Contents

Search

hypertension during pregnancy

180/110 > BP > 140/90 is considered mild Etiology: - no strong evidence supports a causal effect of vitamin D status on gestational hypertension or pre-eclampsia [24] Epidemiology: - prevalence 1.5% of pregnant women [3] Clinical manifestations: - gestational hypertension (HTN) - develops at 20 weeks of gestation or later - not associated with proteinuria or other features of preeclampsia - resolves within 12 weeks of delivery [1] - hypertension during the 1st 20 weeks of gestation suggests chronic hypertension present prior to pregnancy [1] - chronic hypertension continues > 12 weeks post-partum [1] Complications: 1) preeclampsia: a) women with chronic hypertension are at increased risk - RR = 8 [12] b) controlling BP does NOT reduce the risk [1] 2) pheochromocytosis & renovascular hypertension associated with poor maternal & fetal prognosis 3) women with primary hyperaldosteronism have relatively uncomplicated pregnancies [1] 4) diastolic BP of 76-82 mm Hg throughout pregnancy associated with 6-fold risk of developing the metabolic syndrome, relative diastolic BP of 63-65 mm Hg [19] 5) increased long-term risk for post-pregnancy hypertension [21,25] a) black women more likely than white women to be hypertensive postpartum [27] b) controlling BP does NOT reduce the risk [1] 6) hypertension during pregnancy associated with increased risk of cognitive impairment 15 years later [26] 7) increased mortality later life from - diabetes mellitus (RR=2.8) - ischemic heart disease (RR=2.2) - stroke (RR=1.9) - Alzheimer disease (RR=3.4) [20] 8) hypertension during pregnancy associated with increased risk for autism & attention-deficit hyperactivity disorder among offspring [23] 9) increased risk for hypercholesterolemia (RR=1.3) [25] Management: 1) treat hypertension during pregnancy if BP > 140/90 before pregnancy or before 20 weeks gestation or persists > 12 weeks postpartum [1,30] - formerly treatment indicated for persistent systolic BP >= 160 mm Hg or diastolic BP >= 110 mm Hg in women with chronic hypertension [1,2,4,13] - treatment of chronic hypertension (<160/110 mm Hg) is not associated with improved fetal outcomes [1] - persistence of BP > 160/110 mm Hg indicates severe HTN [22] - goal is BP < 150/100 [13]; 120-159/80-109 mm Hg [1] - use lower threshold if chronic renal failure [1] - outcomes better with treatment to target of < 140/90 mm Hg [29] - tight control of blood pressure (target diastolic BP of 85 mm Hg) is not associated with increased perinatal risk or major benefits [13] 2) treatment a) labetolol [1,2,13] (first line) b) alpha-methyldopa (Aldomet) c) hydralazine# [3] d) nifedipine* e) diuretics are OK [2] - diuretics may induce oligohydramnios if initiated during pregnancy [1] f) ACE inhibitors, ARBs are CONTRAINDICATED [2,18] g) atenolol is CONTRAINDICATED [2] 3) vitamin C & vitamin E of no benefit in preventing complications [5] 4) prophylaxis for pre-eclampsia in high-risk patients - magnesium sulfate 4-6 g bolus, followed by 2 g per hour; continue for at least 24 hours after delivery [22] - low dose aspirin 75-150 mg/day to inhibit formation of TxA2 [1,6] * alternative agent (other calcium channel blockers ok) [1] # adverse effects (headache, nausea, vomiting mimick worsening preeclampsia [3]; hydralazine associated with higher risk of adverse outcomes than nifedipine or labetolol [3]

Related

eclampsia

Specific

early onset hypertension with severe exacerbation in pregnancy pregnancy-induced hypertension; gestational hypertension (PIH)

General

pregnancy disorder; obstetric disorder; pregnancy complication hypertension (HTN, high blood pressure, HBP)

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2009, 2012, 2015, 2018, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  2. Prescriber's Letter 8(9):53 2001
  3. Journal Watch 23(24):192, 2003 Magee LA et al, BMJ 327:955, 2003 PMID: 14576246 http://bmj.bmjjournals.com/cgi/content/full/327/7421/955
  4. Prescriber's Letter 15(4): 2008 Treating High Blood Pressure in Pregnancy Detail-Document#: 240412 (subscription needed) http://www.prescribersletter.com
  5. Roberts JM et al Vitamins C and E to Prevent Complications of Pregnancy- Associated Hypertension New Engl J Med 2010, 362:1282-1291 PMID: 20375405 http://content.nejm.org/cgi/content/short/362/14/1282
  6. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 125: Chronic hypertension in pregnancy. Obstet Gynecol. 2012 Feb;119(2 Pt 1):396-407. PMID: 22270315
  7. Seely EW, Ecker J. Clinical practice. Chronic hypertension in pregnancy. N Engl J Med. 2011 Aug 4;365(5):439-46. PMID: 21812673
  8. Yoder SR, Thornburg LL, Bisognano JD. Hypertension in pregnancy and women of childbearing age. Am J Med. 2009 Oct;122(10):890-5 PMID: 19786154
  9. Lykke JA, Langhoff-Roos J, Sibai BM et al Hypertensive pregnancy disorders and subsequent cardiovascular morbidity and type 2 diabetes mellitus in the mother. Hypertension. 2009 Jun;53(6):944-51 PMID: 19433776
  10. Noori M, Donald AE, Angelakopoulou A, Prospective study of placental angiogenic factors and maternal vascular function before and after preeclampsia and gestational hypertension. Circulation. 2010 Aug 3;122(5):478-87. PMID: 20644016
  11. Podymow T, August P. Update on the use of antihypertensive drugs in pregnancy. Hypertension. 2008 Apr;51(4):960-9 PMID: 18259046
  12. Bramham K et al Chronic hypertension and pregnancy outcomes: systematic review and meta-analysis. BMJ 2014;348:g2301 PMID: 24735917 http://www.bmj.com/content/348/bmj.g2301 - Clausen TD and Bergholt T Chronic hypertension during pregnancy. BMJ 2014;348:g2655 PMID: 24736417 http://www.bmj.com/content/348/bmj.g2655
  13. Magee LA et al Less-Tight versus Tight Control of Hypertension in Pregnancy. N Engl J Med 2015; 372:407-417. January 29, 2015 PMID: 25629739 http://www.nejm.org/doi/full/10.1056/NEJMoa1404595 - Solomon CG, Greene MF Control of Hypertension in Pregnancy - If Some Is Good, Is More Worse? N Engl J Med 2015; 372:475-476. January 28, 2015 PMID: 25629746 http://www.nejm.org/doi/full/10.1056/NEJMe1414836 - Bimla Schwarz E Treating Hypertension During Pregnancy: Benefits Seem to Outweigh Risks NEJM Journal Watch. Jan 13, 2015 Massachusetts Medical Society (subscription needed) http://www.jwatch.org - Husten L, Sadoughi S, Saitz R No Major Benefits with Tight Control of Hypertension in Pregnancy Physician's First Watch, Jan 28, 2015 David G. Fairchild, MD, MPH, Editor-in-Chief Massachusetts Medical Society http://www.jwatch.org
  14. Seely EW, Ecker J. Chronic hypertension in pregnancy. Circulation. 2014 Mar 18;129(11):1254-61. PMID: 24637432 Free Article
  15. Abalos E, Duley L, Steyn DW. Antihypertensive drug therapy for mild to moderate hypertension during pregnancy. Cochrane Database Syst Rev. 2014 Feb 6;2:CD002252. Review. PMID: 24504933
  16. 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 Nov;122(5):1122-31 PMID: 24150027
  17. Kattah AG, Garovic VD. The management of hypertension in pregnancy. Adv Chronic Kidney Dis. 2013 May;20(3):229-39. Review. PMID: 23928387 Free PMC Article
  18. Bullo M, Tschumi S, Bucher BS et al Pregnancy outcome following exposure to angiotensin-converting enzyme inhibitors or angiotensin receptor antagonists: a systematic review. Hypertension. 2012 Aug;60(2):444-50. Review. PMID: 22753220 Free Article
  19. Lei Q, Zhou X, Zhou YH et al Prehypertension During Normotensive Pregnancy and Postpartum Clustering of Cardiometabolic Risk Factors. A Prospective Cohort Study. Hypertension. June 27, 2016 PMID: 27354425 http://hyper.ahajournals.org/content/early/2016/06/27/HYPERTENSIONAHA.116.07261.abstract
  20. Theilen LH et al. All-cause and cause-specific mortality after hypertensive disease of pregnancy. Obstet Gynecol 2016 Aug; 128:238 PMID: 27400006
  21. Behrens I, Basit S, Melbye M et al Risk of post-pregnancy hypertension in women with a history of hypertensive disorders of pregnancy: nationwide cohort study. BMJ 2017;358:j3078 PMID: 28701333 http://www.bmj.com/content/358/bmj.j3078 - Timpka S, Stuart JJ, Tanz LJ, Rimm EB, Franks PW, Rich-Edwards JW. Lifestyle in progression from hypertensive disorders of pregnancy to chronic hypertension in Nurses' Health Study II: observational cohort study. BMJ 2017;358:j3024 PMID: 28701338 http://www.bmj.com/content/358/bmj.j3024 - Barrett HL, Callaway LK Hypertensive disorders of pregnancy. BMJ 2017;358:j3245 PMID: 28705906 http://www.bmj.com/content/358/bmj.j3245
  22. Bernstein PS, Martin JN Jr, Barton JR et al. National Partnership for Maternal Safety: Consensus bundle on severe hypertension during pregnancy and the postpartum period. Obstet Gynecol 2017 Aug; 130:347-357 PMID: 28697093 https://insights.ovid.com/crossref?an=00006250-201708000-00013
  23. Maher GM, O'Keeffe GW, Kearney PM et al Association of Hypertensive Disorders of Pregnancy With Risk of Neurodevelopmental Disorders in Offspring. A Systematic Review and Meta-analysis. JAMA Psychiatry. Published online June 6, 2018. PMID: 29874359 https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2681643
  24. Magnus MC. Miliku K, Bauer A et al Vitamin D and risk of pregnancy related hypertensive disorders: mendelian randomisation study. BMJ 2018;361:k2167 PMID: 29925546 https://www.bmj.com/content/361/bmj.k2167
  25. Stuart JJ, Tanz LJ, Missmer SA et al Hypertensive Disorders of Pregnancy and Maternal Cardiovascular Disease Risk Factor Development: An Observational Cohort Study. Ann Intern Med. 2018. July 3 PMID: 29971437 http://annals.org/aim/article-abstract/2686987/hypertensive-disorders-pregnancy-maternal-cardiovascular-disease-risk-factor-development-observational - Fraser A Women's Cardiovascular Health After a Hypertensive Disorder of Pregnancy. Ann Intern Med. 2018. July 3 PMID: 29971435 http://annals.org/aim/article-abstract/2686988/women-s-cardiovascular-health-after-hypertensive-disorder-pregnancy
  26. Adank MC, Hussainali RF, Oosterveer LC et al Hypertensive disorders of pregnancy and cognitive impairment: A prospective cohort study. Neurology. Dec 30, 2020 PMID: 33380500 https://n.neurology.org/content/early/2020/12/30/WNL.0000000000011363
  27. Hauspurg A, Lemon L, Cabrera C et al. Racial differences in postpartum blood pressure trajectories among women after a hypertensive disorder of pregnancy. JAMA Netw Open 2020 Dec 1; 3:e2030815. PMID: 33351087 PMCID: PMC7756239 Free PMC article https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2774429
  28. Bone JN, Sandhu A, Abalos ED et al. Oral antihypertensives for nonsevere pregnancy hypertension: Systematic review, network meta- and trial sequential analyses. Hypertension 2022 Mar; 79:614 PMID: 35138877 PMCID: PMC8823910 Free PMC article https://www.ahajournals.org/doi/10.1161/HYPERTENSIONAHA.121.18415
  29. Tita AT et al. Treatment for mild chronic hypertension during pregnancy. N Engl J Med 2022 Apr 2 PMID: 35363951 https://www.nejm.org/doi/10.1056/NEJMoa2201295
  30. Society for Maternal-Fetal Medicine; Publications Committee. Society for Maternal-Fetal Medicine Statement: Antihypertensive therapy for mild chronic hypertension in pregnancy-The Chronic Hypertension and Pregnancy trial Am J Obstet Gynecol. 2022 Aug;227(2):B24-B27. PMID: 35710594