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..................................................................................................................................................................... 10. Hypertensive disorders

Hypertensive disorders in pregnancy are the most common medical complications, affecting 5–10% of pregnancies worldwide. They remain a major cause of maternal, foetal, and neonatal morbidity and mortality. Maternal risks include placental abruption, stroke, multiple organ failure, and disseminated intravascular coagulation. The foetus is at high-risk of intrauterine growth retardation (25% of cases of preeclampsia), pre-maturity (27% of cases of pre-eclampsia), and intrauterine death (4% of cases of pre-eclampsia).345 The current background information and detailed discussion of the data for the following section of these Guidelines can be found in ESC CardioMed.

10.1 Diagnosis and risk assessment

Repeated BP readings should be performed, preferably on two occasions,346 >_15 min apart in severe hypertension (i.e. >_160/110 mmHg in the obstetric literature).9,347,348

10.1.1 Blood pressure measurement BP in pregnancy should be measured in the sitting position (or the left lateral recumbent during labour) with an appropriately-sized arm cuff at heart level and using Korotkoff V for diastolic BP (DBP). Mercury sphygmomanometers are still the gold standard for BP measurement in pregnancy. Automatic devices tend to under-record the true BP and are unreliable in severe pre-eclampsia. Therefore, only devices validated according to recognized protocols should be used in pregnancy.349,350 The diagnosis of hypertension in pregnancy by ambulatory BP monitoring (ABPM) is superior to routine BP measurement for the prediction of pregnancy outcome.351,352 The devices used for ABPM are technically more accurate than those used for office or home BP measurement. ABPM avoids unnecessary treatment of white-coat hypertension, and is useful in the management of high-risk pregnant women with hypertension and those with diabetic or hypertensive nephropathy.

10.1.2 Laboratory tests Basic laboratory investigations recommended for monitoring pregnant hypertensive patients include urinalysis, blood count, haematocrit, liver enzymes, serum creatinine, and serum uric acid (increased in clinically evident pre-eclampsia, hyperuricaemia in hypertensive pregnancies identifies women at increased risk of adverse maternal and foetal outcomes).353 All pregnant women should be assessed for proteinuria in early pregnancy to detect pre-existing renal disease and, in the second half of pregnancy, to screen for pre-eclampsia. A dipstick test of >_1þ should prompt further investigations, including an albumin:creatinine ratio (ACR),354 which can be quickly determined in a single spot urine sample. A value <30 mg/mmol can reliably rule out proteinuria in pregnancy,355 but a positive test should possibly be followed by a 24 h urine collection. In cases of proteinuria >2 g/day, close monitoring is warranted. However, the result of a 24 h urine collection is often inaccurate356 and delays the diagnosis of pre-eclampsia. Consequently, an ACR cut-off of 30 mg/mmol can be used to identify significant proteinuria.

In addition to basic laboratory tests, the following investigations may be considered: • Ultrasound investigation of the adrenals, and plasma and urinary fractionated metanephrine assays in hypertensive pregnant women with a suggestive clinical presentation of pheochromocytoma in particular. • Doppler ultrasound of uterine arteries (performed after 20 weeks of gestation) is useful to detect those at higher risk of gestational hypertension, pre-eclampsia, and intrauterine growth retardation.357 • An sFlt1 to placental growth factor (sFlt1:PIGF) ratio <_38 can be used to exclude the development of pre-eclampsia in the next week when suspected clinically.358,359

10.2 Definition and classification of

hypertension in pregnancy The definition of hypertension in pregnancy is based only on office (or in-hospital) BP values [systolic BP (SBP) >_140 mmHg and/or DBP >_90 mmHg]360–362 and distinguishes mildly (140–159/ 90–109 mmHg) or severely (>_ 160/110 mmHg) elevated BP, in contrast to the grades used by the joint ESC/ESH Hypertension Guidelines.348

Hypertension in pregnancy is not a single entity but comprises:9 • Pre-existing hypertension: precedes pregnancy or develops before 20 weeks of gestation. It usually persists for more than 42 days post-partum and may be associated with proteinuria. • Gestational hypertension: develops after 20 weeks of gestation and usually resolves within 42 days post-partum. • Pre-eclampsia: gestational hypertension with significant proteinuria (>0.3 g/24 h or ACR >_30 mg/mmol). It occurs more frequently during the first pregnancy, in multiple pregnancy, in hydatidiform mole, in antiphospholipid syndrome, or with preexisting hypertension, renal disease, or diabetes. It is often associated with foetal growth restriction due to placental insufficiency and is a common cause of prematurity. The only cure is delivery.363 As proteinuria may be a late manifestation of preeclampsia, it should be suspected when de novo hypertension is accompanied by headache, visual disturbances, abdominal pain, or abnormal laboratory tests, specifically low platelets and/or abnormal liver function. • Pre-existing hypertension plus superimposed gestational hypertension with proteinuria. • Antenatally unclassifiable hypertension: this term is used when BP is first recorded after 20 weeks of gestation and hypertension is diagnosed; re-assessment is necessary after 42 days post-partum.

10.3 Prevention of hypertension and

pre-eclampsia Women at high or moderate risk of pre-eclampsia should be advised to take 100–150 mg of aspirin daily from week 12 to weeks 36–37.364,365 Downloaded from academic.oup.com/eurheartj/article/39/34/3165/5078465 by guest on 07 October 2026