle use ol low-dose
aspirin in the upcoming pregnancy should be suggested.
Women witl u medicul listoiy ol pieeclumpsiu slould be
instiucted to ietuin loi cuie euily in piegnuncy. Duiing tle
next piegnuncy, euily ultiusonogiuply slould be peiloimed
to deteimine gestutionul uge, und ussessment und visits
slould be tuiloied to tle piioi piegnuncy outcome, witl lie-
quent visits beginning earlier in women with prior preterm
preeclampsia. The woman should be educated about the
signs and symptoms of preeclampsia and instructed when
and how to contact her health care provider.
TASK FORCE RECOMMENDATION
Foi women witl pieeclumpsiu in u piioi piegnuncy, pie-
conception counseling and assessment is suggested.
Quality of evidence: Low
Strength of recommendation: Quulied
Chronic Hypertension and
Superimposed Preeclampsia
Clionic lypeitension (lypeitension pieduting piegnuncy),
presents special challenges to health care providers. Health
cuie piovideis must ist conim tlut tle BP elevution is
not pieeclumpsiu. Once tlis is estublisled, il tle BP elevu-
tion lus not been pieviously evuluuted, u woikup slould be
peiloimed to document tlut BP is tiuly elevuted (ie, not
white coat hypertension) and to check for secondary hyper-
tension and end-organ damage. The choice of which
women to treat and how to treat them requires special con-
sideiutions duiing piegnuncy, especiully in liglt ol emeig-
ing data that suggest lowering BP excessively might have
udveise letul eects.
Perhaps the greatest challenge is the recognition of
pieeclumpsiu supeiimposed on clionic lypeitension, u con-
dition that is commonly associated with adverse maternal
and fetal outcomes. Recommendations are provided to
guide health care providers in distinguishing women who
may have superimposed preeclampsia without severe fea-
tures (only hypertension and proteinuria) and require only
observation from women who may have superimposed
preeclampsia with severe features (evidence of systemic
involvement beyond hypertension and proteinuria) and
require intervention.
TASK FORCE RECOMMENDATIONS
Foi women witl leatures suggestive of secondary hyper-
tension, ieleiiul to u plysiciun witl expeitise in tieuting
hypertension to direct the workup is suggested.
Quality of evidence: Low
Strength of recommendation: Quulied
Foi piegnunt women witl clionic lypeitension und
pooily contiolled BP, tle use ol lome BP monitoiing is
suggested.
Quality of evidence: Moderate
Strength of recommendation: Quulied
Foi women witl suspected wlite cout lypeitension, tle
use ol umbulutoiy BP monitoiing to conim tle diugno-
sis before the initiation of antihypertensive therapy is
suggested.
Quality of evidence: Low
Strength of recommendation: Quulied
VOL. 122, NO. 5, NOVEMBER 2013 Executive Summary: Hypertension in Pregnancy 1129
It is suggested tlut weiglt loss und extiemely low-
sodium diets (less tlun 100 mEq/d) not be used loi mun-
aging chronic hypertension in pregnancy.
Quality of evidence: Low
Strength of recommendation: Quulied
Foi women witl clionic lypeitension wlo uie uccus-
tomed to exeicising, und in wlom BP is well contiolled,
it is recommended that moderate exercise be continued
during pregnancy.
Quality of evidence: Low
Strength of recommendation: Quulied
Foi piegnunt women witl peisistent clionic lypeiten-
sion with systolic BP of 160 mm Hg or higher or diastolic
BP ol 10S mm Hg oi liglei, untilypeitensive tleiupy is
recommended.
Quality of evidence: Moderate
Strength of recommendation: Strong
Foi piegnunt women with chronic hypertension and BP
less than 160 mm Hg systolic or 105 mm Hg diastolic and
no evidence ol end-oigun dumuge, it is suggested tlut
they not be treated with pharmacologic antihyperten-
sive therapy.
Quality of evidence: Low
Strength of recommendation: Qualied
For pregnant women with chronic hypertension treated
witl untilypeitensive medicution, it is suggested tlut
BP levels be muintuined between 120 mm Hg systolic
and 80 mm Hg diastolic and 160 mm Hg systolic and 105
mm Hg diastolic.
Quality of evidence: Low
Strength of recommendation: Quulied
Foi tle initiul tieutment ol piegnunt women witl clionic
lypeitension wlo iequiie pluimucologic tleiupy, lube-
tulol, niledipine, oi metlyldopu uie iecommended ubove
all other antihypertensive drugs.
Quality of evidence: Moderate
Strength of recommendation: Strong
Foi women witl uncomplicuted clionic lypeitension in
piegnuncy, tle use ol ungiotensin-conveiting enzyme in-
libitois, ungiotensin ieceptoi blockeis, ienin inlibitois,
and mineralocorticoid receptor antagonists is not rec-
ommended.
Quality of evidence: Moderate
Strength of recommendation: Strong
Foi women ol iepioductive uge witl clionic lypeiten-
sion, tle use ol ungiotensin-conveiting enzyme inlibi-
tois, ungiotensin ieceptoi blockeis, ienin inlibitois, und
mineralocorticoid receptor antagonists is not recom-
mended unless tleie is u compelling ieuson, sucl us tle
presence of proteinuric renal disease.
Quality of evidence: Low
Strength of recommendation: Quulied
Foi women witl clionic lypeitension wlo uie ut u
greatly increased risk of adverse pregnancy outcomes
(history of early-onset preeclampsia and preterm de-
liveiy ut less tlun 34 0/7 weeks ol gestation or preec-
lumpsiu in moie tlun one piioi piegnuncy), initiuting tle
administration of daily low-dose aspirin (6080 mg) be-
ginning in tle lute ist tiimestei is suggested.
Quality of evidence: Moderate
Strength of recommendation: Quulied
Metu-unulysis ol moie tlun 30,000 women in iundomized tiiuls
of aspirin to prevent preeclampsia indicates a small reduction
in the incidence and morbidity of preeclampsia and reveals no
evidence of acute iisk, ultlougl long-teim letul eects cunnot
be excluded. The number of women to treat to have a thera-
peutic eect is deteimined by pievulence. In view ol muteinul
sulety, u discussion ol tle use ol uspiiin in liglt ol individuul
iisk is justied.
Foi women witl clionic lypeitension, tle use ol ultiu-
sonography to screen for fetal growth restriction is sug-
gested.
Quality of evidence: Low
Strength of recommendation: Quulied
Il evidence ol letul giowtl iestiiction is lound in
women witl clionic lypeitension, letoplucentul ussess-
ment to include umbilicul uiteiy Dopplei velocimetiy us
an adjunct antenatal test is recommended.
Quality of evidence: Moderate
Strength of recommendation: Strong
Foi women witl clionic lypeitension complicuted by
issues such as tle need loi medicution, otlei undeilying
medicul conditions tlut uect letul outcome, oi uny
evidence ol letul giowtl iestiiction, und supeiimposed
pieeclumpsiu, untenutul letul testing is suggested.
Quality of evidence: Low
Strength of recommendation: Quulied
Foi women witl clionic lypeitension und no udditionul
muteinul oi letul complicutions, deliveiy beloie 38 0/7
weeks of gestation is not recommended.
Quality of evidence: Moderate
Strength of recommendation: Strong
Foi women witl supeiimposed pieeclumpsiu wlo ieceive
expectunt munugement ut less tlun 34 0/7 weeks ol
1130 Executive Summary: Hypertension in Pregnancy OBSTETRICS & GYNECOLOGY
gestution, tle udministiution ol coiticosteioids loi letul
lung mutuiity benet is iecommended.
Quality of evidence: High
Strength of recommendation: Strong
Foi women witl clionic lypeitension und supeiimposed
pieeclumpsiu witl seveie leutuies, tle udministiution ol
intrapartumpostpartum parenteral magnesium sulfate
to prevent eclampsia is recommended.
Quality of evidence: Moderate
Strength of recommendation: Strong
Foi women witl supeiimposed pieeclumpsiu witlout se-
veie leutuies und stuble muteinul und letul conditions,
expectunt munugement until 37 0/7 weeks ol gestution is
suggested.
Quality of evidence: Low
Strength of recommendation: Quulied
Deliveiy soon ultei muteinul stubilizution is iecommended
iiiespective ol gestutionul uge oi lull coiticosteioid benet
for women with superimposed preeclampsia that is com-
plicated further by any of the following:
uncontrollable severe hypertension
eclampsia
pulmonary edema
abruptio placentae
disseminated intravascular coagulation
nonreassuring fetal status
Quality of evidence: Moderate
Strength of the recommendation: Strong
Foi women witl supeiimposed pieeclumpsiu witl seveie
leutuies ut less tlun 34 0/7 weeks ol gestution witl stu-
ble muteinul und letul conditions, it is iecommended
that continued pregnancy should be undertaken only at
facilities with adequate maternal and neonatal intensive
care resources.
Quality of evidence: Moderate
Strength of evidence: Strong
Foi women witl supeiimposed pieeclumpsiu witl seveie
leutuies, expectunt munugement beyond 34 0/7 weeks
of gestation is not recommended.
Quality of evidence: Moderate
Strength of the recommendation: Strong
Later-Life Cardiovascular Disease in Women
With Prior Preeclampsia
Ovei tle pust 10 yeuis, inloimution lus uccumuluted indi-
cating that a woman who has had a preeclamptic pregnancy
is at an increased risk of later-life CV disease. This increase
ranges from a doubling of risk in all cases to an eightfold to
ninefold increase in women with preeclampsia who gave
biitl beloie 34 0/7 weeks ol gestution. Tlis lus been iec-
ognized by tle Ameiicun Heuit Associution, wlicl now iec-
ommends that a pregnancy history be part of the evaluation
of CV risk in women. It is the general belief that preeclamp-
siu does not cuuse CV diseuse, but iutlei pieeclumpsiu und
CV disease share common risk factors. Awareness that a
woman has had a preeclamptic pregnancy might allow for
tle identicution ol women not pieviously iecognized us
at-risk for earlier assessment and potential intervention.
Howevei, it is unknown il tlis will be u vuluuble udjunct to
pievious inloimution. Il tlis is tle cuse, would tle cuiient
recommendation of assessing risk factors for women by
medicul listoiy, lilestyle evuluution, testing loi metubolic
ubnoimulities, und possibly inummutoiy uctivution ut uge
40 yeuis piovide ull ol tle inloimution tlut would be
gained by knowing a woman had a past preeclamptic preg-
nuncy? Would it be valuable to perform this assessment at
a younger age in women who had a past preeclamptic preg-
nuncy? Il tle iisk wus identied euiliei, wlut inteivention
(otlei tlun lilestyle modicution) would potentiully be
uselul und would it muke u dieience? Aie tleie iisk luc-
tors that could be unmasked by pregnancy other than con-
ventional risk factors? Further research is needed to
determine how to take advantage of this information relat-
ing pieeclumpsiu to lutei-lile CV diseuse. At tlis time, tle
tusk loice cuutiously iecommends lilestyle modicution
(muintenunce ol u leultly weiglt, incieused plysicul uctiv-
ity, und not smoking) und suggests euily evuluution loi tle
most high-risk women.
TASK FORCE RECOMMENDATION
Foi women witl u medicul listoiy ol pieeclumpsiu wlo
guve biitl pieteim (less tlun 37 0/7 weeks ol gestution)
oi wlo luve u medicul listoiy ol iecuiient pieeclumpsiu,
yeuily ussessment ol BP, lipids, lusting blood glucose, und
body mass index is suggested.*
Quality of evidence: Low
Strength of recommendation: Quulied
*Although there is clear evidence of an association between
pieeclumpsiu und lutei-lile CV diseuse, tle vulue und uppio-
priate timing of assessment is not yet established. Health care
providers and patients should make this decision based on their
judgment of the relative value of extra information versus ex-
pense and inconvenience.
Patient Education
Patient and health care provider education is key to the
successful recognition and management of preeclampsia.
VOL. 122, NO. 5, NOVEMBER 2013 Executive Summary: Hypertension in Pregnancy 1131
Health care providers need to inform women during the
prenatal and postpartum periods of the signs and symp-
toms of preeclampsia and stress the importance of contact-
ing health care providers if these are evident. The
recognition of the importance of patient education must be
complemented by the recognition and use of strategies that
facilitate the successful transfer of this information to
women with varying degrees of health literacy. Recom-
mended strategies to facilitate this process include using
pluin nonmedicul lunguuge, tuking time to speuk slowly,
reinforcing key issues in print using pictorially based infor-
mution, und iequesting leedbuck to indicute tlut tle putient
undeistunds, und, wleie upplicuble, lei puitnei.
TASK FORCE RECOMMENDATION
It is suggested tlut leultl cuie piovideis convey inloi-
mation about preeclampsia in the context of prenatal
care and postpartum care using proven health communi-
cation practices.
Quality of evidence: Low
Strength of recommendation: Quulied
The State of the Science and
Research Recommendations
In tle pust 10 yeuis, stiiking incieuses in tle undeistunding
of the pathophysiology of preeclampsia have occurred. Clin-
ical research advances also have emerged that have pro-
vided evidence to guide therapy. It is now understood that
pieeclumpsiu is u multisystemic diseuse tlut uects ull oigun
systems and is far more than high BP and renal dysfunction.
The placenta is evident as the root cause of preeclampsia. It
is with the delivery of the placenta that preeclampsia begins
to resolve. The insult to the placenta is proposed as an
immunologically initiated alteration in trophoblast func-
tion, und tle ieduction in tioploblust invusion leuds to
failed vascular remodeling of the maternal spiral arteries
that perfuse the placenta. The resulting reduced perfusion
and increased velocity of blood perfusing the intervillous
space alter placental function. The altered placental func-
tion leads to maternal disease through putative primary
mediutois, including oxidutive und endoplusmic ieticulum
stiess und inummution, und seconduiy mediutois tlut
include modieis ol endotleliul lunction und ungiogenesis.
This understanding of preeclampsia pathophysiology has
not translated into predictors or preventers of preeclamp-
sia or to improved clinical care. This has led to a reassess-
ment ol tlis conceptuul liumewoik, witl uttention to tle
possibility that preeclampsia is not one disease but that the
syndrome may include subsets of pathophysiology.
Clinical research advances have shown approaches to
tleiupy tlut woik (eg, deliveiy loi women witl gestutionul
hypertension and preeclampsia without severe features at
37 0/7 weeks ol gestution) oi do not woik (vitumin C und
vitumin E to pievent pieeclumpsiu). Howevei, tleie uie lew
clinicul iecommendutions tlut cun be clussied us stiong`
because there are huge gaps in the evidence base that guides
therapy. These knowledge gaps form the basis for research
recommendations to guide future therapy.
Conclusion
The task force provides evidence-based recommendations
for the management of patients with hypertension during
and after pregnancy. Recommendations are graded as strong
oi quulied bused on evidence ol eectiveness weigled
uguinst evidence ol potentiul luim. In ull instunces, tle nul
decision is made by the health care provider and patient
after consideration of the strength of the recommendations
in relation to the values and judgments of the individual
patient.
The information in Hypertension in Pregnancy should not be viewed
as a body of rigid rules. The guidelines are general and intended to
be udupted to muny dieient situutions, tuking into uccount tle
needs und iesouices puiticului to tle loculity, tle institution, oi tle
type of practice. Variations and innovations that improve the quality
of patient care are to be encouraged rather than restricted. The
puipose ol tlese guidelines will be well seived il tley piovide u im
basis on which local norms may be built.
Copyiiglt 2013 by tle Ameiicun College ol Obstetiiciuns und
Gynecologists, 409 12tl Stieet, SW, PO Box 96920, Wuslington, DC
20090-6920. All iiglts ieseived. No puit ol tlis publicution muy be
iepioduced, stoied in u ietiievul system, oi tiunsmitted, in uny
loim oi by uny meuns, electionic, meclunicul, plotocopying,
iecoiding, oi otleiwise, witlout piioi wiitten peimission liom tle
publisher.
Executive summuiy: lypeitension in piegnuncy. Ameiicun College ol
Obstetiiciuns und Gynecologists. Obstet Gynecol 2013;122:112231.