USPSTF Recommends Screening for Hypertensive Disorders Throughout Pregnancy

Screening for hypertensive disorders with blood pressure measurements is recommended in pregnant women throughout pregnancy, according to a final recommendation statement from the United States Preventive Services Task Force (USPSTF) that was published in JAMA.

The USPSTF concluded with moderate certainty (grade B recommendation) that screening for hypertensive disorders in pregnancy with blood pressure measurements is associated with substantial net benefit.¹ The recommendation is intended for all pregnant persons without a known diagnosis of a hypertensive disorder of pregnancy or chronic hypertension.

The recommendation is based on an updated evidence report and systematic review by Henderson and colleagues² and is consistent with the 2017 recommendation statement on screening for preeclampsia.

A history of eclampsia or preeclampsia during a prior pregnancy, a previous adverse pregnancy outcome, and maternal comorbid conditions such as type 1 or type 2 diabetes before pregnancy, gestational diabetes, chronic hypertension, kidney disease, and autoimmune diseases are associated with an increased risk for preeclampsia.

The USPSTF advises that blood pressure measurements should be obtained in each prenatal care visit throughout pregnancy and that a higher blood pressure reading should be confirmed with repeated measurements. According to the task force, persons who screen positive should receive evidence-based management of hypertensive disorders of pregnancy.

“While it is known that risk continues into the immediate postpartum period, there is little evidence regarding screening during this period,” according to the USPSTF. “A pragmatic approach would be for patients to be counseled regarding signs and symptoms of preeclampsia at hospital discharge and for patients with hypertensive disorders to have subsequent blood pressure checks.”

In addition to screening, identifying hypertensive disorders of pregnancy requires adequate prenatal visits, surveillance, and evidence-based care for changing patient signs and symptoms during pregnancy and the postpartum period to improve health outcomes.

Effective management of patients with diagnosed hypertensive disorders of pregnancy should include fetal and maternal monitoring, antihypertension medications, and magnesium sulfate for seizure prophylaxis when indicated, as well as postpartum blood pressure measurement and clinical monitoring because preeclampsia mortality risks continue postdelivery, according to the task force.

Awareness of the racial and ethnic inequities in the incidence and severity of hypertensive disorders of pregnancy is also key for effectively managing patients. For example, Black and Hispanic/Latino persons have a twofold increased risk of stroke with hypertensive disorders of pregnancy compared with White persons.

“The use of standardized clinical bundles of best practices for disease management of hypertensive disorders of pregnancy could help ensure that all pregnant persons receive appropriate, equitable care,” the USPSTF stated.

The updated evidence report and systematic review included a literature search in MEDLINE and the Cochrane Central Register of Controlled Trials for studies that addressed the comparative effectiveness of screening for hypertensive disorders of pregnancy published between January 1, 2014, and January 4, 2022. A search also was conducted in ClinicalTrials.gov, along with ongoing surveillance of new studies through February 1, 2023.

The analysis included 6 fair-quality studies (5 randomized clinical trials [RCTs] and 1 nonrandomized study with a historical control; N=10,165). The studies compared usual screening with approaches that involved home blood pressure measurement (2 studies, n=2521), prenatal care schedules with less frequent office visits vs the usual number (3 studies), and urine screening tests in patients with specific clinical indications rather than routinely conducted tests (1 study). The included studies were conducted in the prenatal period, and no studies assessed screening for new-onset hypertensive disorders of pregnancy during the postpartum period.

Home blood pressure measurement in addition to office-based measurement was evaluated in 1 fair-quality RCT (n=2441) among individuals with an increased risk of a hypertensive disorder of pregnancy.³ The comparison group had routine office-based screening. A composite outcome of 1 or more serious maternal health complications associated with hypertensive disorders of pregnancy was not statistically different between the groups (relative risk [RR], 0.79; 95% CI, 0.40-1.55). The primary outcome of the mean difference between the groups in days to detection of a hypertensive disorder of pregnancy was less than 2 days (SD, 1.6) and not statistically significant (95% CI, -8.1 to 4.9).

Different prenatal visit schedules in individuals considered at low risk for pregnancy complications were compared in 3 fair-quality RCTs (n=5203). The intervention group had a reduction in prenatal care visits scheduled (6-9 visits) vs standard visits scheduled (approximately 14 visits). No differences were found between study groups regarding preterm delivery, perinatal mortality, placental abruption, or postpartum hemorrhage, or in the proportion diagnosed with preeclampsia. The studies were underpowered for rare, serious health outcomes.

A fair-quality nonrandomized study compared a historical control group with routine urine screening at each prenatal visit vs screening only when clinically indicated (based on weight loss, elevated blood pressure, urinary symptoms; n=2441).⁴ No difference was observed in the proportion of participants diagnosed with a hypertensive disorder of pregnancy after transitioning to indicated urine screening only (RR, 1.00; 95% CI, 0.74-1.36). A decreased risk for preterm delivery with indicated screening was found vs the historical comparison group that had routine screening (RR, 0.64; 95% CI, 0.45-0.90), and no other differences in health outcomes were observed.

“This review did not identify evidence that any alternative screening strategies for hypertensive disorders of pregnancy were more effective than routine blood pressure measurement at in-person prenatal visits,” stated Dr Henderson and colleagues. “Morbidity and mortality from hypertensive disorders of pregnancy can be prevented, yet American Indian/Alaska Native persons and Black persons experience inequitable rates of adverse outcomes. Further research is needed to identify screening approaches that may lead to improved disease detection and health outcomes.”

The USPSTF suggested several approaches to improve disparities in hypertensive disorders of pregnancy, including connections to community resources in the perinatal period, collaborative care provided in medical homes, multilevel interventions to address underlying health inequities that increase health risks in pregnancy, and the use of telehealth and remote monitoring in prenatal and postpartum care.

A draft version of the USPSTF’s recommendation statement was posted for public comment on the task force’s website from February 7, 2023, to March 6, 2023, and the USPSTF clarified its definition of hypertensive disorders of pregnancy in response to comments.

Disclosure: One of the study authors in the updated evidence report and systematic review article declared an affiliation with a pharmaceutical company. Please see the original references for a full list of authors’ disclosures.