Hypertension Management

Initial Treatment

• The European Society of Cardiology recommends Labetalol IV as the first-line treatment for hypertensive emergencies, with the goal of reducing mean arterial pressure by 15-25% to achieve a systolic blood pressure of 140-150 mmHg and diastolic blood pressure of 90-100 mmHg 1
• Nifedipine oral is considered an effective alternative when IV access is not available 1

Contraindications and Precautions

• Methyldopa should not be used for urgent blood pressure reduction 1
• Magnesium sulfate should not be administered concomitantly with calcium channel blockers due to the risk of hypotension from potential synergism 1
• Nifedipine rapid-acting can induce uncontrolled hypotension, particularly when combined with magnesium sulfate, and should be avoided except in low-resource settings 1
• ACE inhibitors and ARBs are absolutely contraindicated due to the risk of fetal toxicity and death, as stated by the American College of Cardiology and the American College of Obstetricians and Gynecologists 2, 3, 4

Safe Medications During Lactation

• The following medications are considered safe during breastfeeding: Labetalol, Nifedipine, Enalapril, Metoprolol, and Amlodipine 1
• Diuretics, such as furosemide, hydrochlorothiazide, and spironolactone, should be used with caution as they may reduce milk production 5, 1
• The European Society of Cardiology suggests that ACE inhibitors, such as enalapril, are preferred for breastfeeding mothers unless the neonate is premature or has renal failure 1

Diagnostic Evaluation and Treatment

• Diagnostic evaluation and possible treatment should be performed in the presence of systolic blood pressure > 160 mmHg, tachycardia, oliguria, persistent headache, or difficulty breathing 1

• The following medications are recommended for severe hypertension:

  Medication	Recommended Dose
  Nifedipine XR	30-60 mg once daily
  Amlodipine	5-10 mg once daily
  Labetalol	200-800 mg divided twice daily or more frequently
  Methyldopa	250-500 mg divided twice daily or more frequently

  5, 6

Postpartum Hypertension Management

• Adequate management of postpartum hypertension is crucial to prevent severe complications such as stroke and eclampsia, which can occur in the postpartum period and significantly contribute to maternal morbidity and mortality 1
• The American Heart Association recommends calcium channel blockers (nifedipine or amlodipine) as first-line treatment for postpartum hypertension, as they are more effective than labetalol in the postpartum period and associated with lower risk of hospital readmission 5
• Women should be monitored closely for 24-72 hours postpartum as hypertension may worsen between days 3-6, and a review should be conducted within 1 week if they still require antihypertensives at hospital discharge, as recommended by the American College of Obstetricians and Gynecologists and the American Heart Association 3, 7
• Antihypertensive treatment should be continued after delivery if needed, according to the American College of Obstetricians and Gynecologists 3

Risk Assessment and Prevention

• The European Society of Cardiology classifies the risk of pregnancy in women with heart disease into four classes, with corresponding mortality rates:

  Class	Description	Mortality
  I	Low risk: Uncomplicated small/mild lesions	<1%
  II	Medium risk: Uncomplicated lesions not in class I or IV	5-10%
  III	High risk: Significant complex lesions	10-25%
  IV	Extremely high risk: Pregnancy contraindicated	25-50% [6]

• Calcium supplementation (at least 1g daily) may reduce the risk of pre-eclampsia, according to the European Heart Association 6
• Low-dose aspirin (75-100 mg/day) prophylactically for women with a history of early-onset (<28 weeks) pre-eclampsia, starting before 16 weeks gestation, is recommended by the European Heart Association 6
• The American Heart Association recommends first-trimester screening for pre-eclampsia risk for all pregnant women, and low-dose aspirin (75-100 mg/day) prophylactically for women with history of early-onset (<28 weeks) pre-eclampsia, starting before 16 weeks gestation and continuing until delivery 1

Lifestyle Modifications

• Modifications to lifestyle, including maintaining an ideal weight and engaging in regular aerobic exercise, are recommended, as well as regular monitoring of blood pressure and control of metabolic factors, according to the European Society of Cardiology 6
• Women should aim to achieve their pre-pregnancy weight by 12 months postpartum, and limiting interpregnancy weight gain through a healthy lifestyle is also recommended, as recommended by the American College of Obstetricians and Gynecologists 7
• Periodic measurement of fasting lipids and blood glucose is necessary, as recommended by Hypertension 7

Multidisciplinary Care

• A multidisciplinary team approach, including cardiologists, obstetricians, anesthesiologists, neonatologists, and geneticists, is recommended for the care of women with heart disease during pregnancy, as recommended by the European Society of Cardiology 6
• Home blood pressure monitoring is recommended, and patients should be monitored closely for 24-72 hours postpartum 1
• Women with pregnancy-related hypertensive disorders should receive cardiovascular risk assessment and lifestyle modifications 1