Management of hypertension in pregnancy

doi:10.1136/bmj.318.7194.1332

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L A Magee, assistant professor (laura.magee@utoronto.ca),
M P Ornstein, resident,
P von Dadelszen, clinical fellow in maternal-fetal medicine.

Departments of Medicine, and Obstetrics and Gynaecology, University of Toronto, Toronto, Canada

Correspondence to: Dr L A Magee, Department of Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada M5G 1X5

Accepted 12 March 1999

Hypertension in pregnancy is not a single entity1 but comprises:

Chronic hypertension, which complicates 1%-5% of pregnancies and is defined as a blood pressure greater than 140/90 mm Hg that either predates pregnancy or develops before 20 weeks of gestation
Pregnancy induced hypertension, which develops after 20 weeks of gestation and complicates 5%-10% of pregnancies
Gestational hypertension, which is pregnancy induced hypertension in isolation; it may reflect a familial predisposition to chronic hypertension, or it may be an early manifestation of pre-eclampsia
Pre-eclampsia, which is pregnancy induced hypertension in association with proteinuria or oedema, or both, and virtually any organ system may be affected.

Summary points

Antihypertensive treatment is well tolerated in pregnancy, with few women needing to change drugs due to side effects

Antihypertensive treatment for mild chronic hypertension benefits the mother, but the impact on perinatal outcomes is less clear, particularly for atenolol

For hypertension presenting later in pregnancy, even near term, the available data do not allow for reliable conclusions to be made about the benefits and risks of restricted activity with or without admission to hospital

Antihypertensive treatment for mild to moderate hypertension later in pregnancy benefits the mother, but the impact on perinatal outcomes may be harmful or beneficial

Women with early, severe pre-eclampsia have better perinatal outcomes if they are managed “expectantly,” but data are insufficient to estimate risks to the mother

For acute severe hypertension later in pregnancy, parenteral hydralazine is not the drug of choice as it is associated with more maternal and perinatal adverse effects than are other drugs, particularly intravenous labetalol or oral or sublingual nifedipine

Antihypertensive treatment given antenatally should probably be reordered postnatally

The types of hypertension in pregnancy differ primarily in the incidence, and not the nature, of maternal and perinatal complications. The UK confidential inquiries into maternal …