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JOGC

Guideline No. 426: Hypertensive Disorders of Pregnancy: Diagnosis, Prediction, Prevention, and Management

      Abstract

      Objective

      This guideline was developed by maternity care providers from obstetrics and internal medicine. It reviews the diagnosis, evaluation, and management of the hypertensive disorders of pregnancy (HDPs), the prediction and prevention of preeclampsia, and the postpartum care of women with a previous HDP.

      Target population

      Pregnant women.

      Benefits, harms, and costs

      Implementation of the recommendations in these guidelines may reduce the incidence of the HDPs, particularly preeclampsia, and associated adverse outcomes.

      Evidence

      A comprehensive literature review was updated to December 2020, following the same methods as for previous Society of Obstetricians and Gynaecologists of Canada (SOGC) HDP guidelines, and references were restricted to English or French. To support recommendations for therapies, we prioritized randomized controlled trials and systematic reviews (if available), and evaluated substantive clinical outcomes for mothers and babies.

      Validation methods

      The authors agreed on the content and recommendations through consensus and responded to peer review by the SOGC Maternal Fetal Medicine Committee. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, along with the option of designating a recommendation as a “good practice point.” See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).The Board of the SOGC approved the final draft for publication.

      Intended users

      All health care providers (obstetricians, family doctors, midwives, nurses, and anesthesiologists) who provide care to women before, during, or after pregnancy.

      RECOMMENDATIONS

      • 1.
        Pre-conception counselling is suggested for women with pre-pregnancy hypertension to advise on individualized management during pregnancy (conditional, low).
      • 2.
        Replacing angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs) with other antihypertensives in women planning pregnancy is recommended unless there is a compelling clinical indication not to (strong, low).
      • 3.
        In early pregnancy, women should be screened, at a minimum, for clinical risk markers for preeclampsia (strong, moderate).
      • 4.
        If testing is available, women should be screened at 11–14 weeks gestation using a combination of clinical risk markers, uterine artery pulsatility index, and placental growth factor (PlGF) to individualize the risk of developing preeclampsia (strong, moderate).
      • 5.
        For women at increased risk of preeclampsia, low-dose acetylsalicylic acid (81 or 162 mg/d) is recommended (strong, high), to be taken at bedtime (strong, moderate), preferably before 16 weeks gestation (conditional, moderate), and discontinued by 36 weeks gestation (conditional, low).
      • 6.
        For all other women, low-dose acetylsalicylic acid is not recommended (strong, moderate).
      • 7.
        For all women with low dietary intake of calcium (<900 mg/d), oral calcium supplementation of at least 500 mg/d is suggested to prevent preeclampsia (conditional, low).
      • 8.
        For all women, vitamin D supplementation over and above Health Canada’s recommendation for adults is not suggested to prevent preeclampsia (conditional, moderate).
      • 9.
        For all women, exercise is recommended to prevent preeclampsia (strong, moderate).
      • 10.
        For women at increased risk of preeclampsia, who are overweight or obese dietary advice (reduce calories and choose foods with a low glycemic index) and exercise are recommended (conditional, moderate).
      • 11.
        Inpatient care should be provided for women with severe hypertension or preeclampsia with 1 or more maternal adverse conditions (good practice point).
      • 12.
        Bed rest is not suggested for any women with preeclampsia (conditional, low).
      • 13.
        Antihypertensive therapy is recommended for pregnant women with an average systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg, regardless of the hypertensive disorder of pregnancy (strong, moderate).
      • 14.
        A diastolic blood pressure of 85 mm Hg should be targeted for pregnant women on antihypertensive therapy with chronic or gestational hypertension (strong, moderate), and a similar target, considered for women with preeclampsia (conditional, low).
      • 15.
        Antihypertensive therapy (oral or parenteral) is urgently recommended for women with severe hypertension (i.e., systolic blood pressure ≥160 mm Hg or diastolic blood pressure ≥110 mm Hg) in pregnancy or postpartum (strong, low).
      • 16.
        Magnesium sulphate is recommended for first-line treatment of eclampsia and prophylaxis against eclampsia in women with preeclampsia and severe hypertension or adverse maternal conditions (strong, high).
      • 17.
        Platelet transfusion should be considered if a woman’s platelet count is <20 × 109/L before vaginal delivery or <50 × 109/L before cesarean delivery, or at any time if there is excessive active bleeding, known platelet dysfunction, rapidly falling platelet count, or coagulopathy (strong, low).
      • 18.
        For women with chronic hypertension, expectant care should be undertaken from fetal viability to <370 weeks gestation, unless there is an indication for birth (strong, very low). Initiation of delivery can be offered at 380 to 396 weeks gestation but should be advised from 400 weeks gestation (conditional, low).
      • 19.
        For women with gestational hypertension, expectant care should be undertaken from fetal viability to <370 weeks, unless there is an indication for birth (strong, low). When gestational hypertension arises before 370 weeks, initiation of delivery can be offered at 380 to 396 weeks gestation but should be advised from 400 weeks gestation (conditional, low). For women who are already at 370 weeks gestation or later and present with gestational hypertension, initiation of delivery should be discussed (strong, moderate).
      • 20.
        For women with preeclampsia, expectant management may be considered from fetal viability until <340 weeks gestation, but only in perinatal centres capable of caring for very preterm infants (conditional, moderate). At 340–356 weeks gestation, initiation of delivery should be discussed, as it decreases maternal but increases neonatal risk, particularly if antenatal corticosteroids are not prescribed (strong, moderate). At 360–366 weeks gestation, initiation of delivery should be considered (strong, moderate). At 370 weeks gestation or later, initiation of delivery is recommended (strong, high).
      • 21.
        Blood pressure should be measured regularly (at least twice) in the first 2 weeks after delivery in women with hypertension (good practice point).
      • 22.
        As women may develop preeclampsia for the first time postpartum, those with new or worsening hypertension and/or symptoms of preeclampsia should be evaluated accordingly (good practice point).
      • 23.
        For lactating women, the following antihypertensive drugs are suggested: labetalol, methyldopa, nifedipine, enalapril, and captopril (conditional, low).
      • 24.
        Clinical follow-up should be provided for women with gestational hypertension and preeclampsia to ensure normalization of hypertension, clinical features, and laboratory test results (good practice point).
      • 25.
        Women with gestational hypertension and preeclampsia may benefit from interventions to reduce their risk of a hypertensive disorder of pregnancy in a future pregnancy and from screening for cardiovascular risk factors (conditional, low).

      Keywords

      Abbreviations:

      ACE (angiotensin-converting enzyme), ACR (albumin:creatinine ratio), ARB (angiotensin-receptor blocker), ASA (acetylsalicylic acid), AST (aspartate aminotransferase), ALT (alanine aminotransferase), CKD (chronic kidney disease), FHR (fetal heart rate), FMF (Fetal Medicine Foundation), HDP (hypertensive disorder of pregnancy), PCR (protein:creatinine ratio), PIERS (Pre-eclampsia Integrated Estimate of Risk Score), PlGF (placental growth factor)
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