CASE-BASED LEARNING

Management of new- clinical review urgently. This is most important in women of

black ethnicity who are at higher risk of hypertensive disorders

onset hypertension in and its associated morbidity and mortality. The 5timesmore
campaign, has encouraged patient-education and implemented a

pregnancy “Six steps” guide to support black women to advocate for

themselves alongside investigating disparities in maternity care
for black women.
Bernadette Jenner Hypertension in pregnancy is defined as a sustained systolic
Ian B Wilkinson blood pressure (sBP) of 140 mmHg or more, or diastolic blood
pressure (dBP) of 90 mmHg or more and severe hypertension
diagnosed when sBP
160 mmHg and/or dBP
110 mmHg.
Abstract Gestational hypertension and pre-eclampsia are most common,
affecting 4.2e7.9% and 1.5e7.7% respectively. Chronic hyper-
Hypertensive disorders affect approximately 8e10% of all pregnan-
tension affects 0.6e2.7% of pregnancies but may be under-
cies and include pre-eclampsia, gestational hypertension and pre-
reported due to a combination of early maternal physiological
existing chronic hypertension, which may be primary or secondary.
adaptations to pregnancy lowering BP, and unknown precon-
New onset hypertension in pregnancy is defined as a sustained
ception blood pressure.
systolic blood pressure (sBP)
140 mmHg and/or diastolic blood
Women who are affected by hypertensive disorders in preg-
pressure (dBP)
90 mmHg, and severe hypertension diagnosed
nancy have an increased risk of developing hypertension in the
when sBP
160 mmHg and/or dBP
110 mmHg. Gestational
immediate postpartum period, and as a group also develop hy-
hypertension and pre-eclampsia are most common, affecting 4.2
pertension up to 10 years earlier than women who had a
e7.9% and 1.5e7.7% respectively. Chronic hypertension affects
normotensive pregnancy. They are also more likely to suffer
0.6e2.7% of pregnancies but may be under-reported due to early
physiological adaptations in pregnancy lowering blood pressure or
from hypertension in future pregnancies. Additionally, they have
a 2e3 fold higher risk of future ischaemic heart disease, stroke
unknown preconception blood pressure. New onset hypertension
and diabetes. Finding appropriate pathways to educate affected
developing at any stage of pregnancy requires a full history, examina-
women about their long-term risk alongside prospective BP/CV
tion, and investigations to delineate an underlying cause, assess for
screening and management postpartum may help to reduce the
target organ damage and the presence of pre-eclampsia to assign
overall incidence of subsequent cardiovascular events.
risk. Developing a hypertensive disorder in pregnancy is associated
with increased life-long cardiometabolic risk and other cardiovascular
risk factors should be minimised to improve a woman’s long-term Definition of hypertension and severe hypertension
health.
Hypertension in pregnancy is defined as a systolic blood pressure
Keywords Blood pressure; cardiovascular; hypertension; pre-
(sBP) of
140 and/or a diastolic (dBP)
90 mmHg and a sBP
eclampsia; pregnancy

160 mmHg and/or dBP
110 mmHg defined as severe hyper-
tension. This should be diagnosed based on at least two readings,
averaged to reflect the BP in clinic. If BP values have a
Introduction >10 mmHg difference, a third measurement should be taken,
and the second and third measurements used for the average.
Hypertensive disorders affect approximately 8e10% of all preg- Although the diagnostic threshold of hypertension in pregnancy
nancies and include pre-eclampsia (PET) and gestational hyper- is internationally recognised, there is still debate and differences
tension, which are specific to pregnancy, and pre-existing in guidelines worldwide regarding the BP threshold required for
chronic hypertension which may be primary or secondary. All treatment of hypertension in pregnancy. The classification of
these forms of hypertension cause significant morbidity and hypertensive disorder of pregnancy can be seen in Figure 1.
mortality. The most recent MBRRACE-UK (Mothers and Babies In the UK, hypertensive thresholds in non-pregnant people
reducing risk through audits and confidential enquiries across remain sBP
140 mmHg and/or a dBP
90 mmHg from clinic
the UK) report found a 4.75-fold increase in deaths from pre- blood pressure measurements, or
135/85 mmHg on home or
eclampsia and eclampsia over the last 6 years. Despite on- ambulatory BP. Whilst the American Heart Association guide-
going education of healthcare professionals, warning signs of lines have reduced diagnostic targets for a diagnosis of stage 1
new onset hypertension are still frequently missed and thus hypertension in non-pregnant people to sBP of 130e139 mmHg
informing women of the signs and symptoms of hypertensive and/or dBP of 80e89 mmHg, these definitions have not been
disease in pregnancy is paramount to ensure that they seek adopted for pregnancy in the UK or US. Identifying women with
stage 1 hypertension may indicate those at increased risk of
adverse pregnancy outcomes including PET. However,
Bernadette Jenner MBBS BSc MRCP PGDip Obstetric Medicine ST6 Clinical Community-Level Interventions for Pre-eclampsia (CLIP) study,
Pharmacology, Obstetric Medicine and GIM, Addenbrookes Hospital, which measured blood pressure in low-middle income countries,
Cambridge, UK. Conflicts of interest: none declared. showed no benefit in reducing the hypertension diagnostic
Ian B Wilkinson MA DM FRCP Professor of Therapeutics, Experimental threshold in pregnancy to 130/80 mmHg. Stage 1 hypertension in
Medicine and Immunotherapeutics, University of Cambridge, UK. this study was not associated with maternal, fetal, or neonatal
Conflicts of interest: none declared. morbidity or mortality. A recent UK prospective longitudinal

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 34:4 101 Ó 2024 Elsevier Ltd. All rights reserved.
 CASE-BASED LEARNING

The classification of hypertensive disorder of pregnancy

Figure 1

cohort study supported
140/90 mmHg as the hypertension score (NEWS) would miss BP rising above pregnancy diagnostic
threshold as women with normal BP values in the 97th centile at thresholds.
40 weeks of gestation had a blood pressure of 143/94 mmHg.
This was slightly higher in nulliparous women (146/96 mmHg)
Prevention of hypertension before and during pregnancy
and lower in parous women (140/92 mmHg) at 40 weeks of
gestation. Preconception health has a significant impact on the health of a
Severe hypertension, defined as a diagnostic threshold of sBP pregnancy as well as impacting on health across generations

160 mmHg and/or
dBP 110 mmHg, is internationally recog- within the life-course. This benefit is also seen in relation to the
nised and is lower than the severe hypertension diagnosis in non- development of new hypertension in pregnancy and its out-
pregnant populations due to the increased risk of haemorrhagic comes. Women with or without chronic hypertension that have a
stroke and aortic dissection in pregnant populations at sBP higher BMI and baseline systolic/diastolic blood pressure, larger

160 mmHg. Women presenting with severe hypertension waist circumference and/or raised lipid levels are more likely to
require admission and urgent assessment in hospital. develop hypertensive disorders in pregnancy. In addition, the
If severe hypertension occurs in the first 20 weeks of preg- long-term CV risk from a pregnancy affected by hypertension is
nancy it is usually due to chronic hypertension which can have associated with pre-existing CV risk factors. Therefore reducing a
either a primary (90% of cases) or secondary cause. Assessment woman’s CV risk profile prior to pregnancy may reduce their
should include understanding the trajectory of blood pressure long-term risk of CV disease independent of the development of a
rise to ensure appropriate response to managing acute-onset hypertensive disorder in pregnancy.
hypertension. Severe hypertension occurring at 20 weeks or Risk stratifying and managing women with chronic hyper-
more of gestation should be considered an emergency due to the tension preconception by investigating for persistent proteinuria,
likely development of PET and risk of end organ damage. chronic kidney disease and/or left-ventricular hypertrophy is
It is important to recognise in the non-pregnant population, helpful to identify those with multiple risk factors for developing
diagnostic and treatment thresholds for hypertension and severe a hypertensive disorder and in whom more intensive antenatal
hypertension are different. This is due to physiological haemo- care and monitoring is required. The choice of antihypertensive
dynamic changes that occur in pregnancy which cause a reduc- should be changed to one accepted in pregnancy e.g. labetalol,
tion in systemic vascular resistance and expected lowering of modified release nifedipine or methyldopa. Although treating
blood pressure in pregnancy. Endothelial dysfunction and the chronic hypertension in pregnancy is beneficial to reduce the risk
loss of cerebral autoregulation that occurs in PET, exacerbates of severe hypertension, this does not reduce the risk of protein-
the effect of hypertension in pregnant women, leading to an uria or developing pre-eclampsia. Women who lose weight prior
increased risk of cerebrovascular injury at lower blood pressure to pregnancy have reduced rates of hypertensive disorders of
values compared to those with hypertension without PET. It is pregnancy, and this is equally important in-between pregnancies.
vital that pregnant women’s observations are documented on a The POPPY study (Preconception to Postpartum cardiometabolic
specific Maternity Early Warning Score, such as the new National study of primigravid pregnancy), a large observational precon-
MEWS score which is being introduced across all maternity units ception study, aims to investigate the impact of preconception
in England. This identifies women with hypertension in preg- cardiometabolic health on the development of hypertensive dis-
nancy early, whereas a non-pregnant National early warning orders in pregnancy and the long-term CV effects of this.

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 34:4 102 Ó 2024 Elsevier Ltd. All rights reserved.
 CASE-BASED LEARNING

Exercise during pregnancy has been shown to be a safe,

effective, and inexpensive way to reduce the risk of developing Risk factors for pre-eclampsia
pre-eclampsia in pregnancy. A systematic review involving 3322
Women are at high risk of pre-eclampsia if they have
women showed exercise during pregnancy (at least 140 minutes
One of the following high-risk Two or more of the following
of moderate-intensity per week), reduced the risk of pre-
factors: moderate-risk factors:
eclampsia by 40% without adverse fetal effects. The definition
A history of hypertensive First pregnancy.
of moderate intensity was exercise that raised the heart rate but
disease during a previous Aged 40 years or older.
still allowed women to talk (although not sing) throughout. A
pregnancy. Pregnancy interval of more
systematic review and meta-analysis of 5939 women also
Chronic kidney disease. than 10 years.
showed a reduction in hypertensive disorders in those who un-
Autoimmune disease, such as Body mass index (BMI) of
dertook yoga or structured training.
systemic lupus erythematosus 35 kg/m2 or greater at the
The ASPRE (Combined Multimarker Screening and Rando-
or antiphospholipid syndrome. first visit.
mised Patient Treatment with Aspirin for Evidence-Based Pre-
Type 1 or type 2 diabetes. Family history of pre-
eclampsia Prevention) study identified a high-risk group of
Chronic hypertension. eclampsia.
women using a multi-variable first trimester screen and
Multiple pregnancy.
randomly assigned women to 150 mg of aspirin at night or pla-
cebo. There was a 62% reduction in the incidence of preterm pre- Table 1
eclampsia (odds ratio, 0.38; 95% CI, 0.20 to 0.74) when aspirin
was taken from 11 to 13 weeks’ gestation until 36 weeks
considered a differential diagnosis in women presenting with new
compared to placebo. As such, NICE guidance now advises those
onset hypertension with or without proteinuria and multi-organ
who are at increased risk of pre-eclampsia in pregnancy (see
involvement.
Table 1) to start aspirin therapy at 11e13 weeks’ gestation.
All women with new onset hypertension in pregnancy should
have a full history, examination and set of investigations
Approach to new onset hypertension occurring at
(Table 2), considering CV risk factors, signs, and symptoms of
£20 weeks of gestation
end organ damage and evidence for secondary causes (Table 3).
Women with new onset severe hypertension in pregnancy
should be managed in hospital regardless of the timing of its
Case 1 onset in pregnancy.
The underlying pathophysiology of hypertension occurring in
A 36-year-old female presented to her midwife at 18 þ 4 weeks of
the first 20 weeks of pregnancy is likely to be different to those
gestation with a history of headache, vomiting, intermittent sweat-
presenting in the last 20 weeks of pregnancy and this should be
ing, and dizziness. Her blood pressure was 220/110 mmHg initially
considered when treatment is chosen and commenced. Addi-
with a repeat measure of 196/101 mmHg. She was transferred to the
tional ultrasound scans should be requested for fetal growth and
labour ward and given oral labetalol 200 mg, at which time her blood
amniotic fluid volume assessment, and umbilical artery Doppler
pressure became 90/60 mmHg and she felt faint. Her blood pressure
velocimetry at 28 weeks, 32 weeks and 36 weeks or as per local
was persistently labile with associated symptoms of headache,
guidance.
nausea, sweating and pallor. A secondary screen for hypertension
was undertaking including plasma and urine metanephrines which
Approach to new onset hypertension occurring at
were raised, and an abdominal MRI showed a large 10 cm
‡20 weeks of gestation
paraganglioma.

Box 1
Case 2
Hypertension occurring in the first 20 weeks of gestation is usu-
ally due to chronic hypertension, which affects 0.6e2.7% of A 28-year-old woman at 33 weeks’ gestation in her second pregnancy
pregnancies. 90% are idiopathic i.e. primary hypertension and the presents to the obstetric unit with a severe headache, new onset
remainder have an underlying cause (secondary hypertension peripheral swelling and visual disturbance. Her BP is 180/110 mmHg
(Box 1)). The prevalence of chronic hypertension in pregnancy and a urine dipstick showed protein 3þ. Initial investigations showed
may be under representative due to the early physiological a thrombocytopenia (platelets 89  109/L), acute kidney injury
reduction in blood pressure, which can mask pre-existing hy- (creatinine 98 mmol/L) and a growth restricted fetus on the 6th cen-
pertension. This physiological adaptation may explain why some tile. She was diagnosed with pre-eclampsia and treated with IV
women develop “new” persistent hypertension postpartum labetalol and Magnesium sulphate and delivery expedited due to
without a prior diagnosis of chronic hypertension if it had not deteriorating symptoms despite initial therapy.
been picked up in the preconception period. Secondary causes of
Box 2
hypertension are usually due to an underlying renal parenchymal
disease e.g. reflux nephropathy or glomerulonephritis, and less New onset hypertension occurring at
20 weeks’ gestation is
commonly fibromuscular dysplasia, primary hyperaldosteronism, usually a pregnancy-induced disorder i.e. gestational hyperten-
or undiagnosed monogenic hypertension. PET is rare in the first sion or pre-eclampsia, or chronic hypertension not previously
20 weeks of gestation although can occur and should be diagnosed. However, diagnostic curiosity should remain for

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 CASE-BASED LEARNING

History, examination, and initial investigations for a patient presenting with new onset hypertension in pregnancy
HPC Headaches/migraines, chest pain, shortness of breath, visual symptoms.
Secondary HTN signs: palpitations, sweating, postural symptoms, weight changes, nocturia.
PET signs: peripheral oedema, epigastric pain, headache, NþV, visual disturbance.
PMH Hypertension, diabetes, obesity, hypercholesterolaemia, obstructive sleep apnoea (OSA), stroke/TIA, antiphospholipid
syndrome (APS), connective tissue disorder.
Previous pregnancies e PET/HELLP/gestational hypertension
Current pregnancy e same partner?
DHx Review medications as a secondary cause of hypertension (see Table 3).
Aspirin PET prophylaxis
FHx Hypertension, diabetes, premature CV disease
PET, connective tissue disorder, APS, T1DM.
SHx Smoking/vaping
Recreational drugs: cocaine and amphetamines
Over the counter medications/herbal remedies/patches/supplements
Exercise
Occupation
Examination Body habitus and BMI
(including end BP in both arms (3) and postural BP
organ damage Palpation and auscultation for heart and carotid arteries e heat murmur or bruit of aortic coarctation.
review) Palpation of peripheral arteries - radio-radial delay, radio-femoral delay.
Neurological examination and cognitive status e clonus, reflexes.
Fundoscopy for hypertensive retinopathy
Secondary hypertension signs: rash (vasculitis) or cafe-au-lait (associated neurofibromatosis and phaechromocytoma)
Abdominal examination - enlarged kidneys/liver, renal bruit.
Features of endocrine disease e Cushings or thyroid disease
Investigations Urine: Dipstick, urine PCR/ACR
Bloods: FBC, UþEs, LFT, HbA1C, VBG, glucose, bone (Ca2þ), clotting
Troponin/BNP
Secondary causes: Plasma and urine metanephrines, TSH, T3þT4, PTH
Toxicology screen e if concerned
Other: ECG, Renal USS, Fetal scan e growth and dopplers.

Table 2

those women who present atypically or in whom antihyperten- - neurological complications: eclampsia, altered mental status,
sive treatments are not working. In addition to pregnancy- blindness, stroke, clonus, severe headache or persistent vi-
specific causes, BP physiologically rises in the second half of sual disturbance (scotomata).
pregnancy towards term back to pre-pregnancy levels and blood - Uteroplacental dysfunction e.g. fetal growth restriction,
pressure in women with pre-existing chronic hypertension may abnormal umbilical artery [UA] Doppler wave form, or
trend upwards. If not frequently monitored and treated, this BP stillbirth)
rise may supersede the hypertension and/or severe hypertension The pathophysiology is complex and involves defective
threshold unnoticed. Women with hypertension, and more so trophoblast invasion and incomplete spiral artery remodelling in
with severe hypertension, are at risk of maternal and fetal the placenta although the causative element remains unknown
morbidity. The additional purpose of diagnosing pre-eclampsia is and on-going research is required. In-turn leading to endothelial
to identify women who are at a higher risk of end-organ damage dysfunction with multi-organ involvement and the clinical fea-
such as haemorrhagic stroke (PET OR 10.4 vs chronic hyper- tures of pre-eclampsia. Approximately 70% of women will pre-
tension 2.6) (Box 2). sent with late-onset pre-eclampsia (
34 weeks’ gestation) which
PET is defined as new-onset hypertension (sBP
140 mmHg appears less severe with a lower risk of developing end-organ
and/or dBP
90 mmHg) occurring at
20 weeks’ gestation with damage and fetal growth restriction compared to those with
either 1 or more new-onset condition below: early-onset disease (34 weeks’ gestation).
- proteinuria (
0.3 g/24 hour or uPCR
30 mg/mmol) Alongside the clinical and biochemical features of pre-eclampsia
- haematological involvement: thrombocytopenia (platelet seen above, angiogenic factors can now be measured to help di-
count <150  109/L), DIC or haemolysis. agnose pre-eclampsia. This is particularly helpful in women who
- acute kidney injury (creatinine >90 mmol/L). have pre-existing hypertension and/or proteinuria where baseline
- liver involvement (elevated transaminase e.g. alanine clinical and biochemical results cross with pre-eclampsia diag-
aminotransferase >40 IU/L or epigastric/right upper quad- nostic thresholds. PlGF and sFLt-1 have been incorporated into
rant pain. NICE guidelines for the diagnosis of pre-eclampsia in pregnancy

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 CASE-BASED LEARNING

Secondary causes of hypertension with investigations and implications in pregnancy

Secondary cause History, signs, and symptoms Diagnosis Implication for pregnancy

Renovascular: History of recurrent UTI/ Urine dipstick [Gestational hypertension and

Chronic kidney disease, chronic pyelonephritis. Urine protein:creatinine ratio PET
pyelonephritis diabetic (uPCR)/urine albumin:creatinine [Risk of renal dysfunction
nephropathy PCKD, (uACR) [UTI
Glomerulonephritis, RCC, Renal USS e morphology and [Prematurity, low birthweight.
obstetric uropathy symmetry
Coarctation of the aorta Upper-limb hypertension  Echo/MRI BP monitoring and management
interarm BP difference. - [risk of aortic rupture and
Absent/weak femoral pulse, rupture of cerebral aneurysm.
radio-femoral delay, Postpartum surgical correction.
suprasternal murmur radiating Echo-?concomitant bicuspid
through to the back. aortic valve.
Concomitant systolic murmur of
bicuspid aortic valve
Turner syndrome
Renal artery stenosis/ Peripheral vascular disease, Renal USS with doppler BP monitoring and management
fibromuscular dysplasia abdominal bruit, resistant HTN Postpartum surgical correction
Primary hyperaldosteronism Hypokalaemia, alkalosis Renal USS  MRI for adrenal Monitor and replace Kþ.
(elevated bicarbonate), plasma adenoma Renin/Aldosterone Spironolactone C.I. as
Na >140, nocturia, polyuria, ratio difficult to interpret in antiandrogenic fetal effects.
muscle weakness. pregnancy, wait until Limited data on eplerenone and
postpartum for accurate testing amiloride in pregnancy.
if BP allows
Cushing’s disease/syndrome Truncal obesity, easy bruising, Gestational increase in cortisol [Risk of gestational diabetes
proximal weakness and striae. causes difficulty in
Development of gestational interpretation e wait until
diabetes postpartum
Phaeochromocytoma/ Labile BP, intermittent Plasma and urine Treat with a-blockade e.g.
paraganglioma hypertension, postural metanephrines (unchanged in phenoxybenzamine/doxazosin
hypotension, headaches, pregnancy) until postural hypotension þ
sweating, palpitations, liberal salt and fluid intake for
abdominal pain and anxiety re-expansion of plasma volume
May require b-blockers for
tachycardia but only after
adequate a-blockade.
Unopposed a-stimulation can
lead to hypertensive crisis.
Genetic testing
Hyper/hypothyroidism Hyper e tremor, anxiety, Thyroid function tests: TSH, T3, Hyper e PTU/carbimazole
sweating, weight loss, T4, anti-TPO, TSH-R antibodies. b-Blockers e (propranolol)
diarrhoea, heat intolerance. symptomatic relief.
Hypo e increased diastolic BP, Thyroidectomy
fatigue, weight gain, dry skin, Hypo e Levothyroxine
hair loss, constipation, and If left untreated, associated with
muscle weakness. miscarriage, preterm birth, low
birthweight, PET and/or
stillbirth.
Hyperparathyroidism Related to hypercalcaemia: Serum calcium and parathyroid Fluid replacement (oral/IV), low
nausea constipation, hormone calcium diet and Vit D
polydipsia, fatigue, depression, USS supplementation
renal impairment and cardiac Calcitonin and cinacalcet -
arrythmias. limited safety data and
bisphosphonate therapy risk of

(continued on next page)

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 CASE-BASED LEARNING

Table 3 (continued )
Secondary cause History, signs, and symptoms Diagnosis Implication for pregnancy

adverse effects on fetal skeletal

development
Associated with miscarriage,
IUD, maternal pancreatitis, renal
dysfunction and PET
Parathyroidectomy during
pregnancy.
Genetic testing
Drugs Liquorice, herbal medications, History and urine Tox screen Dependent on drug used: See
alcohol, cocaine/amphetamines Best Use of Medicine in
Ciclosporin Pregnancy (BUMPS)
COCP
Steroids
Erythropoietin
NSAIDs
ADHD meds e.g.
methylphenidate.
Venlafaxine
Obstructive sleep apnoea Daytime somnolence Epworth sleep score. [Pre-eclampsia
Snoring  apnoeic episodes Sleep study [Diabetes
during sleep
High BMI

Table 3

and can be used to risk stratify women presenting with new hy- hypertension in pregnancy should always be managed and
pertension in pregnancy. The diagnostic thresholds are dependent treated in hospital regardless of the timing of its occurrence in
on the assay used. pregnancy due to the related maternal and fetal morbidity.
Most guidelines recommend the use of parenteral or oral an-
tihypertensives including labetalol, modified-release nifedipine,
Management of new onset hypertension in pregnancy
hydralazine and methyldopa, alongside magnesium sulphate in
There is debate, and international differences, as to when hy- those with pre-eclampsia for its anticonvulsant properties.
pertension in pregnancy should be treated. In the UK, NICE Immediate-release nifedipine is a short-acting calcium channel
recommends pharmacological treatment of blood pressure
140/ blocker and should not be used for BP control due to the risk of
90 mmHg. The Control of Hypertension in Pregnancy Study CV events including myocardial infarction, arrhythmias, and
(CHIPS) trial randomised women with non-severe pregnancy stroke. Antihypertensive treatment options can be seen in
hypertension to a diastolic blood pressure (dBP) target of Table 4. Once an antihypertensive has been started, the BP target
100 mm Hg (“less tight” control) versus 85 mm Hg (“tight” con- varies in international guidelines. NICE guidelines recommend a
trol). Although this study showed no effect of tightly controlled tighter target of <135/85 mmHg for all hypertensive pregnancies
BP (133/85 mmHg) versus less tightly controlled BP (139/ regardless of the starting blood pressure and/or underlying
90 mmHg) on rates of PET or maternal/perinatal mortality, it did pathophysiology. This may be appropriate for pregnant people
show a reduction in severe hypertension (28% versus 41%). Post whose pre-pregnancy BP was near normal but may be delete-
hoc analysis found that severe hypertension was associated with rious for those with pre-existing hypertension who blood pres-
worse maternal and perinatal outcomes independent of PET sure has been chronically higher unless affected by
including birth weight <10th percentile, PET, early delivery, superimposed pre-eclampsia.
thrombocytopenia, elevated liver enzymes and maternal length In pre-eclampsia with severe hypertension, due to the
of stay. These results were similar to those of a systematic review increased risk of stroke and end organ damage, treatment should
of 3485 pregnant women across 31 trials which showed treat- be expeditious and aim to reduce BP to <160/110 mmHg within
ment of mild to moderate BP between 140 and 169/90 hours and maintain a target blood pressure of 110e140/70
e109 mmHg halved the risk of severe maternal hypertension e85 mmHg. It is important to appreciate controlling blood
importantly with no adverse fetal outcomes, but no impact on the pressure in pre-eclampsia does not impact on the multi-organ
risk of PET. The CHAP (Chronic Hypertension And Pregnancy) complications of pre-eclampsia e.g. thrombocytopenia or fetal
study showed targeting a blood pressure of less than 140/ involvement. For those with chronic hypertension, without
90 mmHg was associated with better pregnancy outcomes superimposed pre-eclampsia, treatment can mirror that of the
compared to only treatment for severe hypertension. Severe non-pregnant population i.e. reduce sBP by 25% at most in the

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 34:4 106 Ó 2024 Elsevier Ltd. All rights reserved.
 CASE-BASED LEARNING

Antihypertensive therapy (oral or intravenous) for pregnancy and postpartum

Drug Total dose Women side effects Baby side effects

Oral medications
Labetalol Total dose: 200e2400 mg Headaches (1:10) and shortness Possible temporary low blood
Freq: TDS of breath. sugars after birth
Avoid in asthmatics
Modified-release nifedipine Total dose: 20e90 mg Headache (1:10) None known
Freq: BD
Amlodipine Total dose: 5e10 mg Ankle swelling Limited data for pregnancy but
Freq: OD no evidence of harm
Methlydopa Total dose: 500e3000 mg Low mood and tiredness. None known
Freq: TDS Avoid in postnatal period/
patients with depression
Doxazosin Total dose: 2e16 mg Postural hypotension Limited data for pregnancy but
Freq: BD no evidence of harm
Intravenous medications
Labetalol Bolus: 20e50 mg over 1 Avoid in asthmatics Invasive BP monitoring
e2 minutes repeated every Consider other PET therapy:
10 mins to max. dose 200 mg. IV Magnesium Sulphate
Infusion: 20 mg/hour titrated as Fluid restriction
required every 30 mins to a
max. dose of 160 mg/hour until
BP controlled
Hydralazine Bolus: 5 mg over 10 mins, Hypotension: consider 500 ml Invasive BP monitoring
repeated in 20e30 mins if crystalloid before or at the same
required. time as first IV dose.
Infusion in required: 5 mg/hour,
titrated to blood pressure
Post partum
Enalapril Total dose: 2.5e20 mg Acute kidney injury Do not use in pregnancy as 1st
Freq: BD Hyperkalaemia trimester teratogenesis.
Later oligohydramnios, fetal
and neonatal renal failure.

Table 4

first hour, aiming for a reduction to <160/110 mmHg over 2e6 the postpartum period and healthcare professionals caring for
hours with recurrent clinical assessment. pregnant and postpartum women should be aware of this.
The management of severe hypertension with a concomitant The hypertensive diagnostic threshold remains the same at
emergency e.g. subarachnoid haemorrhage, aortic dissection or
140/90 mmHg in the postnatal period. The choice of treatment
myocardial infarction is not covered in this paper and further is wider in the postpartum period and can include medications
reading of hypertensive crises management can be found in the e.g. ACE-i, that would not be used during pregnancy. Treatment
suggested reading. with a once daily regimen is preferred to help with concordance
in the postnatal period.
Approach to new onset hypertension occurring The most recent MBBRACE-UK reported a case of maternal
postpartum death from postpartum haemorrhagic stroke secondary to hy-
pertension. She had no blood pressure measurements taken
Towards the end of pregnancy, blood pressure gradually rises to
during her 5 postpartum visits, and although NICE Hypertension
pre-pregnancy values, and postpartum there is a blood pressure
in pregnancy guidelines advise on BP measurement for women
peak at day 3e6 in both normotensive women and those affected
who have developed hypertensive disorders in pregnancy,
by hypertension in pregnancy. This peak on average is 6 mmHg
assessment of new onset hypertension in the postnatal period is
systolic and 4 mmHg diastolic in normotensive women, but 12%
lacking. All women at post-natal discharge should be informed of
will have a diastolic above 100 mmHg. This can be accounted for by
the signs and symptoms of hypertensive disorders including pre-
the resolution of pre-pregnancy haemodynamic adaptations to
eclampsia and eclampsia, which can occur for the first time
pregnancy, but also transient causes include pain, medications and
postnatally, to encourage early access for clinical review.
excess salt and fluid administration during delivery. Hypertension
Symptoms include persistent headache, visual disturbance such
secondary to pre-eclampsia or HELLP may occur for the first time in

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 34:4 107 Ó 2024 Elsevier Ltd. All rights reserved.
 CASE-BASED LEARNING

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required a longer duration of antihypertensive treatment, have British and Irish Hypertension Society Position document. J Hum
higher sBP/dBP or BMI and/or those with previous chronic hy- Hypertens 2022 Nov 22; 37: 863e79.
pertension tended to have more sustained hypertension. Magee LA, Nicolaides KH, Von Dadelszen P. Preeclampsia. In:
Approximately 1 in 5 women with hypertension in pregnancy Longo DL, ed. N Engl J Med 2022 May 12; 386: 1817e32.
have persistently raised blood pressure requiring antihyperten- Magee LA, Von Dadelszen P, Rey E, et al. Less-tight versus tight
sive therapy. control of hypertension in pregnancy. N Engl J Med 2015 Jan 29;
Women should be informed, at an appropriate time, of their 372: 407e17.
increased risk of long-term cardiometabolic disease and ideally Mahendru AA, Everett TR, Wilkinson IB, et al. Maternal cardiovascular
would have prospective monitoring and treatment of any changes from pre-pregnancy to very early pregnancy. J Hypertens
developing CV risk. Intensive blood pressure monitoring and 2012 Nov; 30: 2168e72.
management in the immediate postpartum period has a long- MBRRACE-UK. Saving lives, improving mothers’ care - Lessons learned
term positive impact on blood pressure control. to inform maternity care from the UK and Ireland confidential en-
quiries into maternal deaths and morbidity 2019e21. Oxford: Na-
Conclusion tional Perinatal Epidemiology Unit, University of Oxford, 2023 Oct.
Rolnik DL, Wright D, Poon LC, et al. Aspirin versus placebo in preg-
New onset hypertension in pregnancy remains a common
nancies at high risk for preterm preeclampsia. N Engl J Med 2017
complication in pregnancy and causes significant associated
Aug 17; 377: 613e22.
morbidity and mortality for both mother and baby. Due to
Tita AT, Szychowski JM, Boggess K, et al. Treatment for mild chronic
increased multi-morbidity amongst women of child-bearing age
hypertension during pregnancy. N Engl J Med 2022 May 12; 386:
and pregnant women, alongside reproductive techniques which
1781e92.
make pregnancy possible, there is an increasing number of
Wiles K, Damodaram M, Frise C. Severe hypertension in pregnancy.
pregnancies affected by hypertension during pregnancy. The
Clin Med 2021 Sep; 21: e451e6.
mainstay of treatment has been unchanged with antihypertensive
therapy, magnesium sulphate and delivery of the baby for de-
cades. Despite education and updates in guidelines, detection of Practice points
hypertension and its complications remains difficult. Ensuring C New onset of hypertension in pregnancy requires a full history,
that women are informed of the signs and symptoms of new onset examination, and investigations to delineate an underlying diag-
hypertension in pregnancy is paramount to aid detection and nosis, target organ damage and cardiovascular risk
treatment. Improved postnatal care focussing on BP measurement C Hypertension occurring at 20 weeks’ gestation is usually due to
alongside modification of CV risk will aid in reducing the long- chronic hypertension, which may be primary (90% of cases) or
term cardiometabolic disease related to these conditions. A secondary
C Hypertension occurring at
20 weeks’ gestation is usually due to
gestational hypertensive disorders such as gestational hyperten-
FURTHER READING
sion or pre-eclampsia
Behrens I, Basit S, Melbye M, et al. Risk of post-pregnancy hyper-
C Treatment of severe blood pressure should assess for presence or
tension in women with a history of hypertensive disorders of
absence of pre-eclampsia to assign risk and speed of BP-lowering
pregnancy: nationwide cohort study. BMJ, 2017 Jul 12; j3078.
therapy
Garovic VD, Dechend R, Easterling T, et al. Hypertension in pregnancy:
C Women who develop hypertensive disorders in pregnancy have an
diagnosis, blood pressure goals, and pharmacotherapy: a scientific
increased long-term cardiovascular risk. BP monitoring and
statement from the American Heart Association. Hypertension
reduction of CV risks should be undertaken to improve overall
[Internet] 2022 Feb; 79 [cited 2023 Nov 28]. Available from: https://
long term health
www.ahajournals.org/doi/10.1161/HYP.0000000000000208.

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 34:4 108 Ó 2024 Elsevier Ltd. All rights reserved.