What are the guidelines for managing gestational hypertension in India?

Guidelines for Managing Gestational Hypertension in India

The management of gestational hypertension in India should follow the International Society of Hypertension guidelines, which recommend blood pressure control, regular maternal and fetal monitoring, and timely delivery to reduce maternal and fetal morbidity and mortality. 1

Definition and Diagnosis

• Gestational hypertension is defined as blood pressure ≥140/90 mmHg that develops after 20 weeks of gestation and typically resolves within 6 weeks postpartum 2
• Approximately 10-11% of pregnancies in India are affected by hypertensive disorders 3, 4
• Diagnosis requires at least two elevated blood pressure readings on separate occasions 2

Blood Pressure Measurement and Monitoring

• Office BP measurement should follow general guidelines using either:
  • Manual auscultatory device
  • Automated upper-arm cuff device validated specifically for pregnancy and preeclampsia 1
• Home BP monitoring or ambulatory BP monitoring can be used to evaluate white-coat hypertension, especially in women with diabetes or nephropathy 1

Blood Pressure Control

• Blood pressure ≥160/110 mmHg requires urgent treatment in a monitored setting 1
• Acceptable agents for urgent treatment include:
  • Oral nifedipine
  • Intravenous labetalol
  • Intravenous hydralazine 1, 2
• For BP consistently ≥140/90 mmHg, treatment should aim for:
  • Target diastolic BP of 85 mmHg
  • Systolic BP between 110-140 mmHg 1, 2
• First-line antihypertensive agents include:
  • Methyldopa (drug of choice in pregnancy)
  • Labetalol
  • Oxprenolol
  • Nifedipine 1, 5
• Second or third-line agents include:
  • Hydralazine
  • Prazosin 1
• ACE inhibitors and angiotensin II antagonists are contraindicated due to risk of fetopathy 5

Maternal Monitoring

• All women with gestational hypertension should be assessed in hospital when first diagnosed 1
• Regular clinical evaluation including:
  • Blood pressure measurements
  • Assessment for neurological signs and symptoms
  • Urinalysis at each visit to detect proteinuria 1, 2
• Laboratory tests at minimum at 28 and 34 weeks:
  • Hemoglobin
  • Platelet count
  • Liver enzymes
  • Serum uric acid
  • Serum creatinine 1, 2

Fetal Monitoring

• Ultrasound assessment of fetal well-being starting from 26 weeks of gestation 1
• Regular monitoring includes:
  • Fetal biometry
  • Amniotic fluid assessment
  • Umbilical artery Doppler 1
• Frequency of monitoring:
  • Every 2-4 weeks if fetal growth is normal
  • More frequently if fetal growth restriction is suspected 1, 2

Indications for Hospitalization

• Development of preeclampsia 1, 2
• Severe hypertension (≥160/110 mmHg) 1
• Presence of neurological signs or symptoms 1
• Abnormal laboratory tests suggesting disease progression 1, 2

Prevention of Preeclampsia

• Women at high risk (previous hypertension in pregnancy, chronic kidney disease, autoimmune disease, diabetes, chronic hypertension) should receive:
  • Low-dose aspirin (75-162 mg) from weeks 12-36 of pregnancy 1
• Women at moderate risk (first pregnancy in women >40 years, pregnancy interval >10 years, BMI >35 kg/m², family history of preeclampsia, multiple pregnancies) should also receive aspirin prophylaxis 1

Delivery Planning

• For women with gestational hypertension without preeclampsia:
  • Delivery can be delayed until 39+6 weeks if BP is controlled and fetal monitoring is reassuring 1, 2
• For women with preeclampsia:
  • Timing of delivery depends on severity of condition, gestational age, and fetal status 1
• For severe preeclampsia or eclampsia:
  • Immediate delivery is required 1

Magnesium Sulfate Use

• All women with preeclampsia who have proteinuria and severe hypertension, or hypertension with neurological signs/symptoms, should receive MgSO₄ for convulsion prophylaxis 1
• In low-resource settings, all women with preeclampsia should receive MgSO₄:
  • Loading dose of 4 g IV or 10 g IM
  • Followed by 5 g IM every 4 hours or infusion of 1 g/h until delivery and for at least 24 hours postpartum 1
• MgSO₄ should be administered for fetal neuroprotection if delivery is planned before 32 weeks gestation 1

Postpartum Management

• Monitor BP for at least 6 weeks postpartum 1
• Women with a history of hypertensive disorders in pregnancy are at higher risk of developing cardiovascular disease later in life and should have long-term follow-up 6