What is the management plan for pregnancy-induced hypertension?

Management of Pregnancy-Induced Hypertension

For pregnancy-induced hypertension, initiate antihypertensive therapy when blood pressure reaches ≥140/90 mmHg, targeting diastolic BP of 85 mmHg and systolic BP of 110-140 mmHg, using methyldopa, labetalol, or long-acting nifedipine as first-line agents. 1

Blood Pressure Thresholds and Treatment Initiation

The management approach differs based on BP severity and clinical context:

• Start pharmacological treatment at BP ≥140/90 mmHg (or home BP ≥135/85 mmHg) for women with gestational hypertension (new-onset after 20 weeks), pre-existing hypertension with superimposed gestational hypertension, or hypertension with subclinical organ damage or symptoms 1, 2

• For pregnant women with chronic hypertension without these features, treatment begins at BP ≥150/95 mmHg 1

• For BP 140-150/90-99 mmHg without specific concerning features, non-pharmacological management is appropriate initially 1

Severe Hypertension: Immediate Action Required

BP ≥160/110 mmHg constitutes a hypertensive emergency requiring immediate hospitalization and treatment within 15 minutes to prevent maternal stroke 1, 2

Acute management options include:

• Oral immediate-release nifedipine (first-line option) 1, 3
• Intravenous labetalol (equally effective) 1, 2
• Intravenous hydralazine 2, 3

First-Line Medications for Chronic BP Control

Methyldopa, labetalol, and long-acting nifedipine are the three preferred agents for ongoing blood pressure management during pregnancy 1, 2, 3

Critical Drug Interactions and Contraindications:

• Never use labetalol concomitantly with calcium channel blockers due to severe hypotension risk 1
• Never administer magnesium sulfate with calcium channel blockers due to severe hypotension risk 1
• ACE inhibitors and angiotensin receptor blockers are absolutely contraindicated due to fetopathy risk 1, 4
• Avoid methyldopa postpartum due to postnatal depression risk 1

Maternal Monitoring Protocol

Establish a systematic monitoring approach:

• Regular clinical evaluation including assessment for clonus (hyperreflexia indicating neurological involvement) 3
• Urine analysis at each visit to detect proteinuria development 3
• Laboratory tests (hemoglobin, platelet count, liver enzymes, uric acid, creatinine) at minimum at 28 and 34 weeks gestation 3
• Twice-weekly blood pressure monitoring for gestational hypertension without severe features 2

Fetal Monitoring Strategy

• Ultrasound evaluation of fetal well-being starting at 26 weeks gestation 3
• Repeat evaluations every 2-4 weeks if fetal biometry remains normal 3
• More frequent monitoring in the presence of suspected fetal growth restriction 3

Indications for Immediate Hospitalization

Admit immediately for any of the following 1, 2, 3:

• BP ≥160/110 mmHg (severe hypertension)
• Development of preeclampsia features (proteinuria, thrombocytopenia, elevated liver enzymes, renal insufficiency)
• Neurological signs or symptoms (visual disturbances, severe headache, altered mental status)
• Inability to control BP with ≥3 antihypertensive drug classes
• Laboratory abnormalities suggesting disease progression

Preeclampsia-Specific Management

Approximately 25% of gestational hypertension cases progress to preeclampsia, especially those diagnosed before 34 weeks 2, 3

Use magnesium sulfate for seizure prophylaxis in preeclampsia and for treatment of eclampsia 1, 2

Additional interventions:

• Administer antenatal corticosteroids between 24+0 and 34+0 weeks if delivery is likely within 7 days 2
• Induction is indicated with adverse conditions such as visual disturbances, coagulation abnormalities, or fetal distress 1

Timing of Delivery

The delivery timing algorithm depends on disease severity:

• Gestational hypertension without preeclampsia: Delivery can be delayed until 39+6 weeks if BP remains controlled, fetal monitoring is reassuring, and preeclampsia has not developed 1, 2, 3

• Preeclampsia at term (≥37 weeks): Recommend delivery 1, 2

• Preeclampsia with severe features: Immediate stabilization and delivery planning regardless of gestational age 1

Postpartum Management

Blood pressure dynamics change significantly after delivery:

• Record BP shortly after birth and again within 6 hours, continuing antihypertensive treatment to maintain BP <140/90 mmHg 2

• BP typically rises over the first 5 postpartum days; women may become hypertensive again after initial normalization 1

• Switch from methyldopa to alternative agent due to postnatal depression risk 1

• Monitor as inpatient or closely at home for 72 hours postpartum as preeclampsia can worsen or initially present after delivery 2

Long-Term Cardiovascular Risk Counseling

Women with gestational hypertension or preeclampsia have significantly increased lifetime cardiovascular risk, with relative risk of ischemic heart disease more than doubled 1

Risk stratification and follow-up:

• Women with early-onset preeclampsia, stillbirth, or fetal growth retardation are at highest risk 1
• Recommend annual medical review lifelong for cardiovascular risk assessment 1, 2
• Lifestyle modifications and regular blood pressure control are essential to reduce future cardiovascular risk 1
• Control of metabolic factors (diabetes, hyperlipidemia, obesity) is necessary 1

Risk of Recurrence in Future Pregnancies

• Women experiencing hypertension in their first pregnancy are at increased risk in subsequent pregnancies 1
• Earlier onset in the first pregnancy correlates with greater recurrence risk 1