Hypertension in Pregnancy: 5 Things Clinicians Should Know

Hypertension is a serious public health concern, and it is the primary risk factor for the first and fifth leading causes of death, both globally[1]and in the United States. In recent years, hypertension in pregnancy has increased notably.[2] 
Hypertension in pregnancy encompasses chronic hypertension and pregnancy-associated hypertension, including gestational hypertension, preeclampsia, eclampsia, and chronic hypertension with superimposed preeclampsia or eclampsia. Pregnancy-associated hypertension heightens cardiovascular risks for mothers and babies, both immediate and in the long term. These risks may be reduced through timely, effective hypertension management. 
Healthcare teams can use the Hypertension in Pregnancy Change Package, which features ready-to-implement strategies, to improve detection and management and reduce complications related to uncontrolled hypertension during and following pregnancy. Healthcare professionals are also invited to join the Hypertension in Pregnancy Action Forum, an opportunity for clinical, public health, and community-based partners to exchange best and promising practices, identify solutions to common obstacles, and share resources to improve hypertension management during and after pregnancy.
Here are five things healthcare teams should know:
1. A lower target blood pressure is safe and better for mom and baby. 
On the basis of compelling findings from the Chronic Hypertension and Pregnancy (CHAP) randomized controlled trial, clinical guidance has been updated to recommend 140/90 mm Hg (rather than 160/110) as either the threshold to initiate treatment or as the upper limit target blood pressure for mild chronic hypertension in pregnancy.[3,4]
Hypertension in pregnancy is defined as two or more blood pressure readings of at least 140 mm Hg systolic or 90 mm Hg diastolic, measured 4 hours apart. Severe hypertension in pregnancy is defined as blood pressure of at least 160 mm Hg systolic or 110 mm Hg diastolic. For treatment purposes, severe hypertension can be diagnosed with measurements at least 15 minutes apart. Results from the CHAP trial found that women with chronic hypertension who were treated to a blood pressure target of < 140/90 mm Hg had better pregnancy outcomes than the control group, with no increase in births that were small for gestational age.[5]
2. Low-dose aspirin (81 mg) reduces preeclampsia and hypertension-related illness and death. 
Most pregnancy-related deaths stemming from hypertension are preventable, with one California study suggesting that 60% of deaths attributed to preeclampsia or eclampsia had a “good-to-strong chance of being prevented.”[6] To help prevent preeclampsia and its complications, healthcare teams can develop a system to identify and treat pregnant women who can benefit from aspirin prophylaxis.
3. Healthcare teams play pivotal roles in helping ensure health equity. 
Striking health disparities exist among different racial and ethnic groups. For instance, the prevalence of hypertension during delivery hospitalization is highest among non-Hispanic Black (20.9%) and American Indian and Alaska Native (16.4%) women.[2] By understanding risks based on data stratified by race/ethnicity, age, insurance status, preferred language, and other social drivers of health, teams can better identify and address care gaps and ensure equitable outcomes.
Trainings can help staff practice respectful and culturally safe communication; address communication needs, such as health literacy and language barriers; and understand family structures and cultural practices. The Hypertension in Pregnancy Change Package also includes tools for implicit-bias training and other recommended resources. 
4. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) should not be used during pregnancy. 
ACE inhibitors and ARBs are teratogenic or known to cause fetal abnormalities. Oral medications that are safe in pregnancy include labetalol, nifedipine (extended release), and methyldopa as first-line agents. Second-line agents include hydralazine, chlorthalidone or hydrochlorothiazide, and clonidine. Safe medications in lactation include nifedipine (extended release), enalapril, captopril, benazepril, labetalol, hydrochlorothiazide, and hydralazine.[7,8]
Many antihypertensives do not have robust data related to their safety for use in pregnancy and lactation but may be appropriate in life-threatening emergencies. More information is provided in Table 1 of the Hypertension in Pregnancy Change Package. 
5. More than 50% of pregnancy-related deaths occur 7 days to 1 year after the end of pregnancy, and hypertensive disorders are a leading cause. 
The postpartum period is full of transitions — across settings, between clinical teams, and also in blood pressure. Almost half of women who have pregnancy-related hypertension continue to have high readings at 6 weeks postpartum.[9-11] Home or self-measured blood pressure monitoring (SMBP) is an effective tool for managing blood pressure and can help women and care teams recognize these elevated blood pressures and respond quickly. Find information about starting an SMBP program using devices validated for pregnancy, along with other important strategies to improve hypertension care during and following pregnancy, in the Hypertension in Pregnancy Change Package. 
The Hypertension in Pregnancy Change Package was developed by Million Hearts® with CDC’s Division of Reproductive Health and in partnership with the American Academy of Family Physicians, American College of Nurse-Midwives, American College of Obstetricians and Gynecologists, American College of Osteopathic Obstetricians and Gynecologists, American Medical Association, National Association of Nurse Practitioners in Women’s Health, and the Society for Maternal-Fetal Medicine. The change package offers valuable resources for clinical teams in outpatient settings. If these resources are implemented, efficient and effective systems can be created to support patients with hypertension and, ultimately, improve maternal and fetal health.
Follow CDC’s Division for Heart Disease and Stroke Prevention on X. Follow Million Hearts® on LinkedIn.
Join the Million Hearts® Hypertension in Pregnancy Action Forum. For information about the Action Forum, please email [email protected] and include “MH Action Forum” in the subject line. 
Explore the Hypertension in Pregnancy Change Package.
Learn more about Hypertensive Disorders of Pregnancy.
Access CDC’s Hear Her campaign resources.
 
Public Information from the CDC and Medscape