ACOG Practice Bulletin No. 202: Gestational Hypertension and Preeclampsia
Hypertensive disorders of pregnancy constitute one of the leading causes of maternal and perinatal mortality worldwide. It has been estimated that preeclampsia complicates 2–8% of pregnancies globally (1). In Latin America and the Caribbean, hypertensive disorders are responsible for almost 26% of maternal deaths, whereas in Africa and Asia they contribute to 9% of deaths. Although maternal mortality is much lower in high-income countries than in developing countries, 16% of maternal deaths can be attributed to hypertensive disorders (1, 2). In the United States, the rate of preeclampsia increased by 25% between 1987 and 2004 (3). Moreover, in comparison with women giving birth in 1980, those giving birth in 2003 were at 6.7-fold increased risk of severe preeclampsia (4). This complication is costly: one study reported that in 2012 in the United States, the estimated cost of preeclampsia within the first 12 months of delivery was $2.18 billion ($1.03 billion for women and $1.15 billion for infants), which was disproportionately borne by premature births (5). This Practice Bulletin will provide guidelines for the diagnosis and management of gestational hypertension and preeclampsia.
Risk Factors for Preeclampsia
- Nulliparity
- Multifetal gestations
- Preeclampsia in a previous pregnancy
- Chronic hypertension
- Pregestational diabetes
- Gestational diabetes
- Thrombophilia
- Systemic lupus erythematosus
- Prepregnancy body mass index greater than 30
- Antiphospholipid antibody syndrome
- Maternal age 35 years or older
- Kidney disease
- Assisted reproductive technology
- Obstructive sleep apnea
Diagnostic Criteria for Preeclampsia
Blood pressure
- Systolic blood pressure of 140 mm Hg or more or diastolic blood pressure of 90 mm Hg or more on two occasions at least 4 hours apart after 20 weeks of gestation in a woman with a previously normal blood pressure
- Systolic blood pressure of 160 mm Hg or more or diastolic blood pressure of 110 mm Hg or more. (Severe hypertension can be confirmed within a short interval (minutes) to facilitate timely antihypertensive therapy).
- and
- Proteinuria
- 300 mg or more per 24 hour urine collection (or this amount extrapolated from a timed collection) or
- Protein/creatinine ratio of 0.3 mg/dL or more or
- Dipstick reading of 2+ (used only if other quantitative methods not available)
- Or in the absence of proteinuria, new-onset hypertension with the new onset of any of the following:
- Thrombocytopenia: Platelet count less than 100,000 × 109/L
- Renal insufficiency: Serum creatinine concentrations greater than 1.1 mg/dL or a doubling of the serum creatinine concentration in the absence of other renal disease
- Impaired liver function: Elevated blood concentrations of liver transaminases to twice normal concentration
- Pulmonary edema
- ○ New-onset headache unresponsive to medication and not accounted for by alternative diagnoses or visual symptoms
Severe Features
- Systolic blood pressure of 160 mm Hg or more, or diastolic blood pressure of 110 mm Hg or more on two occasions at least 4 hours apart (unless antihypertensive therapy is initiated before this time)
- Thrombocytopenia (platelet count less than 100,000 × 109/L)
- Impaired liver function as indicated by abnormally elevated blood concentrations of liver enzymes (to twice the upper limit normal concentration), and severe persistent right upper quadrant or epigastric pain unresponsive to medication and not accounted for by alternative diagnoses
- Renal insufficiency (serum creatinine concentration more than 1.1 mg/dL or a doubling of the serum creatinine concentration in the absence of other renal disease)
- Pulmonary edema
- New-onset headache unresponsive to medication and not accounted for by alternative diagnoses
- Visual disturbances
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