How is gestational hypertension managed?

Management of Gestational Hypertension

For gestational hypertension, initiate antihypertensive treatment when blood pressure is ≥140/90 mmHg with a target diastolic of 85 mmHg and systolic between 110-140 mmHg, using methyldopa, labetalol, or nifedipine as first-line agents, while monitoring closely for progression to preeclampsia and planning delivery at 37-39 weeks if blood pressure remains controlled. 1, 2

Blood Pressure Thresholds and Treatment Goals

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

• Initiate pharmacological treatment at BP ≥140/90 mmHg for women with gestational hypertension to prevent progression and maternal complications 1, 2
• Target diastolic BP of 85 mmHg and systolic BP between 110-140 mmHg to ensure adequate uteroplacental perfusion while preventing maternal end-organ damage 1, 2
• First-line agents include methyldopa, labetalol, oxprenolol, and nifedipine 1, 2

Severe Hypertension (≥160/110 mmHg)

• BP ≥160/110 mmHg lasting >15 minutes constitutes a hypertensive emergency requiring immediate treatment in a monitored setting 3, 1
• The immediate goal is to decrease mean BP by 15-25% with target SBP 140-150 mmHg and DBP 90-100 mmHg 3
• Intravenous labetalol and oral nifedipine are first-line treatments for hypertensive emergencies 3
• Alternative agents include IV hydralazine (though associated with more maternal hypotension, placental abruption, and fetal tachycardia), IV urapidil, or IV nicardipine 3

Pharmacological Management Details

First-Line Agents for Non-Severe Hypertension

• Methyldopa: Traditional first-line agent, considered safe throughout pregnancy 2, 4
• Labetalol: Alpha-1 and non-selective beta-blocker with efficacy comparable to methyldopa; safe for breastfeeding 3, 2, 5
• Nifedipine (long-acting): Dihydropyridine calcium channel blocker, effective and safe 1, 2

Acute Severe Hypertension Management

• IV labetalol: Starting dose 10-20 mg, titrate 20-80 mg every 10-20 minutes, maximum 300 mg 3
• Oral nifedipine (immediate-release): 10-20 mg, repeat in 30 minutes if needed; avoid combining with magnesium sulfate due to risk of severe hypotension 3, 6
• IV hydralazine: Starting dose 5 mg, titrate 5-10 mg every 20 minutes, maximum 30 mg; requires close monitoring due to risk of abrupt maternal hypotension and fetal distress 3

Critical Drug Precautions

• Methyldopa should NOT be used for urgent BP reduction in hypertensive emergencies 3
• Magnesium sulfate must NOT be given concomitantly with calcium channel blockers due to risk of severe hypotension from synergism 3, 6
• Short-acting oral nifedipine should be avoided except in low-resource settings due to risk of uncontrolled hypotension, particularly when combined with magnesium sulfate 3

Monitoring Requirements

Maternal Monitoring

• Regular clinical evaluation including assessment for clonus and neurological symptoms 1
• Urine analysis at each visit to detect proteinuria and monitor for progression to preeclampsia 1
• Laboratory tests (hemoglobin, platelet count, liver enzymes, uric acid, creatinine) at minimum at 28 and 34 weeks gestation 1
• Monitor for early warning signs: SBP >160 mmHg, DBP >100 mmHg, heart rate <50 or >130 bpm, oxygen saturation <95%, oliguria (<35 mL/h for 2+ hours), altered mental status, non-remitting headache, or shortness of breath 3

Fetal Monitoring

• Ultrasound evaluation of fetal well-being starting at 26 weeks gestation 1
• Subsequent evaluations every 2-4 weeks if fetal biometry is normal 1
• More frequent monitoring if fetal growth restriction is suspected 1

Indications for Hospitalization

Immediate hospitalization is required for: 1

• Development of preeclampsia (new-onset proteinuria ≥0.3 g/day or ≥30 mg/mmol urinary creatinine)
• Severe hypertension ≥160/110 mmHg
• Neurological signs or symptoms (headache, visual disturbances, altered mental status)
• Laboratory abnormalities suggesting disease progression (thrombocytopenia, elevated liver enzymes, elevated creatinine)

Delivery Planning

• Delivery can be delayed until 38-39 weeks if BP remains controlled, fetal monitoring is reassuring, and preeclampsia has not developed 1
• Induction of labor at 37 weeks (37+0) is recommended for women with gestational hypertension or mild preeclampsia to improve maternal outcomes 3, 2
• Delivery is indicated earlier if severe features develop, blood pressure cannot be controlled, or fetal well-being is compromised 1, 2

Special Considerations

Postpartum Management

• Ten percent of maternal deaths from hypertensive disorders occur postpartum, requiring close monitoring in the early postpartum period 3
• Labetalol, nifedipine, enalapril, and metoprolol are considered safe for breastfeeding mothers 3
• Annual medical review lifelong is recommended for women who had hypertensive disorders of pregnancy due to increased cardiovascular risk 2

Common Pitfalls to Avoid

• Do not delay treatment of BP ≥160/110 mmHg—this is associated with adverse maternal outcomes including stroke and pulmonary edema 3
• Avoid using methyldopa for acute BP reduction in emergencies 3
• Never combine magnesium sulfate with calcium channel blockers 3, 6
• Do not use short-acting nifedipine with magnesium sulfate due to risk of severe hypotension 3
• Approximately 25% of gestational hypertension cases progress to preeclampsia, especially when diagnosed before 34 weeks—maintain vigilant monitoring 1