About This Page
This is a clinician-written, evidence-based summary aligned to the USMLE Step 2 CK Content Outline. It is intended for medical students preparing for USMLE Step 2 CK. Management reflects current ACC/AHA, USPSTF, and APA guidelines. Always cross-reference with UpToDate, institutional protocols, and clinical judgment.
The Bottom Line
- Gestational hypertension = BP >=140/90 after 20 weeks without proteinuria or severe features
- Severe-range BP >=160/110 is managed as severe disease even if proteinuria absent
- Progression to preeclampsia is common
- Delivery is recommended at >=37 weeks if no severe features
- Acute severe hypertension is treated with IV labetalol, IV hydralazine, or oral immediate-release nifedipine
Overview
Gestational hypertension is new-onset hypertension after 20 weeks without proteinuria or preeclampsia severe features. Earlier onset has higher progression risk. Severe-range BP requires urgent treatment regardless of proteinuria.
Epidemiology
Risk factors overlap with preeclampsia: nulliparity, obesity, advanced maternal age, prior hypertensive pregnancy disease, chronic hypertension, diabetes, kidney disease, autoimmune disease, and multifetal gestation.
Clinical Features
Symptoms
Usually asymptomatic and detected by routine BP
Headache/visual changes/RUQ pain/dyspnea suggests preeclampsia
Decreased fetal movement
Bleeding or abdominal pain suggests abruption
Postpartum hypertension can persist or worsen
Signs
BP >=140/90 after 20 weeks
No proteinuria or severe labs
Severe BP >=160/110
Clonus, pulmonary edema, RUQ tenderness suggest severe features
Fetal growth restriction may develop
Investigations
First-line
Repeat BPConfirm persistent hypertension using proper technique
Urine protein assessmentProtein/creatinine >=0.3 or 24-hour protein >=300 mg indicates preeclampsia
Preeclampsia labsCBC platelets, creatinine, AST/ALT
Second-line
Fetal growth ultrasoundAssess growth restriction and amniotic fluid
Antenatal testingNST/BPP depending on gestational age and severity
Symptom-directed testingChest imaging or neurologic evaluation if symptoms
Specialist
MFM consultationEarly onset, severe BP, comorbidity, FGR, or uncertainty
Postpartum BP follow-upEarly postpartum assessment due to severe hypertension/preeclampsia risk
1
Without severe features
- Maternal and fetal surveillance until delivery
- Monitor BP, symptoms, labs, and urine protein
- Delivery at >=37 0/7 weeks
- Antihypertensives not routinely needed for mild-range BP
2
Severe-range BP
- Treat promptly with labetalol, hydralazine, or immediate-release nifedipine
- Evaluate for preeclampsia severe features
- Consider magnesium if severe features are present
- Delivery timing follows severe-feature pathway if persistent
3
Counseling
- Low-dose aspirin in future pregnancy if risk criteria met
- Counsel recurrence and long-term cardiovascular risk
- Postpartum BP monitoring and primary care transition
Complications
- Progression to preeclampsia: Especially with early onset
- Stroke: Severe BP creates maternal risk
- Placental abruption: Hypertension increases risk
- Fetal growth restriction: Uteroplacental insufficiency
- Future cardiovascular disease: Hypertensive pregnancy disorders predict later CVD
USMLE Step 2 CK Exam Tips
- 1Gestational hypertension = BP >=140/90 after 20 weeks without proteinuria/severe features
- 2Proteinuria or severe features = preeclampsia
- 3Severe-range BP needs urgent treatment
- 4Delivery at 37 weeks if no severe features
- 5ACE inhibitors and ARBs contraindicated in pregnancy
- 6Acute severe BP meds: labetalol, hydralazine, nifedipine
- 7Edema does not diagnose preeclampsia
practicetest your knowledge on gestational hypertensionApply what you've learnt with USMLE Step 2 CK-style questions from the iatroX Q-Bank — obstetrics & gynecology and beyond.
open q-bank