Management of Hypertension in Pregnant Women

Classification and Diagnosis

The European Society of Cardiology recommends that hypertension in early pregnancy (before 20 weeks) be classified as pre-existing hypertension, which complicates 1-5% of pregnancies 2
The European Society of Cardiology defines gestational hypertension as hypertension that develops after 20 weeks of gestation without proteinuria 3
The European Society of Cardiology defines pre-eclampsia as gestational hypertension with clinically significant proteinuria (≥0.3 g/day in a 24h urine collection or ≥30 mg/mmol urinary creatinine in a spot random urine sample) 3
The European Society of Cardiology states that pre-existing hypertension plus superimposed gestational hypertension with proteinuria occurs when pre-existing hypertension worsens with protein excretion ≥3 g/day after 20 weeks gestation 3

The European Society of Cardiology recommends that for women with gestational hypertension, pre-existing hypertension with superimposed gestational hypertension, or hypertension with subclinical organ damage, treatment should be initiated at BP ≥140/90 mmHg 1, 4
The European Society of Cardiology recommends that in all other pregnant women with hypertension, treatment should be initiated at BP ≥150/95 mmHg 4
The European Society of Cardiology states that target BP should be below 140/90 mmHg but not below 80 mmHg for diastolic BP to ensure adequate uteroplacental perfusion 1
The European Society of Cardiology considers severe hypertension (SBP ≥170 mmHg or DBP ≥110 mmHg) in a pregnant woman as an emergency requiring hospitalization 4, 5

The European Society of Cardiology recommends non-pharmacological management for pregnant women with SBP of 140-150 mmHg or DBP of 90-99 mmHg 4, 6
The European Society of Cardiology advises a normal diet without salt restriction, particularly close to delivery, as salt restriction may induce low intravascular volume 4, 3
The European Society of Cardiology suggests that limitation of activities and some bed rest in the left lateral position may be beneficial 3, 2
The European Society of Cardiology recommends low-dose acetylsalicylic acid (75-100 mg/day) prophylactically in women with a history of early-onset (<28 weeks) pre-eclampsia, administered at bedtime starting before 16 weeks gestation 4, 2

The European Society of Cardiology recommends dihydropyridine calcium channel blockers (preferably extended-release nifedipine), labetalol, and methyldopa as first-line BP-lowering medications for treating hypertension in pregnancy 1, 2
The European Society of Cardiology states that methyldopa has the longest safety record with adequate infant follow-up (7.5 years) 3
The European Society of Cardiology recommends immediate pharmacological treatment with IV labetalol, oral methyldopa, or nifedipine for severe hypertension (SBP ≥170 mmHg or DBP ≥110 mmHg) 4, 5
The European Society of Cardiology states that ACE inhibitors, ARBs, and direct renin inhibitors are strictly contraindicated throughout pregnancy due to severe fetotoxicity 1, 3, 2

The European Society of Cardiology recommends regular BP monitoring throughout pregnancy 2
The European Society of Cardiology advises monitoring for signs of worsening hypertension or development of pre-eclampsia (headache, visual disturbances, epigastric pain) 2
The European Society of Cardiology recommends evaluating for proteinuria to detect pre-eclampsia 2
The European Society of Cardiology states that induction of delivery is indicated in gestational hypertension with proteinuria with adverse conditions such as visual disturbances, coagulation abnormalities, or fetal distress 4

The European Society of Cardiology recommends continuing antihypertensive medications postpartum with gradual tapering rather than abrupt cessation 7
The European Society of Cardiology states that safe antihypertensive medications for breastfeeding mothers include labetalol, nifedipine, methyldopa, enalapril, and beta-blockers 7
The European Society of Cardiology advises that diuretics may reduce milk production and are generally not preferred in breastfeeding women 7
The European Society of Cardiology recommends that all women should be reviewed at 3 months postpartum to ensure BP, urinalysis, and laboratory abnormalities have normalized 7

The European Society of Cardiology states that women with hypertensive disorders of pregnancy have significant long-term cardiovascular risks and require ongoing monitoring 7
The European Society of Cardiology recommends annual medical review lifelong for women who had hypertensive disorders of pregnancy 7
The European Society of Cardiology advises aiming to achieve pre-pregnancy weight by 12 months and adopting a healthy lifestyle that includes regular exercise, healthy diet, and maintaining ideal body weight 7