Managing Chronic Hypertension in Pregnancy: Guidelines and Safe Medications
As a cardiovascular pharmacist, questions about managing chronic hypertension in pregnancy are increasing. Factors like maternal age and obesity contribute to this trend.
Treat all pregnant patients with severe hypertension (160/110 mm Hg or above). The treatment of nonsevere chronic hypertension (140/90 or more) has been less clear due to limited evidence.
- Aim for BP under 140/90. New data suggest targeting BP under 140/90 for nonsevere chronic hypertension in pregnancy improves outcomes, including reducing preeclampsia risk without increasing low-birth-weight babies.
- Recent guidelines recommend this threshold for adding or stepping up treatment, potentially leading to more frequent use of BP meds in pregnancy.
Advise using nifedipine ER or labetalol first. These medications are not linked to significant fetal adverse outcomes. Avoid jumping to other CCBs, as they lack sufficient safety data. Steer clear of atenolol and use caution with beta-blockers other than labetalol, as they may impair fetal growth.
Consider methyldopa if first-line meds aren’t enough. Methyldopa has a long history of safety in pregnancy, but note that it’s currently discontinued with no return date. Save thiazides as a second-line option due to possible hypovolemia, especially in the initial weeks of therapy. Avoid spironolactone or eplerenone due to limited data.
Continue to avoid ACEIs or ARBs. These medications pose a serious risk of fetal injury or death when used in the second or third trimester.
Take-home pointsKey strategies for managing managing chronic hypertension in pregnancy...
- Treat severe hypertension (160/110 mm Hg or above) in all pregnant patients.
- Target BP under 140/90 for nonsevere chronic hypertension to improve outcomes.
- Use nifedipine ER or labetalol as first-line medications for safety.
- Avoid atenolol and other beta-blockers, except labetalol, due to fetal growth concerns.
- Consider methyldopa, but it’s currently unavailable.
- Avoid ACEIs and ARBs due to serious fetal risks in later trimesters.
References
- Tita AT, Szychowski JM, Boggess K, et al. Treatment for Mild Chronic Hypertension during Pregnancy. N Engl J Med. 2022;386(19):1781-1792. doi:10.1056/NEJMoa2201295
- American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Obstetrics (2019). ACOG Practice Bulletin No. 203: Chronic Hypertension in Pregnancy. Obstetrics and gynecology, 133(1), e26–e50. https://doi.org/10.1097/AOG.0000000000003020
- Whelton, P. K., & Carey, R. M. (2017). The 2017 Clinical Practice Guideline for High Blood Pressure. JAMA, 318(21), 2073–2074. https://doi.org/10.1001/jama.2017.18209
Keywords: Chronic hypertension in pregnancy, Pregnancy hypertension management, BP control in pregnancy, Safe blood pressure medications for pregnancy, Hypertension guidelines in pregnancy, Nifedipine ER for pregnancy hypertension, Labetalol in pregnancy, Methyldopa safety in pregnancy, Avoiding ACEIs and ARBs in pregnancy, Beta-blockers and fetal growth, Thiazides and pregnancy, Managing nonsevere hypertension in pregnancy, Maternal age and hypertension, Obesity and pregnancy hypertension
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