What is the management plan for gestational hypertension?

Management of Gestational Hypertension

Blood pressure control is the cornerstone of gestational hypertension management, with urgent treatment required for BP ≥160/110 mmHg using oral nifedipine or intravenous labetalol or hydralazine, while consistently elevated BP ≥140/90 mmHg should be treated with a target diastolic BP of 85 mmHg to reduce maternal complications. 1

Diagnosis and Initial Assessment

• Gestational hypertension is defined as new-onset hypertension (≥140/90 mmHg) after 20 weeks of gestation without proteinuria
• Not a benign condition - approximately 25% of cases will progress to preeclampsia 1
• Risk of progression is highest when gestational hypertension presents before 34 weeks 1
• Initial assessment should include:
  • Blood pressure monitoring
  • Proteinuria assessment
  • Laboratory tests: complete blood count, liver enzymes, creatinine, uric acid
  • Fetal assessment: ultrasound for growth, amniotic fluid, and umbilical artery Doppler

Blood Pressure Management

Severe Hypertension (≥160/110 mmHg)

• Requires urgent treatment in a monitored setting 1
• First-line medications:
  • Oral nifedipine
  • IV labetalol
  • IV hydralazine 1
• Target: Reduce mean BP by 15-25% with systolic BP of 140-150 mmHg and diastolic BP of 90-100 mmHg 2

Non-Severe Hypertension (140-159/90-109 mmHg)

• Treat to target diastolic BP of 85 mmHg and systolic BP <160 mmHg 1
• Acceptable medications:
  • Oral methyldopa (first-line during pregnancy) 3, 4
  • Labetalol (avoid in patients with reactive airway disease) 2
  • Nifedipine
  • Oxprenolol 1
  • Second/third-line: hydralazine, prazosin 1
• Reduce or cease antihypertensives if diastolic BP falls <80 mmHg 1

Monitoring Requirements

Maternal Monitoring

• Regular BP measurements (at least every clinic visit)
• Repeated assessments for proteinuria if not already present
• Blood tests twice weekly: hemoglobin, platelet count, liver enzymes, creatinine, uric acid 1
• Clinical assessment including testing for clonus
• Hospital assessment if:
  • Severe hypertension develops (≥160/110 mmHg)
  • Signs/symptoms of preeclampsia appear
  • Concerns about fetal wellbeing

Fetal Monitoring

• Ultrasound assessment of:
  • Fetal biometry
  • Amniotic fluid volume
  • Umbilical artery Doppler
• Initial assessment at diagnosis
• Repeat every 2 weeks if initial assessment normal
• More frequent monitoring if fetal growth restriction present 1

Timing of Delivery

• If no maternal or fetal complications arise, optimal delivery timing is around 39 weeks 1
• Earlier delivery may be indicated for:
  • Development of preeclampsia
  • Severe uncontrolled hypertension
  • Fetal growth restriction
  • Other maternal or fetal complications

Postpartum Management

• Continue monitoring BP for at least 72 hours postpartum, with checks every 4-6 hours during the first 3 days 2
• Risk of complications is highest during first 1-6 days postpartum 2
• Antihypertensive medications for postpartum period:
  • Labetalol, nifedipine, enalapril, and metoprolol are safe for breastfeeding 1
  • Avoid methyldopa postpartum due to risk of postnatal depression 2
• BP should fully resolve by 12 weeks postpartum 2
• Home BP monitoring is recommended 2

Long-term Follow-up

• Complete evaluation at 3 months postpartum to ensure normalization of BP and laboratory values 2
• Annual medical review is advised lifelong for women with history of hypertensive disorders of pregnancy 2
• Lifestyle modifications:
  • Return to pre-pregnancy weight within 12 months
  • Regular exercise
  • Healthy diet
  • Aim for ideal body weight 2

Important Caveats

• Gestational hypertension is not benign - close monitoring for progression to preeclampsia is essential
• Women who develop gestational hypertension before 34 weeks have the highest risk of developing preeclampsia 1
• Magnesium sulfate should not be given concomitantly with calcium channel blockers due to risk of hypotension 1
• Women with history of gestational hypertension have increased lifetime risk of cardiovascular disease 5