Hypertensive Disorders in Pregnancy (HDP): Diagnostics and Therapy. Guideline of the DGGG, OEGGG and SGGG (S2k-Level, AWMF Registry No. 015/018, June 2024)

Abstract

Aim This S2k guideline of the German Society of Gynecology and Obstetrics (DGGG) contains consensus-based recommendations for the care and treatment of women with hypertension in pregnancy. It aims to serve as a guide for all professions involved in the care of pregnant women and to improve interprofessional and interdisciplinary cooperation. A new focus was placed on patientsʼ long-term health beyond the postpartum period.

Methods The existing S2k guideline was revised and the relevant literature reviewed. Where new questions arose, they were formulated and developed in PICO format. A targeted systematic literature search was carried out using PubMed. Other international guidelines were also consulted. After summarizing and presenting the available data, recommendations and statements were developed, discussed, and agreed on by the guideline group.

Recommendations The recommendations cover prediction, prevention, diagnosis, and treatment from the moment hypertensive disease is detected in pregnancy as well as postpartum, in the puerperium, and during breastfeeding. A major change from the previous version of the guideline is the reduction in blood pressure levels that should be achieved during pregnancy. Suggestions are made on how to proceed with regards to the long-term health of mother and child, which the guideline group believes is currently regulated inadequately in the German healthcare system.

I  Guideline Information

Guidelines program of the DGGG, OEGGG and SGGG

More information on the program is available at the end of the guideline.

Citation format

Hypertensive Disorders in Pregnancy (HDP): Diagnostics and Therapy. Guideline of the DGGG, OEGGG and SGGG (S2k-Level, AWMF Registry No. 015/018, June 2024). Geburtsh Frauenheilk 2025. DOI: 10.1055/a-2522-2347

Guideline documents

The complete long version in German and a slide version of these guidelines together with a list of the conflicts of interest of all the authors is available on the homepage of the AWMF: http://www.awmf.org/leitlinien/detail/ll/015-018.html

Guideline authors

See Tables 1 and 2 .

Table 1  Lead and/or coordinating guideline author.

Author	AWMF medical society
Prof. Dr. med. Ulrich Pecks	German Society for Gynecology and Obstetrics ( Deutsche Gesellschaft für Gynäkologie und Geburtshilfe , DGGG)

Table 2  Contributing guideline authors.

Author Mandate holder	DGGG working group/AWMF/ non-AWMF medical society/ organization/association
Prof. Dr. med. Marc Baumann	SGGG
Prof. Dr. med. Julia Binder	OEGGG
Prof. Dr. med. Ralf Dechend	DHL
Dr. Birgit Enna-Kirchmair	OEGARI
Prof. Dr. med. Thorsten Fischer	OEGGG
Prof. Dr. med. Thierry Girard	SSAPM
Dr. med. Susanne Greve	DGAI
Prof. Dr. med. Tanja Groten	DGGG
Dr. med. Andreas Hartung	BVF
Prof. Dr. med. Sven Kehl	DEGUM
Maria Koch	DGHWI
Andrea Köbke	DHV
Prof. Dr. med. Peter Kranke	DGAI
Prof. Dr. med. Olav Lapaire	SGGG
Silke Mader	EFCNI
Prof. Dr. med. Ulrich Pecks	DGGG, DGPM
Prof. Dr. med. Lars Christian Rump	DGfN
PD Dr. med. Dietmar Schlembach	DGGG, DGPGM
Alexandra Sperling	DHV
Prof. Dr. med. Holger Stepan	DGPM
Prof. Dr. med. Sylvia Stracke	DGfN
Prof. Dr. med. Stefan Verlohren	DGPGM
Prof. Dr. med. Frauke von Versen-Höynck	DGRM
Prof. Dr. med. Karl Winkler	DGKL
Prof. Dr. med. Michael Zemlin	GNPI

The following medical societies/working groups/organizations/associations wanted to contribute to the guideline text and nominated representatives to attend the consensus conference.

Abbreviations

AFLP

acute fatty liver of pregnancy

aHUS

atypical hemolytic uremic syndrome

ASA

acetylsalicylic acid

BMI

body mass index

CO

cardiac output

CT

computed tomography

CTG

cardiotocography

DIC

disseminated intravascular coagulopathy

EPDS

Edinburgh Postnatal Depression Scale

FGR

fetal growth restriction

FMF

Fetal Medicine Foundation

GFR

glomerular filtration rate

GH

general health

GOT

glutamate oxaloacetate transaminase

GPT

glutamate pyruvate transaminase

GW

weeks of gestation

HDL

high-density lipoprotein

HPD

hypertensive disorders of pregnancy

ICP

intrahepatic cholestasis of pregnancy

IUFD

intrauterine fetal death

IV

intravenous

LDH

lactate dehydrogenase

LDL

low-density lipoprotein

LGA

large for gestational age

MEOWS

Modified Early Obstetric Warning Score

MgSO ₄

magnesium sulfate

MRI

magnetic resonance imaging

NIBD

non-invasive blood pressure measurement

PCR

protein creatinine ratio

PETN

pentaerythritol tetranitrate

PI

pulsatility index

PlGF

placental growth factor

PRES

posterior reversible encephalopathy syndrome

sFlt-1

soluble fms-like tyrosine kinase-1

SGA

small for gestational age

TG

triglycerides

TTP

thrombotic thrombocytopenic purpura

VTE

venous thromboembolism  

II  Guideline Application

Target patient group

Pregnant women, patients who are status post HDP, women with (preexisting) hypertensive disease

Purpose and objectives

• Development of a guideline for use in daily clinical practice

• Revision of previous definitions, diagnoses and aids to decision-making

• Improvement of the diagnostic workup and therapy

• Improvement of aftercare/follow-up care with a focus on interdisciplinary co-operation

Target areas of care

• Outpatient care

• Day patient care

• Inpatient care

• Care after discharge from hospital

Target user groups/target audience

This guideline is aimed at the following groups of people:

• Gynecologists in private practice

• Hospital-based gynecologists

• Midwives

• Pediatricians and neonatologists

• Anesthesiologists, anesthetists and intensive care specialists

• General practitioners

• Specialists for laboratory medicine

• Physicians in other medical specialties relating to HDP, e.g., cardiology and nephrology

• Patient associations

Other target groups include (for information):

• Nursing staff

• Social services

• Psychological professions

Adoption and period of validity

The validity of this guideline was confirmed by the executive boards/representatives of the participating medical societies, working groups, organizations, and associations as well as the boards of the DGGG, the DGGG Guidelines Commission, the SGGG and the OEGGG in April 2024 and was thereby approved in its entirety. This guideline is valid from 1 June 2024 through to 30 May 2029. Because of the contents of this guideline, this period of validity is only an estimate. The guideline can be reviewed and updated earlier if urgently required. Similarly, if the guideline still reflects the current state of knowledge, its period of validity can be extended.

III  Method

Basic principles

The method used to prepare this guideline was determined by the class to which this guideline was assigned. The AWMF Guidance Manual (version 1.0) has set out the respective rules and requirements for different classes of guidelines. Guidelines are differentiated into lowest (S1), intermediate (S2), and highest (S3) class. The lowest class is defined as consisting of a set of recommendations for action compiled by a non-representative group of experts. In 2004, the S2 class was divided into two subclasses: a systematic evidence-based subclass (S2e) and a structural consensus-based subclass (S2k). The highest S3 class combines both approaches.

This guideline was classified as: S2k

Grading of recommendations

The grading of evidence based on the systematic search, selection, evaluation, and synthesis of an evidence base which is then used to grade the recommendations of the guideline is not envisaged for S2k guidelines. The individual statements and recommendations are only differentiated by syntax, not by symbols (see Table 3 ).

Table 3  Grading of recommendations (based on Lomotan et al., Qual Saf Health Care 2010.

Description of binding character	Expression
Strong recommendation with highly binding character	must/must not
Regular recommendation with moderately binding character	should/should not
Open recommendation with limited binding character	may/may not

Statements

Expositions or explanations of specific facts, circumstances, or problems without any direct recommendations for action included in this guideline are referred to as “statements.” It is not possible to provide any information about the level of evidence for these statements.

Achieving consensus and level of consensus

At structured NIH-type consensus conferences (S2k/S3 level), authorized participants attending the session vote on draft statements and recommendations. The process is as follows. A recommendation is presented, its contents are discussed, proposed changes are put forward, and all proposed changes are voted on. If a consensus (> 75% of votes) is not achieved, there is another round of discussions, followed by a repeat vote. Finally, the level of consensus is determined, based on the number of participants (see Table 4 ).

Table 4  Level of consensus based on extent of agreement.

Symbol	Level of consensus	Extent of agreement in percent
+++	Strong consensus	> 95% of participants agree
++	Consensus	> 75 – 95% of participants agree
+	Majority agreement	> 50 – 75% of participants agree
–	No consensus	< 51% of participants agree

Expert consensus

As the term already indicates, this refers to consensus decisions relating specifically to recommendations/statements issued without a prior systematic search of the literature (S2k) or where evidence is lacking (S2e/S3). The term “expert consensus” (EC) used here is synonymous with terms used in other guidelines such as “good clinical practice” (GCP) or “clinical consensus point” (CCP). The strength of the recommendation is graded as previously described in the chapter Grading of recommendations but without the use of symbols; it is only expressed semantically (“must”/“must not” or “should”/“should not” or “may”/“may not”).

IV  Guideline

Hypertensive disorders occur in 6 – 8% of all pregnancies, contribute to 20 – 25% of perinatal mortality, and are the leading cause of maternal mortality in industrialized countries.

Severe preeclampsia is a multisystem disorder which typically affects 2 – 5% of pregnant women. It is one of the main causes of maternal and perinatal morbidity and mortality, especially if the condition starts at an early stage of pregnancy. Every year 76 000 women and 500 000 babies die from this disorder worldwide. The condition is also associated with lifelong risks for cardiovascular health requiring structured follow-up care.

Prediction and prevention are still only possible to a limited extent. Relevant evaluations in the first trimester of pregnancy can identify high-risk women, allowing prophylactic measures to be initiated early on. The identification of a “high-risk group” also permits individualized monitoring of the pregnancy to detect and treat complications in their early stages.

In clinical practice, there is a clear overlap with other similar clinical manifestations of placental dysfunction such as fetal growth restriction (FGR). As there is currrently no causal therapy, the focus of treatment is on reducing maternal and fetal morbidity and mortality. As far as possible, the management of this pathology of pregnancy should be evidence-based and interdisciplinary and should be provided by a hospital which can offer the appropriate level of care. This is why this guideline is adressed to medical professionals and specialists involved in the care of women with hypertensive pregnancies.

For an in-depth look which includes the background and literature references, please refer to the long German-language version of the guideline 1 .

1  Classification and definition

Consensus-based statement 1.S1
Expert consensus	Level of consensus +++
Chronic hypertension: Hypertension diagnosed prior to conception or in the first trimester of pregnancy (according to the criteria of the German National Care Guideline on Hypertension).

Consensus-based statement 1.S2
Expert consensus	Level of consensus +++
Gestational hypertension: Systolic blood pressure ≥ 140 and/or diastolic blood pressure ≥ 90 mmHg which develops over the course of pregnancy in a previously normotensive pregnant woman without additional criteria which would meet the definition of preeclampsia.

Consensus-based statement 1.S3
Expert consensus	Level of consensus +++
Preeclampsia: Chronic or gestational hypertension with at least one organ manifestation which developed in pregnancy and cannot be ascribed to any other cause. Typically affected organ systems especially include the placenta (fetal growth restriction), kidneys, central nervous system, liver, hematological system, lungs.

New symptoms are especially likely to develop in the context of preeclampsia if symptoms persist, their causes cannot be explained, and they are resistant to treatment. Table 5 provides an overview of typical symptoms and findings.

Table 5  Organ systems involved in preeclampsia with symptoms/findings.

Organ systems	Symptom/findings
1 Typical laboratory parameters are presented in Table 8 , chapter 4.2.
CNS and sensory organs	Headache
	Tics, clonuses
	Visual disturbances, hearing disorders
	Generalized seizures
	Apoplexy
Liver	Upper abdominal pain (right-sided)
	Epigastric pain
	Retrosternal chest pain
	Elevated liver values 1
Lungs	Dyspnea with or without decreased oxygen saturation SpO 2 < 96%
Kidneys	Oliguria to anuria
	Proteinuria 1
	Elevated retention parameters 1
Gastrointestinal	Nausea, vomiting, diarrhea
Hematopoietic system	Thrombocytopenia 1
	Hemolysis 1
Placenta	SGA/FGR
Angiogenic factors 1	sFlt-1, PlGF

Consensus-based statement 1.S4
Expert consensus	Level of consensus +++
HELLP syndrome: Typical constellation of laboratory findings occurring in pregnancy consists of hemolysis, elevated transaminases and thrombocytopenia < 100 G/l, often associated with preeclampsia.

Consensus-based statement 1.S5
Expert consensus	Level of consensus +++
Eclampsia: Tonic-clonic seizures occurring in pregnancy (often associated with preeclampsia) which cannot be ascribed to other neurological causes (e.g., epilepsy).

Consensus-based statement 1.S6
Expert consensus	Level of consensus +++
Mild preeclampsia and severe preeclampsia are not differentiated as clinical dynamics and manifestations may change.

Consensus-based statement 1.S7
Expert consensus	Level of consensus +++
Severe hypertension is present when repeated measurements show a systolic blood pressure of ≥ 160 and/or a diastolic blood pressure of ≥ 110 mmHg. These blood pressure levels increase the risk of complications such as stroke and death.

Consensus-based statement 1.S8
Expert consensus	Level of consensus +++
When a pregnant woman presents with characteristics and symptoms typical for preeclampsia, a systolic blood pressure of < 140 mmHg and a diastolic blood pressure of < 90 mmHg will not preclude the risk of unfavorable maternal and perinatal events or complications typical for preeclampsia.

Consensus-based statement 1.S9
Expert consensus	Level of consensus +++
Early-onset (< 34 + 0 GW) preeclampsia and late-onset (≥ 34 + 0 GW) preeclampsia are differentiated according to the time of onset of symptoms over the course of the pregnancy.

The division into early-onset vs. late-onset preeclampsia is currently considered not to be clinically relevant for the acute management of this condition. Future phenotype-based strategies for prevention and therapy are looking promising.

2  Risk factors, prediction and screening

Consensus-based statement 2.S10
Expert consensus	Level of consensus +++
Early identification of a higher risk of preeclampsia allows risk-adapted monitoring to be carried out with targeted initiation of prophylactic measures ( Table 6 ).

Table 6  Risk factors for preeclampsia (a priori risks).

Parameter
Advanced maternal age
High maternal BMI
Ethnicity (Caucasian < African < South Asian)
Positive familial history; mother had preeclampsia
Primiparity (compared to multiparity without previous preeclampsia)
Previous pregnancy with preeclampsia (compared to primigravidity)
Conception (assisted reproduction, especially cryo-cycle and egg donation)
Multiple pregnancy
Chronic hypertension
Diabetes mellitus (type I/type II)
Systemic lupus erythematosus
Antiphospholipid antibody syndrome
Nicotine use

2.1  Risk factors, prediction, screening in the 1st trimester

Consensus-based recommendation 2.E1
Expert consensus	Level of consensus +++
All pregnant women must be informed in the 1st trimester of pregnancy about the option of screening for preeclampsia.

Consensus-based recommendation 2.E2
Expert consensus	Level of consensus +++
If preeclampsia screening is carried out in the 1st trimester of pregnancy, it must be carried out using the FMF algorithm.

The FMF algorithm is available free of charge on the website of the FMF.

• https://fetalmedicine.org/research/assess/preeclampsia/first-trimester

If the risk is calculated as 1 : 100, this is considered to indicate a higher risk pregnancy and is an indication for prophylaxis with ASA, but it can vary depending on the regional validation.

2.2  Risk factors, prediction, screening: 2nd/3rd trimester

Consensus-based statement 2.S11
Expert consensus	Level of consensus +++
Preeclampsia screening in the 2nd and 3rd trimester which goes beyond checking maternal blood pressure levels and possibly checking for proteinuria as recommended in the German Maternity Policy Guidelines is not useful.

Consensus-based statement 2.S12
Expert consensus	Level of consensus +++
Doppler sonography of the uterine arteries in the 2nd trimester is a suitable procedure to predict the risk of developing preeclampsia. The crucial information is provided by the pulsatility indices. Imaging of post-systolic notching of the uterine arteries is not suitable.

Determination of the medium pulsatility index (PI) is considered the best marker for the prediction of preeclampsia in the 2nd trimester of pregnancy. Determination of the risk is typically carried out between week 19 + 0 and week 24 + 6 of gestation. The reference values are taken from data provided by Gomez et al. (2005), and the 95th percentiles of the pulsatility indices are presented in Table 7 .

Table 7  Reference values for the pulsatility index of the uterine arteries.

GW	PI of the uterine arteries, 95th percentiles
18	1.79
19	1.70
20	1.61
21	1.54
22	1.47
23	1.41
24	1.35
25	1.30

3  Prevention of preeclampsia

Consensus-based recommendation 3.E3
Expert consensus	Level of consensus +++
Women who have a high-risk medical history and/or are found to have higher risk scores when screened for preeclampsia (based on the FMF algorithm) must start taking oral low-dose acetylsalicylic acid (ASA) 100 – 150 mg/day, preferably in the evening, in early pregnancy (at the latest before the start of week 16 + 0 of gestation).

Consensus-based statement 3.S13
Expert consensus	Level of consensus +++
Current studies have not shown that taking magnesium, selenium, vitamins, calcium, NO donors, or fish oil has a preventive effect against preeclampsia.

Consensus-based statement 3.S14
Expert consensus	Level of consensus +++
The preventive effect of low molecular weight heparin has not been proven.

Targeted physical activity and exercise programs may reduce the risk of developing HDP if they are started in early pregnancy or even prior to conception. Anaerobic training, for example, strength training or yoga, appears to be more effective than aerobic training.

4  Diagnostics

4.1  Blood pressure measurements and interpretation

Consensus-based recommendation 4.E4
Expert consensus	Level of consensus +++
Standardized blood pressure measurements in a healthcare professionalʼs office must be measured manually or using an automated non-invasive blood pressure (NIBP) monitor validated for use in pregnancy.

All therapeutic decisions and recommendations in this guideline are based on accurate blood pressure measurements. Standardized blood pressure measurements performed in the office of a healthcare professional must be carried out in accordance with the recommendations of the German National Care Guideline on Hypertension, and readers should refer to this guideline. A list of NIBP monitors validated for use in pregnancy is available at www.stridebp.org

Consensus-based recommendation 4.E5
Expert consensus	Level of consensus +++
To exclude a difference in measurements between the two side (> 20 mmHg), initial measurements should be done on both arms.

Further measurements should be carried out on the arm with the higher blood pressure readings.

Consensus-based statement 4.S15
Expert consensus	Level of consensus +++
Ambulatory blood pressure monitoring (ABPM) to monitor blood pressure over a period of 24 hours is a suitable method to investigate high blood pressure in pregnancy and enable a further differential diagnostic evaluation to be carried out (to exclude “white coat hypertension”; NB: loss of circadian rhythm is a prognostically unfavorable sign) and check whether antihypertensive measures are effective.

Consensus-based recommendation 4.E6
Expert consensus	Level of consensus +++
Further ambulatory care of the pregnant woman must consist of home blood pressure monitoring (HBPM) using a monitor with an upper arm cuff or another properly validated measurement method and a blood pressure profile must be compiled. When the blood pressure data are being interpreted, the fact that ambulatory NIBP monitors are usually not validated for use in pregnancy must be taken into consideration. How often blood pressure should be measured must be discussed and individually agreed upon with the patient.

When are HBPM values considered abnormal?

The cut-off HBPM value for the diagnosis of hypertension is a systolic pressure of ≥ 135 and a diastolic pressure of ≥ 85 mmHg. When 25% or more of recorded blood pressure values are higher than a defined threshold value, the blood pressure is considered pathological with regards to both the diagnostic threshold for high blood pressure and the target blood pressure.

How often should HBPM be carried out?

Pregnant women with well-regulated chronic hypertension should measure their blood pressure on at least 2 – 3 days every week. On the days when blood pressure is monitored, at least one measurement must be done in the morning. Factors which affect how often individual monitoring should be carried out include the type of hypertensive disease, the risk of preeclampsia, the current regimen used for blood pressure regulation, and the use of antihypertensive medication.

When should measurements be carried out?

The time to measure blood pressure depends on patient-related factors (e.g., daily routines) and when the patient takes her hypertensive medication. With regards to the time when blood pressure is measured relative to the time when antihypertensive medication is taken, there are arguments both for and against measuring blood pressure before taking medication. It is not possible to make an unequivocal recommendation.

4.2  Diagnostic laboratory tests and evaluation

See Table 8 .

Table 8  Typical disease-related changes of laboratory values.

Parameter
PCR = protein creatinine ratio
Hemoglobin	> 13 g/dl or > 8.0 mmol/l
Hematocrit	> 38%
Thrombocytes	< 100 Gpt/l
A progressive decrease in thrombocyte levels must be checked within a few hours, even if values are still within normal ranges (caution: HELLP syndrome, DIC).
GPT (ALT)	Rise to ≥ 2 times the reference range
GOT (AST)	Rise to ≥ 2 times the reference range
LDH	Rise to ≥ 2 times the reference range
Bilirubin (indirectly)	> 1.2 mg/dl or > 20.5 µmol/l
Uric acid	> 5.9 mg/dl or > 350 µmol/l
Creatinine	≥ 0.9 mg/dl or ≥ 79.56 µmol/l
Proteinuria or PCR	≥ 300 mg/dl (≙ PCR 30 mg/mmol = ca. 0.3 g/g)
Haptoglobin	Decrease to below reference range
Other coagulation tests
e.g., rapid increase in D-dimer (indication of DIC), monitor changes
sFlt-1 and PlGF or ratio of the two	see Table 9

4.2.1  Proteinuria

Consensus-based recommendation 4.E7
Expert consensus	Level of consensus +++
A positive result of ≥ 1+ albumin on a urine strip test must be quantified.

Consensus-based recommendation 4.E8
Expert consensus	Level of consensus +++
The protein creatinine ratio (from spontaneous urine) should be preferably used to quantify proteinuria. A result of ≥ 30 mg/mmol (which corresponds to about 300 mg/g or 0.3 g/g) is an indication of significant proteinuria and correlates with a protein excretion of ≥ 300 mg/d.

Consensus-based statement 4.S16
Expert consensus	Level of consensus +++
If significant proteinuria has been confirmed, repeated measurements to estimate prognosis or monitor preeclampsia are not useful because the extent of proteinuria has no predictive value.

4.2.2  Hemolysis

Consensus-based statement 4.S17
Expert consensus	Level of consensus +++
The best proof of hemolysis is provided by determining the haptoglobin levels.

4.2.3  Angiogenic factors sFlt-1 and PlGF

Consensus-based statement 4.S18
Expert consensus	Level of consensus +++
The determination of angiogenic factors in blood is useful to estimate the risk of manifest preeclampsia when pregnancy-related risk factors are present or there are clinical indications of incipient preeclampsia.

Consensus-based recommendation 4.E9
Expert consensus	Level of consensus +++
Screening using the sFlt-1/PlGF ratio or PlGF must not be carried out in all pregnant women because of the limited prevalence and the very low prediction rates.

Consensus-based recommendation 4.E10
Expert consensus	Level of consensus +++
PlGF alone or in combination with sFlt-1 (sFlt-1/PlGF ratio) may be measured in the blood of a pregnant woman at high risk of preeclampsia to exclude preeclampsia or detect incipient preeclampsia at an early stage.

Risk constellations relate especially to findings which could be associated with preeclampsia. According to the PROGNOSIS trial, they include:

• New onset of an increase in blood pressure (not necessarily > 140/90 mmHg)

• Exacerbation of existing hypertension

• New onset of increased protein excretion (not necessarily > 300 mg/d)

• Exacerbation of existing proteinuria

• Upper abdominal pain

• Edemas of the face, hands or feet

• Headache

• Visual disorders

• Excessive weight gain > 1 kg/week in the 3rd trimester

• Decreased thrombocyte count

• Elevated liver values

• Suspected FGR

• Higher resistance of the uterine arteries in the 2nd trimester

According to the German Schedule of Fees for Physicians (assessment by the Federal Joint Committee from August 14, 2019), the preconditions for invoicing health insurance companies for the cost of determining sFlt-1 and PlGF are:

• New-onset or preexisting hypertension

• Preclampsia-related results of organ examinations

• Preeclampsia-related diagnostic laboratory test results

• Fetal growth restriction

• Abnormal uterine artery Doppler sonography findings

Consensus-based recommendation 4.E11
Expert consensus	Level of consensus +++
The determination of angiogenic factors may be used to support and complement clinical examinations carried out to confirm or exclude the diagnosis of preeclampsia or assess progression of the disorder.

Consensus-based statement 4.S19
Expert consensus	Level of consensus +++
The different threshold values of the various analysis methods and the week of gestation must be taken into account when determining angiogenic factors.

Consensus-based recommendation 4.E12
Expert consensus	Level of consensus +++
Abnormal angiogenic markers must not be used as an indication to deliver the child.

5  Differential diagnosis

5.1  Upper abdominal or retrosternal pain

Consensus-based recommendation 5.E13
Expert consensus	Level of consensus +++
HELLP syndrome must be excluded in the second half of pregnancy when investigating upper abdominal or retrosternal pain.

5.2  Seizures and severe neurological symptoms

Consensus-based recommendation 5.E14
Expert consensus	Level of consensus +++
Women who do not immediately recover after eclampsia or who develop severe neurological symptoms must be referred for a neurological consultation without delay. Imaging (MRI, CT) should be considered and approved to exclude intracranial events (bleeding, PRES).

5.3  Preeclampsia-like constellations

Consensus-based recommendation 5.E15
Expert consensus	Level of consensus +++
If thrombocytopenia, anemia, and/or kidney failure occur late in pregnancy or peripartum, the differential diagnosis must also consider other causes such as thrombotic thrombocytopenic purpura (TTP), atypical hemolytic uremic syndrome (aHUS), or acute fatty liver of pregnancy (AFLP) ( Table 10 ).

Table 10  “Typical” differential diagnoses for constellations of laboratory results and findings.

Criteria	HELLP	AFLP	TTP	aHUS	Viral hepatitis	ICP
* Secondary
Hemolysis	++	−/+	+++	+++	–	–
Increased transaminases	++	++	−/+	−/+	+++	+
Thrombocytopenia	++	+*	+++	+++	–	–
Hypertension	++	+	−/+	+++*	–	–
Proteinuria	+++	+	+	++	–	–
Leukocytosis	–	+++	–	–	++	–
Renal insufficiency	+/+++	+*	+	+++	–	–
Neurological symptoms	+/+++	++	+++	+	–	–
Jaundice	−/+	+	++	++	+++	++
Abdominal pain	+++	++	++	++	–	−/+
Fever	–	+	+	–	+	–
Nausea/vomiting	++	++	++	++	–	−/+
Other	DIC, elevated sFlt-1/PlGF	hypoglycemia, DIC, elevated sFlt-1/PlGF	decreased ADAMTS-13 activity	poss. complement C3/C4 activation	elevated bilirubin, viral serology	pruritus/ cholestasis parameter

Table 9  Threshold values of different analysis systems for PlGF and sFlt-1/PlGF which are used to include (rule-in) or exclude (rule-out) preeclampsia.

Parameter	Triage PLGF test	Elecsys sFlt-1/PlGF ratio	DELFIA Xpres PlGF 1 – 2 – 3 test	BRAHMS sFlt-1/PlGF plus ratio
It should be noted that the different test methods must only be used as directed by the manufacturer (especially with regards to the week of gestation). * According to a personal communication of the manufacturer, the threshold value for BRAHMS Kryptor has changed to 66. The general approach must be to adhere to the manufacturerʼs specifications or the reference ranges of laboratories.
Rule-out	≥ 100 pg/ml	≤ 38	≥ 150 pg/ml	< 40*
Rule-in	< 12 pg/ml	< 34 + 0 GW > 85 ≥ 34 + 0 GW > 110	< 50 pg/ml	> 40*
Relevant studies	PELICAN PARROT	PROGNOSIS INSPIRE	COMPARE	PRAECIS

6  Ambulatory monitoring and care

Consensus-based recommendation 6.E16
Expert consensus	Level of consensus +++
Pregnant women with a history of HDP or with manifest hypertension during or before pregnancy are high-risk pregnant women and must be identified at the first prenatal examination.

Consensus-based recommendation 6.E17
Expert consensus	Level of consensus +++
If risk constellations such as the one described above are present, the pregnant woman and her fetus must be closely monitored and cared for.

Consensus-based recommendation 6.E18
Expert consensus	Level of consensus +++
In addition to be taught the correct way to carry out blood pressure monitoring at home (blood pressure protocol) and the recommendation to regularly monitor weight gain , pregnant women must be made aware of the need to watch out for prodromal symptoms typical of preeclampsia such as headache, visual disorders, upper abdominal pain, nausea, vomiting, thoracic pain, and dyspnea.

Consensus-based recommendation 6.E19
Expert consensus	Level of consensus +++
Measures to reduce stress must be individually reviewed with the pregnant woman to avoid exacerbating hypertensive complications of pregnancy.

Consensus-based statement 6.S20
Expert consensus	Level of consensus +++
Physical rest coupled with moderate exercise may have a positive impact on maternal and fetal weight gain and reduce disorder-related complications.

Consensus-based statement 6.S21
Expert consensus	Level of consensus +++
The guideline authors agree that a pregnancy with hypertension should be checked more often than the general intervals provided for in the Maternity Policy Guidelines. It is not possible to make an evidence-based recommendation on the intervals between examinations and the required monitoring measures. Depending on the situation, assessment of the condition of the mother and the fetus is advised. Assessments can be carried out using Doppler sonography, amniotic fluid monitoring, fetometry, CTG, diagnostic laboratory tests, clinical examinations, and inquiries into symptoms.

If FGR is detected, which is often associated with HDP, the fetus must be monitored in accordance with the AWMF guideline on Fetal Growth Restriction .

7  Antihypertensives in pregnancy

7.1  Indications and goals of blood pressure therapy

Consensus-based statement 7.S22
Expert consensus	Level of consensus +++
Pregnant women with a systolic blood pressure of ≥ 160 mmHg and/or a diastolic blood pressure of ≥ 110 mmHg have a higher risk of developing preeclampsia-related complications, kidney failure, stroke, and preterm birth.

Consensus-based recommendation 7.E20
Expert consensus	Level of consensus +++
Women with recurrent systolic blood pressure measurements of ≥ 140 mmHg and/or a diastolic blood pressure of ≥ 90 mmHg must be treated with medication.

Consensus-based recommendation 7.E21
Expert consensus	Level of consensus +++
The target blood pressure values must be a systolic pressure of ≤ 135 mmHg and a diastolic pressure of ≤ 85 mmHg.

The recommended target blood pressure must be understood as an average daily value . The guideline authors also acknowledge that in individual cases it will not be possible to achieve target blood pressure values despite maximum escalation of therapy. Whether this should lead to additional measures being implemented must be decided on a case-by-case basis.

Consensus-based statement 7.S23
Expert consensus	Level of consensus +++
It is important to be aware that a drastic drop in blood pressure could result in placental underperfusion and this could lead to acute fetal impairment. The rule when regulating blood pressure is “start low, go slow”.

Consensus-based recommendation 7.E22
Expert consensus	Level of consensus +++
If the mean diastolic blood pressure drops below 80 mmHg on consecutive days, the current medication should be reduced. The cause of hypertension (e.g., preeclampsia versus chronic hypertension versus renal disease) must be taken into account when reducing medication.

Consensus-based recommendation 7.E23
Expert consensus	Level of consensus +++
When medication-based therapy is initiated in a patient with a systolic blood pressure of ≥ 160 mmHg and/or a diastolic blood pressure of ≥ 110 mmHg, initiation must be done on inpatient basis.

Consensus-based recommendation 7.E24
Expert consensus	Level of consensus +++
In a hypertensive emergency (acute severe hypertension with a systolic pressure of ≥ 160 mmHg and/or a diastolic pressure of ≥ 110 mmHg which continues for more than 15 min with a life-threatening risk of organ damage, e.g., hypertensive encephalopathy with visual disturbances, dizziness, severe headache, disorientation, neurological deficits or pulmonary edemas), blood pressure must be reduced immediately using medication.

7.2  Choice of medication for mild hypertension

Consensus-based recommendation 7.E25
Expert consensus	Level of consensus +++
Women with chronic hypertension who wish to have children must be treated with medication which is compatible with pregnancy.

Consensus-based statement 7.S24
Expert consensus	Level of consensus +++
α-methyldopa, nifedipine and labetalol/metoprolol are the first-choice drugs for antihypertensive therapy in pregnancy ( Table 11 ).

Table 11  Long-term treatment with oral antihypertensives in pregnancy.

	Medication	Dosage	Comments
* Apart from antihypertensive therapy, there may be other indications that justify the use of diuretics in preeclampsia. If a diuretic is required in pregnancy, hydrochiorothiazide should be considered.
Suitable	α-methyldopa	250 – 500 mg orally (3 – 4×/d)/max. 2 g/d	Long-lasting experience in pregnancy. Caution: monitor patient for postpartum depression.
	labetalol (Austria, Switzerland)	initial dosage 3 × 200 mg/d max. 4 × 300 mg/d	Stronger antihypertensive effect than alpha-methyldopa; contraindicated in cases with poorly controlled bronchial asthma; higher risk of neonatal bradycardia and hypoglycemia. Higher risk of SGA.
	nifedipine retard	20 – 60 mg ret. oral max. 120 mg/d	Stronger antihypertensive effect than alpha-methyldopa; contraindicated in cases of maternal aortic stenosis. Less well studied alternative from the calcium channel blockers group: amlodipine .
	selective β-1-receptor blockers like metoprolol	Dosage 25 – 100 mg (2× daily)	Higher risk of SGA; contraindicated in cases with poorly controlled bronchial asthma; metoprolol increases the risk of neonatal bradycardia and hypoglycemia.
Unsuitable	diuretics*		Potential impairment of uteroplacental perfusion due to additional reduction of plasma volume.
	ACE inhibitors		No proven teratogenic effects. Contraindicated in the 2nd/3rd trimester of pregnancy: associated with acute renal failure in neonates, oligohydramnios.
	angiotensin AT1 antagonists		Oligohydramnios, cranial hypoplasia, potentially teratogenic and nephrotoxic for neonates.
	all other antihypertensives		Insufficient information on use in pregnancy.

Consensus-based statement 7.S25
Expert consensus	Level of consensus +++
α-methyldopa has the longest clinical experience. However, the use of α-methyldopa is still controversially discussed because of suggestions that it could be connected to the development of mental disorders and has an unfavorable effect on an existing disorder.

Consensus-based statement 7.S26
Expert consensus	Level of consensus +++
Nifedipine is superior to α-methyldopa in terms of preventing severe hypertension. Nifedipine has been found to be more effective compared to other antihypertensives (α-methyldopa and labetalol) with shorter intervals and fewer doses required until reaching the target blood pressure but with the same level of fetal and maternal safety. This justifies its off-label use.

Consensus-based statement 7.S27
Expert consensus	Level of consensus +++
Labetalol/metoprolol are superior to α-methyldopa with regards to the prevention of severe hypertension. Labetalol is not available for use in Germany. Beta blockers are associated with SGA.

Consensus-based statement 7.S28
Expert consensus	Level of consensus +++
The guideline AWMF 015/090 Chronic Kidney Disease and Pregnancy provides information on the treatment of pregnant patients with chronic renal disease. Diuretics should only be used with great caution and the indications for their use must be very stringent.

Consensus-based recommendation 7.E26
Expert consensus	Level of consensus +++
Antihypertensive therapy must be expanded if it is not possible to reach the target blood pressure with monotherapy. A different substance class should be used if the dosage was increased to the middle dosage range without achieving target values.

7.3  Choice of medication for severe hypertension

Consensus-based statement 7.S29
Expert consensus	Level of consensus +++
Urapidil, nifedipine and dihydralazine are available in Germany for the initial treatment of severe hypertension in pregnancy. Labetalol IV is additionally available in Austria and Switzerland ( Table 12 ).

Table 12  Antihypertensives for acute therapy in pregnancy.

Medication		Dosage regimen
Antihypertensive therapy
Urapidil	IV	Initial slow administration of 6.25 mg IV (for 2 min), followed by 3 – 24 mg/h (with a perfusor)
Labetalol (Austria/Switzerland)	IV	Initial slow administration of 50 mg (20 – 80 mg) IV (for 1 – 3 min), poss. repeat after 10 – 30 min, perfusor: 120 mg/h
Nifedipine	p. o.	Initial administration of 5 mg p. o., repeat if necessary after 20 min
Dihydralazine	IV	Initial administration of 5 mg IV (for 2 min), followed by 2 – 20 mg/h (with a perfusor) or 5 mg every 20 min Note: onset of action occurs after 3 – 5 min, in some cases only after 20 min, especially with bolus administration (and then often excessive effect)
For pulmonary edema/cardiac insufficiency
Furosemide	IV	10 – 20 mg, repeat if necessary using higher dose
Nitroglycerin	SL/IV	0.4 – 0.8 mg sublingually, then 2 – 10 ml/h IV (perfusor 50 mg/50 ml)
Anticonvulsive prophylaxis and therapy
Magnesium sulfate (antidote: calcium gluconate 1 g IV)	IV	Initially 4 – 6 g (in 50 ml) over 15 – 20 min (as a short infusion or with a perfusor) Maintenance dose: 1 – 2 g/h

Consensus-based statement 7.S30
Expert consensus	Level of consensus +++
Dihydralazine has been approved for antihypertensive therapy in pregnancy but maternal side effects occur significantly more often compared to urapidil (especially severe headache, reflex tachycardia) which can make differentiating the diagnosis from progressive preeclampsia more difficult.

Consensus-based recommendation 7.E27
Expert consensus	Level of consensus +++
Before administering dihydralazine, up to 500 ml of an electrolyte solution should be infused to reduce the risk of sudden severe decrease in blood pressure with a consequent risk for the fetus.

8  Prophylaxis and treatment of eclampsia

The cornerstones of eclampsia therapy include:

• Trauma prevention

• Prevention of maternal hypoxemia

• Antihypertensive therapy (see chapter 7)

• Prevention of recurrent seizures (see chapter 8.1)

• Assess whether delivery of the infant is indicated (see chapter 12.5)

With eclampsia, fetal bradycardia (ca. 3 – 5 min) often occurs during or immediately after the seizure. In the postictal stage, the fetus presents with tachycardia with a loss of oscillation and poss. transient decelerations. If the fetal heart rate pattern does not recover, the possibility of preterm placental abruption must be considered and the child must be delivered immediately.

8.1  Anticonvulsive prophylaxis and therapy

Consensus-based recommendation 8.E28
Expert consensus	Level of consensus +++
The medication of choice for the prophylaxis and treatment of eclampsia must be magnesium sulfate (MgSO 4 ) IV 4 – 6 g administered over a period of 20 minutes followed by 1 – 2 g/h.

Consensus-based recommendation 8.E29
Expert consensus	Level of consensus +++
A pregnant woman (receiving magnesium therapy) must be monitored more intensively. This includes controlling the reflex status, breathing frequency and renal function. Calcium gluconate should be ready as an antidote for immediate intravenous injection (1 ampoule = 10 ml calcium gluconate 10%).

Consensus-based statement 8.S31
Expert consensus	Level of consensus +++
Monitoring serum magnesium levels is not necessary if the further course is uneventful.

Consensus-based statement 8.S32
Expert consensus	Level of consensus +++
A combination of calcium antagonists and magnesium IV does not increase magnesium-related side effects.

9  Other medications

9.1  Corticosteroid therapy

Consensus-based statement 9.S33
Expert consensus	Level of consensus +++
There is currently no evidence that the administration of corticosteroids is beneficial when treating HELLP syndrome and preeclampsia with the aim of prolonging the pregnancy.

This does not affect corticosteroid therapy for antenatal treatment of the fetus to induce lung maturation.

Consensus-based recommendation 9.E30
Expert consensus	Level of consensus +++
Corticoids are not suitable for the treatment of preeclampsia/ HELLP syndrome and must not be administered postpartum.

9.2  Anticoagulation thrombosis prophylaxis

Consensus-based recommendation 9.E31
Expert consensus	Level of consensus +++
The necessity of initiating thrombosis prophylaxis must be evaluated on a case-by-case basis for every patient with preeclampsia.

In the context of the currently published evidence mainly obtained from retrospective studies, preeclampsia was uniformly identified as a risk factor for postpartum venous thromboembolic events. See chapter 14.3.1 Management of other postpartum complications: thromboembolism . However, the relevant studies did not find evidence of an increased antenatal risk of thromboembolism.

10  Admission to hospital

Consensus-based recommendation 10.E32
Expert consensus	Level of consensus +++
A pregnant woman should be admitted to a hospital providing the relevant level of care (perinatal center) if she presents with a risk constellation typical for HDP and her condition appears to be worsening according to the assessment by her treating physician.

Such an assessment can, of course, also be carried out by other professionals working in the same field of care. Midwives have a special role to play and bear a special responsibility in this context.

Consensus-based statement 10.S34
Expert consensus	Level of consensus +++
The timely presentation of the pregnant woman to hospital is to ensure that the pregnant woman and the maternity hospital have enough time to determine the pregnant womanʼs specific risk and decide on further monitoring procedures together with the pregnant woman in a quiet elective setting.

Consensus-based recommendation 10.E33
Expert consensus	Level of consensus +++
A pregnant woman must be admitted to hospital if preeclampsia is diagnosed.

Consensus-based recommendation 10.E34
Expert consensus	Level of consensus +++
A pregnant woman must be admitted to hospital if her systolic blood pressure is ≥ 160 mmHg or her diastolic blood pressure is ≥ 110 mmHg.

Consensus-based recommendation 10.E35
Expert consensus	Level of consensus +++
A pregnant woman must be immediately admitted to hospital if clinical symptoms or laboratory test are suspicious for HELLP syndrome, especially if the woman has persistent upper abdominal pain.

Consensus-based recommendation 10.E36
Expert consensus	Level of consensus +++
A pregnant woman must be immediately transferred to hospital by emergency transport if she presents with eclampsia, preeclampsia with severe neurological prodromal symptoms, dyspnea and/or a life-threatening hypertensive crisis.

Consensus-based statement 10.S35
Expert consensus	Level of consensus +++
Fetal indications for admission to hospital may be present irrespective of the maternal situation.

11  Inpatient monitoring

Consensus-based statement 11.S36
Expert consensus	Level of consensus +++
As part of an initial assessment of the condition of the mother and fetus, the first step must be to investigate whether there is an acute maternal or fetal emergency. This is done based on: CTG (if neccesary, computerized CTG) Blood pressure measurements Taking the womanʼs medical history A clinical examination including an assessment of indicative neurological symptoms and the reflex status (patellar reflex) Evaluation for proteinuria with poss. quantification of proteinuria (protein creatinine ratio) Laboratory tests according to hospital standards (cf. Table 8 ) Ultrasound (biometry, amniotic fluid volume, placental assessment) Feto-placental and maternal Doppler

11.1  Maternal diagnostics

Inpatient monitoring of women with HDP should include:

• regular blood pressure monitoring (the interval between measurements should be based on the clinical symptoms)

• monitoring the progression of clinical symptoms: upper abdominal pain, headache, visual disorders, hyperreflexia, impaired consciousness, dyspnea, bleeding tendency

• daily weight measurements

• monitoring the urinary output (oliguria: < 0.5 ml/kg/h)

• monitoring breathing (e.g., pulse oximetry)

• laboratory tests

We recommend using a standardized evaluation system for maternal clinical monitoring, e.g., the modified early obstetric warning score (MEOWS, Table 13 ). It is not clear how often examinations with assessment of the condition of mother and fetus should be routinely carried out. For patients with chronic hypertension and gestational hypertension, the interval between examinations should be adapted according to the leading clinical symptoms. Clinical and paraclinical checks must be adjusted to the patientʼs specific symptoms and findings, and assessments may need to be carried out more often to exclude an immediate threat.

Table 13  Modified Early Obstetric Warning Score (MEOWS) according to Donders et al.

MEOW Score	3	2	1	0	1	2	3
SpO 2 (%)	≤ 85	86 – 89	90 – 95	≥ 96
Respiratory frequency (/min)		< 10		10 – 14	15 – 20	21 – 29	≥ 30
Pulse (/min)		< 40	41 – 50	51 – 100	101 – 110	110 – 129	≥ 130
Systolic BP (mmHg)	≤ 70	71 – 80	81 – 100	101 – 139	140 – 149	150 – 159	≥ 160
Diastolic BP (mmHg)			≤ 49	50 – 89	90 – 99	100 – 109	≥ 110
Diuresis (ml/h)	0	≤ 20	≤ 35	35 – 200	≥ 200
Neurology			agitated	conscious	responds to verbal stimuli	responds to pain	no reaction
Temperature (°C)		≤ 35	35 – 36	36 – 37.4	37.5 – 38.4	≥ 38.5
MEOWS 0 – 1	Normal
MEOWS 2 – 3	Stable
MEOWS 4 – 5	Unstable
MEOWS ≥ 6	Critical

It is also not clear whether and how often laboratory tests should be routinely carried out. It is recommended that laboratory tests (blood count, creatinine and transaminases) are carried out at least twice a week in pregnant women with preeclampsia.

Consensus-based recommendation 11.E37
Expert consensus	Level of consensus +++
Regular checks of the reflex status (especially of the patellar reflex) of a pregnant woman with preeclampsia should be part of the daily round during inpatient monitoring.

Consensus-based recommendation 11.E38
Expert consensus	Level of consensus +++
In cases with HELLP syndrome, laboratory tests must initially be repeated at 6 – 8-hour intervals, especially if there have been only discrete changes of lab values at the start of the disorder or if the changes to the classic triad of symptoms are incomplete.

11.2  Fetal diagnostic workup

Preeclampsia and gestational hypertension are risk factors for developing FGR. Monitoring of HDP must therefore also exclude or take account of FGR. For further information, refer to the AWMF guideline 015 – 080 on fetal growth restriction.

12  Counseling on the birth and delivery

Terminating the pregnancy is the only causal treatment for gestational hypertension, preeclampsia, and HELLP syndrome. Reasons to delay the delivery and prolong the pregnancy may include avoiding a preterm birth (benefit for the child) but also avoiding an intervention (benefit for the mother). Whereas previous guidelines recommended delivering the infant in week 37 + 0 of gestation at the latest in cases with HDP, the current international consensus is that prolonging the pregnancy until the due date, at least in cases with simple hypertension, is a valid option.

12.1  Management from 37 + 0 GW

Consensus-based recommendation 12.E39
Expert consensus	Level of consensus +++
Gestational hypertension: Women with gestational hypertension may be offered the option of prolonging the pregnancy beyond week 37 + 0 of gestation as an alternative to terminating the pregnancy if the blood pressure is being monitored, fetal well-being is ensured, and preeclampsia is excluded. Prolonging the pregnancy beyond the due date should not be recommended.

Consensus-based recommendation 12.E40
Expert consensus	Level of consensus +++
Chronic hypertension: Women with chronic hypertension may be offered the option of prolonging the pregnancy beyond week 38 + 0 of gestation as an alternative to terminating the pregnancy if the blood pressure is being monitored, fetal well-being is ensured, and preeclampsia is excluded. Prolonging the pregnancy beyond the due date should not be recommended.

Consensus-based statement 12.S37
Expert consensus	Level of consensus +++
Prolonging the pregnancy beyound week 37 + 0 of gestation is not recommended in cases with preeclampsia .

The guideline group acknowledge that, in general, prolonging the pregnancy until week 39 + 0 of gestation improves neonatal maturity which can further reduce morbidity. Early delivery must be set against the non-quantifiable potential risk for mother and child which may arise from complications of preeclampsia. Prolonging the pregnancy until the due date may be justified in individual cases as long as the mother and fetus are closely monitored.

12.2  Management between 34 + 0 and 36 + 6 GW

Consensus-based recommendation 12.E41
Expert consensus	Level of consensus +++
If termination of pregnancy is considered in a woman with preeclampsia at or beyond 34 + 0 weeks of gestation, this must be weighted up against the still elevated risk of neonatal morbidity due to primaturity.

A thorough risk-benefit assessment with regards to the date of delivery of the infant should be carried out. Compared to infants born at term, late preterm infants exhibit more complications of prematurity such as respiratory distress syndrome and adaptation disorders; their mortality is higher (3.5 – 5.5 times higher); postnatal late mortality (28 days – 12 months) is double that of infants born at term.

On the other hand, there is a risk of intrauterine fetal death , which is reported to be 3/1000 pregnancies at the end of pregnancy (≥ 36 + 0 GW). In cases with severe preeclampsia, the IUFD rate rises to 21/1000. The IUFD rate is significantly lower (9/1000) in cases with preeclampsia without severe symptoms. The rate of neonatal complications also increases depending on the extent of fetal growth restriction (especially if the fetus is < 3rd percentile). The overall approach must take all of this into account because of the common association between both complications of pregnancy.

Consensus-based recommendation 12.E42
Expert consensus	Level of consensus +++
From week 34 + 0 of gestation, delivery of the infant must be carried out as soon as possible after weighing up the maternal and fetal risks in every pregnant woman with severe progressive preeclampsia, i.e., with signs of central nervous system symptoms, pulmonary edema, cardiac decompensation, increasing renal insufficiency, systolic blood pressure of ≥ 160 mmHg or diastolic pressure of ≥ 110 mmHg resistant to therapy, eclamptic seizure, or persistent upper abdominal pain.

12.3  Management between 24 + 0 and 33 + 6 GW

Consensus-based recommendation 12.E43
Expert consensus	Level of consensus +++
In cases with preeclampsia in weeks 24 + 0 to 33 + 6 of gestation, a conservative approach should be primarily considered depending on the severity of preeclampsia and in consultation with the mother. A conservative approach is preferable if no serious effects on the mother are expected under continuous monitoring and it would clearly benefit the infant. A similar overall approach is considered appropriate for HELLP syndrome.

12.4  Management before 24 + 0 GW

Consensus-based recommendation 12.E44
Expert consensus	Level of consensus +++
In cases with preeclampsia before week 24 + 0 of gestation, the focus must be on the motherʼs condition. Counseling should be provided in a level I perinatal center and be based on the AWMF guideline 024 – 019 on infants at the limits of viability .

12.5  Preeclampsia with severe complications

Consensus-based statement 12.S38
Expert consensus	Level of consensus +++
In addition to fetal indications, the following maternal conditions are indications to deliver the infant, although in each case, the benefits of concluding ACS (antenatal corticosteroid) therapy must be weighed up against the need to urgently terminate the pregnancy because of maternal indications: severe hypertension refractive to therapy increasing renal insufficiency/acute renal failure maternal pulse oximetry value < 90% cardiac decompensation acute pulmonary edema disseminated intravascular coagulation progressive thrombocytopenia or platelet count of < 50 G/l preterm placental abruption intrauterine fetal death persistent severe upper abdominal pain emerging severe central nervous system symptoms eclampsia

Consensus-based statement 12.S39
Expert consensus	Level of consensus +++
FGR is by itself not an indication to deliver the infant in cases with preeclampsia before week 34 + 0 of gestation as long as the specific criteria for delivering an FGR infant (AWMF guideline 015 – 080) are not present.

12.6  Delivery mode

Consensus-based recommendation 12.E45
Expert consensus	Level of consensus +++
A vaginal birth is possible if mother and child are stable as there is no increased risk to the infant provided intensive maternal and fetal monitoring.

13  Anesthesia

13.1  Analgesic and anesthetic procedure at delivery

Consensus-based recommendation 13.E46
Expert consensus	Level of consensus +++
Antihypertensive therapy must be initiated or adapted in cases with severe hypertension when initiating surgery to prevent a further rise in blood pressure.

Consensus-based recommendation 13.E47
Expert consensus	Level of consensus +++
When general anesthesia is administered to a pregnant woman with HDP prior to caesarean delivery, a rise in blood pressure under laryngoscopy must be prevented with an intravenous opioid and/or antihypertensive drug.

Consensus-based recommendation 13.E48
Expert consensus	Level of consensus +++
Neuraxial regional anesthesia may be administered to a pregnant woman with preeclampsia during vaginal delivery after weighing up the overall benefits and risks.

Consensus-based recommendation 13.E49
Expert consensus	Level of consensus +++
If time permits, neuraxial regional anesthesia should be preferred to a general anesthesia in a pregnant woman with HDP who will be delivered by caesarean section after the patient-specific benefits and risks have been considered,

Consensus-based recommendation 13.E50
Expert consensus	Level of consensus +++
Phenylephrine, ephedrine, noradrenaline or theodrenaline/cafedrine may be used to treat spinal anesthesia-induced hypotension.

Consensus-based recommendation 13.E51
Expert consensus	Level of consensus +++
The spinal anesthesia for caesarean section administered to a pregnant women with HDP must consist of a combination of a low-dose local anesthetic plus a lipophilic opioid (sufentanil, fentanyl). Neuraxial administration of morphine may be additionally considered for postoperative analgesia.

13.2  Monitoring, intensive monitoring and treatment

Consensus-based recommendation 13.E52
Expert consensus	Level of consensus +++
Pulse contour analysis may be used for targeted hemodynamic optimization (GDT) based on volume and/or catecholamines to monitor a pregnant woman with (pre)eclampsia in the context of regional or general anesthesia.

Consensus-based recommendation 13.E53
Expert consensus	Level of consensus +++
Perioperative echocardiography may be useful in cases with preeclampsia to plan further hemodynamic therapy.

Consensus-based recommendation 13.E54
Expert consensus	Level of consensus +++
Echocardiography should be carried out in cases with preeclampsia and associated complications of the cardiopulmonary system (pulmonary edema, pleural effusions, suspicion of reduced CO) to exclude peripartum cardiomyopathy.

14  Postpartum management

The recommendations for postpartum management refer to the period which starts with delivery of the infant and ends with discharge of the woman from inpatient care. In principle, all women with HDP are at risk of exacerbation of the disorder for up to 7 days postpartum. In view of the syndromal nature of the clinical picture (preeclampsia), differential diagnoses must be considered at all times and physicians from other specialties should be consulted if required; this also applies to the postpartum phase.

14.1  Blood pressure monitoring and antihypertensive therapy

Consensus-based recommendation 14.E55
Expert consensus	Level of consensus +++
In the immediate postpartum period every woman with preeclampsia must be monitored continuously for at least 4 h until she has stabilized. Regular blood pressure, pulse and temperature measurements, monitoring of the fluid balance, breathing, and oxygen saturation, and laboratory tests must be carried out. The frequency and the intervals between measurements depend on the clinical symptoms.

Consensus-based recommendation 14.E56
Expert consensus	Level of consensus +++
Intensified blood pressure measurements must be carried out regularly postpartum. Gestational hypertension: daily measurement of blood pressure for a minimum of 2 days postpartum or longer, according to clinical necessity Preeclampsia: blood pressure measurement (≥ 4×/day) until discharge

Consensus-based recommendation 14.E57
Expert consensus	Level of consensus +++
Blood pressure of women with HDP must be monitored for at least 12 weeks postpartum.

Consensus-based recommendation 14.E58
Expert consensus	Level of consensus +++
Blood pressure medication administered regularly antenatelly must be continued postpartum and adapted to the current blood pressure. If necessary, the medication may be switched to oral administration.

Consensus-based recommendation 14.E59
Expert consensus	Level of consensus +++
Postpartum, blood pressure should be adjusted to the target values of < 135/85 mmHg.

Consensus-based recommendation 14.E60
Expert consensus	Level of consensus +++
If blood pressure medication during pregnancy consisted of alpha-methyldopa, this may be switched after the birth to another medication compatible with breastfeeding due to better pharmacodynamics and greater user-friendliness.

Consensus-based recommendation 14.E61
Expert consensus	Level of consensus +++
Medication with alpha-methyldopa should not be initiated postpartum if this is the first time that the mother requires blood pressure medication.

Because of the known side-effects profile of alpha-methyldopa with its suspected higher risk of developing depressive disorders, limited effectiveness, and problems with compliance when taking several doses per day, calcium antagonists and ACE inhibitors are better alternatives.

The oral antihypertensive drugs compatible with breastfeeding are listed in Table 14 . There is currently no data on angiotensin receptor blockers and their compatibility with breastfeeding (for details, see also www.embryotox.de , toxnet.nlm.nih.gov or the Drugs and Lactation Database [LactMed ^® ] https://www.ncbi.nlm.nih.gov/books/NBK501922/#IX-E ).

Table 14  Possible antihypertensive drugs in the postpartum period.

Name	Substance group	Lactation	Side effects	Contraindications	Dosage*
* For dosages, please consult the relevant information leaflets.
Amlodipine	calcium channel blocker	no neonatal compromise	headache		5 mg/d up to max. of 10 mg/d
Captopril	ACE inhibitor	no neonatal compromise	Cough		Start with 1 × 12.5 mg up to max. 3× per day
Enalapril	ACE inhibitor	no neonatal compromise	Cough		Start with 1 × 2.5 mg up to max. of 2 × 10 mg/d
Labetalol	combined alpha and beta blocker	no neonatal compromise	bradycardia	asthma	Start with 3 × 100 mg up to maximum of 1600 mg/d
Methyldopa	alpha-2 agonist	no neonatal compromise	depression, methyldopa hepatitis	mental disorders	Up to 4 × 500 mg
Metoprolol	beta blocker	neonatal hypoglycemia	bradycardia	asthma	Start with 1 × 47.5 mg, maximum of 200 mg/d
Nifedipine	calcium channel blocker	no neonatal compromise	headache		2 × 10 or 20 mg retard up to 160 mg/d

14.2  Anticonvulsive therapy postpartum

Consensus-based recommendation 14.E62
Expert consensus	Level of consensus +++
If intravenous administration of magnesium sulfate was already started antepartum, administration should be continued for up to 48 hours postpartum.

Consensus-based recommendation 14.E63
Expert consensus	Level of consensus +++
Prophylactic treatment against eclampsia/the recurrence of eclampsia should be started in cases with postpartum preeclampsia/eclampsia by administering magnesium sulfate (MgSO 4 ) IV.

Consensus-based recommendation 14.E64
Expert consensus	Level of consensus +++
Because of the considerable overlap in symptoms with cerebrovascular complications of pregnancy (preeclampsia, posterior reversible encephalopathy syndrome [PRES] and hemorrhagic or ischemic insults), neurological symptoms emerging postpartum should be investigated immediately by an interdisciplinary team.

14.3  Management of other postpartum complications

14.3.1  Thromboembolism

Consensus-based statement 14.S40
Expert consensus	Level of consensus +++
HDP is a risk factor for postpartum thromboembolic events and must be included in the considerations underlying the decision to initiate prophylactic anticoagulation.

In the currently published evidence taken mainly from retrospective studies, preeclampsia was consistently identified as a risk factor for postpartum venous thromboembolic events. Depending on the study, the risk was estimated to be 3 to 5 times higher than that of a reference group with uncomplicated pregnancies. When combined with co-factors the risk appeared to be even higher, e.g., if FGR was present; in such cases the risk was 7 times higher. A precise categorization of HDP using prospectively compiled data from primary and secondary care in the United Kingdom showed that the risk of VTE rose from chronic hypertension (IRR 1.68 [95% CI: 1.01 – 2.78]) to gestational hypertension (IRR 2.10 [95% CI: 1.28 – 3.43]) to preeclampsia (IRR 3.54 [95% CI: 2.05 – 6.11]). It is especially important to emphasize that the VTE risk in cases with preeclampsia remains elevated during the entire 6 weeks of the puerperium and may persist further for 6 to 12 weeks.

14.3.2  Pulmonary edema

Up to 3% of patients with preeclampsia go on to develop pulmonary edema, and 70% of cases occur postpartum. Antenatal development of pulmonary edema may make it necessary to deliver the infant. The postpartum treatment of a woman with pulmonary edema who has given birth should not differ from the therapy given to other patients with pulmonary edema.

14.3.3  Postpartum management of oliguria/renal failure

There may be many reasons for oliguria (< 0.5 ml/kg/h) in the postpartum period. In addition to excluding postrenal kidney failure, the further diagnostic workup and treatment should follow the general guidelines for non-obstetric patients.

14.3.4  Peripartum cardiomyopathy

Peripartum cardiomyopathies are four times more prevalent in patients who are status post preeclampsia. An echocardiography should always be carried out promptly if symptoms such as breathlessness, shortness of breath, prolonged fatigue, or acute deterioration of GH occur peripartum. For additional diagnostic examinations and treatment, refer to the relevant European guidelines such as the 2018 ESC Clinical Practice Guidelines on the Management of Cardiovascular Diseases during Pregnancy.

14.4  Supporting mother-child bonding and breastfeeding

Consensus-based recommendation 14.E65
Expert consensus	Level of consensus +++
To support mother-child bonding as early as possible, contact between mother and baby must be enabled directly after the birth. Optimal care must also be provided to promote bonding, breastfeeding, and expressing breast milk. These recommendations apply irrespective of whether the birth was an emergency birth or required transfer to the intensive care unit.

The guideline authors explicitly support the current position papers and guidelines of the WHO and EFCNI on the care of preterm infants and kangaroo mother care which recommend at least 8 hours skin-to-skin contact every day, even for very early preterm neonates, and 24/7 (unlimited) maternal access to the newborn baby.

• https://who.canto.global/v/Prematurity/album/JG67H

• https://www.who.int/news/item/16-05-2023-new-resources-released-to-help-more-preterm-and-low-birthweight-babies-benefit-from-kangaroo-mother-care

• https://www.efcni.org/activities/efcni-academy/kmc/

Antenatal colostrum harvesting may also be useful.

14.5  Psychosocial support

Consensus-based recommendation 14.E66
Expert consensus	Level of consensus +++
Postpartum care should include an evaluation of the psychological stress situation of the woman who has given birth. The Edinburgh Postnatal Depression Scale (EPDS) is a useful and suitable diagnostic aid to assess the situation.

The EPDS is easy to administer and helps to identify patients who should be referred immediately to psychological care. The advantage of this standardized and evaluated test is that the EPDS can also be administered in different languages.

• https://postpartale-depression.ch/de/informationen/downloads.html

Signs of postpartum depression should be observed, discussed and, if necessary, additionally treated by providing psychological support. Together with the medical service the midwife plays a key role. Irrespective of the level of the motherʼs psychological stress as shown by the EPDS, it is important to provide professional psychological support, especially in the context of the experienced borderline situation.

14.6  Final discussion and health counseling

Consensus-based recommendation 14.E67
Expert consensus	Level of consensus +++
A final discussion must be held with the woman who has given birth about the disorder, her specific course, and the further consequences. Where possible, this discussion should be held with womanʼs partner present and include the offer of another discussion, e.g., before planning/starting another pregnancy.

Consensus-based recommendation 14.E68
Expert consensus	Level of consensus +++
Counseling in the postpartum period should cover the following topics: Information about continuing ambulatory blood pressure measurements and the target blood pressure values Information about the increased risk of thromboembolism The patient should be advised about the increased risk of cardiovascular disease for mother and infant The patient should be advised about primary prevention measures by changing her lifestyle The couple should be advised about the probability of recurrence in a subsequent pregnancy Information about the importance and possible substance of follow-up care (see chapter 15) The offer of another counseling session prior to a further planned pregnancy or immediately after the start of another pregnancy and an explanation of the care provided in pregnancy as well as the possible prophylactic measures.

Based on the extensive evidence about the negative impact on long-term health of HDP and especially after preeclampsia, providing detailed and sensitive counseling before an affected woman who has given birth is discharged is especially important and significant. See also chapter 15 on aftercare. It may be useful for the woman to point her to self-help groups such as Arbeitsgemeinschaft Gestose-Betroffene e. V., Bundesverband Das Frühgeborene Kind e. V., and the European Foundation for the Care of Newborn Infants.

• www.gestose-betroffene.de

• www.fruehgeborene.de

• www.efcni.org

Consensus-based recommendation 14.E69
Expert consensus	Level of consensus +++
A woman with preeclampsia who has given birth must be followed up very closely with regards to her cardiovascular risk. Chapter 15 provides a proposal for the further course of action. An aftercare passport can be provided for support and to document the course of the disorder (see the attachment to the guideline) .

15  Aftercare and long-term health after HDP

Women with hypertension in pregnancy have a higher risk of a long-term negative impact on their health. The cardiovascular system is particularly affected. The risk of high blood pressure and cardiovascular disease is 2 – 6 times higher and depends on the severity of the disorder, the time when the disorder emerged during pregnancy, the number of previous pregnancies with complications the mother has had as well as other accompanying factors such as preexisting maternal diseases/disorders. Other organ systems may be affected in addition to the cardiovascular system. There is also a risk of recurrence of a hypertensive disorder in any subsequent pregnancy ( Table 15 ).

Table 15  Possible long-term consequences for maternal health.

Long-term consequences of hypertension in pregnancy
Risk of recurrence of HDP in subsequent pregnancy gestational hypertension preeclampsia eclampsia HELLP syndrome
Long-term cardiovascular risks chronic hypertension coronary heart disease peripheral vascular disease including venous thromboembolic events cardiac insufficiency stroke death from cardiovascular disease
Neurological disease epilepsy dementia
Renal disease chronic renal insufficiency
Metabolic disease diabetes mellitus type 2 obesity lipid metabolism disorders, hypercholesterolemia microalbuminuria

Adequate blood pressure monitoring and aftercare is important to prevent progression of the disorder at an early stage. For this, the definition of the target blood pressure values and the choice of drug therapy used to adjust blood pressure levels after discharge from hospital must explicitly follow the recommendations of the German National Care Guideline on Hypertension.

As there are currently no consistent recommendations or financial structures in the DACH countries (Germany, Austria, Switzerland) relating to long-term follow-up of affected women after preeclampsia, the guideline authors agreed upon a list of suggestions which have been summarized in Table 16 , based on the Best Practice Advice published on this issue by FIGO in 2023.

Table 16  Suggestions for follow-up care after HDP (based on FIGO 2023).

When?	Where/Who?	What?
1 Still requires medication after 6 months to maintain the target values of the German National Care Guideline on Hypertension. 2 The risk of cardiovascular disease is especially high in cases with current/persistent hypercholesterolemia. Statin therapy should be considered for women who are status post severe HDP with persistent hypercholesterolemia.
At 6 weeks Repeat at 6 months, 12 months, and then yearly	Gynecologistʼs office	Blood pressure: target based on the relevant German National Care Guideline on Hypertension (120/80 mmHg for a young woman at risk) Ensure blood pressure monitoring can be carried out at home using an automated blood pressure monitor with an upper arm cuff Reduce medication when average daily readings fall below the target figures If blood pressure 1 levels remain high, further investigation into the causes of hypertension by a general practitioner or medical specialist is indicated. Weight: (target BMI < 25) Lifestyle counselling, promotion of physical activity or programs to promote better health Abstain from using nicotine Laboratory tests: cholesterol 2 , HDL, LDL, TG, GFR, proteinuria, creatinine, HbA 1c If anomalies are detected, refer patient to general practitioner or medical specialist for further investigation and therapy.
The prevention program should be maintained every year by the gynecologist, general practitioner or specialist for internal medicine.

A template for an aftercare passport as demanded by patient organizations and proposed by FIGO can be viewed here using the following QR code ( Fig. 1 ).

Fig. 1.

 QR code for an aftercare passport after hypertensive disorder of pregnancy.