What are the management options for Hypertensive Disorders of Pregnancy (HDP)?

Management of Hypertensive Disorders of Pregnancy (HDP)

The management of hypertensive disorders of pregnancy requires a structured approach including preventive measures, antihypertensive therapy, close monitoring, and long-term follow-up to reduce maternal and fetal morbidity and mortality. 1

Classification of HDP

HDP encompasses several conditions:

• Pre-existing (chronic) hypertension
• Gestational hypertension
• Preeclampsia
• Pre-existing hypertension with superimposed preeclampsia
• HELLP syndrome (hemolysis, elevated liver enzymes, low platelets)
• Eclampsia

Prevention Strategies

For women at high risk of preeclampsia:

• Low-dose aspirin (75-100 mg/day) should be started before 16 weeks gestation and continued until delivery 1
• Calcium supplementation (1.2-2.5 g/day) is recommended for women with likely low calcium intake (<600 mg/day) 2
• When calcium intake cannot be assessed, providing supplementation is reasonable 2
• Low molecular weight heparin is not indicated for preeclampsia prevention, even with prior early-onset preeclampsia 2
• Regular exercise during pregnancy is recommended to maintain health, appropriate weight, and reduce hypertension risk 2

Antihypertensive Treatment

First-line medications:

• Methyldopa: 250-500 mg divided twice daily or more frequently
• Labetalol: 200-800 mg divided twice daily or more frequently
• Nifedipine XR: 30-60 mg once daily
• Amlodipine: 5-10 mg once daily 1

Treatment thresholds:

• Severe hypertension (≥160/110 mmHg): Immediate treatment required to prevent central nervous system complications 3
• Non-severe hypertension (140-159/90-109 mmHg): Treatment should be initiated for women with gestational hypertension, pre-existing hypertension with superimposed gestational hypertension, or hypertension with organ damage 1

Hypertensive emergencies:

• IV labetalol is the preferred first-line treatment for BP ≥160/110 mmHg 1
• Alternatives include parenteral hydralazine and oral nifedipine capsules 3

Contraindicated medications:

• ACE inhibitors and ARBs are absolutely contraindicated due to risk of fetal toxicity and death 1

Monitoring During Pregnancy

• Regular blood pressure monitoring
• Laboratory evaluation (complete blood count, liver function, renal function, urine protein)
• Fetal assessment (growth scans, amniotic fluid assessment, umbilical artery Doppler) 4
• Consider PlGF or sFlt-1/PlGF ratio testing within clinical trials 2

Delivery Considerations

• Delivery timing should be individualized based on:
  • Severity of maternal condition
  • Gestational age
  • Fetal status
• Delivery is the definitive treatment for preeclampsia, especially at term 2
• Antenatal corticosteroids should be used to enhance fetal lung maturity if delivery is likely within 7 days at <34 weeks gestation 2
• Magnesium sulfate is recommended for seizure prophylaxis in severe preeclampsia and treatment of eclampsia 2

Postpartum Management

• Women with preeclampsia should be considered high-risk for at least 3 days postpartum 2
• BP and clinical condition should be monitored at least every 4 hours while awake 2
• Antihypertensive medications should be continued postpartum and withdrawn slowly, not abruptly 2
• NSAIDs for postpartum analgesia should be avoided, especially with renal disease, placental abruption, or acute kidney injury 2
• Close monitoring for 24-72 hours is essential as hypertension may worsen between days 3-6 1
• Follow-up within 1 week if still requiring antihypertensives at discharge 1

Long-term Follow-up

• All women should be reviewed at 3 months postpartum to ensure BP, urinalysis, and laboratory abnormalities have normalized 2
• If proteinuria or hypertension persists, referral for further investigation is needed 2
• Women with HDP have significant long-term cardiovascular risks 2, 1
• Annual medical review is advised lifelong 2
• Aim to achieve pre-pregnancy weight by 12 months postpartum 2, 1
• Adopt healthy lifestyle with regular exercise and healthy eating 2
• Periodic measurement of fasting lipids and blood glucose is necessary 1

Common Pitfalls and Caveats

• Eclamptic seizures may develop for the first time in the early postpartum period 2
• Underestimating the severity of hypertension can lead to central nervous system complications
• Overaggressive treatment of mild hypertension may impair fetal growth 3
• Failure to recognize that HDP may develop or progress in the postpartum period 4
• Neglecting long-term cardiovascular risk assessment and management after HDP 1
• Not providing adequate patient education about urgent maternal warning signs 5

HDP remains a leading cause of maternal mortality and morbidity globally 6, 5, with 31.6% of deaths during delivery hospitalization having documented HDP 5. Proper management requires vigilance throughout pregnancy and the postpartum period, with attention to both immediate complications and long-term cardiovascular health.