Optimization of Ambulatory Blood Pressure Monitoring during Pregnancy: A Path Toward Risk Stratification Improvement and Management of Hypertensive Disorders

Hypertensive disorders of pregnancy (HDP) pose substantial risks to both maternal and fetal health, thereby highlighting the need for precise and comprehensive blood pressure (BP) monitoring methods. Ambulatory blood pressure monitoring (ABPM) offers advantages over traditional office BP measurements by enabling continuous 24-hour assessment, thus capturing circadian BP variations, including nocturnal and morning hypertension, which are often missed when BP is measured in a medical office. This capacity for detailed monitoring allows ABPM to identify specific BP phenotypes, such as normotension, white-coat hypertension, masked hypertension, and sustained hypertension. Each of these phenotypes has unique implications for risk stratification, which helps to identify high-risk pregnancies early and potentially improve outcomes through more targeted interventions. Despite these advantages, three key challenges have limited the widespread adoption of ABPM during pregnancy. First, the complex dynamics in BP variations throughout gestation are influenced by physiological adaptations, such as uterine artery remodeling, which lowers BP before 20 weeks and increases mean arterial pressure after 20 weeks to support fetal growth. Second, adaptive changes in the maternal arterial system alter vascular mechanical properties, complicating accurate BP assessments. Third, diagnostic thresholds specific to pregnancy that are directly linked to adverse pregnancy outcomes are lacking. Therefore, this review addresses the role of ABPM in managing HDP, examining BP dynamics and the suitability of monitoring devices, and ongoing efforts to develop diagnostic thresholds tailored to pregnancy. By exploring these aspects, this review underscores the importance of ABPM in advancing more precise, effective strategies for HDP management and multidisciplinary management programs for pregnant women to enhance clinical decision-making and maternal-fetal outcomes.