The diagnosis of gestational hypertension has been in our obstetric lexicon since at least 1976 when it was described in the 15th edition of Williams as “...hypertension that develops during the latter half of pregnancy or during the first 24 hours after delivery. It is not accompanied by other evidence of preeclampsia or hypertensive vascular disease, and it disappears within 10 days following parturition.”1 That edition of Williams went on to say that it is most likely a variant of preeclampsia. There is little in that edition on recommendations for management of women with gestational hypertension, but it is noted that “Bed rest throughout much of the day is essential…” for hospital management in women with pregnancy-induced hypertension.
I do not have an earlier version of Williams Obstetrics and if anyone does, please search for gestational hypertension and let me know what you find. But suffice it to say that most currently practicing ob/gyns accept gestational hypertension as a real entity and most would say that a significant proportion of women with gestational hypertension will develop preeclampsia at some time during pregnancy. Furthermore, the prevailing management of gestational hypertension includes ruling out preeclampsia, and if ruled out, outpatient observation with frequent blood pressure checks, visits to the provider office, fetal assessment, and delivery for development of preeclampsia, severe hypertension or by 39 weeks.2 Thus, the management was different for gestational hypertension than for preeclampsia, for which (depending on presence or absence of severe features) delivery was recommended at 34 (with severe features) or 37 weeks (without severe features). By the way, wasn’t it easier to just say (or type) mild preeclampsia rather than preeclampsia without severe features?
However, the American College of Obstetricians and Gynecologists (ACOG) has been struggling with what to recommend for management of women with gestational hypertension since the HYPITAT trial was published in 2009.3 This trial, performed in the Netherlands, randomized women with gestational hypertension or mild preeclampsia at 36 to 41 weeks’ gestation to induction of labor or expectant management. They reported that the women randomized to induction had a significantly lower rate of the maternal composite adverse outcome (i.e., HELLP (hemolysis, elevated liver enzymes, low platelet count), eclampsia, abruption, pulmonary edema, progression to severe disease, thromboembolic disease or major postpartum hemorrhage) (31%) than those in the expectant group (44%). Further, there was no difference in cesarean delivery rates or neonatal outcome. So it seems clearly reasonable to cite this paper as Level A evidence for the recommendation that all women with gestational hypertension should be induced at 37 weeks, not 37 completed weeks, but 37 0/7 weeks, which is the same recommendation for women with preeclampsia without severe features.4 Reasonable, right?
What might give us pause, as noted above, the ACOG experts have struggled with this recommendation over the last 6 years, releasing multiple documents with varying guidelines for delivery timing for women with gestational hypertension (Table 1). In 2013 they even had two different recommendations in the same year. Do not be misled by my questioning of ACOG. I am a strong advocate of ACOG’s work and highly grateful for and respectful of the documents released as guidelines to help ob/gyns provide the best care based on ever-changing data.
Sometimes, however, we have to use our own judgment and look a little deeper. In this example of the ACOG 2019 recommendation that women with either gestational hypertension or preeclampsia without severe features be managed exactly the same, suggesting that these are the same disease, I do take issue.4
The author reports no potential conflicts of interest with regard to this editorial.
- Pritchard JA, MacDonald PC. Williams Obstetrics. New York: Appleton-Century-Crofts, 1976.
- Spong CY, Mercer BM, D’Alton M, Kilpatrick S, Blackwell S, Saade G. Timing of indicated late-preterm and early-term birth. Obstet Gynecol. 2011;118:323-333.
- Koopmans CM, Bijlenga D, Groen H, Vijgen SM, Aarnoudse JG, Bekedam DJ et al. Induction of labour versus expectant monitoring for gestational hypertension or mild preeclampsia after 36 weeks’ gestation (HYPITAT): a multicenter, open label randomized controlled trial. HYPITAT study group. Lancet. 2009;374:979-988.
- American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 202: Gestational hypertension and preeclampsia. Obstet Gynecol. 2019;133:e1-25.
- Cruz MO, Gao W, Hibbard JU. Obstetrical and perinatal outcomes among women with gestational hypertension, mild preeclampsia, and mild chronic hypertension. Am J Obstet Gynecol. 2011;205:260 e1-9.
- American College of Obstetricians and Gynecologists. ACOG committee opinion no. 560: Medically indicated late-preterm and early term deliveries. Obstet Gynecol. 2013;121:908-10. (reaffirmed in 2015)
- American College of Obstetricians and Gynecologists. Executive summary: hypertension in pregnancy. Obstet Gynecol. 2013;122:1122-1131.