Hypertension in Pregnancy (ISH 2026)
Hypertension in pregnancy = BP ≥140/90 mmHg; affects 5–10% of pregnancies. Maternal risks: abruption, stroke, organ failure, DIC, eclampsia. Fetal risks: growth restriction, preterm birth, intrauterine death.
Step 1 — Classify the disorder
| Type | Definition |
|---|
| Pre-existing hypertension | Before pregnancy, or diagnosed <20 weeks, persisting >12 weeks postpartum (± proteinuria) |
| Gestational hypertension | Develops ≥20 weeks, no proteinuria, resolves within 12 weeks postpartum |
| Preeclampsia | Hypertension ≥20 weeks with proteinuria or other maternal organ dysfunction or uteroplacental dysfunction |
| Eclampsia | Preeclampsia with seizures — immediate treatment and consider prompt delivery |
Preeclampsia risk factors: pre-existing hypertension, previous preeclampsia, pre-existing diabetes, CKD, nulliparity, multifetal pregnancy, autoimmune disease, assisted reproduction, obesity, maternal age >40.
Preeclampsia warning symptoms: severe headache, visual disturbance, abdominal pain, nausea/vomiting, reduced urine output, HELLP (haemolysis, elevated liver enzymes, low platelets).
Step 2 — Investigate (ESSENTIAL)
- FBC, urinalysis, creatinine, uric acid, liver enzymes
- Proteinuria: early pregnancy (pre-existing renal disease) and second half (preeclampsia). Positive dipstick → UACR or protein-to-creatinine ratio
Step 3 — Measure BP correctly
- ESSENTIAL: sOBP with calibrated manual auscultatory device, or automated upper-arm device validated specifically in pregnancy and preeclampsia (stridebp.org)
- OPTIMAL: home or ambulatory BP to detect white-coat and masked hypertension; home monitoring with pregnancy-validated devices
Step 4 — Treat by BP level (ESSENTIAL)
Target sOBP: <140/90 mmHg — but avoid BP that is too low.
| sOBP | Action |
|---|
| 140–159 / 90–109 | Start first-line monotherapy: labetalol or long-acting nifedipine. Alternative: methyldopa (raises post-partum depression risk). Also acceptable (less data): metoprolol, bisoprolol, felodipine, nitrendipine, amlodipine, isradipine |
| >160/110 | Emergency — hospitalise. Lower BP to <160/105 within 2–3 h with IV labetalol (or nicardipine, esmolol, hydralazine, urapidil), oral methyldopa, nifedipine or nicardipine. Consider delivery (cures preeclampsia, but risk persists early postpartum) |
| Preeclampsia or severe hypertension | Hospitalise |
CONTRAINDICATED: ACE inhibitors, ARBs, direct renin inhibitors — adverse fetal and neonatal outcomes.
For severe preeclampsia, eclampsia or HELLP: SBP <160 and DBP <105 immediately with labetalol or nicardipine + magnesium sulphate (see ish-htn-emergency).
Step 5 — Postpartum and breastfeeding
- Monitor BP daily on days 3–7 postpartum
- Postpartum: any recommended drug except methyldopa (post-partum depression)
- Breastfeeding: enalapril, long-acting nifedipine, amlodipine preferred; beta-blockers may be used; ARB data limited — check prescribing information
Step 6 — Long-term follow-up
Hypertensive disorders of pregnancy raise later risk of hypertension, stroke, ischaemic heart disease and CKD (and count as a CV risk factor — see ish-htn-risk-assessment-workup).
- Counsel on future pregnancies
- Annual BP and renal function check
- Lifestyle changes
Step 7 — Prevent preeclampsia (ESSENTIAL)
- Low-to-moderate intensity exercise unless contraindicated
- Women at increased risk: aspirin 100–150 mg from weeks 12–36
- Low dietary calcium (<600 mg/day): oral calcium ~1 g/day
Guardrails
- Never use ACEi, ARB or renin inhibitors in pregnancy — switch before or as soon as pregnancy is known
- Avoid methyldopa postpartum — depression risk
- Don't over-lower BP — target <140/90 but avoid hypotension (placental perfusion)
- ≥160/110 is an emergency — hospitalise and lower within 2–3 h
- Use devices validated for pregnancy — many standard devices are not
- Preeclampsia can develop without proteinuria — organ dysfunction or uteroplacental dysfunction also count
- Start aspirin by week 12 in high-risk women, not late
- Arrange lifelong follow-up — previous hypertensive pregnancy is a CV risk factor
Related MD2SKILL skills
ish-htn-emergency — severe preeclampsia/eclampsia/HELLPjes-pa-pregnancy-htn-treatment — primary aldosteronism in pregnancypdm-* (diabetes in pregnancy) skills
Source
Stergiou GS, Kario K, Aristizabal D, et al. 2026 International Society of Hypertension Global Hypertension Practice Guidelines. J Hypertens. 2026;44. DOI: 10.1097/HJH.0000000000004451. Section 9.5. A separate ISH 2026 position paper on hypertension in pregnancy is cited by the guideline (DOI 10.1097/HJH.0000000000004389).