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The Treatment of Hypertension During Pregnancy: When Should Blood Pressure Medications Be Started?

  • Hypertension (M Sorrentino, Section Editor)
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Abstract

Hypertensive pregnancy disorders (HPD) are important causes of maternal and fetal morbidity and mortality worldwide. In addition, a history of HPD has been associated with an increased risk for maternal cardiovascular disease later in life, possibly because of irreversible vascular and metabolic changes that persist beyond the affected pregnancies. Therefore, treatment of HPD may not only improve immediate pregnancy outcomes, but also maternal long-term cardiovascular health. Unlike the recommendations for hypertension treatment in the general population, treatment recommendations for HPD have not changed substantially for more than 2 decades. This is particularly true for mild to moderate hypertension in pregnancy, defined as a blood pressure of 140–159/90–109 mm Hg. This review focuses on the goals of therapy, treatment strategies, and new developments in the field of HPD that should be taken into account when considering blood pressure targets and pharmacologic options for treatment of hypertension in pregnant women.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Report of the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy. Am J Obstet Gynecol. 2000;183:S1–22.

    Google Scholar 

  2. Dolea C, AbouZahr C. Global burden of hypertensive disorders of pregnancy in the year 2000. In: Evidence and Information for Policy (EIP), World Health Organization. 2003. Available at: http://www.who.int/healthinfo/statistics/bod_hypertensivedisordersofpregnancy.pdf.

  3. Wallis AB, Saftlas AF, Hsia J, Atrash HK. Secular trends in the rates of pre-eclampsia, eclampsia, and gestational hypertension, United States, 1987–2004. Am J Hypertens. 2008;21:521–6.

    Article  PubMed  Google Scholar 

  4. Khan KS, Wojdyla D, Say L, Gulmezoglu AM, Van Look PF. WHO analysis of causes of maternal death: a systematic review. Lancet. 2006;367:1066–74. doi:10.1016/S0140-6736(06)68397-9.

    Article  PubMed  Google Scholar 

  5. Berg CJ, Callaghan WM, Syverson C, Henderson Z. Pregnancy-related mortality in the United States, 1998 to 2005. Obstet Gynecol. 2010;116:1302–9. doi:10.1097/AOG.0b013e3181fdfb11.

    Article  PubMed  Google Scholar 

  6. • Kuklina EV, Ayala C, Callaghan WM. Hypertensive disorders and severe obstetric morbidity in the United States. Obstet Gynecol. 2009;113:1299–306. doi:10.1097/AOG.0b013e3181a45b25. This paper examines recent trends in the rates of HPD in the United States and immediate maternal morbidity.

    PubMed  Google Scholar 

  7. Metcalfe J, Ueland K. Maternal cardiovascular adjustments to pregnancy. Prog Cardiovasc Dis. 1974;16:363–74.

    Article  PubMed  CAS  Google Scholar 

  8. Curran-Everett D, Morris Jr KG, Moore LG. Regional circulatory contributions to increased systemic vascular conductance of pregnancy. Am J Physiol. 1991;261(6 Pt 2):H1842–7.

    PubMed  CAS  Google Scholar 

  9. Chapman AB, Abraham WT, Zamudio S, Coffin C, Merouani A, Young D, et al. Temporal relationships between hormonal and hemodynamic changes in early human pregnancy. Kidney Int. 1998;54:2056–63. doi:10.1046/j.1523-1755.1998.00217.x.

    Article  PubMed  CAS  Google Scholar 

  10. Pritchard JA. Changes in the blood volume during pregnancy and delivery. Anesthesiology. 1965;26:393–9.

    Article  PubMed  CAS  Google Scholar 

  11. Ferrer RL, Sibai BM, Mulrow CD, Chiquette E, Stevens KR, Cornell J. Management of mild chronic hypertension during pregnancy: A review. Obstet Gynecol. 2000;96(5 Pt 2):849–60.

    Article  PubMed  CAS  Google Scholar 

  12. Meekins JW, Pijnenborg R, Hanssens M, McFadyen IR, van Asshe A. A study of placental bed spiral arteries and trophoblast invasion in normal and severe pre-eclamptic pregnancies. Br J Obstet Gynaecol. 1994;101:669–74.

    Article  PubMed  CAS  Google Scholar 

  13. Khong TY, De Wolf F, Robertson WB, Brosens I. Inadequate maternal vascular response to placentation in pregnancies complicated by pre-eclampsia and by small-for-gestational age infants. Br J Obstet Gynaecol. 1986;93:1049–59.

    Article  PubMed  CAS  Google Scholar 

  14. Genbacev O, Zhou Y, Ludlow JW, Fisher SJ. Regulation of human placental development by oxygen tension. Science. 1997;277:1669–72.

    Article  PubMed  CAS  Google Scholar 

  15. Maynard SE, Min JY, Merchan J, Lim KH, Li J, Mondal S, et al. Excess placental soluble fms-like tyrosine kinase 1 (sFlt1) may contribute to endothelial dysfunction, hypertension, and proteinuria in pre-eclampsia. J Clin Invest. 2003;111:649–58. doi:10.1172/JCI17189.

    PubMed  CAS  Google Scholar 

  16. • Herse F, Lamarca B. Angiotensin II type 1 receptor autoantibody (AT1-AA)-mediated pregnancy hypertension. Am J Reproduct Immunol. 2013;69:413–8. doi:10.1111/aji.12072. This recent review summarizes evidence for the role of the AT1 receptor antibody in the pathogenesis of hypertensive pregnancy.

    Article  CAS  Google Scholar 

  17. Wagner SJ, Craici IM, Grande JP, Garovic VD. From placenta to podocyte: Vascular and podocyte pathophysiology in pre-eclampsia. Clin Nephrol. 2012;78:241–9.

    Article  PubMed  CAS  Google Scholar 

  18. • Wagner SJ, Acquah LA, Lindell EP, Craici IM, Wingo MT, Rose CH, et al. Posterior reversible encephalopathy syndrome and eclampsia: pressing the case for more aggressive blood pressure control. Mayo Clinic Proc. 2011;86:851–6. This report demonstrates that PRES and eclampsia may develop at relatively modest BP elevations, further emphasizing the need to readress the treatment targets in HPD guidelines.

    Article  Google Scholar 

  19. Moser M. Historical perspectives on the management of hypertension. J Clin Hypertens. 2006;8(8 Suppl 2):15–20. quiz 39.

    Article  Google Scholar 

  20. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo Jr JL, et al. The seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure: The JNC 7 report. JAMA. 2003;289:2560–72. doi:10.1001/jama.289.19.2560.

    Article  PubMed  CAS  Google Scholar 

  21. National High Blood Pressure Education Program Working Group Report on High Blood Pressure in Pregnancy. Am J Obstet Gynecol. 1990;163(5 Pt 1):1691–712.

    Google Scholar 

  22. Lindheimer MD, Taler SJ, Cunningham FG. Hypertension in pregnancy. J Am Soc Hypertens. 2010;4:68–78. doi:10.1016/j.jash.2010.03.002.

    Article  PubMed  CAS  Google Scholar 

  23. Redman CW. Hypertension in pregnancy: The NICE guidelines. Heart. 2011;97:1967–9. doi:10.1136/heartjnl-2011-300949.

    Article  PubMed  CAS  Google Scholar 

  24. European Society of G, Association for European Paediatric C, German Society for Gender M, Authors/Task Force M, Regitz-Zagrosek V, Blomstrom Lundqvist C, et al. ESC Guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). Eur Heart J. 2011;32:3147–97. doi:10.1093/eurheartj/ehr218.

    Google Scholar 

  25. Magee LA, Abalos E, von Dadelszen P, Sibai B, Easterling T, Walkinshaw S, et al. How to manage hypertension in pregnancy effectively. Br J Clin Pharmacol. 2011;72:394–401.

    Article  PubMed  CAS  Google Scholar 

  26. Sibai BM, Anderson GD. Pregnancy outcome of intensive therapy in severe hypertension in first trimester. Obstet Gynecol. 1986;67:517–22.

    PubMed  CAS  Google Scholar 

  27. •• Orbach H, Matok I, Gorodischer R, Sheiner E, Daniel S, Wiznitzer A, et al. Hypertension and antihypertensive drugs in pregnancy and perinatal outcomes. Am J Obstet Gynecol. 2012. doi:10.1016/j.ajog.2012.11.011. This very recent report presents evidence for increasing fetal morbidity with chronic hypertension, regardless of treatment status.

    PubMed  Google Scholar 

  28. Su CY, Lin HC, Cheng HC, Yen AM, Chen YH, Kao S. Pregnancy outcomes of antihypertensives for women with chronic hypertension: A population-based study. PLoS One. 2013;8:e53844. doi:10.1371/journal.pone.0053844.

    Article  PubMed  CAS  Google Scholar 

  29. Ray JG, Vermeulen MJ, Burrows EA, Burrows RF. Use of antihypertensive medications in pregnancy and the risk of adverse perinatal outcomes: McMaster Outcome Study of Hypertension In Pregnancy 2 (MOS HIP 2). BMC Pregnancy Childbirth. 2001;1:6.

    Article  PubMed  Google Scholar 

  30. Sibai BM, Mabie WC, Shamsa F, Villar MA, Anderson GD. A comparison of no medication vs methyldopa or labetalol in chronic hypertension during pregnancy. Am J Obstet Gynecol. 1990;162:960–6. discussion 6–7.

    Article  PubMed  CAS  Google Scholar 

  31. Abalos E, Duley L, Steyn DW, Henderson-Smart DJ. Antihypertensive drug therapy for mild to moderate hypertension during pregnancy. Cochrane Database Syst Rev. 2007:CD002252. doi:10.1002/14651858.CD002252.pub2

  32. • Ankumah N, Tita A, Cantu J, Chapman-Jauk V, Biggio J, Hauth J, et al. Pregnancy outcome vary by blood pressure level in women with mild-range chronic hypertension. Am J Obstet Gynecol. 2013;208:S261. Although only in abstract form, these data are based on the best characterized cohort of women with chronic hypertension in pregnancy and present important evidence of increased morbidity with mild to moderate hypertension in pregnancy.

    Article  Google Scholar 

  33. Caritis S, Sibai B, Hauth J, Lindheimer MD, Klebanoff M, Thom E, et al. Low-dose aspirin to prevent pre-eclampsia in women at high risk. National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units. N Engl J Med. 1998;338:701–5.

    Article  PubMed  CAS  Google Scholar 

  34. Ferrer RL, Sibai BM, Mulrow CD, Chiquette E, Stevens KR, Cornell J. Management of mild chronic hypertension during pregnancy: A review. Obstet Gynecol. 2000;96(5 Pt 2):849–60.

    Article  PubMed  CAS  Google Scholar 

  35. August P. Preeclampsia: New thoughts on an ancient problem. J Clin Hypertens. 2000;2:115–23.

    Google Scholar 

  36. Gradman AH, Basile JN, Carter BL, Bakris GL. Combination therapy in hypertension. J Am Soc Hypertens. 2010;4:42–50.

    Article  PubMed  CAS  Google Scholar 

  37. von Dadelszen P, Ornstein MP, Bull SB, Logan AG, Koren G, Magee LA. Fall in mean arterial pressure and fetal growth restriction in pregnancy hypertension: A meta-analysis. Lancet. 2000;355:87–92.

    Article  Google Scholar 

  38. de Swiet M. Maternal blood pressure and birthweight. Lancet. 2000;355:81–2. doi:10.1016/S0140-6736(99)00288-3.

    Article  PubMed  Google Scholar 

  39. Jannet D, Carbonne B, Sebban E, Milliez J. Nicardipine vs metoprolol in the treatment of hypertension during pregnancy: A randomized comparative trial. Obstet Gynecol. 1994;84:354–9.

    PubMed  CAS  Google Scholar 

  40. Macones GA, Odibo A, Cahill A. Discussion: ‘hypertension and antihypertensives in pregnancy,’ by Orbach H, et al. Am J Obstet Gynecol. 2013. doi:10.1016/j.ajog.2013.02.024.

    Google Scholar 

  41. Martin Jr JN, Thigpen BD, Moore RC, Rose CH, Cushman J, May W. Stroke and severe pre-eclampsia and eclampsia: A paradigm shift focusing on systolic blood pressure. Obstet Gynecol. 2005;105:246–54.

    Article  PubMed  Google Scholar 

  42. Hinchey J, Chaves C, Appignani B, Breen J, Pao L, Wang A, et al. A reversible posterior leukoencephalopathy syndrome. N Engl J Med. 1996;334:494–500.

    Article  PubMed  CAS  Google Scholar 

  43. Cockburn J, Moar VA, Ounsted M, Redman CW. Final report of study on hypertension during pregnancy: The effects of specific treatment on the growth and development of the children. Lancet. 1982;1:647–9.

    Article  PubMed  CAS  Google Scholar 

  44. Moser M, Brown CM, Rose CH, Garovic VD. Hypertension in pregnancy: Is it time for a new approach to treatment? J Hypertens. 2012;30:1092–100. doi:10.1097/HJH.0b013e3283536319.

    Article  PubMed  CAS  Google Scholar 

  45. Schaefer C. Angiotensin II-receptor-antagonists: Further evidence of fetotoxicity but not teratogenicity. Birth defects research Part A. Clin Molec Teratol. 2003;67:591–4. doi:10.1002/bdra.10081.

    Article  CAS  Google Scholar 

  46. Cooper WO, Hernandez–Diaz S, Arbogast PG, Dudley JA, Dyer S, Gideon PS, et al. Major congenital malformations after first-trimester exposure to ACE inhibitors. N Engl J Med. 2006;354:2443–51. doi:10.1056/NEJMoa055202.

    Article  PubMed  CAS  Google Scholar 

  47. Shotan A, Widerhorn J, Hurst A, Elkayam U. Risks of angiotensin-converting enzyme inhibition during pregnancy: Experimental and clinical evidence, potential mechanisms, and recommendations for use. Am J Med. 1994;96:451–6.

    Article  PubMed  CAS  Google Scholar 

  48. Sibai BM, Grossman RA, Grossman HG. Effects of diuretics on plasma volume in pregnancies with long-term hypertension. Am J Obstet Gynecol. 1984;150:831–5.

    PubMed  CAS  Google Scholar 

  49. McDonald SD, Malinowski A, Zhou Q, Yusuf S, Devereaux PJ. Cardiovascular sequelae of pre-eclampsia/eclampsia: A systematic review and meta-analyses. Am Heart J. 2008;156:918–30. doi:10.1016/j.ahj.2008.06.042.

    Article  PubMed  Google Scholar 

  50. Lykke JA, Langhoff-Roos J, Sibai BM, Funai EF, Triche EW, Paidas MJ. Hypertensive pregnancy disorders and subsequent cardiovascular morbidity and type 2 diabetes mellitus in the mother. Hypertension. 2009;53:944–51. doi:10.1161/hypertensionaha.109.130765.

    Article  PubMed  CAS  Google Scholar 

  51. Bellamy L, Casas JP, Hingorani AD, Williams DJ. Pre-eclampsia and risk of cardiovascular disease and cancer in later life: Systematic review and meta-analysis. BMJ. 2007;335:974. doi:10.1136/bmj.39335.385301.BE.

    Article  PubMed  Google Scholar 

  52. Ray JG, Vermeulen MJ, Schull MJ, Redelmeier DA. Cardiovascular health after maternal placental syndromes (CHAMPS): Population-based retrospective cohort study. Lancet. 2005;366:1797–803. doi:10.1016/s0140-6736(05)67726-4.

    Article  PubMed  Google Scholar 

  53. •• Ray JG, Schull MJ, Kingdom JC, Vermeulen MJ. Heart failure and dysrhythmias after maternal placental syndromes: HAD MPS Study. Heart. 2012;98:1136–41. doi:10.1136/heartjnl-2011-301548. This very large population based study is the first to report the association between maternal placental syndromes, including pre-eclampsia, and an increased risk of HF and arrhythmias.

    Article  PubMed  Google Scholar 

  54. Campos O. Doppler Echocardiography during pregnancy: Physiological and abnormal findings. Echocardiography. 1996;13:135–46.

    Article  PubMed  Google Scholar 

  55. Savu O, Jurcut R, Giusca S, van Mieghem T, Gussi I, Popescu BA, et al. Morphological and functional adaptation of the maternal heart during pregnancy. Circulation Cardiovascular Imaging. 2012;5:289–97. doi:10.1161/CIRCIMAGING.111.970012.

    Article  PubMed  Google Scholar 

  56. Zanati Bazan SG, Borges VM, Martin LC, Magalhaes CG, Hueb JC, de Arruda Silveira LV, et al. Disproportionate pregnancy-induced myocardial hypertrophy in women with essential hypertension. Am J Hypertens. 2013. doi:10.1093/ajh/hpt023.

    PubMed  Google Scholar 

  57. • Melchiorre K, Sutherland GR, Baltabaeva A, Liberati M, Thilaganathan B. Maternal cardiac dysfunction and remodeling in women with pre-eclampsia at term. Hypertension. 2011;57:85–93. doi:10.1161/HYPERTENSIONAHA.110.162321. This studiy explores the effects of hypertensive pregnancy on maternal cardiac structure and function.

    Article  PubMed  CAS  Google Scholar 

  58. Ingec M, Yilmaz M, Gundogdu F. Left atrial mechanical functions in pre-eclampsia. J Obstet Gynaecol Res. 2005;31:535–9. doi:10.1111/j.1447-0756.2005.00332.x.

    Article  PubMed  Google Scholar 

  59. Melchiorre K, Sutherland GR, Watt-Coote I, Liberati M, Thilaganathan B. Severe myocardial impairment and chamber dysfunction in preterm pre-eclampsia. Hypertens Pregnancy. 2012;31:454–71. doi:10.3109/10641955.2012.697951.

    Article  PubMed  Google Scholar 

  60. Melchiorre K, Sutherland GR, Liberati M, Thilaganathan B. Preeclampsia is associated with persistent postpartum cardiovascular impairment. Hypertension. 2011;58:709–15. doi:10.1161/HYPERTENSIONAHA.111.176537.

    Article  PubMed  CAS  Google Scholar 

  61. • Strobl I, Windbichler G, Strasak A, Weiskopf-Schwendinger V, Schweigmann U, Ramoni A, et al. Left ventricular function many years after recovery from pre-eclampsia. BJOG. 2011;118:76–83. doi:10.1111/j.1471-0528.2010.02780.x. This is an echocardiographic study investigating the effect of hypertensive pregnancy on the maternal heart longterm.

    Article  PubMed  CAS  Google Scholar 

  62. •• Mannisto T, Mendola P, Vaarasmaki M, Jarvelin MR, Hartikainen AL, Pouta A, et al. Elevated blood pressure in pregnancy and subsequent chronic disease risk. Circulation. 2013;127:681–90. doi:10.1161/CIRCULATIONAHA.112.128751. This report demonstrates that all types of hypertensive pregancy, not only pre-eclampsia, are associated with longterm maternal cardiac morbidity, even in the absence of other known cardiovascular disease risk factors. This further underscores the impact of hypertension in pregnancy itself as a risk factor for CVD.

    Article  PubMed  Google Scholar 

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Acknowledgments

The project described was supported by Award Number P-50 AG44170 (V.D. Garovic) from the National Institute on Aging. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The writing of the manuscript and the decision to submit it for publication were solely the authors’ responsibilities.

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Conflict of Interest

Dawn C. Scantlebury declares that she has no conflict of interest. Gary L. Schwartz declares that he has no conflict of interest. Letitia A. Acquah declares that she has no conflict of interest. Wendy M. White declares that she has no conflict of interest. Marvin Moser declares that he has no conflict of interest.

Vesna D. Garovic has patents filed, but not licensed.

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This article does not contain any studies with human or animal subjects performed by any of the authors.

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Authors and Affiliations

  1. Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA

    Dawn C. Scantlebury

  2. Division of Nephrology and Hypertension, Mayo Clinic, 200 First Street SW, Rochester, MN, USA

    Gary L. Schwartz & Vesna D. Garovic

  3. General Internal Medicine, Mayo Clinic, Rochester, MN, USA

    Letitia A. Acquah

  4. Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA

    Wendy M. White

  5. Department of Medicine/Cardiology, Yale University School of Medicine, New Haven, CT, USA

    Marvin Moser

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  1. Dawn C. Scantlebury
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  2. Gary L. Schwartz
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  5. Marvin Moser
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  6. Vesna D. Garovic
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Correspondence to Vesna D. Garovic.

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This article is part of the Topical Collection on Hypertension

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Scantlebury, D.C., Schwartz, G.L., Acquah, L.A. et al. The Treatment of Hypertension During Pregnancy: When Should Blood Pressure Medications Be Started?. Curr Cardiol Rep 15, 412 (2013). https://doi.org/10.1007/s11886-013-0412-0

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