Abstract
Purpose of Review
Hypertensive disorders of pregnancy (HDP)—gestational hypertension, preeclampsia, and eclampsia—are a leading cause of adverse maternal and perinatal outcomes internationally. Prevention, timely diagnosis, and prompt management can reduce associated morbidity. The purpose of this review is to compare international guidelines pertaining to HDP.
Recent Findings
Fourteen HDP guidelines were compared relative to guidelines for the United States (US) where the authors practice. Aspirin is universally recommended for high-risk women to reduce preeclampsia risk. Recommended dose and gestational age at initiation vary. Diagnoses of chronic hypertension, gestational hypertension, and preeclampsia in pregnant women are similar, although blood pressure (BP) thresholds for antihypertensive medication initiation and treatment targets vary due to the limitations in high-quality evidence.
Summary
There are differences among international HDP guidelines related to dose and timing of aspirin initiation, thresholds for antihypertensive medication initiation, and BP targets. However, all guidelines acknowledge the significant morbidity associated with HDP and advocate for timely diagnosis and management to reduce associated morbidity and mortality. More research is needed to understand optimal BP thresholds at which to initiate antihypertensive medication regimens and BP targets in pregnancy.
Similar content being viewed by others
References
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
Xiong T, Mu Y, Liang J, Zhu J, Li X, Li J, et al. Hypertensive disorders in pregnancy and stillbirth rates: a facility-based study in China. Bull World Health Organ. 2018;96(8):531–9. https://doi.org/10.2471/blt.18.208447.
Lanssens D, Vandenberk T, Smeets CJ, De Cannière H, Vonck S, Claessens J, et al. Prenatal remote monitoring of women with gestational hypertensive diseases: cost analysis. J Med Internet Res. 2018;20(3):e102. https://doi.org/10.2196/jmir.9552.
Ananth CV, Basso O. Impact of pregnancy-induced hypertension on stillbirth and neonatal mortality. Epidemiology. 2010;21(1):118–23. https://doi.org/10.1097/EDE.0b013e3181c297af.
Battarbee AN, Sinkey RG, Harper LM, Oparil S, Tita ATN. Chronic hypertension in pregnancy. Am J Obstet Gynecol. 2019;222:532–41. https://doi.org/10.1016/j.ajog.2019.11.1243.
Sutton ALM, Harper LM, Tita ATN. Hypertensive disorders in pregnancy. Obstet Gynecol Clin N Am. 2018;45(2):333–47. https://doi.org/10.1016/j.ogc.2018.01.012.
Bellizzi S, Sobel HL, Ali MM. Signs of eclampsia during singleton deliveries and early neonatal mortality in low- and middle-income countries from three WHO regions. Int J Gynaecol Obstet. 2017;139(1):50–4. https://doi.org/10.1002/ijgo.12262.
Un Nisa S, Shaikh AA, Kumar R. Maternal and fetal outcomes of pregnancy-related hypertensive disorders in a tertiary care hospital in Sukkur. Pakistan Cureus. 2019;11(8):e5507. https://doi.org/10.7759/cureus.5507.
Martin Jr JN. Severe systolic hypertension and the search for safer motherhood. Seminars in perinatology: Elsevier; 2016. p. 119–23.
Bernstein PS, Martin JN, Barton JR, Shields LE, Druzin ML, Scavone BM, et al. National partnership for maternal safety: consensus bundle on severe hypertension during pregnancy and the postpartum period. 2017;125(2):540–7.
Shields LE, Wiesner S, Klein C, Pelletreau B, Hedriana HLJAjoo, gynecology. Use of maternal early warning trigger tool reduces maternal morbidity. 2016;214(4):527. e1-e6.
•• ACOG Practice Bulletin No. 202: Gestational hypertension and preeclampsia. Obstet Gynecol. 2019;133(1):e1–e25. https://doi.org/10.1097/aog.0000000000003018ACOG Practice Bulletins 202 and 203 provide state-of-the art, contemporary recommendations for the management of hypertensive disorders of pregnancy including chronic hypertension, gestational hypertension and preeclampsia. These guidelines were published following the updated ACC/AHA Guideline and address implications of the new recommendations for pregnant women entering prenatal care. Practice Bulletins 202 and 203 provide key recommendations to reduce maternal and perinatal morbidity associated with HDP.
•• ACOG Practice Bulletin No. 203: Chronic hypertension in pregnancy. Obstet Gynecol. 2019;133(1):e26–50 https://doi.org/10.1097/aog.0000000000003020ACOG Practice Bulletins 202 and 203 provide state-of-the art, contemporary recommendations for the management of hypertensive disorders of pregnancy including chronic hypertension, gestational hypertension and preeclampsia. These guidelines were published following the updated ACC/AHA Guideline and address implications of the new recommendations for pregnant women entering prenatal care. Practice Bulletins 202 and 203 provide key recommendations to reduce maternal and perinatal morbidity associated with HDP.
ACOG Committee Opinion No. 743: Low-dose aspirin use during pregnancy. Obstet Gynecol. 2018;132(1):e44–52. https://doi.org/10.1097/aog.0000000000002708.
• Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Himmelfarb CD, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines 2018;71(6):e13-e115. doi: doi:https://doi.org/10.1161/HYP.0000000000000065The 2017 ACC/AHA Guideline revolutionized hypertension management by lowering diagnostic and therapeutic blood pressure thresholds. This critical change resulted from evidence showing harm from lower than previously recognized blood pressure thresholds and evidence demonstrating that treatment of blood pressure to lower than previously recommended thresholds reduces cardiovascular disease associated morbidity and mortality.
Brown MA, Magee LA, Kenny LC, Karumanchi SA, McCarthy FP, Saito S, et al. Hypertensive disorders of pregnancy: ISSHP classification, diagnosis, and management recommendations for international practice. Hypertension. 2018;72(1):24–43. https://doi.org/10.1161/hypertensionaha.117.10803.
Queensland Clinical Guidelines. Maternity and neonatal clinical guideline. Hypertensive disorders of pregnancy. Publication date: August 2015. Amendment date: August 2016. Review date: August 2020.
Butalia S, Audibert F, Cote AM, Firoz T, Logan AG, Magee LA, et al. Hypertension Canada's 2018 guidelines for the Management of Hypertension in pregnancy. Can J Cardiol. 2018;34(5):526–31. https://doi.org/10.1016/j.cjca.2018.02.021.
Lowe S, Bowyer L, Lust K, McMahon L, Morton M, North R, et al. The Management of hypertensive disorders of pregnancy. 2014.
Malachias M, Figueiredo C, Sass N, Antonello I, Torloni M, Bortolotto M. 7th Brazilian guideline of arterial hypertension: chapter 9-Arterial Hypertension in pregnancy. 2016;107(3):49–52.
Stepan H, Kuse-Föhl S, Klockenbusch W, Rath W, Schauf B, Walther T, et al. Diagnosis and treatment of hypertensive pregnancy disorders. Guideline of DGGG (S1-Level, AWMF Registry No. 015/018, December 2013). Geburtshilfe Frauenheilkd. 2015;75(9):900–14. https://doi.org/10.1055/s-0035-1557924.
Clinical Practice Guideline: the management of hypertension in pregnancy. Institute of Obstetricians and Gynaecologists, Royal College of Physicians of Ireland and the Clinical Strategy and Programmes Division, Health Service Executive. Version 1.0. Guideline number 37. Publication Date: May 2016. Revision Date: May 2019.
Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, et al. 2018 ESC/ESH guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH). Eur Heart J. 2018;39(33):3021–104. https://doi.org/10.1093/eurheartj/ehy339.
Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013;122(5):1122–31. https://doi.org/10.1097/01.Aog.0000437382.03963.88.
Regitz-Zagrosek V, Blomstrom Lundqvist C, Borghi C, Cifkova R, Ferreira R, Foidart JM, et al. ESC guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). Eur Heart J. 2011;32(24):3147–97. https://doi.org/10.1093/eurheartj/ehr218.
Henderson JT, Thompson JH, Burda BU, Cantor A. Preeclampsia screening: evidence report and systematic review for the US preventive services task Force. Jama. 2017;317(16):1668–83. https://doi.org/10.1001/jama.2016.18315.
LeFevre ML. Low-dose aspirin use for the prevention of morbidity and mortality from preeclampsia: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;161(11):819–26. https://doi.org/10.7326/m14-1884.
Force UPT. Guide to clinical preventive services. Alexandria: International Medical Publishing; 1996.
Bibbins-Domingo K, Grossman DC, Curry SJ, Barry MJ, Davidson KW, Doubeni CA, et al. Screening for preeclampsia: US Preventive Services Task Force recommendation statement. Jama. 2017;317(16):1661–7. https://doi.org/10.1001/jama.2017.3439.
Organization WH. WHO recommendations for prevention and treatment of pre-eclampsia and eclampsia. 2011.
Organization WH. WHO recommendations for prevention and treatment of pre-eclampsia and eclampsia: evidence base: World Health Organization; 2011.
Organization WH. WHO recommendations: policy of interventionist versus expectant management of severe pre-eclampsia before term. 2018.
Poon LC, Shennan A, Hyett JA, Kapur A, Hadar E, Divakar H, et al. The International Federation of Gynecology and Obstetrics (FIGO) initiative on pre-eclampsia: a pragmatic guide for first-trimester screening and prevention. Int J Gynaecol Obstet. 2019;145(Suppl 1):1–33. https://doi.org/10.1002/ijgo.12802.
Wright D, Wright A, Nicolaides KH. The competing risk approach for prediction of preeclampsia. Am J Obstet Gynecol. 2019;223:12–23.e7. https://doi.org/10.1016/j.ajog.2019.11.1247.
Martin JA, Hamilton BE, Osterman MJK, Driscoll AK, Drake P. Births: final data for 2017. Natl Vital Stat Rep. 2018;67(8):1–50.
Magee LA, von Dadelszen P, Rey E, Ross S, Asztalos E, Murphy KE, et al. Less-tight versus tight control of hypertension in pregnancy. N Engl J Med. 2015;372(5):407–17. https://doi.org/10.1056/NEJMoa1404595.
Behrens I, Basit S, Lykke JA, Ranthe MF, Wohlfahrt J, Bundgaard H, et al. Hypertensive disorders of pregnancy and peripartum cardiomyopathy: a nationwide cohort study. PLoS One. 2019;14(2):e0211857. https://doi.org/10.1371/journal.pone.0211857.
Bello NA, Woolley JJ, Cleary KL, Falzon L, Alpert BS, Oparil S, et al. Accuracy of blood pressure measurement devices in pregnancy: a systematic review of validation studies. Hypertension (Dallas, Tex: 1979). 2018;71(2):326–35. https://doi.org/10.1161/hypertensionaha.117.10295.
Petersen EE, Davis NL, Goodman D, Cox S, Syverson C, Seed K, et al. Racial/ethnic disparities in pregnancy-related deaths—United States, 2007–2016. MMWR Morb Mortal Wkly Rep. 2019;68(35):762.
Moodley J. Maternal deaths associated with hypertensive disorders of pregnancy: a population-based study. Hypertens Pregnancy. 2004;23(3):247–56. https://doi.org/10.1081/prg-200030301.
Nyfløt LT, Ellingsen L, Yli BM, Øian P, Vangen S. Maternal deaths from hypertensive disorders: lessons learnt. Acta Obstet Gynecol Scand. 2018;97(8):976–87.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of Interest
The authors declare no conflicts of interest relevant to this manuscript.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Additional information
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
This article is part of the Topical Collection on Preeclampsia
Rights and permissions
About this article
Cite this article
Sinkey, R.G., Battarbee, A.N., Bello, N.A. et al. Prevention, Diagnosis, and Management of Hypertensive Disorders of Pregnancy: a Comparison of International Guidelines. Curr Hypertens Rep 22, 66 (2020). https://doi.org/10.1007/s11906-020-01082-w
Published:
DOI: https://doi.org/10.1007/s11906-020-01082-w