INTERIM UPDATE
ACOG PRACTICE BULLETIN
Clinical Management Guidelines for Obstetrician–Gynecologists
NUMBER 222 (Replaces Practice Bulletin No. 202, December 2018)
Committee on Practice Bulletins—Obstetrics. This Practice Bulletin was developed by the American College of Obstetricians and
Gynecologists’ Committee on Practice Bulletins—Obstetrics in collaboration with Jimmy Espinoza, MD, MSc; Alex Vidaeff, MD,
MPH; Christian M. Pettker, MD; and Hyagriv Simhan, MD.
INTERIM UPDATE: The content of this Practice Bulletin has been updated as highlighted (or removed as necessary) to
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include limited, focused editorial corrections to platelet counts, diagnostic criteria for preeclampsia (Box 2), and pre-
eclampsia with severe features (Box 3).
Gestational Hypertension and
Preeclampsia
Hypertensive disorders of pregnancy constitute one of the leading causes of maternal and perinatal mortality
worldwide. It has been estimated that preeclampsia complicates 2–8% of pregnancies globally (1). In Latin
America and the Caribbean, hypertensive disorders are responsible for almost 26% of maternal deaths,
whereas in Africa and Asia they contribute to 9% of deaths. Although maternal mortality is much lower in
high-income countries than in developing countries, 16% of maternal deaths can be attributed to hypertensive
disorders (1, 2). In the United States, the rate of preeclampsia increased by 25% between 1987 and 2004 (3).
Moreover, in comparison with women giving birth in 1980, those giving birth in 2003 were at 6.7-fold increased
risk of severe preeclampsia (4). This complication is costly: one study reported that in 2012 in the United States,
the estimated cost of preeclampsia within the first 12 months of delivery was $2.18 billion ($1.03 billion for
women and $1.15 billion for infants), which was disproportionately borne by premature births (5). This
Practice Bulletin will provide guidelines for the diagnosis and management of gestational hypertension and
preeclampsia.
Background Definitions and Diagnostic Criteria for
Hypertensive Disorders of Pregnancy
Risk Factors Preeclampsia (With and Without
A variety of risk factors have been associated with Severe Features)
increased probability of preeclampsia (Box 1) (6–
12). Nonetheless, it is important to remember that Preeclampsia is a disorder of pregnancy associated with
most cases of preeclampsia occur in healthy nullipa- new-onset hypertension, which occurs most often after 20
rous women with no obvious risk factors. Although weeks of gestation and frequently near term. Although
the precise role of genetic–environmental inter- often accompanied by new-onset proteinuria, hypertension
actions on the risk and incidence of preeclampsia is and other signs or symptoms of preeclampsia may present
unclear, emerging data suggest the tendency to in some women in the absence of proteinuria (17). Reli-
develop preeclampsia may have some genetic com- ance on maternal symptoms may be occasionally problem-
ponent (13–16). atic in clinical practice. Right upper quadrant or epigastric
VOL. 135, NO. 6, JUNE 2020 OBSTETRICS & GYNECOLOGY e237
© 2020 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
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