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    Figure 1

    Maternal complications of hypertensive disorders of pregnancy

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    Figure 2

    Fetal complications of hypertensive disorders of pregnancy

  • 1.

    Garovic VD, et al. Hypertension in pregnancy: Diagnosis, blood pressure goals, and pharmacotherapy: A scientific statement from the American Heart Association. Hypertension 2022; 79:e21e41. doi: 10.1161/HYP.0000000000000208

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    • Search Google Scholar
    • Export Citation
  • 2.

    Whelton P, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension 2018; 71:e13115, doi: 10.1161/HYP.0000000000000065; Erratum in Hypertension 2018; 71:e140−e144. doi: 10.1161/HYP.0000000000000076

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  • 3.

    Roberts J, et al. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet Gynecol 2013; 122:11221131. doi: 10.1097/01.AOG.0000437382.03963.88

    • Search Google Scholar
    • Export Citation
  • 4.

    Shah S, Gupta A. Hypertensive disorders of pregnancy. Cardiol Clin 2019; 37:345354. doi: 10.1016/j.ccl.2019.04.008

  • 5.

    American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 125: Chronic hypertension in pregnancy. Obstet Gynecol 2012; 119:396407. doi: 10.1097/AOG.0b013e318249ff06

    • Search Google Scholar
    • Export Citation
  • 6.

    Brown MA, et al. Hypertensive disorders of pregnancy: ISSHP classification, diagnosis & management recommendations for international practice. Hypertension 2018; 72:2443. doi: 10.1016/j.preghy.2018.05.004

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    • Search Google Scholar
    • Export Citation
  • 7.

    Bello NA, et al. Prevalence of hypertension among pregnant women when using the 2017 American College of Cardiology/American Heart Association Blood Pressure Guidelines and association with maternal and fetal outcomes. JAMA Netw Open 2021; 4:e213808. doi: 10.1001/jamanetworkopen.2021.3808

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Hypertension in Pregnancy: Diagnosis, Blood Pressure Goals, and Pharmacotherapy: A Scientific Statement from the American Heart Association

Priti MeenaPriti Meena, MBBS, MD, DNB, is with the Department of Nephrology, All India Institute of Medical Sciences, Bhubaneswar, India. Silvi Sha, MD, MS, is Associate Professor of Medicine with the Division of Nephrology, Kidney C.A.R.E. Program, University of Cincinnati, Ohio.

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Silvi ShahPriti Meena, MBBS, MD, DNB, is with the Department of Nephrology, All India Institute of Medical Sciences, Bhubaneswar, India. Silvi Sha, MD, MS, is Associate Professor of Medicine with the Division of Nephrology, Kidney C.A.R.E. Program, University of Cincinnati, Ohio.

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The American Heart Association (AHA) recently published a scientific statement on the diagnosis, blood pressure goals, and pharmacotherapy of hypertension in pregnancy (1). Although hypertensive disorders of pregnancy are associated with high maternal and fetal mortality and morbidity (Figures 1 and 2), little has changed in their diagnosis and treatment in the United States over the past decades. Hypertension in pregnancy continues to be defined as blood pressure ≥140/90 mm Hg by most societies, including the International Society for the Study of Hypertension in Pregnancy (ISSHP), despite lowering the threshold in the general population to 130/80 mm Hg for the diagnosis of stage 1 hypertension by the joint American College of Cardiology (ACC)/AHA guidelines in 2017 (2, 3). The AHA scientific statement on hypertension in pregnancy is timely and much needed, especially with the increasing incidence of women with hypertensive disorders of pregnancy, its associated higher immediate and long-term cardiovascular risks, and variability in anti-hypertensive treatment thresholds—blood pressure ≥160/110 mm Hg by the American College of Obstetricians and Gynecologists (ACOG) and blood pressure ≥140/90 mm Hg by other societies, such as ISSHP (1). Hypertensive disorders of pregnancy are a heterogenous disease, based on their distinct clinical presentations and unique pathological mechanisms, and are classified into chronic hypertension, gestational hypertension, preeclampsia/eclampsia, and preeclampsia superimposed on chronic hypertension (4).

Figure 1
Figure 1

Maternal complications of hypertensive disorders of pregnancy

Citation: Kidney News 14, 4

Figure 2
Figure 2

Fetal complications of hypertensive disorders of pregnancy

Citation: Kidney News 14, 4

However, there is no clear consensus about the threshold blood pressure for initiating therapy and target blood pressure for titrating anti-hypertensive therapy. The new AHA scientific statement summarizes and synthesizes the various recommendations without endorsing any one in particular. Although the ACOG guidelines recommend initiating anti-hypertensive therapy at a systolic blood pressure ≥160 mm Hg or diastolic blood pressure ≥110 mm Hg, with a treatment goal of 120−160 mm Hg systolic/80−110 mm Hg diastolic, most other hypertension societies, such as ISSHP and the National Institute for Health and Care Excellence (NICE), endorse a more aggressive approach and recommend anti-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 complication of preeclampsia, such as intracerebral hemorrhage in the mother, and may permit prolongation of pregnancies, thereby reducing preterm births. Furthermore, strict blood pressure control may be particularly important for women with multiple pregnancies, who spend several years of their lives being pregnant with uncontrolled hypertension. It is well known that hypertension in pregnancy increases the risk of immediate and postpartum complications, such as acute cardiovascular and cerebrovascular diseases.

Nevertheless, the conclusive evidence regarding the benefits of treating non-severe hypertension for the short duration of pregnancy to prevent maternal morbidity in young women without cardiovascular disease risk is lacking, which may explain the higher blood pressure target threshold by ACOG. Moreover, with aggressive maternal blood pressure control, there are concerns of potential fetal risks due to reductions in utero-placental circulation and in utero exposure to anti-hypertensive medications. Therefore, while awaiting more conclusive data, the AHA scientific statement currently endorses shared, informed decision-making with patients regarding whether similar blood pressure targets recommended outside of pregnancy would be beneficial and safe for the mother and fetus, with attention to risk factors, including preexisting heart or kidney diseases or individuals of Black race and vulnerable ethnicity and with obesity (1).

With the emerging evidence that tighter blood pressure control during pregnancy reduces the risk of severe hypertension without increasing the risk of pregnancy loss and the increasing recognition of morbidity associated with postpartum hypertension and preeclampsia, we recommend lowering blood pressure targets for women with preexisting kidney diseases and initiating anti-hypertensive therapy when the blood pressure is ≥140/90 mm Hg. Nifedipine and labetalol remain widely used first-line drugs for effective treatment. It may also be appropriate to lower the blood pressure threshold for the diagnosis of hypertensive disorders of pregnancies to systolic ≥130 mm Hg or diastolic ≥80 mm Hg, which may better identify women at risk for developing preeclampsia and adverse pregnancy outcomes (7). Lastly, to give optimal care to women with kidney diseases and hypertensive disorders of pregnancy, close collaboration is needed among nephrologists, internists, and obstetrics and gynecology specialists.

In conclusion, there remains a pressing need for evidence-based consensus on a global level for the diagnostic and treatment thresholds for hypertensive disorders of pregnancy. Future research and guidelines should emphasize long-term cardiovascular and kidney diseases risk assessment to further improve women's health during and after pregnancy.

References

  • 1.

    Garovic VD, et al. Hypertension in pregnancy: Diagnosis, blood pressure goals, and pharmacotherapy: A scientific statement from the American Heart Association. Hypertension 2022; 79:e21e41. doi: 10.1161/HYP.0000000000000208

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2.

    Whelton P, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension 2018; 71:e13115, doi: 10.1161/HYP.0000000000000065; Erratum in Hypertension 2018; 71:e140−e144. doi: 10.1161/HYP.0000000000000076

    • Search Google Scholar
    • Export Citation
  • 3.

    Roberts J, et al. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet Gynecol 2013; 122:11221131. doi: 10.1097/01.AOG.0000437382.03963.88

    • Search Google Scholar
    • Export Citation
  • 4.

    Shah S, Gupta A. Hypertensive disorders of pregnancy. Cardiol Clin 2019; 37:345354. doi: 10.1016/j.ccl.2019.04.008

  • 5.

    American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 125: Chronic hypertension in pregnancy. Obstet Gynecol 2012; 119:396407. doi: 10.1097/AOG.0b013e318249ff06

    • Search Google Scholar
    • Export Citation
  • 6.

    Brown MA, et al. Hypertensive disorders of pregnancy: ISSHP classification, diagnosis & management recommendations for international practice. Hypertension 2018; 72:2443. doi: 10.1016/j.preghy.2018.05.004

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7.

    Bello NA, et al. Prevalence of hypertension among pregnant women when using the 2017 American College of Cardiology/American Heart Association Blood Pressure Guidelines and association with maternal and fetal outcomes. JAMA Netw Open 2021; 4:e213808. doi: 10.1001/jamanetworkopen.2021.3808

    • Crossref
    • Search Google Scholar
    • Export Citation
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