Managing Hypertension in Pregnancy

Introduction to Hypertension Management

The American College of Cardiology recommends targeting 110-135/85 mmHg during pregnancy for patients with chronic hypertension, to balance maternal cardiovascular protection with adequate uteroplacental perfusion 1
The European Society of Cardiology recommends initiating drug treatment in pregnant women with chronic hypertension when systolic BP is ≥140 mmHg or diastolic BP ≥90 mmHg, highlighting the importance of early intervention 5

Aim for BP <140/90 mmHg but not below 80 mmHg diastolic to balance maternal cardiovascular protection with adequate uteroplacental perfusion, according to the European Heart Journal 5, 6, 1
Extended-release nifedipine is a preferred first-line agent with strongest safety data and once-daily dosing for improved adherence, as recommended by the American College of Cardiology 1
Labetalol is an excellent alternative, particularly if no reactive airway disease, and is recommended by the European Society of Cardiology 1
Methyldopa has the longest safety record with long-term infant outcome data, though use cautiously if depression risk, as noted by the American College of Cardiology 2, 4, 1

Start low-dose aspirin (75-150 mg) at bedtime to reduce preeclampsia risk, as recommended by the American College of Cardiology 1
Perform baseline laboratory assessment, including CBC, liver enzymes, serum creatinine, electrolytes, uric acid, and urinalysis with protein-to-creatinine ratio, to identify potential complications early 1
Screen for secondary hypertension if diagnosed before age 40, unless obesity suggests sleep apnea as primary cause, to rule out underlying conditions 1
Assess for target organ damage, including retinopathy, renal disease, ventricular hypertrophy, to determine the extent of hypertension-related damage 1

Never continue ACE inhibitors, ARBs, direct renin inhibitors, or mineralocorticoid receptor antagonists due to fetal teratogenicity and oligohydramnios, as warned by the European Society of Cardiology 1
Avoid atenolol due to association with intrauterine growth restriction, as noted by the American College of Cardiology 1
Generally avoid diuretics during pregnancy planning due to risk of reducing uteroplacental perfusion, as recommended by the European Society of Cardiology 1
Don't use short-acting nifedipine for chronic management, only extended-release formulations should be used, as advised by the American College of Cardiology 1