The American College of Obstetricians and Gynecologists (ACOG, 2013) published revised guidelines for management of hypertension in pregnancy. Hypertensive disorders complicate >10% of pregnancies and are a leading cause of morbidity and mortality; incidence has increased 25% in the last 20 years in the United States (ACOG, 2013). Seizure prophylaxis is important in preeclampsia management; however, control of severe hypertension warrants equal care and concern. Blood pressures (BP) in the severe range (>=160 systolic or 110 diastolic) require prompt confirmation and treatment. Using strict guidelines that could delay treatment has contributed to past morbidity and mortality.

There are four categories to describe hypertension in pregnancy: preeclampsia-eclampsia, chronic hypertension, chronic hypertension with superimposed preeclampsia, and gestational hypertension. "Mild" is no longer used to distinguish the severity of preeclampsia; those who meet criteria simply have preeclampsia either with or without severe features (ACOG, 2013).

Proteinuria is not required to diagnose preeclampsia nor used in severity ranking. Although proteinuria with BP criteria remains a diagnosis of preeclampsia, elevated BP (per criteria) and evidence of organ injury or damage (certain lab abnormalities, pulmonary edema, or central nervous system involvement) may be diagnostic for preeclampsia when proteinuria is absent (ACOG, 2013). If there is new hypertension with lab abnormalities, waiting for proteinuria to administer treatment is no longer acceptable.

Women with preeclampsia without severe features should give birth at 37 0/7 weeks; women with preeclampsia with severe features at 34 0/7 weeks. If unstable (including but not limited to eclampsia, uncontrolled severe hypertension, and HELLP) and less than 33 6/7 weeks, steroids may be given but birth should not be delayed past maternal stabilization (ACOG, 2013).

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