Hypertensive Disorders of Pregnancy

Abstract

These recommendations from the ISSHP are based upon available literature and expert opinion. It is intended that this be a 'living' document, to be updated when needed as more research becomes available to influence good clinical practice. Unfortunately there is a relative lack of high quality randomised trials in the field of Hypertension in Pregnancy compared with studies in essential hypertension outside of pregnancy and ISSHP encourages greater funding and uptake of collaborative research in this field. Accordingly, the quality of evidence for the recommendations in this document has not been graded, though relevant references and explanations are provided for each recommendation. The document will be a 'living' guideline and we hope to be able to grade recommendations in the future.Guidelines and recommendations for management of hypertension in pregnancy are typically written for implementation in an ideal setting. It is acknowledged that in many parts of the world, it will not be possible to adopt all of these recommendations; for this reason, options for management in less-resourced settings are discussed separately in relation to diagnosis, evaluation, and treatment. This document has been endorsed by the International Society of Obstetric Medicine (ISOM) and the Japanese Society for the Study of Hypertension in Pregnancy (JSSHP). 5 KEY POINTS: All units managing hypertensive pregnant women should maintain and review uniform departmental management protocols and conduct regular audits of maternal & fetal outcomes.The cause(s) of pre-eclampsia and the optimal clinical management of the hypertensive disorders of pregnancy remain uncertain; therefore, we recommend that every hypertensive pregnant woman be offered an opportunity to participate in research, clinical trials and follow-up studies. Classification1. Hypertension in pregnancy may be chronic (pre-dating pregnancy or diagnosed before 20 weeks of pregnancy) or de novo (either pre-eclampsia or gestational hypertension).2. Chronic hypertension is associated with adverse maternal and fetal outcomes and is best managed by tightly controlling maternal blood pressure (BP 110-140/85 mmHg), monitoring fetal growth and repeatedly assessing for the development of pre-eclampsia and maternal complications. This can be done in an outpatient setting.3. White-coat hypertension refers to elevated office/ clinic (≥140/90mmHg) blood pressure but normal blood pressure measured at home or work (<135/85mmHg); it is not an entirely benign condition and conveys an increased risk for pre-eclampsia. 6 4. Masked hypertension is another form of hypertension, more difficult to diagnose, characterised by blood pressure that is normal at a clinic or office visit but elevated at other times, most typically diagnosed by 24 hour ambulatory BP monitoring (ABPM) or automated home blood pressure monitoring (HBPM). 5.Gestational hypertension is hypertension arising de novo after 20 weeks' gestation in the absence of proteinuria and without biochemical or haematological abnormalities. It...

Pre‐eclampsia and long‐term cardiac dysfunction: A review of asymptomatic cardiac changes existing well beyond the post‐partum period

“…alanine aminotransferase or aspartate aminotransferase >40 IU/L), neurological complications, haematological complications (thrombocytopenia, disseminated intravascular coagulation, haemolysis) or uteroplacental dysfunction. 2 The presentation of pre-eclampsia can then be subclassified as 'preterm' requiring delivery before 37 weeks and 'early onset' based on diagnosis before 34 weeks of gestation. These are not mutually exclusive entities but reflect severity of disease that has been increasingly associated with poorer outcomes with regard to fetal growth as well as long-term maternal health.…”

Blood pressure measurement in pregnancy and in hypertensive disorders of pregnancy: devices, techniques and challenges

“…Each year, over 70 000 maternal deaths and over 500 000 foetal and neonatal deaths occur as a result of pre-eclampsia (PE). 1 In 2015, a global maternal mortality ratio of 216 deaths per 100 000 live births was reported, 2 and hypertensive disorders of pregnancy (HDP), mainly the category PE, accounted for 14% of these deaths with most of the mortalities occurring in low-and middle-income countries (LMIC). 3 In the 2014-2016 triennium in South Africa, HDP accounted for an in-hospital maternal mortality ratio of 24.01 per 100 000 live births.…”

“…1 Notably, the blood pressure threshold that is used to define hypertension is dependent on the situation of measurement: clinic ≥ 140/90 mmHg; home ≥ 135/85 mmHg; ambulatory blood pressure prior to 22 weeks' gestational age ≥ 126/76 mmHg (24-hour average), ≥ 132/79 mmHg (awake average) and ≥ 114/66 mmHg (sleep average). 1 In 2018, the International Society for the Study of Hypertension in Pregnancy (ISSHP) classified HDP as PE, transient gestational hypertension, gestational hypertension, white-coat hypertension, masked hypertension, chronic hypertension and chronic hypertension with superimposed PE. 1 PE is the development of new-onset hypertension in pregnancy at or beyond the gestational age of 20 weeks, with the presence of significant proteinuria and/or maternal organ dysfunction or placental insufficiency.…”

“…1 PE is the development of new-onset hypertension in pregnancy at or beyond the gestational age of 20 weeks, with the presence of significant proteinuria and/or maternal organ dysfunction or placental insufficiency. 1 Gestational hypertension is a new-onset hypertension after 20 weeks of gestational age. Transient gestational hypertension is transient occurrence of hypertension at any stage of pregnancy with spontaneous resolution without treatment.…”

“…White-coat hypertension is the occurrence of hypertension only in a medical practitioner's office/clinic with normalisation of the blood pressure (< 135/85 mmHg) outside the health facility. 1,32 Masked hypertension is the occurrence of hypertension in other settings other than the medical practitioner's office/clinic setting.…”