CC BY-NC-ND 4.0 · Rev Bras Ginecol Obstet 2017; 39(09): 496-512
DOI: 10.1055/s-0037-1604471
Review Article
Thieme Revinter Publicações Ltda Rio de Janeiro, Brazil


José Geraldo Lopes Ramos
1   Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
Nelson Sass
2   Universidade Federal de São Paulo, São Paulo, SP, Brazil
Sérgio Hofmeister Martins Costa
1   Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
› Author Affiliations
Further Information

Publication History

05 December 2016

29 March 2017

Publication Date:
09 August 2017 (online)


The authors review hypertensive disease during pregnancy with an academic and practical view, and using the best evidence available. This disease, which is the most important clinical disease in Brazilian pregnant women, may have its incidence reduced with prevention through the use of calcium and aspirin in pregnant women at risk. Previously, it was a disease that presented with hypertension with proteinuria, but it has now been classified with new clinical parameters besides proteinuria. Morbidity and mortality should be reduced in a continental country such as Brazil using protocols for the early treatment of complications by calculating severe outcomes in preeclampsia. The early treatment of acute hypertension, use of magnesium sulfate and early hospitalization in cases of preeclampsia are concepts to pursue the reduction of our pregnant women's mortality.


Os autores revisam a doença hipertensiva na gestação com uma visão acadêmica e prática, utilizando as melhores evidências disponíveis. A doença clínica mais importante na gestante brasileira pode ter sua incidência diminuída com a prevenção por meio do uso de cálcio e aspirina em gestantes de risco. Antes uma doença que apresentava hipertensão arterial com proteinúria, agora vem sendo classificada com novos parâmetros clínicos além da proteinúria. A morbidade e mortalidade devem ser diminuídas, em um país continental como o Brasil, utilizando-se protocolos para o tratamento precoce de suas complicações mediante o cálculo de desfechos graves em pré-eclâmpsia. O tratamento precoce da hipertensão arterial, o uso do sulfato de magnésio e a internação precoce em casos de pré-eclâmpsia são conceitos para perseguirmos a diminuição da mortalidade de nossas gestantes.

* This review is part of the Series, Guidelines and Recommendations of the Federação Brasileira das Associações de Ginecologia e Obstetrícia – FEBRASGO, and was prepared by the National Specialized Commission for the Hypertension in Pregnancy.

  • References

  • 1 Abalos E, Cuesta C, Grosso AL, Chou D, Say L. Global and regional estimates of preeclampsia and eclampsia: a systematic review. Eur J Obstet Gynecol Reprod Biol 2013; 170 (01) 1-7 Review
  • 2 Giordano JC, Parpinelli MA, Cecatti JG. , et al. The burden of eclampsia: results from a multicenter study on surveillance of severe maternal morbidity in Brazil. PLoS One 2014; 9 (05) e97401
  • 3 de Oliveira LG, Karumanchi A, Sass N. Preeclampsia: oxidative stress, inflammation and endothelial dysfunction. Rev Bras Ginecol Obstet 2010; 32 (12) 609-616
  • 4 Smets EM, Visser A, Go AT, van Vugt JM, Oudejans CB. Novel biomarkers in preeclampsia. Clin Chim Acta 2006; 364 (1-2): 22-32
  • 5 Tranquilli AL, Dekker G, Magee L. , et al. The classification, diagnosis and management of the hypertensive disorders of pregnancy: A revised statement from the ISSHP. Pregnancy Hypertens 2014; 4 (02) 97-104
  • 6 American College of Obstetricians and Gynecologists; Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Obstet Gynecol 2013; 122 (05) 1122-1131
  • 7 Martins-Costa SH, Vettorazzi J, Valério E. , et al. Protein creatinine ratio in random urine sample of hypertensive pregnant women: maternal and perinatal outcomes. Hypertens Pregnancy 2011; 30 (03) 331-337
  • 8 Magee LA, Pels A, Helewa M, Rey E, von Dadelszen P. ; Canadian Hypertensive Disorders of Pregnancy (HDP) Working Group. Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy. Pregnancy Hypertens 2014; 4 (02) 105-145 Review
  • 9 Ramos JG, Martins-Costa SH, Mathias MM, Guerin YL, Barros EG. Urinary protein/creatinine ratio in hypertensive pregnant women. Hypertens Pregnancy 1999; 18 (03) 209-218
  • 10 Ramos JG, Martins-Costa S, Edelweiss MI, Costa CA. Placental bed lesions and infant birth weight in hypertensive pregnant women. Braz J Med Biol Res 1995; 28 (04) 447-455
  • 11 Beaufils M, Uzan S, DonSimoni R, Brault D, Colau JC. Metabolism of uric acid in normal and pathologic pregnancy. Contrib Nephrol 1981; 25: 132-136
  • 12 Pollak VE, Nettles JB. The kidney in toxemia of pregnancy: a clinical and pathologic study based on renal biopsies. Medicine (Baltimore) 1960; 39: 469-526
  • 13 Chesley LC. Hypertensive disorders in pregnancy. New York: Appleton Century Crofts; 1978
  • 14 Weiner CP. Disseminated intravascular coagulopathy associated with pregnancy. In: Clark SL, DB Cotton DB, Hankins GD, Phelan FP. , editors. Critical care obstetrics. 2nd ed. Oxford: Blackwell Scientific; 1991: 180-199
  • 15 Ramos JG, Martins-Costa SH, Kessler JB, Costa CA, Barros E. Calciuria and preeclampsia. Braz J Med Biol Res 1998; 31 (04) 519-522
  • 16 Report of the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy. Am J Obstet Gynecol 2000; 183 (01) S1-S22
  • 17 Yu CK, Papageorghiou AT, Parra M, Palma Dias R, Nicolaides KH. ; Fetal Medicine Foundation Second Trimester Screening Group. Randomized controlled trial using low-dose aspirin in the prevention of pre-eclampsia in women with abnormal uterine artery Doppler at 23 weeks' gestation. Ultrasound Obstet Gynecol 2003; 22 (03) 233-239
  • 18 Duckitt K, Harrington D. Risk factors for pre-eclampsia at antenatal booking: systematic review of controlled studies. BMJ 2005; 330 (7491): 565 Review
  • 19 Grill S, Rusterholz C, Zanetti-Dällenbach R. Potentialmarkers of preeclampsia–a review. Reprod Biol Endocrinol 2009; 7: 70
  • 20 Duley L, Henderson-Smart DJ, Meher S, King JF. Antiplatelet agents for preventing pre-eclampsia and its complications. Cochrane Database Syst Rev 2007; (02) CD004659 Review
  • 21 Roberge S, Nicolaides KH, Demers S, Villa P, Bujold E. Prevention of perinatal death and adverse perinatal outcome using low-dose aspirin: a meta-analysis. Ultrasound Obstet Gynecol 2013; 41 (05) 491-499
  • 22 Hofmeyr GJ, Lawrie TA, Atallah AN, Duley L. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Cochrane Database Syst Rev 2010; (08) CD001059
  • 23 Levine RJ, Hauth JC, Curet LB. , et al. Trial of calcium to prevent preeclampsia. N Engl J Med 1997; 337 (02) 69-76
  • 24 Norwitz ER, Robinson JN, Repke JT. Prevention of preeclampsia: is it possible?. Clin Obstet Gynecol 1999; 42 (03) 436-454 Review
  • 25 Corrêa Júnior MD. Aguiar, RA, Corrêa MD. Fisiopatologia da préeclâmpsia: aspectos atuais. Femina 2009; 37 (05) 247-253
  • 26 Sibai B, Dekker G, Kupferminc M. Pre-eclampsia. Lancet 2005; 365 (9461): 785-799 Review
  • 27 Cnossen JS, ter Riet G, Mol BW. , et al. Are tests for predicting pre-eclampsia good enough to make screening viable? A review of reviews and critical appraisal. Acta Obstet Gynecol Scand 2009; 88 (07) 758-765
  • 28 Giguère Y, Charland M, Bujold E. , et al. Combining biochemical and ultrasonographic markers in predicting preeclampsia: a systematic review. Clin Chem 2010; 56 (03) 361-375
  • 29 Myatt L, Clifton RG, Roberts JM. , et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU) Network. First-trimester prediction of preeclampsia in nulliparous women at low risk. Obstet Gynecol 2012; 119 (06) 1234-1242
  • 30 Verlohren S, Galindo A, Schlembach D. , et al. An automated method for the determination of the sFlt-1/PlGF ratio in the assessment of preeclampsia. Am J Obstet Gynecol 2010; 202 (02) 161.e1-161.e11
  • 31 Nicolaides KH. Turning the pyramid of prenatal care. Fetal Diagn Ther 2011; 29 (03) 183-196
  • 32 von Dadelszen P, Payne B, Li J. , et al; PIERS Study Group. Prediction of adverse maternal outcomes in pre-eclampsia: development and validation of the fullPIERS model. Lancet 2011; 377 (9761): 219-227
  • 33 Akkermans J, Payne B, von Dadelszen P. , et al. Predicting complications in pre-eclampsia: external validation of the fullPIERS model using the PETRA trial dataset. Eur J Obstet Gynecol Reprod Biol 2014; 179: 58-62
  • 34 Barron WM. Hypertension. In: Barron WM, Lindheimer MD. Medical disorders during pregnancy. 2nd ed. St. Louis: Mosby; 1995. . Cap. 1. p. 1–36.
  • 35 Barton JR, Witlin AG, Sibai BM. Management of mild preeclampsia. Clin Obstet Gynecol 1999; 42 (03) 455-469 Review
  • 36 Martin Jr JN, Thigpen BD, Moore RC, Rose CH, Cushman J, May W. Stroke and severe preeclampsia and eclampsia: a paradigm shift focusing on systolic blood pressure. Obstet Gynecol 2005; 105 (02) 246-254
  • 37 World Health Organization (WHO). WHO recommendations for prevention and treatment of preeclampsia and eclampsia. Geneva: World Health Organization; 2011
  • 38 Magee LA, von Dadelszen P, Rey E. , et al. Less-tight versus tight control of hypertension in pregnancy. N Engl J Med 2015; 372 (05) 407-417
  • 39 Martins Costa S, Ramos JG, Barros E, Bruno RM, Costa CA, Goldin JR. Randomized, controlled trial of hydralazine versos nifedipine in preeclamptic women with acute hypertension. Clin Exp Hypertens B 1992; 11 (01) 25-44
  • 40 Magee LA, Cham C, Waterman EJ, Ohlsson A, von Dadelszen P. Hydralazine for treatment of severe hypertension in pregnancy: meta-analysis. BMJ 2003; 327 (7421): 955-960
  • 41 Montán S. Drugs used in hypertensive diseases in pregnancy. Curr Opin Obstet Gynecol 2004; 16 (02) 111-115 Review
  • 42 Sibai BM. Treatment of hypertension in pregnant women. N Engl J Med 1996; 335 (04) 257-265 Review
  • 43 Paula LG, Martins Costa S. Tratamento anti-hipertensivo na gestação e lactação. Femina 2003; 31 (09) 803-808
  • 44 Altman D, Carroli G, Duley L. , et al; Magpie Trial Collaboration Group. Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate? The Magpie Trial: a randomised placebo-controlled trial. Lancet 2002; 359 (9321): 1877-1890
  • 45 Livingston JC, Livingston LW, Ramsey R, Mabie BC, Sibai BM. Magnesium sulfate in women with mild preeclampsia: a randomized controlled trial. Obstet Gynecol 2003; 101 (02) 217-220
  • 46 Chowdhury JR, Chaudhuri S, Bhattacharyya N, Biswas PK, Panpalia M. Comparison of intramuscular magnesium sulfate with low dose intravenous magnesium sulfate regimen for treatment of eclampsia. J Obstet Gynaecol Res 2009; 35 (01) 119-125
  • 47 von Dadelszen P, Magee L. What matters in preeclampsia are the associated adverse outcomes: the view from Canada. Curr Opin Obstet Gynecol 2008; 20 (02) 110-115
  • 48 Bhattacharya S, Campbell DM, Smith NC. Pre-eclampsia in the second pregnancy: does previous outcome matter?. Eur J Obstet Gynecol Reprod Biol 2009; 144 (02) 130-134
  • 49 Koopmans CM, Bijlenga D, Groen H. , et al; HYPITAT study group. Induction of labour versus expectant monitoring for gestational hypertension or mild pre-eclampsia after 36 weeks' gestation (HYPITAT): a multicentre, open-label randomised controlled trial. Lancet 2009; 374 (9694): 979-988
  • 50 Stutchfield P, Whitaker R, Russell I. ; Antenatal Steroids for Term Elective Caesarean Section (ASTECS) Research Team. Antenatal betamethasone and incidence of neonatal respiratory distress after elective caesarean section: pragmatic randomised trial. BMJ 2005; 331 (7518): 662
  • 51 Royal College of Obstetricians and Gynaecologists. Antenatal corticosteroids to reduce neonatal morbidity and mortality [Internet]. London: Royal College of Obstetricians and Gynaecologists; 2010. . (Green-top Guideline no 7). [cited 2017 Feb 12]. Available from:
  • 52 Sibai BM, Barton JR. Expectant management of severe preeclampsia remote from term: patient selection, treatment, and delivery indications. Am J Obstet Gynecol 2007; 196 (06) 514.e1-514.e9
  • 53 Haddad B, Sibai BM. Expectant management in pregnancies with severe pre-eclampsia. Semin Perinatol 2009; 33 (03) 143-151 Review
  • 54 Bombrys AE, Barton JR, Nowacki EA. , et al. Expectant management of severe preeclampsia at less than 27 weeks' gestation: maternal and perinatal outcomes according to gestational age by weeks at onset of expectant management. Am J Obstet Gynecol 2008; 199 (03) 247.e1-247.e6
  • 55 Sibai BM, Taslimi MM, el-Nazer A, Amon E, Mabie BC, Ryan GM. Maternal-perinatal outcome associated with the syndrome of hemolysis, elevated liver enzymes, and low platelets in severe preeclampsia-eclampsia. Am J Obstet Gynecol 1986; 155 (03) 501-509
  • 56 Martin Jr JN, Macann EF, Blake PG, Martin RM, Pwry Jr KG, Roberts WE. Analysis of 454 pregnancies with severe preeclampsia/eclampsia HELLP syndrome using the 3 class system of classification. [abstract] Am J Obstet Gynecol 1993; 168 (01) 386
  • 57 Haddad B, Barton JR, Livingston JC, Chahine R, Sibai BM. Risk factors for adverse maternal outcomes among women with HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome. Am J Obstet Gynecol 2000; 183 (02) 444-448
  • 58 Cavkaytar S, Ugurlu EN, Karaer A, Tapisiz OL, Danisman N. Are clinical symptoms more predictive than laboratory parameters for adverse maternal outcome in HELLP syndrome?. Acta Obstet Gynecol Scand 2007; 86 (06) 648-651
  • 59 Ramos JG, Martins-costa S, Vettorazzi-Stuczynski J, Brietzke E. Morte materna em um hospital terciário do Rio Grande do Sul – Brasil: um estudo de 20 anos. Ver Bras Ginecol Obstet. 2003; 25 (06) 431-436
  • 60 Wicke C, Pereira PL, Neeser E, Flesch I, Rodegerdts EA, Becker HD. Subcapsular liver hematoma in HELLP syndrome: Evaluation of diagnostic and therapeutic options--a unicenter study. Am J Obstet Gynecol 2004; 190 (01) 106-112
  • 61 Katz L, Amorim MM, Miranda GV, Pinto e Silva JL. Clinical and laboratorial profile and complications of patients with HELLP syndrome admitted in an obstetric intensive care unit. Rev Bras Ginecol Obstet 2008; 30 (02) 80-86
  • 62 O'Brien JM, Barton JR. Controversies with the diagnosis and management of HELLP syndrome. Clin Obstet Gynecol 2005; 48 (02) 460-477 Review
  • 63 Martin Jr JN, Thigpen BD, Rose CH, Cushman J, Moore A, May WL. Maternal benefit of high-dose intravenous corticosteroid therapy for HELLP syndrome. Am J Obstet Gynecol 2003; 189 (03) 830-834
  • 64 Fonseca JE, Méndez F, Cataño C, Arias F. Dexamethasone treatment does not improve the outcome of women with HELLP syndrome: a double-blind, placebo-controlled, randomized clinical trial. Am J Obstet Gynecol 2005; 193 (05) 1591-1598
  • 65 Woudstra DM, Chandra S, Hofmeyr GJ, Dowswell T. Corticosteroids for HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome in pregnancy. Cochrane Database Syst Rev 2010; (09) CD008148 Review
  • 66 Ganzevoort W, Sibai BM. Temporising versus interventionist management (preterm and at term). Best Pract Res Clin Obstet Gynaecol 2011; 25 (04) 463-476
  • 67 Podymow T, August P. Hypertension in pregnancy. Adv Chronic Kidney Dis 2007; 14 (02) 178-190 Review
  • 68 Ascarelli MH, Johnson V, McCreary H, Cushman J, May WL, Martin Jr JN. Postpartum preeclampsia management with furosemide: a randomized clinical trial. Obstet Gynecol 2005; 105 (01) 29-33
  • 69 Vikse BE, Irgens LM, Leivestad T, Skjaerven R, Iversen BM. Preeclampsia and the risk of end-stage renal disease. N Engl J Med 2008; 359 (08) 800-809
  • 70 Irgens HU, Reisaeter L, Irgens LM, Lie RT. Long term mortality of mothers and fathers after pre-eclampsia: population based cohort study. BMJ 2001; 323 (7323): 1213-1217
  • 71 Canti IC, Komlós M, Martins-Costa SH, Ramos JG, Capp E, Corleta Hv. Risk factors for cardiovascular disease ten years after preeclampsia. Sao Paulo Med J 2010; 128 (01) 10-13