Navigate Hypertensive Disorders During and After Pregnancy

“Roughly 6% of all maternal deaths in the United States are due to a hypertensive disorder of pregnancy,” said Joan Briller, MD, of the University of Illinois, Chicago, in a presentation at the American College of Physicians (ACP-IM) Internal Medicine Meeting 2025.

This estimate, based on data from the Centers for Disease Control and Prevention from 2017 to 2019, is lower than other causes of pregnancy-related deaths but still represents a substantial portion of maternal mortality, Briller said.

Having a hypertensive disorder of pregnancy has been associated with a variety of complications postpartum, including heart failure, stroke, chronic kidney disease, and diabetes, she said.

Managing Hypertension During Pregnancy

Research has shown that the odds of a cardiovascular complication postpartum are highest in women who had more severe hypertension during pregnancy, Briller said.

She cited a 2020 study from the Journal of the American College of Cardiology that showed a 2.3-fold risk for hypertension, 1.8-fold risk for stroke, and 1.6-fold risk for coronary artery disease later in life among women who had hypertension during pregnancy.

“How we define high blood pressure is not always the same,” Briller said in the presentation. During pregnancy, hypertension is defined differently, and a blood pressure up to 140/90 mmHg is considered normal, she added.

Also, hypertension in pregnancy is characterized into four types, said Briller.

1. Chronic hypertension: High blood pressure before pregnancy or before 20 weeks’ gestation, or that persists more than 12 weeks postpartum.
2. Gestational hypertension: Hypertension that develops after 20 weeks’ gestation with no severe features.
3. Preeclampsia: Hypertension plus proteinuria or other abnormalities after 20 weeks’ gestation in patients with previously normal blood pressure.
4. Chronic hypertension with superimposed preeclampsia: This diagnostically challenging condition involves a combination of chronic hypertension and other abnormalities and risk factors.

Ideal blood pressure targets during pregnancy are guided by the category of hypertension, Briller said.

Overall, chronic hypertension has increased in the United States, but is often missed in young women, Briller noted. For those on blood pressure medication, with mildly elevated pressures, past guidelines advised stopping the medication during pregnancy, she said.

However, a 2022 study on the treatment of mild chronic hypertension in pregnancy, known as the CHAP study, was a game-changer, said Briller in her presentation.

In the study, published in The New England Journal of Medicine, researchers found a significant decrease in the prevalence of severe preeclampsia and preterm deliveries, with no significant change in maternal or neonatal complications, in women with mild chronic hypertension who received antihypertensive medications during pregnancy compared with those who did not.

The American College of Obstetrics and Gynecology now states that there is no need to discontinue safe blood pressure medications at the start of pregnancy, “but pay attention beyond 20 weeks’ gestation to ensure that blood pressure is well controlled,” said Briller.

Postpartum Risk Reduction

Most of hypertension-associated maternal mortality occurs postpartum; Briller offered guidance for management and reduction of risk for future comorbidities.

Patients with chronic hypertension should resume their home regimens postpartum unless contraindicated and should start blood pressure therapy in the event of two confirmed blood pressure measures of 140/90 mmHg. Options for therapy in these patients include nifedipine or amlodipine, as well as labetalol and enalapril (beware of the potential for teratogenicity), Briller said. Patients who achieve blood pressure measurements below 140/90 mmHg but above 120/70 mmHg should continue current medications, but those whose blood pressure drops below 110-120 mmHg can start decreasing medications in reverse order, she noted.

Although guidance on the best methods of screening for postpartum hypertension is not consistent among organizations, the bottom line is that risk factors for postpartum hypertension do not improve with time, said Briller in her presentation. Screening strategies include a medical history with data on smoking; physical activity; breastfeeding; history of hypertension, diabetes, or cardiovascular disease; and family history, she said. A postpartum hypertension screening exam should include resting blood pressure and heart rate, body mass index, and waist circumference, with lab work to include lipids, diabetes, and urine protein-creatinine ratio, Briller added.

Recent research published in the European Journal of Heart Failure suggests that hypertensive disorders of pregnancy may contribute to adverse cardiovascular outcomes through persistent abnormal remodeling during postpartum recovery, Briller noted.

Social disparities also must be considered. Briller cited a 2022 study showing increased risk for in-hospital mortality after preeclampsia for Black, Hispanic, and Asian/Pacific Islander women compared with White women and increased odds for cardiovascular complications among high-income Black women compared with low-income White women.

In primary care as well as overall, risk for cardiovascular complications for women with hypertensive disorders of pregnancy may be reduced by identifying patients by assessing their individual risk factors and addressing them with lifestyle and medication interventions, Briller said.

Clinical Pearls for Primary Care

“Several pregnancy complications are clues that a woman is at higher risk for subsequent cardiovascular disease,” Briller said in an interview. “In addition to hypertensive disorders of pregnancy, gestational diabetes, preterm delivery, a small-for-gestational-age baby, and pregnancy loss or placental abruption have all been associated with increased risk of cardiac disease in later life,” she said.

“Close follow-up and extending postpartum care beyond the first 12 weeks allow us to screen for traditional CVD [cardiovascular disease] risk factors and provide prevention counseling or therapy when it is indicated,” said Briller.

Red Flags for Referrals

Briller suggests referring patients with a history of hypertensive disorders of pregnancy to a cardiologist if standard therapies are not effective. Suspected underlying conditions, such as chronic kidney disease, renovascular disease, adrenal disease, thyroid disease, obstructive sleep apnea, as well as symptoms of untreated heart disease, warrant referrals, she told Medscape Medical News.

Seeking New Strategies

More research is needed to understand the mechanisms leading to the development of preeclampsia, including the roles of maternal and fetal genetics, social determinants of health, autoimmunity, and obesity, Briller told Medscape Medical News.

“We need improved strategies to identify patients at risk during pregnancy for a hypertensive disorder of pregnancy, to determine the optimal strategy for early detection of preeclampsia, and to determine the optimal monitoring strategy to prevent development of superimposed preeclampsia in women with chronic hypertension,” she said.

“Early research addressing innovative approaches, such as self-monitoring of blood pressure, remote monitoring devices, telemedicine or group visits, and community health worker interventions, suggests novel approaches have the potential to increase care access and empower patients,” she added.

Primary Care Can Catch Changes

Hypertensive disorders of pregnancy are associated with a higher risk for cardiovascular diseases, including chronic kidney disease, in later life, said Silvi Shah, MD, associate professor of internal medicine at the University of Cincinnati, Cincinnati, in an interview.

Given the high potential for cardiovascular morbidity, it is important for clinicians to counsel, educate, and monitor patients with cardiovascular risk factors or with a history of hypertensive disorders of pregnancy, she said.

Many of these patients are lost to follow-up, so taking a pregnancy history and identifying patients who developed hypertensive disorders of pregnancy is essential in primary care, Shah told Medscape Medical News.

Greater education of physicians and patients on the importance of monitoring and follow-ups and the need for timely referrals if evidence suggests chronic kidney disease or cardiovascular disease can help reduce the risk for future complications after hypertensive disorders of pregnancy, she said.

“More research is needed to identify interventions and medications that may lead to reduction in risk of cardiovascular disease in later life following preeclampsia,” Shah added.

Briller disclosed receiving research grants from the National Institutes of Health unrelated to hypertensive disorders of pregnancy, as well as serving as a consultant for Medtronic and receiving honoraria from the American Heart Association and other academic cardio-obstetric conferences. She also disclosed serving as an unpaid consultant to the Illinois Department of Public Health and committee service for the American College of Cardiology. Shah had no financial conflicts to disclose.