What Defines “Refractory” HTN for Preterm sPreE Delivery?

The ACOG PB 222 states, “In women with preeclampsia with severe features at less than 34 0/7 weeks of gestation, with stable maternal and fetal condition, expectant management may be considered”. The expectant management of preeclampsia with severe features before 34 0/7 weeks of gestation is based on strict selection criteria of those appropriate candidates and is best accomplished in a setting with resources appropriate for maternal and neonatal care. BOX 4 in that ACOG guidance lists “Conditions Precluding Expectant management”, with one of the conditions being “Uncontrolled severe-range blood pressures (persistent systolic blood pressure 160 mm Hg or more or diastolic blood pressure 110 mm Hg or more not responsive to antihypertensive medication” (i.,e. persistent and refractory to appropriate medication). But what defines “uncontrolled hypertension”? When is preterm delivery indicated based on that feature? In this episode, we will answer this real-world clinical question. So, for a patient who is otherwise stable, asymptomatic, without HELLP syndrome, whose fetus is stable but is under 34 weeks, when can “uncontrolled hypertension” be diagnosed to prompt delivery? Listen in for details as we highlight the 2022 SMFM Special Report on that matter.

1. ACOG PB 222

2. SMFM Special report: Preeclampsia: a report and recommendations of the workshop of the Society for Maternal-Fetal Medicine and the Preeclampsia Foundation, Nov 2022

3. De Backer J, Haugaa KH, Hasselberg NE, et al. 2025 ESC Guidelines for the Management of Cardiovascular Disease and Pregnancy. European Heart Journal. 2025

4. SOGC Clinical Practice Guideline: Diagnosis, Evaluation, and Management of the Hypertensive Disorders of Pregnancy: Executive Summary; No. 307, May 2014

5. ISSHP (2018): The hypertensive disorders of pregnancy: ISSHP classification, diagnosis & management recommendations for international practice. Preg Hypertension. chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/http://www.isshp.org/wp-content/uploads/2018/06/1-s2.0-S2210778918301260-main.pdf