Current concepts in the management of hypertension in hypertensive disorders of pregnancy: a systematic review of international guidelines

BACKGROUND AND OBJECTIVE: Hypertensive disorders of pregnancy (HDP) are a leading cause of adverse maternal and perinatal outcomes worldwide. This systematic review aims to compare international practice guidelines for the management gestational hypertension (GH) and pre-eclampsia (PE). Our objective is to identify similarities and differences in the classification, diagnosis and management of these condition. METHODS: Published guidelines from January 2010 to April 2024 were searched, utilising MEDLINE, EMBASE, the Emergency Care Research Institute (ECRI) Guidelines Trust, and the Guidelines International Network's website (GIN) as databases. Guidelines were included if in English and not derived from other guidelines. All the guidelines were compared for definitions, diagnostic criteria, recommendations for pharmacological and non-pharmacological management, and contraindications. The AGREE II score tool was used to assess quality of included guidelines. RESULTS: The 12 included guidelines were consistent in their definition of GH and PE and which antihypertensive agents to avoid. Guidelines differed in the recommended blood pressure thresholds for initiation of antihypertensive medication and treatment targets. The use of aspirin was universally recommended, but guidance on non-pharmacological interventions was controversial. CONCLUSION: All guidelines acknowledge the significant morbidity associated with HDP and advocate for timely diagnosis and management. However, there are significant discrepancies in many aspects including definition and pharmacological management. More research is needed to understand optimal blood pressure thresholds at which to initiate antihypertensive medication regimens, the choice of antihypertensive, and the efficacy and benefits of non-pharmacological interventions in HDP. These findings exhibit knowledge gaps, which should be addressed in future research.