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ob.gestational-hypertension.v1PRODUCTION
ob.gestational-hypertension.v1

Gestational Hypertension (without severe features)

obstetricssubacutechronicadultpregnancy
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0 / 13
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm gestational HTN (new HTN ≥140/90 after 20 wk, NO proteinuria, NO severe features) vs chronic HTN vs pre-eclampsia vs superimposed — ACOG 2020 (PB 222); ISSHP 2021

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4
Actions
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Advance rule
Set
Advance when

classification assigned

Patient inputs (15)

GHTN defined as new HTN AFTER 20 weeks; drives delivery timing (≥37+0)

Severe-feature symptom = reclassification trigger

Severe-feature symptom (scotomata, blurred vision)

Severe-feature symptom (HELLP / liver capsule stretch)

Fetal compromise — triggers NST/BPP and possible delivery

Distinguishes GHTN from chronic / superimposed

Recurrence ≥20%; aspirin indication

UPCR or 24-h urine — distinguishes GHTN from pre-eclampsia

<100K = severe feature → reclassify to PE

Cr ≥1.1 or doubling = severe feature

AST/ALT ≥2× ULN = severe feature

Severity stratification: 140–159 vs ≥160; ACOG 767 trigger

90–109 non-severe vs ≥110 severe

ACEi/ARB teratogen check; aspirin status; CCB choice

Serial growth scans for FGR (gestational HTN doubles FGR risk)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (13)

13 need judgement
  • informationalseveresustained_severe_htn_160_110_in_ghtn
    BP ≥160/110 sustained × 15 min in patient with gestational HTN — ACOG 767 (2017)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereprogression_to_pe_proteinuria
    New proteinuria (UPCR ≥0.3 OR 24-h ≥300 mg) developing in known gestational HTN — ACOG 2020 (PB 222)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereprogression_to_pe_severe_features
    New severe feature (severe HA, vision changes, RUQ pain, plt <100K, AST/ALT ≥2× ULN, Cr ≥1.1 or doubling, pulmonary edema) — ACOG 2020 (PB 222)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverefetal_compromise
    Decreased fetal movement, non-reassuring NST, or FGR <10th percentile in known GHTN — ACOG 2020 (PB 222)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepostpartum_severe_htn_late
    New severe HTN ≥160/110 up to 6 weeks postpartum after GHTN diagnosis — AHA 2021; ACOG 2020 (PB 222)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebp_sustained_above_160_110
    BP sustained ≥160/110 × 15 min in known gestational HTN antepartum or intrapartum → immediate antihypertensive load + admit for severe-feature workup (CBC, LFT, Cr, LDH, UPCR, fetal monitoring) — ACOG 767 (2019); ACOG 222 (reaff 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_features_emergence
    Any single severe feature emerges in known gestational HTN — ANY of: sustained SBP ≥160 / DBP ≥110, AST/ALT ≥2× ULN, plt <100×10⁹/L, creatinine ≥1.1 mg/dL OR doubling from baseline, persistent severe headache, visual changes (scotomata, blurred vision, photopsia), pulmonary edema, persistent severe epigastric / RUQ pain — ACOG 222 (2020, reaff 2024); ISSHP 2024
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremagnesium_prophylaxis_required
    Severe features confirmed OR eclamptic seizure occurs → magnesium 4-6 g IV load over 15-20 min + 1-2 g/h infusion × 24 h after delivery OR 24 h after last seizure — ACOG 222 (2020, reaff 2024); Magpie Trial Lancet 2002 (PMID 12057549)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverefetal_growth_restriction
    Estimated fetal weight (EFW) <10th percentile + abdominal circumference (AC) <10th percentile + abnormal umbilical artery Doppler (absent or reversed end-diastolic flow) in known gestational HTN → MFM consult + close growth surveillance + delivery timing per ACOG / SMFM consensus
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepostpartum_severe_hypertension
    BP ≥160/110 within 6 weeks postpartum in patient with GHTN history → ED for assessment + IV antihypertensive + consider magnesium prophylaxis; routes to cardio.htn.core.v1 for long-term management if BP fails to normalise by 12 wk — AHA 2021; ACOG 767 (2019); ACOG 222 (reaff 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverechap_eligible_chronic_htn_overlap
    Chronic HTN diagnosed pre-pregnancy OR in first 20 wks gestation → start antihypertensive at sustained ≥140/90 per CHAP NEJM 2022 (PMID 35452981) — distinct from GHTN diagnostic criterion (BP ≥140/90 AFTER 20 wk in previously normotensive woman)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateterm_delivery_indicator
    GA ≥37+0 weeks with confirmed gestational HTN — ACOG 2020 (PB 222)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildmasked_chronic_htn_unmasking
    BP ≥140/90 noted before 20 wk gestation in patient labelled "gestational HTN" — ISSHP 2021
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONoptionalDrives severity classification
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Recommended regimen

Gestational HTN — severity-tiered (non-severe PO maintenance; severe acute IV)
axis: gestational_htn_severity_tierstep 1 - Tier 1 — Aspirin prophylaxis (12–28 wk; ideally start ≤16 wk)
Selected step "Tier 1 — Aspirin prophylaxis (12–28 wk; ideally start ≤16 wk)" — Any high-risk factor (chronic HTN, T1/T2DM, CKD, autoimmune, multiple gestation, prior PE) OR ≥2 moderate-risk factors
  • aspirin
    first line
    antiplatelet
    81 mg • PO • once daily
    triggers: high_or_moderate_PE_risk
    USPSTF 2021 + ACOG 2020 (PB 222) — preeclampsia prevention from 12 wk through 36 wk
    rxcui 1191

outpatient playbook — drug actions (4)

  1. 1. aspirin 81 mg (ASPRE-criterion if not already on)
    81-150 mg PO daily 12-28 wk (ideally ≤16 wk) • PO • daily 12–28 wk
    trigger: ≥1 high-risk OR ≥2 moderate-risk factors — USPSTF 2021
    USPSTF 2021 (PMID 34581729) + ASPRE 2017 (PMID 28657417) PE prevention
  2. 2. labetalol PO
    100 mg BID, titrate up to 600 mg TID (1800 mg/day max) • PO • BID-TID
    trigger: Sustained BP ≥140/90 — CHAP target <140/90
    CHAP (Tita NEJM 2022, PMID 35452981) + CHIPS (Magee NEJM 2015, PMID 25602002) target <140/90
  3. 3. nifedipine ER
    30 mg daily, titrate up to 120 mg/day • PO • daily
    trigger: Alternative first-line — CHAP (Tita NEJM 2022)
    CHAP (Tita NEJM 2022) equivalent option
  4. 4. methyldopa
    250 mg BID, titrate up to 1.5 g TID (max 3 g/day) • PO • BID-TID
    trigger: Intolerance / contraindication to labetalol or nifedipine — ACOG 2020 (PB 222)
    Pregnancy-safe alternative; less effective than labetalol/nifedipine for tight control per CHIPS (Magee NEJM 2015, PMID 25602002)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: New BP ≥140/90 after 20 weeks (no prior chronic HTN); BP ≥160/110 in pregnancy (route urgently — severe HTN); Prior pre-eclampsia or gestational HTN — high-risk surveillance.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Gestational Hypertension (without severe features)** (ob.gestational-hypertension.v1).
Phenotype framing: Phenotype: gestational HTN, transient HTN of pregnancy, masked/white-coat HTN, chronic HTN missed pre-pregnancy, pre-eclampsia, superimposed PE — ISSHP 2021; ACOG 2020 (PB 222)
Scope: Confirm gestational HTN (new HTN ≥140/90 after 20 wk, NO proteinuria, NO severe features) vs chronic HTN vs pre-eclampsia vs superimposed — ACOG 2020 (PB 222); ISSHP 2021

No severity triggers fired against current inputs.

Plan

Regimen axis: **Gestational HTN — severity-tiered (non-severe PO maintenance; severe acute IV)** — step "Tier 1 — Aspirin prophylaxis (12–28 wk; ideally start ≤16 wk)".
1. aspirin 81 mg PO once daily (antiplatelet, first line) — USPSTF 2021 + ACOG 2020 (PB 222) — preeclampsia prevention from 12 wk through 36 wk

Setting playbook (outpatient) — Confirm GHTN, screen for severe features + proteinuria, initiate PO antihypertensive at <140/90 target, surveil for progression to PE, plan delivery at 37+0, postpartum surveillance through 6-12 wk + lifelong CV-risk plan — ACOG 2020 (PB 222, reaff 2024); CHAP (Tita NEJM 2022); USPSTF 2021; AHA 2021
2. aspirin 81 mg (ASPRE-criterion if not already on) 81-150 mg PO daily 12-28 wk (ideally ≤16 wk) PO daily 12–28 wk — ≥1 high-risk OR ≥2 moderate-risk factors — USPSTF 2021 (USPSTF 2021 (PMID 34581729) + ASPRE 2017 (PMID 28657417) PE prevention)
3. labetalol PO 100 mg BID, titrate up to 600 mg TID (1800 mg/day max) PO BID-TID — Sustained BP ≥140/90 — CHAP target <140/90 (CHAP (Tita NEJM 2022, PMID 35452981) + CHIPS (Magee NEJM 2015, PMID 25602002) target <140/90)
4. nifedipine ER 30 mg daily, titrate up to 120 mg/day PO daily — Alternative first-line — CHAP (Tita NEJM 2022) (CHAP (Tita NEJM 2022) equivalent option)
5. methyldopa 250 mg BID, titrate up to 1.5 g TID (max 3 g/day) PO BID-TID — Intolerance / contraindication to labetalol or nifedipine — ACOG 2020 (PB 222) (Pregnancy-safe alternative; less effective than labetalol/nifedipine for tight control per CHIPS (Magee NEJM 2015, PMID 25602002))

Non-pharmacologic actions:
- Home BP cuff training + 3-day home BP self-monitoring at diagnosis — CHAP (Tita NEJM 2022); ISSHP 2024
- Severe-feature symptom education + return precautions — ACOG 2020 (PB 222)
- Daily kick counts — ACOG 2020 (PB 222)
- Sodium-moderation counselling (no strict restriction) — NICE NG133 2023
- Activity not strictly bed rest (no proven benefit; VTE harm) — ISSHP 2024
- Vaccinations review (flu, Tdap, COVID, RSV-mat) — ACOG 2020 (PB 222)
- ASPRE-criterion aspirin counselling and confirmation — USPSTF 2021 (PMID 34581729) + ASPRE (Rolnik NEJM 2017, PMID 28657417)
- Postpartum BP self-monitoring × 6-12 wk + 6-week postpartum visit + 6-month CV-risk screening + lifelong CV-disease counseling — AHA 2021; ACOG 2025
- Next-pregnancy aspirin counselling at 6-week postpartum visit: 81-150 mg PO daily from 12 wk per USPSTF 2021 (PMID 34581729); pre-pregnancy weight / BP optimisation — ACOG 2020 (PB 222)

AVOID / contraindication checks:
- Never_ACE_ARB_in_pregnancy — ACOG 2020 (PB 222)
- Never_renin_inhibitor_in_pregnancy — ACOG 2020 (PB 222)
- Avoid_atenolol_pregnancy_FGR_risk — NICE 2019
- Nitroprusside_caution_cyanide_toxicity_after_4h — ACOG 2020 (PB 222)
- Methylergonovine_avoid_in_HTN_postpartum — ACOG 2020 (PB 222)
- NSAIDs_avoid_postpartum_in_PE_or_GHTN — ACOG 2020 (PB 222)

Monitoring

Regimen monitoring:
- home BP BID for outpatient GHTN — CHAP (Tita NEJM 2022)
- office BP q1 2 weeks — ACOG 2020 (PB 222)
- UPCR weekly after diagnosis — ACOG 2020 (PB 222)
- CBC LFT Cr q1 2 weeks — ACOG 2020 (PB 222)
- fetal kick counts daily — ACOG 2020 (PB 222)
- NST or BPP weekly after 32 weeks — ACOG 2020 (PB 222)
- growth US q3 4 weeks — ACOG 2020 (PB 222)
- postpartum BP at 3 to 7d 1 to 2wk 4 to 6wk — AHA 2021

Setting (outpatient) monitoring:
- Weekly office BP + 3-day BP self-monitoring at home (BID) — CHAP (Tita NEJM 2022)
- Office BP + symptom check q1-2 wk — ACOG 2020 (PB 222)
- Weekly urine dipstick proteinuria + UPCR if positive — ACOG 2020 (PB 222)
- CBC/CMP/LFT q1-2 wk — ACOG 2020 (PB 222)
- Growth US q4-6 wk — ACOG 2020 (PB 222)
- Biweekly NST starting at 32 wk — ACOG 2020 (PB 222)
- Postpartum BP: daily × 1 wk → weekly through 6-12 wk + visits at 3-7 d, 1-2 wk, 4-6 wk, 6-week comprehensive visit — AHA 2021; ACOG 2025
- Annual CV-risk screening (BP, lipids, glucose, BMI, UACR) lifelong post-GHTN — AHA 2021

Follow-up plan: Postpartum BP at 3–7 d, 1–2 wk, 4–6 wk (HTN often persists 6–12 wk); aspirin from 12 wk in next pregnancy; lifelong CV risk follow-up (GHTN doubles future CV risk per AHA 2021)
- Close-out criterion: postpartum BP normalized OR transitioned to chronic HTN management

Monitoring phase: BP twice weekly (or daily home BP) — CHAP (Tita NEJM 2022); UPCR weekly; CBC/LFT/Cr q1–2 wk; fetal kick counts daily; NST/BPP q1 wk after 32 wk; growth scan q3–4 wk — ACOG 2020 (PB 222)

Disposition

Current setting: outpatient — Confirm GHTN, screen for severe features + proteinuria, initiate PO antihypertensive at <140/90 target, surveil for progression to PE, plan delivery at 37+0, postpartum surveillance through 6-12 wk + lifelong CV-risk plan — ACOG 2020 (PB 222, reaff 2024); CHAP (Tita NEJM 2022); USPSTF 2021; AHA 2021

Disposition criteria:
- Continue outpatient if BP <160/110 on PO regimen, no severe features, fetal status reassuring — ACOG 2020 (PB 222)
- Plan induction at 37+0 weeks — ACOG 2020 (PB 222)
- 6-week postpartum: BP <140/90 on oral regimen (or off), no severe features, CV-risk screen complete, next-pregnancy aspirin counseling documented → transition to long-term annual CV surveillance — AHA 2021

Escalation triggers (move to higher acuity):
- BP >=160/110 sustained x 15 min → ED / L&D + IV antihypertensive within 30-60 min — ACOG 767 (2019)
- Any severe-feature symptom (severe HA, vision changes, RUQ pain) → ED / L&D — ACOG 2020 (PB 222)
- Decreased fetal movement → L&D for NST — ACOG 2020 (PB 222)
- New proteinuria UPCR >=0.3 → reclassify and route to ob.pre-eclampsia.core.v1 — ACOG 2020 (PB 222)
- Cr rising or platelets falling → admit + reclassify to PE if severe-feature lab threshold met — ACOG 2020 (PB 222)
- Postpartum severe HTN ≥160/110 within 6 wk → ED for IV antihypertensive + magnesium prophylaxis — AHA 2021; ACOG 767
- sFlt-1/PlGF ratio > 38 at diagnosis → intensified surveillance + admit-low-threshold — PROGNOSIS 2016 (PMID 26735990); PARROT 2019 (PMID 30995940)
- Postpartum BP fails to normalise by 12 wk → reclassify as chronic HTN; route to cardio.htn.core.v1 — ISSHP 2024

Patient Action Plan

**Gestational hypertension home action plan — ACOG 2020 (PB 222)**
Personalised values: baseline_BP, home_BP_targets, controller_meds, OB_provider_contact.

**Stable — BP <140/90 at home, no symptoms, normal kick counts** (green):
Triggers:
- Home BP <140/90 — CHAP (Tita NEJM 2022)
- No severe-feature symptoms — ACOG 2020 (PB 222)
- Normal fetal kick counts (≥10 in 2 h) — ACOG 2020 (PB 222)
Actions:
- Continue PO antihypertensive as prescribed — CHAP (Tita NEJM 2022)
- Continue aspirin 81 mg daily through 36 weeks if started — USPSTF 2021
- Home BP twice daily; log values — CHAP (Tita NEJM 2022)
- Daily kick counts — ACOG 2020 (PB 222)
- Attend all scheduled prenatal visits + NSTs — ACOG 2020 (PB 222)

**Caution — BP 140–159 / 90–109, mild symptoms, or any new concern** (yellow):
Triggers:
- Home BP 140–159/90–109 sustained — ACOG 2020 (PB 222)
- Mild headache responding to acetaminophen — ACOG 2020 (PB 222)
- Reduced (but not absent) fetal movement — ACOG 2020 (PB 222)
- Mild swelling progression — ACOG 2020 (PB 222)
Actions:
- Recheck BP in 15 min after rest — ACOG 2020 (PB 222)
- Take any prescribed PRN dose if instructed — ACOG 2020 (PB 222)
- Drink water + lie left-side — ACOG 2020 (PB 222)
- Call OB office same day — ACOG 2020 (PB 222)
- Increase home BP checks to QID — CHAP (Tita NEJM 2022)
Contact provider when:
- BP remains ≥140/90 on repeat after 15 min — ACOG 2020 (PB 222)
- Symptoms persist >2 h — ACOG 2020 (PB 222)
- Reduced fetal movement persists after a snack and 1 h focused counting — ACOG 2020 (PB 222)

**Medical alert — go to L&D / ED now** (red):
Triggers:
- BP ≥160/110 on home cuff (any single reading) or two readings ≥150/100 in 15 min — ACOG 767 (2017)
- Severe headache not relieved by acetaminophen — ACOG 2020 (PB 222)
- Visual changes (scotomata, blurred vision, photopsia) — ACOG 2020 (PB 222)
- Persistent right-upper-quadrant or epigastric pain — ACOG 2020 (PB 222)
- Sudden swelling of face/hands — ACOG 2020 (PB 222)
- Decreased fetal movement (<10 kicks in 2 h after focused counting) — ACOG 2020 (PB 222)
- Vaginal bleeding, leaking fluid, contractions — ACOG 2020 (PB 222)
- Seizure or loss of consciousness — ACOG 2020 (PB 222)
Actions:
- Go to L&D / ED immediately — do not wait — ACOG 2020 (PB 222)
- Call 911 if seizing or unable to travel safely — ACOG 2020 (PB 222)
- Bring medication list and home BP log — ACOG 2020 (PB 222)
Contact provider when:
- Any red-zone trigger — proceed to L&D, do not call first — ACOG 2020 (PB 222)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] BP ≥160/110 sustained × 15 min in patient with gestational HTN — ACOG 767 (2017)
- [SEVERE] New proteinuria (UPCR ≥0.3 OR 24-h ≥300 mg) developing in known gestational HTN — ACOG 2020 (PB 222)
- [SEVERE] New severe feature (severe HA, vision changes, RUQ pain, plt <100K, AST/ALT ≥2× ULN, Cr ≥1.1 or doubling, pulmonary edema) — ACOG 2020 (PB 222)

Citations

- ACOG Practice Bulletin 222 (2020, reaffirmed 2024) + ACOG Committee Opinion 767 (severe HTN, 2019) + ACOG 203 (chronic HTN, CHAP) + CHAP (Tita NEJM 2022) + CHIPS (Magee NEJM 2015) + ISSHP 2024 (Mol et al; supersedes ISSHP 2021) + USPSTF 2021 (aspirin) + ASPRE 2017 + HYPITAT-II Lancet 2015 + PARROT Lancet 2019 + PROGNOSIS NEJM 2016 + Magpie Trial Lancet 2002 + NICE NG133 (2023) + AHA 2021 postpartum HTN scientific statement [PMID:35452981](https://pubmed.ncbi.nlm.nih.gov/35452981/)
- Cited evidence (PMID 25629739) [PMID:25629739](https://pubmed.ncbi.nlm.nih.gov/25629739/)
- Cited evidence (PMID 33979951) [PMID:33979951](https://pubmed.ncbi.nlm.nih.gov/33979951/)
- Cited evidence (PMID 25776532) [PMID:25776532](https://pubmed.ncbi.nlm.nih.gov/25776532/)
- Cited evidence (PMID 25602002) [PMID:25602002](https://pubmed.ncbi.nlm.nih.gov/25602002/)

Last reconciled with current guidelines: 2026-05-14.
References
  • ACOG Practice Bulletin 222 (2020, reaffirmed 2024) + ACOG Committee Opinion 767 (severe HTN, 2019) + ACOG 203 (chronic HTN, CHAP) + CHAP (Tita NEJM 2022) + CHIPS (Magee NEJM 2015) + ISSHP 2024 (Mol et al; supersedes ISSHP 2021) + USPSTF 2021 (aspirin) + ASPRE 2017 + HYPITAT-II Lancet 2015 + PARROT Lancet 2019 + PROGNOSIS NEJM 2016 + Magpie Trial Lancet 2002 + NICE NG133 (2023) + AHA 2021 postpartum HTN scientific statement — PMID:35452981
  • Cited evidence (PMID 25629739) — PMID:25629739
  • Cited evidence (PMID 33979951) — PMID:33979951
  • Cited evidence (PMID 25776532) — PMID:25776532
  • Cited evidence (PMID 25602002) — PMID:25602002