April 2022 | ASN Kidney News | 29

Hypertension in Pregnancy: Diagnosis, Blood Pressure

T
he American Heart Association (AHA) recently sure control during pregnancy reduces the risk of severe References
published a scientific statement on the diagno- hypertension without increasing the risk of pregnancy loss 1. Garovic VD, et al. Hypertension in pregnancy: Diag-
sis, blood pressure goals, and pharmacotherapy and the increasing recognition of morbidity associated with
nosis, blood pressure goals, and pharmacotherapy: A
of hypertension in pregnancy (1). Although hy- postpartum hypertension and preeclampsia, we recommend
pertensive disorders of pregnancy are associated with high scientific statement from the American Heart Asso-
lowering blood pressure targets for women with preexist-
maternal and fetal mortality and morbidity (Figures 1 and ing kidney diseases and initiating anti-hypertensive therapy ciation. Hypertension 2022; 79:e21−e41. doi: 10.1161/
2), little has changed in their diagnosis and treatment in the when the blood pressure is ≥140/90 mm Hg. Nifedipine HYP.0000000000000208
United States over the past decades. Hypertension in preg- and labetalol remain widely used first-line drugs for effec- 2. Whelton P, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/
nancy continues to be defined as blood pressure ≥140/90 tive treatment. It may also be appropriate to lower the blood AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for
mm Hg by most societies, including the International So- pressure threshold for the diagnosis of hypertensive disor- the Prevention, Detection, Evaluation, and Management
ciety for the Study of Hypertension in Pregnancy (ISSHP), ders of pregnancies to systolic ≥130 mm Hg or diastolic ≥80 of High Blood Pressure in Adults: A report of the American
despite lowering the threshold in the general population to mm Hg, which may better identify women at risk for de- College of Cardiology/American Heart Association Task
130/80 mm Hg for the diagnosis of stage 1 hypertension veloping preeclampsia and adverse pregnancy outcomes (7). Force on Clinical Practice Guidelines. Hypertension 2018;
by the joint American College of Cardiology (ACC)/AHA Lastly, to give optimal care to women with kidney diseases 71:e13−115, doi: 10.1161/HYP.0000000000000065;
guidelines in 2017 (2, 3). The AHA scientific statement on and hypertensive disorders of pregnancy, close collaboration Erratum in Hypertension 2018; 71:e140−e144. doi:
hypertension in pregnancy is timely and much needed, es- is needed among nephrologists, internists, and obstetrics and 10.1161/HYP.0000000000000076
pecially with the increasing incidence of women with hy- gynecology specialists.
3. Roberts J, et al. Hypertension in pregnancy. Report of
pertensive disorders of pregnancy, its associated higher im- In conclusion, there remains a pressing need for evidence-
mediate and long-term cardiovascular risks, and variability the American College of Obstetricians and Gynecolo-
based consensus on a global level for the diagnostic and treat-
in anti-hypertensive treatment thresholds—blood pressure ment thresholds for hypertensive disorders of pregnancy. gists’ Task Force on Hypertension in Pregnancy. Ob-
≥160/110 mm Hg by the American College of Obstetricians Future research and guidelines should emphasize long-term stet Gynecol 2013; 122:1122−1131. doi: 10.1097/01.
and Gynecologists (ACOG) and blood pressure ≥140/90 cardiovascular and kidney diseases risk assessment to further AOG.0000437382.03963.88
mm Hg by other societies, such as ISSHP (1). Hypertensive improve women’s health during and after pregnancy. 4. Shah S, Gupta A. Hypertensive disorders of pregnan-
disorders of pregnancy are a heterogenous disease, based on cy. Cardiol Clin 2019; 37:345−354. doi: 10.1016/j.
their distinct clinical presentations and unique pathologi- Priti Meena, MBBS, MD, DNB, is with the Department ccl.2019.04.008
cal mechanisms, and are classified into chronic hyperten- of Nephrology, All India Institute of Medical Sciences, Bhu- 5. American College of Obstetricians and Gynecologists.
sion, gestational hypertension, preeclampsia/eclampsia, and baneswar, India. Silvi Sha, MD, MS, is Associate Professor of ACOG Practice Bulletin No. 125: Chronic hypertension
preeclampsia superimposed on chronic hypertension (4). Medicine with the Division of Nephrology, Kidney C.A.R.E. in pregnancy. Obstet Gynecol 2012; 119:396−407. doi:
However, there is no clear consensus about the threshold Program, University of Cincinnati, Ohio. 10.1097/AOG.0b013e318249ff06
blood pressure for initiating therapy and target blood pres-
6. Brown MA, et al. Hypertensive disorders of pregnancy:
sure for titrating anti-hypertensive therapy. The new AHA Dr. Meena reports no conflicts of interest. Dr. Shah is sup-
scientific statement summarizes and synthesizes the various ISSHP classification, diagnosis & management recom-
ported by the National Institutes of Health K23 Career De-
recommendations without endorsing any one in particular. mendations for international practice. Hypertension 2018;
velopment Award (1K23HL151816-01A1).
Although the ACOG guidelines recommend initiating anti- 72:24−43. doi: 10.1016/j.preghy.2018.05.004
hypertensive therapy at a systolic blood pressure ≥160 mm Hg Disclosures: The content is solely the responsibility of the au- 7. Bello NA, et al. Prevalence of hypertension among preg-
or diastolic blood pressure ≥110 mm Hg, with a treatment thors and does not necessarily represent the official views of nant women when using the 2017 American College
goal of 120−160 mm Hg systolic/80−110 mm Hg diastolic, the National Institutes of Health. The funders of the study of Cardiology/American Heart Association Blood Pres-
most other hypertension societies, such as ISSHP and the had no role in study design; collection, analysis, and inter- sure Guidelines and association with maternal and fetal
National Institute for Health and Care Excellence (NICE), pretation of data; writing the report; and the decision to sub- outcomes. JAMA Netw Open 2021; 4:e213808. doi:
endorse a more aggressive approach and recommend anti- mit the report for publication. 10.1001/jamanetworkopen.2021.3808
hypertensive therapy when blood pressure is ≥140/90 mm
Hg (5, 6). It is arguable that aggressive blood pressure control
reduces the risk of severe hypertension and neurological com-
Figure 1. Maternal complications of hypertensive disorders of pregnancy
plication of preeclampsia, such as intracerebral hemorrhage
in the mother, and may permit prolongation of pregnancies, Short term Long term
thereby reducing preterm births. Furthermore, strict blood
• Mortality • Hypertension and diabetes mellitus
pressure control may be particularly important for women
with multiple pregnancies, who spend several years of their • Myocardial infarction • Hyperlipidemia
lives being pregnant with uncontrolled hypertension. It is
well known that hypertension in pregnancy increases the risk • Stroke • Stroke and vascular dementia
of immediate and postpartum complications, such as acute • Peripartum cardiomyopathy • Atrial fibrillation and venous
cardiovascular and cerebrovascular diseases. thromboembolism
Nevertheless, the conclusive evidence regarding the ben-
efits of treating non-severe hypertension for the short dura- • Spontaneous coronary artery • Chronic kidney disease and kidney failure
tion of pregnancy to prevent maternal morbidity in young dissection
women without cardiovascular disease risk is lacking, which • Postpartum hemorrhage and • Cardiovascular diseases
may explain the higher blood pressure target threshold by placental abruption
ACOG. Moreover, with aggressive maternal blood pres-
sure control, there are concerns of potential fetal risks due
to reductions in utero-placental circulation and in utero ex-
Figure 2. Fetal complications of hypertensive disorders of pregnancy
posure to anti-hypertensive medications. Therefore, while Short term Long term
awaiting more conclusive data, the AHA scientific statement
currently endorses shared, informed decision-making with • Small for gestational age • Cardiovascular disease
patients regarding whether similar blood pressure targets rec-
ommended outside of pregnancy would be beneficial and • Stillbirth • Stroke
safe for the mother and fetus, with attention to risk factors,
• Preterm delivery • Hypertension
including preexisting heart or kidney diseases or individuals
of Black race and vulnerable ethnicity and with obesity (1). • Higher body mass index
With the emerging evidence that tighter blood pres-