Management of Gestational Hypertension

Diagnosis and Assessment

The American College of Cardiology recommends performing a complete evaluation for preeclampsia in patients with gestational hypertension showing decreasing hemoglobin and platelet counts, as these may indicate progression to preeclampsia 1, 3
Check for other signs of organ dysfunction, including liver enzymes, renal function, and uric acid levels, as elevated levels are associated with worse maternal and fetal outcomes 1, 4
Assess for proteinuria, as a urine protein/creatinine ratio ≥30 mg/mmol or ≥0.3 mg/mg is abnormal and may indicate progression to preeclampsia 3, 5
Evaluate for neurological symptoms, such as headache and visual disturbances, which may indicate severe preeclampsia 3, 4

If blood pressure is ≥160/110 mmHg, the European Society of Cardiology recommends urgent treatment in a monitored setting with oral nifedipine or IV labetalol or hydralazine 2, 3
If blood pressure is consistently ≥140/90 mmHg, initiate or adjust antihypertensive therapy targeting diastolic blood pressure of 85 mmHg and systolic blood pressure between 110-140 mmHg 2, 3
The American Heart Association recommends preferred medications, including methyldopa, labetalol, or nifedipine, and avoiding ACE inhibitors, ARBs, and direct renin inhibitors as they are contraindicated in pregnancy 3, 5, 6

The American College of Obstetricians and Gynecologists recommends maternal monitoring, including blood pressure monitoring at least twice daily and blood tests twice weekly, to assess for progression to preeclampsia 2, 3
Fetal monitoring should include ultrasound assessment of fetal biometry and growth, amniotic fluid assessment, and umbilical artery Doppler studies, with more frequent monitoring if fetal growth restriction is present 2, 3
Deliver at 37 weeks' gestation if stable gestational hypertension, but consider earlier delivery if progressive thrombocytopenia, abnormal renal or liver function tests, severe hypertension, or abnormal neurological features develop 2, 3

If preeclampsia develops, administer magnesium sulfate for seizure prophylaxis if severe features are present, and consider antenatal corticosteroids if preterm delivery is anticipated (24-34 weeks) 2, 3
Avoid ACE inhibitors, ARBs, and direct renin inhibitors as they are contraindicated in pregnancy, and consider switching to labetalol or nifedipine if hemoglobin continues to decrease 3, 5

Women with gestational hypertension have increased long-term cardiovascular risk and should receive appropriate follow-up after pregnancy, according to the European Heart Journal 5
Gestational hypertension is not a benign condition, with approximately 25% of cases progressing to preeclampsia, and the risk of complications is higher when gestational hypertension develops before 34 weeks 2, 7