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Hypertensive disorders of pregnancy

ACOG differentiation of chronic and gestational hypertension, preeclampsia surveillance, severe-feature escalation and CHAP-informed treatment.

JurisdictionUnited States
Source check2026-08-20
Clinical reviewiatroX editorial team 路 Clinical editorial review 路 reviewed 2026-08-20 路 due 2027-08-20
AudienceUnited States obstetric, primary-care and emergency healthcare professionals
This is an iatroX educational summary of named United States sources, not an official guideline. It does not replace the complete source documents, local policy, specialist advice or clinical judgement. Use the named authority, current FDA labeling, applicable state law, payer rules and local protocol where relevant.

Scope of this summary

Pregnant and postpartum patients with chronic hypertension, gestational hypertension or suspected preeclampsia.
sources for this section:ACOG PB 222ACOG CHAP advisory

The Bottom Line

  • Distinguish hypertension present before pregnancy or before 20 weeks from new hypertension after 20 weeks, then assess proteinuria, symptoms, laboratory abnormalities and fetal status for preeclampsia.
  • For mild chronic hypertension in pregnancy, ACOG鈥檚 CHAP advisory uses 140/90 mm Hg as the threshold to initiate or titrate treatment; it did not establish one universal target.
  • Severe-range pressure, persistent neurologic symptoms, pulmonary edema, liver injury, thrombocytopenia, kidney dysfunction or concerning fetal findings moves care into an urgent preeclampsia pathway.
  • Use low-dose aspirin prevention only for patients meeting ACOG or USPSTF risk criteria and begin within the source-supported gestational window after contraindications are checked.
  • Continue surveillance after birth because preeclampsia can present or worsen postpartum, when headache, visual change, dyspnea or epigastric pain may be the first warning.
sources for this section:ACOG PB 222ACOG CHAP advisory

Practical clinical workflow

1
Confirm elevated blood pressure with correct cuff and technique while assessing gestational age, prior readings, medicines, headache, vision, right-upper-quadrant pain, dyspnea, edema and fetal movement.
2
Obtain urine protein assessment, blood count, creatinine and liver tests and arrange fetal growth or wellbeing assessment according to the suspected disorder and gestation.
3
For chronic hypertension, review teratogenic or unsuitable medicines, use pregnancy-compatible therapy and perform third-trimester growth surveillance under the obstetric plan.
4
For gestational hypertension or preeclampsia without severe features, document monitoring frequency, home warning signs, fetal surveillance and the exact threshold for hospital reassessment.
5
At delivery and postpartum transition, reconcile antihypertensives, ensure timely blood-pressure review and communicate long-term cardiovascular risk to primary care.
sources for this section:ACOG PB 222ACOG CHAP advisory

Safety boundaries and escalation

  • Confirmed acute-onset severe hypertension requires urgent treatment under an obstetric emergency protocol; do not wait for proteinuria or outpatient follow-up.
  • Eclampsia, stroke symptoms, pulmonary edema, oxygen impairment, placental abruption or fetal compromise requires immediate multidisciplinary stabilization and delivery planning.
  • A normal earlier visit does not exclude postpartum preeclampsia; new severe headache, visual symptoms, chest pain, dyspnea, seizures or upper-abdominal pain after birth needs emergency assessment.
  • ACE inhibitors, angiotensin receptor blockers and other agents have pregnancy-specific restrictions; verify current labeling and lactation compatibility rather than extending a nonpregnant regimen automatically.
sources for this section:ACOG PB 222ACOG CHAP advisory

Localization

This page uses ACOG Practice Bulletin 222 and the reaffirmed CHAP practice advisory. US hospital protocols, state perinatal systems and medication availability govern implementation.
sources for this section:ACOG PB 222ACOG CHAP advisory

Source documents

Use the linked source documents for complete recommendations, evidence grading, exclusions and implementation detail.

  1. American College of Obstetricians and GynecologistsGestational Hypertension and PreeclampsiaPractice Bulletin No. 222 路 Reaffirmed 2026 路 published 2020-06-01 路 accessed 2026-08-20
    view source
  2. American College of Obstetricians and GynecologistsClinical Guidance for the Integration of the Findings of the Chronic Hypertension and Pregnancy (CHAP) StudyReaffirmed March 2025 路 published 2022-04-01 路 accessed 2026-08-20
    view source
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