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ACOG
PRACTICE
BULLETIN
CLINICAL MANAGEMENT GUIDELINES FOR
OBSTETRICIANGYNECOLOGISTS
NUMBER 29, JULY 2001
(Replaces Technical Bulletin Number 219, January 1996)

This Practice Bulletin was

developed by the ACOG Committee on Practice Bulletins
Obstetrics with the assistance
of Larry C. Gilstrap III, MD
and Susan M. Ramin, MD.
The information is designed to
aid practitioners in making
decisions about appropriate
obstetric and gynecologic care.
These guidelines should not be
construed as dictating an exclusive course of treatment or procedure. Variations in practice
may be warranted based on the
needs of the individual patient,
resources, and limitations
unique to the institution or type
of practice.

Chronic Hypertension
in Pregnancy
Chronic hypertension occurs in up to 5% of pregnant women; rates vary
according to the population studied and the criteria used for confirming the
diagnosis (1, 2). This complication may result in significant maternal, fetal, and
neonatal morbidity and mortality. There has been confusion over the terminology and criteria used to diagnose this complication, as well as the benefit and
potential harm of treatment during pregnancy. The purpose of this document is
to review the effects of chronic hypertension on pregnancy, to clarify the terminology and criteria used to define and diagnose it during pregnancy, and to
review the available evidence for treatment options.

Background
Definition
According to the National High Blood Pressure Education Program Working
Group on High Blood Pressure in Pregnancy, chronic hypertension is defined as
hypertension present before the 20th week of pregnancy or hypertension present
before pregnancy (3). The blood pressure (BP) criteria used to define hypertension are a systolic pressure of 140 mmHg, a diastolic pressure of 90 mmHg,
or both (see the box). Chronic hypertension during pregnancy is most commonly classified as mild (BP >140/90 mmHg) or as severe (BP 180/110 mmHg)
(4). The diagnosis is relatively easy to make in women taking antihypertensive
medications before conception. However, the diagnosis can be difficult to establish or distinguish from preeclampsia when the woman presents with hypertension late in gestation. In this latter scenario, hypertension that persists longer
than the postpartum period (12 weeks post delivery) is classified as chronic.
Hypertension should be documented on more than one occasion.
According to the National High Blood Pressure Education Program Working

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Criteria for Diagnosis of Chronic Hypertension

in Pregnancy
Systolic blood pressure 140 mmHg
Diastolic blood pressure 90 mmHg
Severe: Systolic blood pressure 180 mmHg
Diastolic blood pressure 110 mmHg
Use of antihypertensive medications before pregnancy
Onset of hypertension before 20th week of gestation
Persistence of hypertension beyond the usual postpartum period

Mild:

Group on High Blood Pressure in Pregnancy, the diastolic blood pressure is that pressure at which the sound
disappears (Korotkoff phase V) (3). In order to reduce
inaccurate readings, an appropriate size cuff should be
used (length 1.5 times upper arm circumference or a cuff
with a bladder that encircles 80% or more of the arm).
Pressure should be taken with the patient in an upright
position, after a 10-minute or longer rest period. For
patients in the hospital, the blood pressure can be taken
with either the patient sitting up or in the left lateral
recumbent position with the patients arm at the level of
the heart (5). The patient should not use tobacco or caffeine for 30 minutes preceding the measurement (6, 7).
Although validated electronic devices can be used, a mercury sphygmomanometer is preferred (6, 7).
Chronic hypertension usually can be distinguished
from preeclampsia because preeclampsia typically
appears after 20 weeks of gestation in a woman who was
normotensive before pregnancy. Moreover, preeclampsia
resolves during the postpartum period. Additionally,
preeclampsia is frequently associated with proteinuria
and characteristic symptoms such as headache, scotomata, or epigastric pain. Women with preeclampsia also may
have hemolysis, elevated liver enzymes, and low platelet
count (HELLP syndrome). However, the development of
superimposed preeclampsia in pregnant women with
chronic hypertension is relatively common and is often
difficult to diagnose. The acute onset of proteinuria and
worsening hypertension in women with chronic hypertension is suggestive of superimposed preeclampsia.
An additional diagnostic complication may arise in
women with chronic hypertension who begin prenatal
care after 20 weeks of gestation. A physiologic decrease
in blood pressure normally occurs early in the second
trimester, and may be exaggerated in women with chronic hypertension. This decrease may lead to an erroneous
assumption that the blood pressure is normal at this stage
of gestation (3). By the third trimester, the blood pressure
usually returns to its prepregnancy level (5).

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Effects of Chronic Hypertension

on Pregnancy
Chronic hypertension complicates pregnancy and is associated with several adverse outcomes, including premature birth, intrauterine growth restriction (IUGR), fetal
demise, placental abruption, and cesarean delivery (4).
The incidence of these potential adverse effects is related
to the degree and duration of hypertension and to the
association of other organ system involvement or damage. As many as one third of women with severe chronic
hypertension may have a small-for-gestational-age
(SGA) infant, and two thirds may have a preterm delivery (8). In a study of 211 pregnant women with mild
chronic hypertension, the uncorrected perinatal mortality
rate was 28 per 1,000 and was highest in the 21 pregnancies complicated by superimposed preeclampsia. The
perinatal mortality rate was 5 per 1,000 in the 190 pregnancies not complicated by preeclampsia (9).
In another study, pregnancy outcomes were reviewed
in 44 pregnant women with severe chronic hypertension
in the first trimester (10). Slightly more than half developed superimposed preeclampsia; in this subgroup of
patients, perinatal death and neonatal morbidity were significantly increased. Comparing women who developed
superimposed preeclampsia with women who did not, the
incidence of prematurity was 100% versus 38%, the incidence of SGA infants was 78% versus 15%, and the perinatal mortality rate was 48% versus 0%.
Other studies also have reported an increase in perinatal mortality of 24 times more than the general population (1113). For example, a study of 337 pregnancies
complicated by chronic hypertension reported a perinatal
mortality rate of 45 per 1,000 compared with a rate of 12
per 1,000 in the general population (11).
A study of outcomes in 763 pregnant women with
chronic hypertension indicated that women with baseline
proteinuria (300 mg or greater of urinary protein in 24
hours at initial evaluation at 1326 weeks of gestation)
were at significant risk of preterm delivery (odds ratio
[OR], 3.1; 95% confidence interval [CI], 1.85.3) and
SGA infants (OR, 2.8; 95% CI, 1.65.0) independent of
superimposed preeclampsia (14). The development of
preeclampsia (defined as new-onset proteinuria) was significantly associated with perinatal death (OR, 2.3; 95%
CI, 1.14.8). Preeclampsia also was associated with an
increase in placental abruption (3% versus 1%). In a metaanalysis of seven casecontrol and six cohort studies, the
risk of placental abruption was related to both cigarette
smoking and chronic hypertension, as well as preeclampsia (15). A systematic review of the management of chronic hypertension during pregnancy revealed that chronic
hypertension doubled the risk for placental abruption (OR,
2.1; 95% CI, 1.1, 3.9) and tripled the risk for perinatal

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mortality (OR, 3.4; 95% CI, 3.0, 3.7) (4, 16). Several of
the studies included in this review also showed an association between chronic hypertension and preeclampsia
(variously defined) and preterm, SGA, or low-birthweight infants when compared with normotensive women
or the general obstetric population. The risk of these complications was increased even in the absence of superimposed preeclampsia, although the absolute increased risk
from mild hypertension could not be calculated from the
available data (4).

Effects of Pregnancy on Hypertension

Clinical Considerations and

Recommendations

In the initial evaluation of a pregnant

woman with hypertension, which clinical
tests are useful?

The age of onset, results of previous evaluation, severity

and duration of hypertension, and physical examination
are important determinants of which clinical tests may be
useful. Ideally, a woman with chronic hypertension should
be evaluated before conception to ascertain potentially
reversible causes and possible end-organ involvement (eg,
heart or kidney). Women who have had hypertension for
several years are more likely to have cardiomegaly,
ischemic heart disease, renal involvement, and retinopathy (3). Thus, these women are more likely to benefit
from various specialized clinical tests at the initial evaluation during pregnancy or preconceptionally. Tests may
include electrocardiography, echocardiography, ophthalmologic examination, and renal ultrasonography (7).
The information obtained from these tests may prove useful in assessing risks of hypertension during pregnancy,

VOL. 98, NO. 1, JULY 2001

Several physiologic changes occur in pregnant women

that can affect chronic hypertension. One of the most significant changes is the increase in blood volume, which
may further burden an already stressed heart and, along
with the decrease in colloid oncotic pressure, may lead to
cardiac decompensation. Another important change is the
physiologic decrease in blood pressure, which begins by
the end of the first trimester and reaches its lowest level
at 1618 weeks of gestation (16). This change can mask
either the course or the detection of chronic hypertension
in early pregnancy (3). Besides superimposed preeclampsia or eclampsia, pregnancy complicated by chronic
hypertension (especially if severe) may be associated
with worsening or malignant hypertension, central nervous system hemorrhage, cardiac decompensation, and
renal deterioration or failure.

as well as providing information for prenatal counseling.

Women with significant left ventricular hypertrophy secondary to hypertension may experience cardiac decompensation and heart failure as pregnancy progresses.
Women with significant renal disease (serum creatinine >1.4 mg/dL) may experience deterioration of renal
function, although it may be difficult to separate the
effects of pregnancy from the disease process (3, 17, 18).
Many women with the diagnosis of peripartum cardiomyopathy are found to have underlying causes, chronic
hypertension being one of the most common (19, 20).
However, most pregnant women with mild chronic hypertension have uneventful pregnancies with no end-organ
involvement.

Are other adjunctive tests useful in evaluating a pregnant woman with hypertension?

Many women with chronic hypertension are under the

care of a primary care physician and already have been
evaluated for causes of secondary hypertension, such as
pheochromocytoma or Cushings disease. However,
young women in whom hypertension has been diagnosed for the first time in early pregnancy, especially
those with severe hypertension (systolic pressure 180
mmHg or diastolic pressure 110 mmHg), are more likely to have secondary hypertension and to benefit from
further evaluation for potentially reversible causes (3).
Women with paroxysmal hypertension, frequent hypertensive crisis, seizure disorders, or anxiety attacks
should be evaluated for pheochromocytoma with measurements of 24-hour urine vanillylmandelic acid,
metanephrines, or unconjugated catecholamines (21).
Magnetic resonance imaging after the first trimester or
computed tomography also may be useful for adrenal
tumor localization (19).
Cushings syndrome is rare in pregnancy and is difficult to diagnose because of pregnancy-related changes
in steroids (22). Fortunately, this condition is diagnosed
in most women before pregnancy. Primary aldosteronism also is rare in pregnancy. Women with this disorder
may present with severe hypertension and hypokalemia.
Imaging studies may be helpful in demonstrating an
adrenal adenoma.
A young woman (younger than 30 years) with
severe hypertension (especially with no family history)
who has not been previously evaluated may benefit from
Doppler flow studies or magnetic resonance angiography to detect renal artery stenosis (7). Renal artery
stenosis appears to be more prevalent in patients with
type-2 diabetes and coexistent hypertension (23, 24).
Negative results from renal ultrasonography do not rule
out renal artery stenosis.

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Are laboratory tests useful in evaluating a

pregnant woman with essential hypertension?

In pregnant women with known essential hypertension

(primary hypertension or hypertension not secondary to
underlying renal or adrenal disease), baseline laboratory
evaluations that may prove clinically useful include tests
of renal function such as serum creatinine, blood urea
nitrogen, and 24-hour urine evaluation for total protein
and creatinine clearance (1, 7, 25). This initial laboratory
assessment is important in identifying women with
underlying renal disease because this complication may
adversely affect pregnancy outcome (26). The subsequent development of proteinuria in a woman with essential hypertension also may be helpful in identifying the
development of superimposed preeclampsia.
As pregnancy progresses, other laboratory testsin
addition to repeating those mentioned previouslymay
be clinically useful in evaluating worsening renal disease
and in diagnosing superimposed preeclampsia. These
include liver function tests, hemoglobin/hematocrit evaluation, and platelet count (27). Periodic measurement of
urine protein may be useful in detecting worsening renal
disease or the development of superimposed preeclampsia (28). It has been reported that the random proteincreatinine ratio may be useful for the quantitation of
proteinuria during pregnancy. The correlation coefficient
between this ratio and the 24-hour urine total protein was
0.94 (29). Investigators also reported high sensitivity and
specificity between the protein/creatinine ratio from a
single urine sample and proteinuria of 300 mg or greater
in a 24-hour specimen (30).
Although an elevated serum uric acid level represents a useful confirmatory test for the diagnosis of
preeclampsia, it has very poor predictive value among
patients without preexisting hypertension. However,
when the patient has chronic hypertension, the serum uric
acid level may be of some value. One investigator has
reported that a serum uric acid level of 5.5 mg/dL could
identify women with an increased likelihood of having
superimposed preeclampsia (31).

Who are candidates for treatment of chronic

hypertension in pregnancy?

Women with mild hypertension (140179 mmHg systolic or 90109 mmHg diastolic pressure) generally do
well during pregnancy and do not, as a rule, require antihypertensive medication (3). There is, to date, no scientific evidence that antihypertensive therapy will improve
perinatal outcome (25, 3234). In a review of 263 women
with mild hypertension randomized to methyldopa,
labetalol, or no treatment at 613 weeks of gestation,

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treatment with antihypertensive medications did not

decrease the incidence of complications such as IUGR,
superimposed preeclampsia, placental abruption, or perinatal mortality (25).
There also is a paucity of scientific data regarding the
most appropriate management of women with well-controlled or mild hypertension already taking antihypertensive medications at the time of pregnancy. Although such
therapy may offer long-term benefits to the mother, such
therapy is of unproven short-term benefit and could interfere with uteroplacental blood flow and fetal growth (3,
35). In one review of 298 pregnant women in whom antihypertensive medications were stopped or whose dosage
was reduced, there was no difference in the incidence of
preeclampsia, placental abruption, or perinatal death compared with untreated groups (11). In a meta-analysis of
623 women with mild chronic hypertension from 7 trials
comparing antihypertensive treatment to no treatment,
treatment was associated with a decrease in the incidence
of severe hypertension but did not improve perinatal outcomes (36). In a follow-up meta-analysis that included
these 7 trials of pregnant women with chronic hypertension and 38 trials of women with late-onset hypertension
receiving therapy versus no therapy, there was an increase
in the frequency of SGA infants associated with treatment-induced reduction in mean arterial pressure (35).
Thus, the data are inconclusive with regard to both the
benefits and potential adverse fetal effects of treatment of
mild chronic hypertension during pregnancy. It would
seem reasonable not to start antihypertensive therapy in
women with mild hypertension who become pregnant
unless they have other complicating factors (eg, cardiovascular or renal disease) and to either stop or reduce medication in women who are already taking antihypertensive
therapy. As suggested by the National High Blood
Pressure Education Program Working Group on High
Blood Pressure in Pregnancy, therapy could be increased
or reinstituted for women with blood pressures exceeding
150 160 mmHg systolic or 100110 mmHg diastolic
(3). In women with severe chronic hypertension (systolic
pressure 180 mmHg or diastolic pressure 110 mmHg),
antihypertensive therapy should be initiated or continued
(10).
In addition, a systematic review of management of
chronic hypertension during pregnancy concluded that
the evidence base regarding pharmacologic management of chronic hypertension during pregnancy is too
small to either prove or disprove moderate to large benefits (>20 percent improvements) of antihypertensive therapy (16). The report further concluded that the efficacy
of antihypertensive therapy for chronic hypertension in

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What medications are most often prescribed

for the treatment of chronic hypertension in
pregnancy?

Is there a role for fetal surveillance in pregnancies complicated by hypertension?

There is no consensus as to the most appropriate fetal

surveillance test(s) or the interval and timing of testing in
women with chronic hypertension. Thus, such testing
should be individualized and based on clinical judgment
and on severity of disease. A recent systematic review
concluded that there are no conclusive data to address
either the benefits or the harms of various monitoring
strategies for pregnant women with chronic hypertension
(16). However, other studies have indicated that most of
the increased morbidity associated with this condition is
secondary to superimposed preeclampsia or IUGR (3).
Thus, these investigators recommend that baseline ultrasonography be obtained at 1820 weeks of gestation and
that ultrasonography should be repeated at 2832 weeks
of gestation and monthly thereafter until delivery to monitor fetal growth. If growth restriction is detected or suspected, fetal status should be monitored frequently with
nonstress testing or biophysical profile testing (3). If
growth restriction is not present and superimposed
preeclampsia is excluded, these tests are not indicated
(3).

VOL. 98, NO. 1, JULY 2001

Are certain medications used to treat chronic

hypertension contraindicated during pregnancy?

Angiotensinconverting enzyme (ACE) inhibitors are

contraindicated during the second and third trimesters of
pregnancy. Although the data regarding their use during
pregnancy are limited to captopril, enalapril, and lisinopril, the teratogenic risk appears to be similar for the
entire drug class. These ACE inhibitors have been associated with severely underdeveloped calvarial bone, renal
failure, oligohydramnios, anuria, renal dysgenesis, pulmonary hypoplasia, IUGR, fetal death, neonatal renal
failure, and neonatal death (4246). Fetal risks with ACE
inhibitors depend on timing and dose. For example, the
use of ACE inhibitors during the first trimester (before
renal tubular function begins) has not been associated
with an increase in birth defects (47, 48).

Although there are numerous antihypertensive agents

that have been used for the treatment of chronic hypertension during pregnancy, methyldopa has been commonly used. It is preferred by most practitioners, and it
appears to be relatively safe (3, 16, 37, 38). Methyldopa
appears to have limited effects on uteroplacental blood
flow (3, 32, 33, 38).
Labetalol, a combined alpha- and beta-blocker, also
can be used during pregnancy as an alternative to methyldopa. In one study on the treatment of chronic hypertension with labetalol versus methyldopa, the authors reported
no differences in outcomes between the two medications
(25).
In a meta-analysis of beta-receptor blockers prescribed for pregnancies complicated by hypertension,
there was an increase in SGA infants born to those
women who took oral beta-blockers for mild hypertension
(OR, 2.46; 95% CI, 1.02, 5.92) (39). Calcium-channel
blockers or antagonists also have been used with limited
experience (1, 3). In one randomized study that compared
nifedipine (n=145) versus expectant management
(n=138) for mild hypertension in pregnancy, there was no
benefit to pregnancy outcome but also no increase in
adverse effects (34).
Diuretics also have been used to treat chronic hypertension, but there has been concern regarding the potential effect of these medications on normal blood volume
expansion associated with pregnancy. In one study of 20
women with mild hypertension, diuretics prevented normal expansion of the blood volume but did not adversely
affect perinatal outcome (40). Moreover, a meta-analysis
of 9 trials involving diuretics during pregnancy reported
no increase in adverse perinatal effects (41). The
National High Blood Pressure Education Program
Working Group on High Blood Pressure in Pregnancy
concluded, If diuretics are indicated, they are safe and
efficacious agents that can markedly potentiate the
response to other antihypertensive agents and are not
contraindicated in pregnancy except in settings in which
uteroplacental perfusion is already reduced (preeclampsia and IUGR) (3).

pregnant women was still uncertain. In this latter systematic review, the authors also were unable to identify trials
that compared nonpharmacologic interventions with antihypertensive agents or with no interventions for chronic
hypertension.

Should patients with chronic hypertension be

delivered before term?

Pregnant women with uncomplicated chronic hypertension of a mild degree generally can be delivered vaginally at term (25); most have good maternal and neonatal
outcomes (3). Cesarean delivery should be reserved for
other obstetric indications. Women with mild hypertension during pregnancy and a prior adverse pregnancy

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outcome (eg, stillbirth) may be candidates for earlier

delivery after documentation of fetal lung maturity (as
long as fetal status is reassuring). Women with severe
chronic hypertension during pregnancy most often either
deliver prematurely or have to be delivered prematurely
for fetal or maternal indications (10).
There are no randomized clinical trials that specifically address the timing of delivery in women with
chronic hypertension and superimposed preeclampsia.
However, the combination of chronic hypertension and
superimposed preeclampsia represents a complicated situation, and the clinician should consider consultation
with someone who has expertise in such clinical matters.
Delivery should be considered in all women with superimposed severe preeclampsia at or beyond 28 weeks of
gestation and in women with mild superimposed
preeclampsia at or beyond 37 weeks of gestation (49).
Women with superimposed severe preeclampsia in whom
it is elected to continue the pregnancy should be monitored in a center with maternal and neonatal intensive
care capability (49). In women with superimposed severe
preeclampsia and the HELLP syndrome (a form of severe
preeclampsia) delivery should be considered, even
remote from term.

Are there intrapartum concerns unique to

pregnant women with chronic hypertension?

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The majority of pregnant women with chronic hypertension have uncomplicated mild hypertension and can be
managed the same as normal, nonhypertensive women
during the intrapartum period. In contrast, women with
severe hypertension or hypertension that is complicated
by cardiovascular or renal disease may present special
problems during the intrapartum period. Women with
severe hypertension may require antihypertensive medications for acute elevation of blood pressure. Although no
well-designed studies specifically address the treatment of
severe chronic hypertension during the intrapartum period, it is generally recommended that antihypertensive
medications be given to women with preeclampsia for
systolic blood pressure of >160 mmHg or diastolic blood
pressure of 105110 mmHg or greater (3).
Women with chronic hypertension complicated by
significant cardiovascular or renal disease require special
attention to fluid load and urine output because they may
be susceptible to fluid overload with resultant pulmonary
edema. There are insufficient data to address the benefits
and potential harm of central invasive hemodynamic
monitoring in women with pregnancy related hypertensive disorders (3, 50).
There are limited data to address the issue of analgesia
or anesthesia in pregnant women with chronic hypertension. In one study of 327 women with severe hypertension

in labor (158 of whom had chronic hypertension), there

was no increase in maternal pulmonary edema, renal failure, or cesarean delivery in women with an epidural
(n=209) or without an epidural (n=118). However, there
was a higher cesarean delivery rate in the subgroup of
women with chronic hypertension who received an epidural (51). There also were no significant differences in
neonatal outcomes between the two groups. Mild hypertension was not addressed in this cohort. The authors
concluded that the data regarding safety of epidural anesthesia in women with severe hypertension are limited by
both the heterogeneity of diagnoses and the uncontrolled
nature of the study. It would seem reasonable to conclude
that if regional anesthetic techniques are used in women
with severe hypertension, clinicians with specialized training in obstetric anesthesia should be available.
General anesthesia may pose a risk in pregnant
women with severe hypertension or superimposed
preeclampsia. Intubation and extubation may be associated with acute and significant elevations in blood pressure
and an agent such as labetalol usually is given acutely to
minimize this effect (3). Ketamine, because of its association with hypertension, is not considered first line therapy for the induction of general anesthesia (52).
Magnesium sulfate should be used for women with
superimposed severe preeclampsia to prevent seizures.
However, its benefit in women with mild preeclampsia is
unclear (3).

How is chronic hypertension distinguished

from preeclampsia when the woman presents
late in pregnancy?

It is often difficult, if not impossible, to distinguish worsening chronic hypertension from superimposed severe
preeclampsia, especially when the patient presents late in
pregnancy. In the woman with chronic hypertension and
renal disease, it may not be possible to distinguish
between the two entities. If the same woman has only
hypertension without proteinuria and no symptoms of
preeclampsia, such as headache, epigastric pain, or scotomata, the diagnosis may be more difficult. However,
the vast majority of young, nulliparous women presenting with hypertension for the first time during late pregnancy will have preeclampsia. In addition to testing for
proteinuria, other tests that may be helpful include
hemoglobin and hematocrit evaluation, platelet count,
and liver function tests. These latter tests are useful in the
diagnosis of the HELLP syndrome. Oliguria and an elevated hemoglobin/hematocrit level usually indicate
hemoconcentrationmore indicative of preeclampsia.
Serum creatinine levels also may be elevated in women
with preeclampsia.

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Summary of
Recommendations
The following recommendation is based on good
and consistent scientific evidence (Level A):

Angiotensin-converting enzyme inhibitors are contraindicated during pregnancy and are associated
with fetal and neonatal renal failure and death.

The following recommendations are based on limited or inconsistent scientific evidence (Level B):

during pregnancy: a review. Obstet Gynecol 2000;96:

849860 (Level III)
5. Garovic VD. Hypertension in pregnancy: diagnosis and
treatment. Mayo Clin Proc 2000;75:10711076 (Level
III)
6. Helewa MF, Burrows RF, Smith J, Williams K, Brain P,
Rabkin SW. Report of the Canadian Hypertension Society
Consensus Conference: 1. Definitions, evaluation and
classification of hypertensive disorders in pregnancy.
CMAJ 1997;157:715725 (Level III)
7. The sixth report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood
pressure. Arch Intern Med 1997;157:24132446 [erratum
in Arch Intern Med 1998;158:573] (Level III)

Treatment of women with uncomplicated mild

chronic hypertension is not beneficial because it
does not improve perinatal outcome.

10. Sibai BM, Anderson GD. Pregnancy outcome of intensive

therapy in severe hypertension in first trimester. Obstet
Gynecol 1986;67:517522 (Level II-2)

9. Sibai BM, Abdella TN, Anderson GD. Pregnancy outcome in 211 patients with mild chronic hypertension.
Obstet Gynecol 1983;61:571576 (Level II-3)

Methyldopa and labetalol are appropriate first-line

antihypertensive therapies.

8. McCowan LM, Buist RG, North RA, Gamble G. Perinatal

morbidity in chronic hypertension. Br J Obstet Gynaecol
1996;103:123129 (Level II-2)

Antihypertensive therapy should be used for pregnant women with severe hypertension for maternal
benefit.

The beta-blocker atenolol may be associated with

growth restriction and is not recommended for use
in pregnancy.

11. Rey E, Couturier A. The prognosis of pregnancy in

women with chronic hypertension. Am J Obstet Gynecol
1994; 171:410416 (Level II-3)

The following recommendations are based primarily on consensus and expert opinion (Level C):

12. Ananth CV, Savitz DA, Bowes WA Jr. Hypertensive disorders of pregnancy and stillbirth in North Carolina, 1988
to 1991. Acta Obstet Gynecol Scand 1995;74:788793
(Level II-3)

Women with chronic hypertension should be evaluated for potentially reversible etiologies, preferably
prior to pregnancy.

13. Jain L. Effect of pregnancy-induced and chronic hypertension on pregnancy outcome. J Perinatol 1997;
17:425427 (Level II-3)

Women with long-standing hypertension should be

evaluated for end-organ disease, including cardiomegaly, renal insufficiency, and retinopathy,
preferably prior to pregnancy.

When chronic hypertension is complicated by IUGR

or preeclampsia, fetal surveillance is warranted.

14. Sibai BM, Lindheimer M, Hauth J, Caritis S, VanDorsten

P, Klebanoff M, et al. Risk factors for preeclampsia,
abruptio placentae, and adverse neonatal outcomes among
women with chronic hypertension. National Institute of
Child Health and Human Development Network of
Maternal-Fetal Medicine Units. N Engl J Med 1998;
339:667671 (Level I)

References
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15. Ananth CV, Smulian JC, Vintzileos AM. Incidence of placental abruption in relation to cigarette smoking and
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2. National High Blood Pressure Education Program

Working Group Report on High Blood Pressure in
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4. Ferrer RL, Sibai BM, Mulrow CD, Chiquette E, Stevens

KR, Cornell J. Management of mild chronic hypertension

18. Jones DC. Pregnancy complicated by chronic renal disease. Clin Perinatol 1997;24:483496 (Level III)

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19. Cunningham FG, Pritchard JA, Hankins GD, Anderson

PL, Lucas MK, Armstrong KF. Peripartum heart failure:
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34. Nifedipine versus expectant management in mild to moderate hypertension in pregnancy. Gruppo di Studio
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20. Mabie WC, Hackman BB, Sibai BM. Pulmonary edema

associated with pregnancy: echocardiographic insights
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The MEDLINE database, the Cochrane Library, and

ACOGs own internal resources and documents were used
to conduct a literature search to locate relevant articles published between January 1985 and August 2000. The search
was restricted to articles published in the English language.
Priority was given to articles reporting results of original
research, although review articles and commentaries also
were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate
for inclusion in this document. Guidelines published by organizations or institutions such as the National Institutes of
Health and the American College of Obstetricians and Gynecologists were reviewed, and additional studies were
located by reviewing bibliographies of identified articles.
When reliable research was not available, expert opinions
from obstetriciangynecologists were used.
Studies were reviewed and evaluated for quality according
to the method outlined by the U.S. Preventive Services Task
Force:
I

Evidence obtained from at least one properly designed randomized controlled trial.
II-1 Evidence obtained from well-designed controlled
trials without randomization.
II-2 Evidence obtained from well-designed cohort or
casecontrol analytic studies, preferably from more
than one center or research group.
II-3 Evidence obtained from multiple time series with or
without the intervention. Dramatic results in uncontrolled experiments could also be regarded as this
type of evidence.
III Opinions of respected authorities, based on clinical
experience, descriptive studies, or reports of expert
committees.
Based on the highest level of evidence found in the data,
recommendations are provided and graded according to the
following catetories:
Level ARecommendations are based on good and consistent scientific evidence.
Level BRecommendations are based on limited or inconsistent scientific evidence.
Level CRecommendations are based primarily on consensus and expert opinion.
Copyright July 2001 by the American College of Obstetricians and
Gynecologists. All rights reserved. No part of this publication may be
reproduced, stored in a retrieval system, or transmitted, in any form or
by any means, electronic, mechanical, photocopying, recording, or
otherwise, without prior written permission from the publisher.
Requests for authorization to make photocopies should be directed to
Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA
01923, (978) 750-8400.
The American College of Obstetricians and Gynecologists
409 12th Street, SW,
PO Box 96920
Washington, DC 20090-6920
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Chronic Hypertension in Pregnancy. ACOG Practice Bulletin No. 29.
American College of Obstetricians and Gynecologists. Obstet Gynecol
2001;98:177185

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