Hypertension in Pregnancy: Diagnosis, Blood Pressure Goals, and Pharmacotherapy: A Scientific Statement From the American Heart Association

Abstract

Hypertensive disorders of pregnancy (HDP) remain one of the major causes of pregnancy-related maternal and fetal morbidity and mortality worldwide. Affected women are also at increased risk for cardiovascular disease later in life, independently of traditional cardiovascular disease risks. Despite the immediate and long-term cardiovascular disease risks, recommendations for diagnosis and treatment of HDP in the United States have changed little, if at all, over past decades, unlike hypertension guidelines for the general population. The reasons for this approach include the question of benefit from normalization of blood pressure treatment for pregnant women, coupled with theoretical concerns for fetal well-being from a reduction in utero-placental perfusion and in utero exposure to antihypertensive medication. This report is based on a review of current literature and includes normal physiological changes in pregnancy that may affect clinical presentation of HDP; HDP epidemiology and the immediate and long-term sequelae of HDP; the pathophysiology of preeclampsia, an HDP commonly associated with proteinuria and increasingly recognized as a heterogeneous disease with different clinical phenotypes and likely distinct pathological mechanisms; a critical overview of current national and international HDP guidelines; emerging evidence that reducing blood pressure treatment goals in pregnancy may reduce maternal severe hypertension without increasing the risk of pregnancy loss, high-level neonatal care, or overall maternal complications; and the increasingly recognized morbidity associated with postpartum hypertension/preeclampsia. Finally, we discuss the future of research in the field and the pressing need to study socioeconomic and biological factors that may contribute to racial and ethnic maternal health care disparities.

Hypertensive Disorders in Pregnancy and Mortality at Delivery Hospitalization — United States, 2017–2019

“…An HDP diagnosis code was documented in approximately one in three deaths occurring during delivery hospitalization. Timely diagnosis and treatment of HDP are critical to preventing severe complications and mortality ( 1 ).…”

“…Hypertensive disorders in pregnancy (HDPs), defined as prepregnancy (chronic) or pregnancy-associated hypertension, are common pregnancy complications in the United States. * HDPs are strongly associated with severe maternal complications, such as heart attack and stroke ( 1 ), and are a leading cause of pregnancy-related death in the United States. † CDC analyzed nationally representative data from the National Inpatient Sample to calculate the annual prevalence of HDP among delivery hospitalizations and by maternal characteristics, and the percentage of in-hospital deaths with an HDP diagnosis code documented.…”

“…Among deaths that occurred during delivery hospitalization, 31.6% had any HDP documented. Clinical guidance for reducing complications from HDP focuses on prompt identification and preventing progression to severe maternal complications through timely treatment ( 1 ). Recommendations for identifying and monitoring pregnant persons with hypertension include measuring blood pressure throughout pregnancy, § including self-monitoring.…”

“…Recommendations for identifying and monitoring pregnant persons with hypertension include measuring blood pressure throughout pregnancy, § including self-monitoring. Severe complications and mortality from HDP are preventable with equitable implementation of strategies to identify and monitor persons with HDP ( 1 ) and quality improvement initiatives to improve prompt treatment and increase awareness of urgent maternal warning signs ( 2 ).…”

Management of hypertension in pregnancy

“…Many international and national clinical practice guidelines and scientific statement have been published on this topic. The last one was Hypertension in Pregnancy: Diagnosis, Blood Pressure Goals, and Pharmacotherapy: A Scientific Statement from the American Heart association (AHA) in December 2021 (5).…”