Treating Chronic Hypertension in Pregnancy

Persistent hypertension all through pregnancy will increase the chance of inadequate pregnancy and birth results.

Circumstance: A 35-calendar year-old female provides to clinic. She is actively attempting for being pregnant and now stopped her delivery regulate. Her health-related history involves a 5-calendar year heritage of hypertension treated with an ACE inhibitor.

Currently her blood pressure is 124/68 mmHg and BMI 27 kg/ m2. What suggestions do you have for administration of this patient’s scenario?

Long-term hypertension in pregnancy is described as >140/90mmHg.1 The prevalence of hypertension in pregnant girls is estimated to be around 3%, with opportunity association with females obtaining children at a afterwards age.4

Serious hypertension throughout pregnancy raises the threat of lousy being pregnant and birth outcomes.3,4 While consensus exists to use antihypertensive therapy to treat severe hypertension (systolic ≥160, diastolic ≥105-110 mmHg) for the duration of being pregnant, the rewards and protection for managing moderate persistent hypertension during pregnancy are unclear.

According to the American School of Obstetricians and Gynecologists’ Job Drive on Hypertension in Pregnancy, the controversy in moderate to chronic hypertension in pregnancy is owing to the absence of proof to manual therapy.1

Methyldopa, a centrally performing alpha agonist has ordinarily been initially line for hypertension in being pregnant.3 But a prevalent adverse influence (AE) of methyldopa is somnolence.

Drs Seely and Ecker, authors of “Chronic Hypertension in Pregnancy” advocate labetalol. Labetalol, a combined alpha and beta blocker, has fewer AEs than methyldopa.3 A prevalent AE of labetalol is dizziness.2

Nifedipine, a extensive-performing calcium channel blocker, was also an alternate antihypertensive drug.3,4 ACEis/ARBs are contraindicated because they induce oligohydramnios from impaired fetal advancement.3

The Chronic Hypertension and Pregnancy (CHAP) trial looked at cure of delicate serious hypertension in being pregnant. This multi middle, open up label, randomized, controlled trial enrolled 2408 females with delicate chronic hypertension and singleton fetus at <23 weeks’ gestation.

The active treatment group had 1202 women and wanted to achieve a systolic blood pressure <140/<90mmHg. The standard treatment group, also 1202 women, received no treatment unless severe hypertension developed ≥160/≥105 mmHg.

The active treatment group received labetalol or extended release nifedipine, or other drugs such as amlodipine or methyldopa by preference.4 Doses were escalated to the maximum dose to achieve the target blood pressure.

The primary outcome was a composite of preeclampsia with severe features, medically indicated preterm birth before 35 weeks, placental abruption, or fetal or neonatal death. The active treatment group’s primary outcome was significantly lower than standard treatment, with an approximate incidence of 30.2% versus 37.0%.4

The safety outcome of the incidence was small for gestational age birth weight below the 10th percentile and did not differ significantly between the active treatment group and standard treatment group.4 In an analysis of secondary outcomes, composites of serious maternal complications or serious neonatal complications occurred infrequently.

The results suggest lower rates of pre-eclampsia and preterm birth with antihypertensive therapy.4 Some limitations were that women were aware of their treatment, there was a high ratio of women screened to women enrolled, and this trial was not powered to see treatment effects across subgroups. The authors conclude that treating mild chronic hypertension during pregnancy reduced adverse pregnancy outcomes without impairing fetal growth.4

Based on this information, the patient in our case should be counseled on contraception until she has her pre-pregnancy evaluation. If she has a reversible cause of chronic hypertension, that should be addressed along with changing her ACE inhibitor to a drug that is safe in pregnancy such as methyldopa, labetalol, or nifedipine. She should also be closely followed during her pregnancy, receive interdisciplinary care from obstetrics and gynecology practitioners, and be educated on pre-eclampsia.

About the Author

Momi Talukdar, PharmD candidate, Northeast Ohio Medical University, Class of 2024, 2022 Mayo Clinic pharmacy intern.

References

  1. Hypertension in Pregnancy. American College of Obstetricians and Gynecologists. 2013122(5):1122-1133. Accessed June 27, 2022. https://oce.ovid.com/article/00006250-201311000-00036/PDF
  2. Labetalol. Lexi-Drugs. Lexicomp. Wolters Kluwer Health. Inc. Riverwoods, IL. Available at: http://online.lexi.com. Accessed July 3, 2022
  3. Seely,E., Ecker, J. 2011. Chronic Hypertension in Pregnancy | NEJM. [online] New England Journal of Medicine. Available at: [Accessed 27 June 2022].
  4. Tita, A., Szychowski, J. and Boggess, K., 2022. Treatment method for Moderate Continual Hypertension through Pregnancy | NEJM. [online] New England Journal of Drugs. Out there at: [Accessed 24 June 2022].