What is the management of gestational hypertension?

Management of Gestational Hypertension

The management of gestational hypertension requires close monitoring of blood pressure, laboratory evaluation, and timely delivery at 37 weeks' gestation to prevent maternal and fetal complications. 1

Diagnosis and Classification

Gestational hypertension is defined as:

• New-onset hypertension after 20 weeks of gestation
• Systolic BP ≥140 mmHg and/or diastolic BP ≥90 mmHg
• Absence of proteinuria or other features of preeclampsia
• Confirmed on at least two separate occasions or at least 15 minutes apart in severe hypertension (≥160/110 mmHg) 2

Monitoring and Evaluation

For women diagnosed with gestational hypertension:

• Regular blood pressure monitoring:

  • Office or hospital measurements
  • Home BP monitoring when appropriate
  • Daily or twice daily BP checks in the first week after diagnosis 1

• Laboratory assessment:

  • Baseline hemoglobin, platelet count, serum creatinine
  • Urinalysis and quantification of urinary protein
  • Liver function tests 2, 1

• Fetal assessment:

  • Serial ultrasound for fetal growth
  • Antenatal testing for fetal well-being 3

Treatment Approach

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

• Antihypertensive therapy should be initiated at BP ≥150/95 mmHg according to the European Society of Cardiology guidelines 2

• Consider initiating treatment at BP ≥140/90 mmHg in women with:

  • Gestational hypertension with or without proteinuria
  • Pre-existing hypertension with superimposed gestational hypertension
  • Hypertension with organ damage or symptoms 2, 1

• First-line medications:

  • Methyldopa: Safe during pregnancy 4, 1
  • Labetalol: Effective alternative with efficacy comparable to methyldopa 5, 1
  • Nifedipine XR (extended-release): 30-60 mg once daily 1

• Medications to avoid:

  • ACE inhibitors, ARBs, and direct renin inhibitors (contraindicated due to fetal toxicity)
  • Atenolol (risk of intrauterine growth restriction) 1

Severe Hypertension (≥160/110 mmHg)

Requires immediate intervention to prevent complications such as stroke:

• Labetalol IV: 20 mg IV bolus, then 40 mg 10 minutes later, followed by 80 mg every 10 minutes for 2 additional doses (maximum 220 mg)
• Hydralazine IV: 5 mg IV bolus, then 10 mg every 20-30 minutes (maximum 25 mg)
• Nifedipine (oral): 10 mg orally, repeated every 20 minutes (maximum 30 mg) 1

Timing of Delivery

• For uncomplicated gestational hypertension: Delivery at 37 weeks' gestation 1, 3
• For gestational hypertension without complications: Delivery can be delayed until 39+6 weeks 1
• Earlier delivery may be indicated if:
  • Severe uncontrolled hypertension
  • Development of preeclampsia features
  • Fetal compromise 2

Postpartum Management

• Blood pressure should be recorded shortly after birth and again within 6 hours
• Continue monitoring for at least 24-72 hours postpartum
• Follow-up within 7-10 days after discharge 2, 1
• Antihypertensive medication may be continued postpartum if needed:
  • Nifedipine is considered safe during breastfeeding
  • Labetalol and methyldopa are also appropriate options 1

Long-term Follow-up

• Annual cardiovascular risk assessments are recommended lifelong for women with a history of hypertensive disorders in pregnancy
• Lifestyle modifications:
  • Return to pre-pregnancy weight within 12 months
  • Regular exercise
  • Healthy diet 1

Important Considerations and Pitfalls

• Avoid concomitant administration of magnesium sulfate with calcium channel blockers due to risk of synergistic hypotension 1
• Be vigilant for progression to preeclampsia, which requires different management
• Postpartum hypertension can worsen or initially present after delivery and accounts for up to 44% of pregnancy-related deaths in the first six days postpartum 3
• Methyldopa may interfere with certain laboratory tests, including urinary catecholamines, which could affect diagnosis of pheochromocytoma 4

Following these management guidelines can significantly reduce maternal and fetal morbidity and mortality associated with gestational hypertension.