Hypertensive disorders of pregnancy (HDP) constitute one of the leading causes of pregnancy related adverse outcomes worldwide (1). It has been estimated that HDP complicates up 5-10% of all pregnancies and this situation might worsen as a result of advanced age at first pregnancy and increased prevalence of obesity and other cardiometabolic risk factors among women of childbearing age (2, 3).

Affected women are also at increased risk for cardiovascular disease (CVD) later in life, independently of traditional cardiovascular disease risks (4).

In the primary healthcare setting prevention, timely diagnosis, and treatment of HDP are associated with reduced maternal, fetal and neonatal morbidity and mortality. Many international and national clinical practice guidelines and scientific statement have been published on this topic. The last one was Hypertension in Pregnancy: Diagnosis, Blood Pressure Goals, and Pharmacotherapy: A Scientific Statement from the American Heart association (AHA) in December 2021 (5).

Here we summarize the European Society of Cardiology (ESC) and the AHA scientific statement key diagnostic and treatment approaches to management HDP (Table 1).

ESC guideline for the management of cardiovascular diseases during pregnancy presents only a few focused recommendations in chapter Hypertensive disorders (7). The Scientific Statement from the American Heart Association is based on report of the American College of Obstetricians and Gynecologists task force on hypertension on pregnancy.

Analysis revealed consistency for the definitions of hypertension on pregnancy, chronic and gestational hypertension, and the preventive strategies of a low dose aspirin for women at increased risk of preeclampsia, antihypertensive treatment of hypertension, delivery for women with preeclampsia.

Significant variations include: different aspirin doses for prophylaxis of eclampsia, definitions of preeclampsia that reflect evolving of the multisystem nature of the disease, different antihypertensive treatment thresholds and targets among women with non-severe HDP, and postpartum monitoring for maternal safety and improvement of long-term cardiovascular health.

These variations arise from limited evidence to drive clinical practice and reflect the reality that many aspects of the guidelines emanate from expert opinion rather than high quality evidence. These are areas requiring further research and consensus-building for optimizing management of a high-risk group of women.

Since the main differences are related to the target blood pressure (BP) level, here the arguments for tight and less tight BP control in pregnancy from the AHA scientific statement.

Arguments in favor of a tight BP control in pregnancy

First, there are no measurable immediate or long-term health benefits of stricter BP treatment for the relatively short duration of pregnancy (4–9 months, depending on type of HDP) in young women without other CVD risks.

Second, there are concerns that lowering maternal BP may compromise utero-placental circulation and negatively affect fetal well-being and growth.

Third, therapeutic options are limited because of concerns about potential adverse fetal effects, particularly malformations from intrauterine exposure to antihypertensive medications.

Arguments for considering tight BP control

 First, more aggressive treatment of hypertension in pregnancy prevents the development of severe hypertension, as demonstrated by both a systematic review of randomized trials (8) and Control of Hypertension in Pregnancy Study (CHIPS) (9).

Second, there is evidence that the women with preeclampsia may be more susceptible to severe neurological outcomes such as intracerebral hemorrhage at lower systolic BP (e.g., 150–170 mmHg) compared with nonpregnant subjects.

Third, treatment of nonsevere hypertension in pregnancy (e.g., BPs 140–155/90–109 mmHg) may permit prolongation of pregnancy in women without other severe features of preeclampsia who would require delivery.

Fourth, ACOG guidelines recommend withholding antihypertensive therapy for patients with preeclampsia unless BP approaches 160/110 mmHg. They also recommend urgent delivery for women with severe features of preeclampsia, which include uncontrollable hypertension with BP ≥160/110 mmHg, even for pregnancies <34 gestational weeks, unless high-level care is available in facilities with adequate maternal and neonatal intensive care resources (10). Lowering thresholds for treatment may allow timely BP control and avoidance of rushed deliveries that commonly lead to prematurity and related complications.

Fifth, there are current epidemiological and demographic trends toward advanced age at first pregnancy and higher CVD risk (subclinical or diagnosed). This could also be relevant among women with multiple pregnancies, who may spend several years of their lives either pregnant or breastfeeding with uncontrolled hypertension. In addition, modern fertility techniques facilitate pregnancy in women with preexisting conditions associated with elevated CVD risk (diabetes, chronic kidney disease, and polycystic ovary syndrome). Preexisting chronic kidney disease and heart disease are present in 3% and 1% to 4% of pregnancies in high-income countries, respectively (11).