Human pregnancy, normally characterized by systemic vasodilation and modest hypotension, can be complicated by underlying maternal hypertension and several unique hypertensive disorders, including pre-eclampsia. Although well-designed and adequately powered clinical trials are critically needed, there have been several recent meta-analyses of this large literature, along with consensus statements and treatment guidelines from three distinct multidisciplinary groups of clinicians and investigators. In this paper we review recent analyses and guidelines, advising on our current approach to antihypertensive therapy in pregnant women.
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References and Recommended Reading
Redman CWG, Beilin LJ, Bonnar J, Ounsted MK: Fetal outcome in trial of antihypertensive treatment in pregnancy. Lancet 1976, 2:753–756.
Lindheimer MD, Roberts JM, Cunningham FG: Chesley’ Hypertensive Disorders in Pregnancy, edn 2. Stamford: Appleton & Lange; 1999. This 654-page, multiauthored text provides the most comprehensive review available of cardiovascular physiology and pathophysiology in pregnancy, insights to the pathogenesis of pre-eclampsia, and critical review of strategies for the clinical management of these patients.
Report of the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy. NIH Publication No. 00-3029, July 2000. Accessible at www.nhlbi.nih.gov/health/prof/heart/hbp_preg.htm This consensus statement, revised 10 years after its initial publication, provides useful guidelines for the evaluation and management of hypertensive gravidas.
Brown MA, Hague WM, Higgins J, et al.: The detection, investigation and management of hypertension in pregnancy: full consensus statement. Aust N Z J Obstet Gynecol 2000, 40:139–155. This consensus statement of the Australasian Society for the Study of Hypertension in Pregnancy provides useful guidelines with minor specific differences from the NHBPEP Working Group.
Rey E, LeLorier J, Burgess E, et al.: Report of the Canadian Hypertension Society consensus conference. 3. Pharmacologic treatment of hypertensive disorders in pregnancy. Can Med Assoc J 1997, 157:1245–1254. The Canadian Hypertension Society statement, based on a critical literature review, preceded publication of references 3 and 4, above. These three sets of clinical guidelines are in essential agreement, reflecting perhaps appropriate circumspection in the face of limited data.
Shear R, Leduc L, Rey E, Moutquin JM: Hypertension in pregnancy: new recommendations for management. Curr Hypertens Rep 1999, 1:529–539.
Walker JJ: Pre-eclampsia. Lancet 2000, 356:1260–1265.
Sibai BM, Abdella TN, Anderson GD: Pregnancy outcome in 211 patients with mild chronic hypertension. Obstet Gynecol 1983, 61:571–576.
Sibai BM, Lindheimer MD, Hauth J, et al.: Risk factors for preeclampsia, abruptio placentae, and adverse neonatal outcomes among women with chronic hypertension. N Engl J Med 1998, 339:667–671.
Rey E, Couturier A: The prognosis of pregnancy in women with chronic hypertension. Am J Obstet Gynecol 1994, 171:410 416.
Ferrer RL, Sibai BM, Mulrow CD, et al.: Management of mild chronic hypertension during pregnancy: a review. Obstet Gynecol 2000, 96:849–860. This presents a summary of an evidence-based review conducted for the US Agency for Healthcare Research and Quality; the full report is available from their web site at http://www.ahcpr.gov/clinic/ evrptfiles.htm.
Magee LA, Ornstein MP, von Dadelszen P: Management of hypertension in pregnancy. BMJ 1999, 318:1332–1336. A thoughtful review with meta-analysis of recent relevant trials.
Sibai BM: Treatment of hypertension in pregnant women. N Engl J Med 1996, 335:257–265. A thoughtful, selective review, including specific treatment guidelines, from one of the most prolific clinical investigators in the field.
Abalos E, Duley L, Steyn DW, Henderson-Smart DJ: Antihypertensive drug therapy for mild to moderate hypertension during pregnancy. Cochrane Database Syst Rev 2001, 2:CD002252. A new meta-analysis from the Cochrane library. First to raise the possibility of differences between classes of antihypertensive agents.
Magee LA, Duley L: Oral beta blockers for mild to moderate hypertension during pregnancy. Cochrane Database Syst Rev 2000, 4:CD002863. Largest meta-analysis of β-blocker use in pregnancy.
Duley L, Henderson-Smart DJ: Drugs for rapid treatment of very high blood pressure during pregnancy. Cochrane Database Syst Rev 2000, 2:CD001449. Meta-analysis results are much in accord with latest guidelines from Canadian, Australasian, and US groups.
Huisjes HJ, Hadders-Algra M, Touwen BC: Is clonidine a behavioural teratogen in the human? Early Hum Dev 1986, 14:43–48.
Reynolds B, Butters L, Evans J, et al.: First year of life after the use of atenolol in pregnancy associated hypertension. Arch Dis Child 1984, 59:1061–1063.
Bortolus R, Ricci E, Chatenoud L, Parazzini F: Nifedipine administered in pregnancy: effect on the development of children at 18 months. Br J Obstet Gynaecol 2000, 107:792–794.
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, 1:647–649.
von Dadelszen P, Ornstein MP, Bull SB, et al.: Fall in mean arterial pressure and fetal growth restriction in pregnancy hypertension: a meta-analysis. Lancet 2000, 355:87–92.
August P, Lenz T, Ales KL, et al.: Longitudinal study of the renin-angiotensin-aldosterone system in hypertensive pregnant women: deviations related to development of superimposed preeclampsia. Am J Obstet Gynecol 1990, 163:1612–1621.
Visser W, Wallenburg HCS: Central hemodynamic observations in untreated preeclamptic patients. Hypertension 1991, 17:1072–1077.
Bosio PM, McKenna PJ, Conroy R, O’Herlihy C: Maternal central hemodynamics in hypertensive disorders of pregnancy. Obstet Gynecol 1999, 94:978–984.
Easterling TR, Brateng D, Schmucker B, et al.: Prevention of preeclampsia: A randomized trial of atenolol in hyperdynamic patients before onset of hypertension. Obstet Gynecol 1999, 93:725–733.
Schobel HP, Fischer T, Heuszer K, et al.: Preeclampsia-a state of sympathetic overactivity. N Engl J Med 1996, 335:1480–1485.
August P, Mueller FB, Sealey JE, Edersheim TG: Role of renin-angiotensin system in blood pressure regulation in pregnancy. Lancet 1995, 345:896–897.
Wallukat G, Homuth V, Fischer T, et al.: Patients with preeclampsia develop agonistic autoantibodies against the angiotensin AT1 receptor. J Clin Invest 1999, 103:945–952.
Pryde PG, Sedman AB, Nugent CE, Barr MJr: Angiotensinconverting enzyme inhibitor fetopathy. J Am Soc Nephrol 1993, 3:1575–1582.
Buttar HS: An overview of the influence of ACE inhibitors on fetal-placental circulation and perinatal development. Mol Cell Biochem 1997, 176:61–71.
Spence SG, Zacchei AG, Lee LL, et al.: Toxicokinetic analysis of losartan during gestation and lactation in the rat. Teratology 1996, 53:245–252.
Tomlinson AJ, Campbell J, Walker JJ, Morgan C: Malignant primary hypertension in pregnancy treated with lisinopril. Ann Pharmacother 2000, 34:180–182.
Easterling TR, Carr DB, Davis C, et al.: Low-dose, short-acting, angiotensin-converting enzyme inhibitors as rescue therapy in pregnancy. Obstet Gynecol 2000, 96:956–961.
Montan S, Anandakumar C, Arulkumaran S, et al.: Effects of methyldopa on uteroplacental and fetal hemodynamics in pregnancy-induced hypertension. Am J Obstet Gynecol 1993, 168:152–156.
Butters L, Kennedy S, Rubin PC: Atenolol in essential hypertension during pregnancy. BMJ 1990, 301:587–589.
Lip GY, Beevers M, Churchill D, et al.: Effect of atenolol on birthweight. Am J Cardiol 1997, 79:1436–1438.
Gallery EDM, Ross MR, Gyory AZ: Antihypertensive treatment in pregnancy: analysis of different responses to oxprenolol and methyldopa. BMJ 1985, 291:563–566.
Collins R, Yusuf S, Peto R: Overview of randomised trials of diuretics in pregnancy. BMJ 1985, 290:17–23.
Bolte AC, van Geijn HP, Dekker GA: Pharmacological treatment of severe hypertension in pregnancy: the role of serotonin 2 receptor blockers. Eur J Obstet Gynecol Reprod Biol 2001, 95:22–36.
Steyn DW, Odendaal HJ: Serotonin antagonism and serotonin antagonists in pregnancy: role of ketanserin. Obstet Gynecol Surv 2000, 55:582–589.
Visser W, Wallenburg HC: A comparison between the hemodynamic effects of oral nifedipine and intravenous dihydralazine in patients with severe preeclampsia. J Hypertens 1995, 13:791–795.
Gallery ED, Gyory AZ: Sublingual nifedipine in human pregnancy. Aust N Z J Med 1997, 27:538–542.
van Harten J, Burggraaf K, Danhof M, et al.: Negligible sublingual absorption of nifedipine. Lancet 1987, 2:1363–1365.
Fenakel K, Fenakel G, Appelman Z, et al.: Nifedipine in the treatment of severe preeclampsia. Obstet Gynecol 1991, 77:331–337.
Blea CW, Barnard JM, Magness RR, et al.: Effect of nifedipine on fetal and maternal hemodynamics and blood gases in the pregnant ewe. Am J Obstet Gynecol 1997, 176:922–930.
Scardo JA, Vermillion ST, Hogg BB, Newman RB: Hemodynamic effects of oral nifedipine in preeclamptic hypertensive emergencies. Am J Obstet Gynecol 1996, 175:336–338.
Martinez-Abundis E, Gonzalez-Ortiz M, Hernandez-Salazar F, Huerta-J-Lucas MT: Sublingual isosorbide dinitrate in the acute control of hypertension in severe preeclampsia. Gynecol Obstet Invest 2000, 50:39–42.
Aya AG, Mangin R, Hoffet M, Eledjam JJ: Intravenous nicardipine for severe hypertension in preeclampsia-effects of treatment on mother and foetus. Intensive Care Med 1999, 25:1277.
Shoemaker CT, Meyers M: Sodium nitroprusside for control of severe hypertensive disease of pregnancy: a case report and discussion of potential toxicity. Am J Obstet Gynecol 1984, 149:171–173.
Wasserstrum N: Nitroprusside in preeclampsia. Circulatory distress and paradoxical bradycardia. Hypertension 1991, 18:79–84.
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Umans, J.G., Lindheimer, M.D. Antihypertensive therapy in pregnancy. Current Science Inc 3, 392–399 (2001). https://doi.org/10.1007/s11906-001-0056-0