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ACOG
PRACTICE
BULLETIN
CLINICAL MANAGEMENT GUIDELINES FOR
OBSTETRICIANGYNECOLOGISTS
NUMBER 29, JULY 2001
(Replaces Technical Bulletin Number 219, January 1996)
Chronic Hypertension
in Pregnancy
Chronic hypertension occurs in up to 5% of pregnant women; rates vary
according to the population studied and the criteria used for confirming the
diagnosis (1, 2). This complication may result in significant maternal, fetal, and
neonatal morbidity and mortality. There has been confusion over the terminology and criteria used to diagnose this complication, as well as the benefit and
potential harm of treatment during pregnancy. The purpose of this document is
to review the effects of chronic hypertension on pregnancy, to clarify the terminology and criteria used to define and diagnose it during pregnancy, and to
review the available evidence for treatment options.
Background
Definition
According to the National High Blood Pressure Education Program Working
Group on High Blood Pressure in Pregnancy, chronic hypertension is defined as
hypertension present before the 20th week of pregnancy or hypertension present
before pregnancy (3). The blood pressure (BP) criteria used to define hypertension are a systolic pressure of 140 mmHg, a diastolic pressure of 90 mmHg,
or both (see the box). Chronic hypertension during pregnancy is most commonly classified as mild (BP >140/90 mmHg) or as severe (BP 180/110 mmHg)
(4). The diagnosis is relatively easy to make in women taking antihypertensive
medications before conception. However, the diagnosis can be difficult to establish or distinguish from preeclampsia when the woman presents with hypertension late in gestation. In this latter scenario, hypertension that persists longer
than the postpartum period (12 weeks post delivery) is classified as chronic.
Hypertension should be documented on more than one occasion.
According to the National High Blood Pressure Education Program Working
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Mild:
Group on High Blood Pressure in Pregnancy, the diastolic blood pressure is that pressure at which the sound
disappears (Korotkoff phase V) (3). In order to reduce
inaccurate readings, an appropriate size cuff should be
used (length 1.5 times upper arm circumference or a cuff
with a bladder that encircles 80% or more of the arm).
Pressure should be taken with the patient in an upright
position, after a 10-minute or longer rest period. For
patients in the hospital, the blood pressure can be taken
with either the patient sitting up or in the left lateral
recumbent position with the patients arm at the level of
the heart (5). The patient should not use tobacco or caffeine for 30 minutes preceding the measurement (6, 7).
Although validated electronic devices can be used, a mercury sphygmomanometer is preferred (6, 7).
Chronic hypertension usually can be distinguished
from preeclampsia because preeclampsia typically
appears after 20 weeks of gestation in a woman who was
normotensive before pregnancy. Moreover, preeclampsia
resolves during the postpartum period. Additionally,
preeclampsia is frequently associated with proteinuria
and characteristic symptoms such as headache, scotomata, or epigastric pain. Women with preeclampsia also may
have hemolysis, elevated liver enzymes, and low platelet
count (HELLP syndrome). However, the development of
superimposed preeclampsia in pregnant women with
chronic hypertension is relatively common and is often
difficult to diagnose. The acute onset of proteinuria and
worsening hypertension in women with chronic hypertension is suggestive of superimposed preeclampsia.
An additional diagnostic complication may arise in
women with chronic hypertension who begin prenatal
care after 20 weeks of gestation. A physiologic decrease
in blood pressure normally occurs early in the second
trimester, and may be exaggerated in women with chronic hypertension. This decrease may lead to an erroneous
assumption that the blood pressure is normal at this stage
of gestation (3). By the third trimester, the blood pressure
usually returns to its prepregnancy level (5).
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mortality (OR, 3.4; 95% CI, 3.0, 3.7) (4, 16). Several of
the studies included in this review also showed an association between chronic hypertension and preeclampsia
(variously defined) and preterm, SGA, or low-birthweight infants when compared with normotensive women
or the general obstetric population. The risk of these complications was increased even in the absence of superimposed preeclampsia, although the absolute increased risk
from mild hypertension could not be calculated from the
available data (4).
Are other adjunctive tests useful in evaluating a pregnant woman with hypertension?
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Women with mild hypertension (140179 mmHg systolic or 90109 mmHg diastolic pressure) generally do
well during pregnancy and do not, as a rule, require antihypertensive medication (3). There is, to date, no scientific evidence that antihypertensive therapy will improve
perinatal outcome (25, 3234). In a review of 263 women
with mild hypertension randomized to methyldopa,
labetalol, or no treatment at 613 weeks of gestation,
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pregnant women was still uncertain. In this latter systematic review, the authors also were unable to identify trials
that compared nonpharmacologic interventions with antihypertensive agents or with no interventions for chronic
hypertension.
Pregnant women with uncomplicated chronic hypertension of a mild degree generally can be delivered vaginally at term (25); most have good maternal and neonatal
outcomes (3). Cesarean delivery should be reserved for
other obstetric indications. Women with mild hypertension during pregnancy and a prior adverse pregnancy
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182
The majority of pregnant women with chronic hypertension have uncomplicated mild hypertension and can be
managed the same as normal, nonhypertensive women
during the intrapartum period. In contrast, women with
severe hypertension or hypertension that is complicated
by cardiovascular or renal disease may present special
problems during the intrapartum period. Women with
severe hypertension may require antihypertensive medications for acute elevation of blood pressure. Although no
well-designed studies specifically address the treatment of
severe chronic hypertension during the intrapartum period, it is generally recommended that antihypertensive
medications be given to women with preeclampsia for
systolic blood pressure of >160 mmHg or diastolic blood
pressure of 105110 mmHg or greater (3).
Women with chronic hypertension complicated by
significant cardiovascular or renal disease require special
attention to fluid load and urine output because they may
be susceptible to fluid overload with resultant pulmonary
edema. There are insufficient data to address the benefits
and potential harm of central invasive hemodynamic
monitoring in women with pregnancy related hypertensive disorders (3, 50).
There are limited data to address the issue of analgesia
or anesthesia in pregnant women with chronic hypertension. In one study of 327 women with severe hypertension
It is often difficult, if not impossible, to distinguish worsening chronic hypertension from superimposed severe
preeclampsia, especially when the patient presents late in
pregnancy. In the woman with chronic hypertension and
renal disease, it may not be possible to distinguish
between the two entities. If the same woman has only
hypertension without proteinuria and no symptoms of
preeclampsia, such as headache, epigastric pain, or scotomata, the diagnosis may be more difficult. However,
the vast majority of young, nulliparous women presenting with hypertension for the first time during late pregnancy will have preeclampsia. In addition to testing for
proteinuria, other tests that may be helpful include
hemoglobin and hematocrit evaluation, platelet count,
and liver function tests. These latter tests are useful in the
diagnosis of the HELLP syndrome. Oliguria and an elevated hemoglobin/hematocrit level usually indicate
hemoconcentrationmore indicative of preeclampsia.
Serum creatinine levels also may be elevated in women
with preeclampsia.
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Summary of
Recommendations
The following recommendation is based on good
and consistent scientific evidence (Level A):
Angiotensin-converting enzyme inhibitors are contraindicated during pregnancy and are associated
with fetal and neonatal renal failure and death.
The following recommendations are based on limited or inconsistent scientific evidence (Level B):
9. Sibai BM, Abdella TN, Anderson GD. Pregnancy outcome in 211 patients with mild chronic hypertension.
Obstet Gynecol 1983;61:571576 (Level II-3)
Antihypertensive therapy should be used for pregnant women with severe hypertension for maternal
benefit.
The following recommendations are based primarily on consensus and expert opinion (Level C):
12. Ananth CV, Savitz DA, Bowes WA Jr. Hypertensive disorders of pregnancy and stillbirth in North Carolina, 1988
to 1991. Acta Obstet Gynecol Scand 1995;74:788793
(Level II-3)
Women with chronic hypertension should be evaluated for potentially reversible etiologies, preferably
prior to pregnancy.
13. Jain L. Effect of pregnancy-induced and chronic hypertension on pregnancy outcome. J Perinatol 1997;
17:425427 (Level II-3)
References
1. Haddad B, Sibai BM. Chronic hypertension in pregnancy.
Ann Med 1999;31:246252 (Level III)
15. Ananth CV, Smulian JC, Vintzileos AM. Incidence of placental abruption in relation to cigarette smoking and
hypertensive disorders during pregnancy: a meta-analysis
of observational studies. Obstet Gynecol 1999;93:
622 628 (Meta-analysis)
16. Agency for Healthcare Research and Quality. Management of chronic hypertension during pregnancy. Evidence
Report/Technology Assessment no. 14. AHRQ Publication
No. 00-E011. Rockville, Maryland: AHRQ, 2000 (Level
III)
18. Jones DC. Pregnancy complicated by chronic renal disease. Clin Perinatol 1997;24:483496 (Level III)
183
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34. Nifedipine versus expectant management in mild to moderate hypertension in pregnancy. Gruppo di Studio
Ipertensione in Gravidanza. Br J Obstet Gynaecol 1998;
105:718722 (Level I)
35. von Dadelszen P, Ornstein MP, Bull SB, Logan AG, Koren
G, Magee LA. Fall in mean arterial pressure and fetal
growth restriction in pregnancy hypertension: a metaanalysis. Lancet 2000;355:8792 (Meta-analysis)
184
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Evidence obtained from at least one properly designed randomized controlled trial.
II-1 Evidence obtained from well-designed controlled
trials without randomization.
II-2 Evidence obtained from well-designed cohort or
casecontrol analytic studies, preferably from more
than one center or research group.
II-3 Evidence obtained from multiple time series with or
without the intervention. Dramatic results in uncontrolled experiments could also be regarded as this
type of evidence.
III Opinions of respected authorities, based on clinical
experience, descriptive studies, or reports of expert
committees.
Based on the highest level of evidence found in the data,
recommendations are provided and graded according to the
following catetories:
Level ARecommendations are based on good and consistent scientific evidence.
Level BRecommendations are based on limited or inconsistent scientific evidence.
Level CRecommendations are based primarily on consensus and expert opinion.
Copyright July 2001 by the American College of Obstetricians and
Gynecologists. All rights reserved. No part of this publication may be
reproduced, stored in a retrieval system, or transmitted, in any form or
by any means, electronic, mechanical, photocopying, recording, or
otherwise, without prior written permission from the publisher.
Requests for authorization to make photocopies should be directed to
Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA
01923, (978) 750-8400.
The American College of Obstetricians and Gynecologists
409 12th Street, SW,
PO Box 96920
Washington, DC 20090-6920
12345/54321
Chronic Hypertension in Pregnancy. ACOG Practice Bulletin No. 29.
American College of Obstetricians and Gynecologists. Obstet Gynecol
2001;98:177185
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