What is the initial management for a pregnant woman with gestational hypertension?

Management of Gestational Hypertension

For a pregnant woman with gestational hypertension, initiate antihypertensive treatment when blood pressure is consistently ≥140/90 mmHg in the office (or ≥135/85 mmHg at home), targeting a diastolic BP of 85 mmHg and systolic BP of 110-140 mmHg, using methyldopa, labetalol, or long-acting nifedipine as first-line agents. 1, 2

Initial Assessment and Hospitalization

• All women should be assessed in hospital when gestational hypertension is first diagnosed to confirm the diagnosis, evaluate for preeclampsia features, and establish baseline maternal and fetal status 1, 3
• After initial assessment, stable patients without severe features may be managed as outpatients if they can reliably monitor BP and report symptoms 1
• Immediate hospitalization is required for:
  • BP ≥160/110 mmHg (severe hypertension) 1, 3
  • Development of preeclampsia features (proteinuria, symptoms, laboratory abnormalities) 3
  • Neurological signs or symptoms 1

Blood Pressure Management

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

• Start pharmacological treatment at BP ≥140/90 mmHg to reduce progression to severe hypertension and complications 1, 2
• First-line medications (all acceptable, choose based on availability and patient factors):
  • Oral methyldopa 1, 2, 4
  • Oral labetalol 1, 2, 5
  • Long-acting oral nifedipine 1, 2
• Target BP: diastolic 85 mmHg and systolic 110-140 mmHg to balance maternal safety with adequate uteroplacental perfusion 1, 2
• Reduce or discontinue antihypertensives if diastolic BP falls <80 mmHg to avoid compromising placental perfusion 1

Severe Hypertension (≥160/110 mmHg)

• This is a hypertensive emergency requiring urgent treatment within 15 minutes in a monitored setting due to stroke risk 1, 2
• Acceptable agents for acute management:
  • Oral immediate-release nifedipine 1, 2
  • Intravenous labetalol 1, 2
  • Intravenous hydralazine 1, 2
• Oral labetalol may be used if the above are unavailable 1

Maternal Monitoring Protocol

• Blood pressure monitoring: Measure at each visit; consider home BP monitoring for stable outpatients 1, 3
• Urinalysis at every visit to detect new-onset proteinuria (progression to preeclampsia) 3
• Clinical assessment for preeclampsia symptoms:
  • Severe headache, visual disturbances, epigastric/right upper quadrant pain 1
  • Check for clonus 1
• Laboratory testing if preeclampsia suspected: Complete blood count (platelets, hemoglobin), liver enzymes, creatinine, uric acid 1

Critical caveat: Approximately 25% of women with gestational hypertension will progress to preeclampsia, with highest risk in those diagnosed before 34 weeks 1, 3. This is not a benign condition and requires vigilant monitoring.

Fetal Monitoring

• Ultrasound assessment starting at 26 weeks' gestation 1, 3
• Serial monitoring every 2-4 weeks if initial assessment normal:
  • Fetal biometry (growth assessment) 3
  • Amniotic fluid volume 3
  • Umbilical artery Doppler 3
• More frequent monitoring if fetal growth restriction suspected 1, 3

Timing of Delivery

• Delivery at 39+0 to 39+6 weeks' gestation is optimal for gestational hypertension without preeclampsia features, provided BP remains controlled and fetal monitoring is reassuring 1, 2, 3
• Earlier delivery indicated if:
  • Preeclampsia develops (deliver at ≥37 weeks) 1, 2
  • Severe hypertension uncontrolled with ≥3 antihypertensive classes 1
  • Non-reassuring fetal status 1

Special Considerations

Magnesium Sulfate

• Not routinely indicated for gestational hypertension alone 3
• Required only if preeclampsia develops with severe hypertension or neurological symptoms for seizure prophylaxis 1, 3

Postpartum Management

• Monitor BP closely for at least 6 weeks postpartum as gestational hypertension typically resolves by this time 3
• Continue antihypertensives as needed to maintain BP <140/90 mmHg 2
• Review at 3 months postpartum to ensure BP and urinalysis have normalized; if not, refer for further evaluation 1

Long-Term Cardiovascular Risk

• Women with gestational hypertension have increased lifetime cardiovascular risk 1, 2
• Recommend annual medical review lifelong with focus on cardiovascular risk factor modification 1, 2
• Encourage return to pre-pregnancy weight by 12 months and healthy lifestyle (exercise, diet) 1

Common Pitfalls to Avoid

• Do not delay treatment waiting for "severe" hypertension - treating at ≥140/90 mmHg reduces progression to severe hypertension and complications 1, 2
• Do not over-treat - diastolic BP <80 mmHg may compromise placental perfusion 1
• Do not assume gestational hypertension is benign - 25% progress to preeclampsia, requiring vigilant surveillance 1, 3
• Do not use ACE inhibitors or angiotensin receptor blockers - these are contraindicated in pregnancy due to fetopathy risk 6