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ACOG: Chronic Hypertension in Pregnancy

Obstet Gynecol; ePub 2019 Jan; Vidaeff, et al

Daily low-dose aspirin should be initiated for women with chronic hypertension between 12 weeks and 28 weeks of gestation, and should be continued until delivery, according to new clinical management guidelines from the American College of Obstetricians and Gynecologists (ACOG). The purpose of the revised best practice recommendations is to provide a rational approach to chronic hypertension in pregnancy based on new research data and relevant pathophysiologic and pharmacologic considerations. Among the ACOG recommendations:

  • For women with chronic hypertension, it is recommended to initiate daily low-dose aspirin (81 mg) between 12 weeks and 28 weeks of gestation (optimally before 16 weeks) and to continue this therapy until delivery. (Level A)
  • Initiation of antihypertensive therapy is recommended for persistent chronic hypertension when systolic pressure is 160 mm Hg or more, diastolic pressure is 110 mm Hg or more, or both. In the setting of comorbidities or underlying impaired renal function, treating at lower blood pressure thresholds may be appropriate. (Level B)
  • For the long-term treatment of pregnant women who require pharmacologic therapy, labetalol or nifedipine are reasonable options and are recommended above all other antihypertensive drugs. The use of angiotensin-converting-enzyme inhibitors, angiotensin receptor blockers, renin inhibitors, and mineralocorticoid receptor antagonists is generally not recommended. (Level B)
  • Antihypertensive treatment should be initiated expeditiously for acute-onset severe hypertension (systolic blood pressure of 160 mm Hg or more or diastolic blood pressure of 110 mm Hg or more, or both) that is confirmed as persistent (15 minutes or more). The available literature suggests that antihypertensive agents should be administered within 30–60 minutes. (Level B)
  • For women with chronic hypertension and with no additional maternal or fetal complications supporting earlier delivery, if not prescribed maintenance antihypertensive medications, delivery before 38 0/7 weeks of gestation is not recommended. (Level B)
  • If prescribed maintenance antihypertensive medications, delivery before 37 0/7 weeks of gestation is not recommended. (Level B)
  • Women with severe acute hypertension that is not controlled with traditional chronic antihypertensive regimens or women who develop superimposed preeclampsia with severe features should be delivered upon diagnosis at 34 0/7 weeks of gestation or more. (Level B).


Chronic hypertension in pregnancy. ACOG Practice Bulletin No. 203. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2019;133:e26–50.

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