CMQCC PREECLAMPSIA TOOLKIT

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CLASSIFICATION AND DIAGNOSIS OF HYPERTENSIVE DISORDERS OF
PREGNANCY

Maurice Druzin, MD, Stanford University School of Medicine

The diagnosis and classification of hypertensive disorders of pregnancy was primarily

based on ACOG Practice Bulletin No. 33, January 2002, reaffirmed 2012.1 The current
diagnosis and classification is based on Hypertension in Pregnancy: Report of the
American College of Obstetricians and Gynecologists’ Task Force on Hypertension in
Pregnancy published November 2013.2 The definition of hypertension in pregnancy is a
blood pressure of ≥ 140 mm Hg systolic or ≥ 90 mm Hg diastolic. The criteria for the
diagnosis of preeclampsia, which is a pregnancy specific syndrome usually occurring
after 20 weeks of gestation, include new onset:  

1. Blood pressure of 140 mm Hg systolic or higher or 90 mm Hg diastolic or higher

that occurs after 20 weeks gestation in a women with previously normal blood
pressure AND  
 
2. Proteinuria, defined as urinary excretion of 0.3 grams protein or higher in a 24-
hour urine specimen,2 OR  

3. In the absence of proteinuria, new-onset hypertension with the new onset of

any of the following:  

a. Thrombocytopenia: platelet count less than 100,000/microliter

b. Renal insufficiency: serum creatinine concentrations greater than 1.1
mg/dL or a doubling of the serum creatinine concentration in the
absence of other renal disease
c. Impaired liver function: elevated blood concentrations of liver
transaminases to twice normal concentration
d. Pulmonary edema
e. Cerebral or visual symptoms2

4. Preexisting hypertension prior to 20 weeks gestation would be considered

chronic hypertension. Preexisting proteinuria prior to 20 weeks gestation would
be suggestive of chronic renal disease.  

New onset hypertension without proteinuria but with signs and symptoms of major end
organ involvement such as headache, upper abdominal pain, hepatic dysfunction,
pulmonary edema, or severe renal dysfunction, would potentially be indicative of “atypical
preeclampsia.”3 The updated ACOG Executive Summary has deleted the term ‘atypical’,
and a diagnosis of “preeclampsia” is recommended in patients with this presentation.2

The term gestational hypertension is used to describe cases in which elevated blood
pressure without proteinuria develops in a woman after 20 weeks gestation and blood

 
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pressure levels return to normal postpartum (National High Blood Pressure working
Group). As many as one quarter of women with gestational hypertension will develop
proteinuria, i.e. preeclampsia.4

There is clearly potential for overlap of all these conditions, as a patient may present with
gestational hypertension and progress to the preeclampsia/eclampsia syndrome very
rapidly.  
   

 
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Table 1: Classification of hypertension in pregnancy
• BP of ≥ 140 mm Hg systolic or 90 mm Hg diastolic predating conception  
• Identified prior to 20 weeks gestation  
Chronic hypertension   • Persists > 12 weeks postpartum  
• Use of antihypertensive medications before pregnancy  
Superimposed • New onset in a woman with hypertension prior to 20 weeks  
preeclampsia or • Sudden increase in proteinuria if already present in early gestation  
eclampsia on chronic • Sudden increase in BP  
hypertension • Development of HELLP syndrome  
• Development of headache, scotomata, or epigastric pain  
Gestational • 140 mm Hg systolic or ≥ 90 mm Hg without proteinuria occurring after 20
hypertension   weeks gestation  
• Transient diagnosis with normalization of BP by 12 weeks postpartum  
• May represent pre-proteinuric phase of preeclampsia or recurrence of
chronic hypertension abated in mid-pregnancy  
• May evolve to preeclampsia  
• Retrospective diagnosis  
Preeclampsia • Occurring after 20 weeks of pregnancy  
• BP ≥ 140 mm Hg systolic or ≥ 90 mm Hg diastolic or higher  
• Proteinuria 0.3 grams protein or higher in a 24-hour urine specimen OR ≥+1
per dipstick OR P/C ratio > 0.3 mg/dL
Eclampsia   • Presence of new onset grand mal seizures in a pregnant woman with
preeclampsia (rule out idiopathic seizure disorder or other central nervous
system pathology such as intracranial hemorrhage, bleeding arteriovenous
malformation, ruptured aneurysm)  
• New onset seizures 48-72 hours postpartum (other central nervous system
pathology is the likely reason for the seizure after 7 days)  
Severe preeclampsia If one or more of the following criteria are present:
1. Blood pressure of 160 mm Hg systolic or higher or 110 mm Hg diastolic or
higher on two occasions at least 6 hours apart while the patient is on bed
rest
2. Oliguria of less than 500 ml in 24 hours
3. Cerebral or visual disturbances
4. Pulmonary edema or cyanosis
5. Epigastric or right upper-quadrant pain
6. Impaired liver function as indicated by abnormally elevated blood
concentrations of liver enzymes (to twice normal concentration), severe
persistent right upper quadrant or epigastric pain unresponsive to
medication and not accounted for by alternative diagnoses, or both
7. Thrombocytopenia
8. Renal insufficiency
HELLP Syndrome Hemolysis Elevated Liver enzymes Low Platelets
(subset of severe
preeclampsia)
1
Adapted from ACOG Practice Bulletin #33, Reaffirmed 2013 and Hypertension in Pregnancy: Report of the
American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy,
2
November 2013.

 
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Table 2: Hypertension in Pregnancy: Recommendations of the ACOG Task Force on
Hypertension in Pregnancy: Executive Summary, published November 20132
PRIOR Terminology Hypertension In Pregnancy: Report of the ACOG Task Force on
(ACOG Bulletin #33, Hypertension In Pregnancy, November 2013
2002, reaffirmed 2012)

Mild preeclampsia (BP > (The Term ‘mild preeclampsia’ is discouraged for clinical
140/90 mm Hg) classification)
Diagnostic Criteria: Preeclampsia Without Severe Features*

Chronic hypertension No Change in Definition

Gestational
hypertension
Superimposed
preeclampsia
Severe preeclampsia: Diagnostic Criteria: Severe Preeclampsia*
If one or more of the
following criteria are
present:

*Copyright permission received for use of tables inserted above.

 
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Other common associations with Preeclampsia:

HELLP Syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) is suggested

when women with severe preeclampsia develop hepatic and hematologic manifestations
as the predominant clinical picture, and is associated with an increased risk of adverse
outcomes.4-6
 
Chronic Hypertension complicating pregnancy is diagnosed by high blood pressure, BP
≥140/90 or greater, known to predate conception. When preconception blood pressures
are not known, elevated blood pressure detected before 20 weeks of gestation is often
due to chronic hypertension. The most common etiology of chronic hypertension is most
likely essential hypertension, although secondary hypertension as a result of renal
disease, autoimmune disease, or vascular disease should be considered depending on
the clinical presentation of the patient.

Superimposed Preeclampsia/Eclampsia chronic or gestational hypertension with

superimposed preeclampsia is a common finding. Patients with underlying renal or
vascular disease have a high risk of developing superimposed preeclampsia, as do those
with essential hypertension.  

There have been a number of recommendations to further divide preeclampsia according

to the gestational age of presentation into the following categories:  

Less than 34 weeks gestation – early preeclampsia

Greater than 34 weeks gestation – late preeclampsia  

Preeclampsia is either mild or severe under the prior accepted definitions. However, the
ACOG Executive Summary is recommending the elimination of the use of the term “mild.”
The recommendation is to use the terms “preeclampsia without severe features” or
“preeclampsia with severe features.” The prior rigid assignment of patients with this
disease into a category of “mild preeclampsia” was often detrimental to the appropriate
management of patients. This disease is often not stable or static, but may evolve from
“mild“ preeclampsia to severe preeclampsia, HELLP Syndrome and/or eclampsia within a
matter of hours. Rapid progression is typically seen in preeclampsia with onset prior to 34
weeks.7

EVIDENCE GRADING
Level of Evidence: II-2, II-3

REFERENCES

1. ACOG. Diagnosis and Management of Preeclampsia and Eclampsia #33.

American Congress of Obstetricians and Gynecologists Practice Bulletin Number
33. 2002 (Reaffirmed 2012).

 
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2. ACOG. Hypertension in Pregnancy: Report of the American College of
Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy.
Obstet Gynecol. 2013;122(5):1122-1131.
3. Sibai BM, Stella CL. Diagnosis and management of atypical preeclampsia-
eclampsia. Am J Obstet Gynecol. May 2009;200(5):481 e481-487.
4. Sibai B, Ramadan M, Chari R, Friedman S. Pregnancies complicated by HELLP
syndrome (hemolysis, elevated liver enzymes, and low platelets): subsequent
pregnancy outcome and long-term prognosis. Am J Obstet Gynecol.
1995;172:125-129.
5. Sibai B, Ramadan M, Usta I, Salama M, Mercer B, Friedman S. Maternal morbidity
and mortality in 442 pregnancies with hemolysis, elevated liver enzymes, and low
platelets ( HELLP Syndrome). Am J Obstet Gynecol. 1993;169:1000-1006.
6. Barton J, Sibai B. Hepatic imaging in HELLP syndrome (hemolysis, elevated liver
enzymes, and low platelet count). Am J Obstet Gynecol. 1996;174(1820-1825
discussion 1825-1827).
7. Sibai BM. Evaluation and management of severe preeclampsia before 34 weeks'
gestation. Am J Obstet Gynecol. Sep 2011;205(3):191-198.