Hypertensive Disorders in Pregnancy: A Birth Worker's Guide

Gestational hypertension. Preeclampsia. HELLP syndrome. Eclampsia. Four names for one spectrum, and it's the spectrum every birth worker will meet sooner or later, whether that's in a client's chart, a hospital hallway, or a phone call about a headache that won't quit. This week's mentoring session is built around it, so here's the overview and the data to sit with before we meet.

https://youtu.be/CRhGx8A7Dqg?si=jK0WXcr5XlUj9kXM

The spectrum, briefly

Gestational hypertension is new-onset high blood pressure after 20 weeks, without protein in the urine or other signs of organ involvement. It can resolve after birth or progress.

Preeclampsia adds evidence that the disease is affecting other systems: protein in the urine, or signs of liver, kidney, neurological, or clotting involvement, plus severe headache, visual changes, or upper abdominal pain. It can show up with normal blood pressure readings in between, which is part of why it's easy to miss if you're only watching the cuff.

HELLP syndrome stands for hemolysis, elevated liver enzymes, and low platelets. It's often treated as a variant of severe preeclampsia and can develop fast, sometimes without the blood pressure numbers you'd expect to see first.

Eclampsia is the seizure. It's rare, but it's the outcome every step before it is designed to prevent.

How common this actually is right now

The short version: more common than most training materials from even a decade ago suggest, and the rate is still climbing.

CDC data released this year found that gestational hypertension affected roughly 1 in 10 pregnant people in 2024, up from about 1 in 17 in 2016. That's a 73 percent increase in eight years, and it rose in all 50 states. Preeclampsia specifically complicates around 1 in 25 pregnancies nationally, and its incidence rose 25 percent between 1993 and 2014 alone. Looking at delivery hospitalizations, the overall prevalence of hypertensive disorders in pregnancy climbed from 13.3 percent to 15.9 percent between just 2017 and 2019. Zoom out further and the increase from 1989 to 2018 was 149 percent.

Hypertensive disorders are now a leading cause of pregnancy-related death in the US. This isn't a rare complication to mention in passing. It's a baseline you should expect to see in your caseload.

What's driving the increase

Some of this tracks with broader shifts in the reproductive-age population: chronic hypertension among pregnant people more than doubled between 2010 and 2021 (a 125 percent relative increase), and pregestational diabetes rose alongside it. Rising rates of obesity and advancing maternal age both contribute. People are entering pregnancy with more chronic conditions already present, and those conditions interact with pregnancy physiology in ways that raise risk for the whole hypertensive spectrum.

But the risk isn't distributed evenly, and the reasons why matter as much as the mechanism.

Systemic racism as a contributing factor

Black birthing people in the US develop preeclampsia at a rate about 60 percent higher than white birthing people. Eclampsia and preeclampsia are among the leading causes of maternal death for Black women, at roughly five times the rate seen in white women. And a 2022 analysis found Black women face a 53 percent higher risk of dying in the hospital during childbirth regardless of income, insurance type, or other social determinants of health, which rules out poverty alone as the explanation.

Research on US-born Black women compared with foreign-born Black women found that race alone doesn't account for the disparity either.

What does track is chronic exposure to racism itself: the accumulated physiological toll of navigating a healthcare system (and a broader society) shaped by structural racism functions as sustained stress on the body, and sustained stress is a known driver of hypertension and preeclampsia. Add to that documented differences in how patient concerns get heard and acted on, gaps in shared decision-making, and inconsistent use of evidence-based practice across racial lines, and the disparity stops looking like a mystery.

For those of us supporting birthing people through this, that means two things at once: watching the clinical signs carefully for every client, and staying alert to whether a Black client's symptoms are being taken seriously by the care team around her. Advocacy is part of the clinical picture here, not separate from it.

I've added a video for you to watch before Monday that goes deeper on preeclampsia specifically. Come with questions.